HomeMy WebLinkAbout03-0342PETITION FOR PROBATE and GRANT OF LETTERS
Estate of Helen ~. Kelly No.
also known as To:
, Deceased.
Social Security No. 194,12-6589
The petition of the undersigned respectfully represents that:
Register of Wills for the
County of Cumberland
Commonwealth of Pennsylvania
in the
Your petitioner(s), who is/are 18 years of age or older an the execut rix named
in the last will of the above~0e~edent, datexl May 1~(,..2~0y~/,., ~ ,//~/~/
and codicil(s) dated ._.~C/_//_)c~/F'_,C"/ ,/~,. , .... /7//). ~_~ _77,
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decedent was domiciled at death in Cumberland County, Pennsylvania, with
h ~r . . last family or principal residence at 1701 Warren Street. New Cumberland, PA 17070
(list street, number and municipality)
Decedent, then 81 years of age, died 3/18/2003
at Harrisburo. PA
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 ajudicated
incompetent:
Decedent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$
$
1701 Warren Street, New Cumberland, PA 17070
150.000.00
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters testamentary
thereon.
Ann M. Wilson '
(testamentary; administration c.t.a4 administration d.b.n.c.t.a.)
119 Cricket Lane
Camp Hill , , PA 17011
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA 3
COUNTY OF Cumberland ~ SS
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well andlrt0ty administer t[a;/~cc~rding to law.
Sworn to or affirn~d and subscribed t" /~/~OL ~, ~=~
b~fore me this ~f'J~ day of / ~
No. t-aa-34 -
Estate of Helen E. K~II¥ , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
ANDNOW ~1r~ ~. Iq, ~O~03 , in consideration ofthe petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated 5/18/2000
described therein be admitted to probate and filed of record as the last will of Helen E. Kelly
and Letters Testamenta~
are hereby granted to
Ann M. Wilson
FEES
Probate, Letters, Etc ......... $
Short Certificates (
~~v,~,42~' . $ Q. oo
$ IO. 6)o
TOTAL $
Filed....$4:-~ I.q.-. 9.-3. ............
[ Register of Wills ff t 611~
Mafielle F. Hazen, Esquire
68003
ATTORNEY (Sup. Ct. LD, No.)
2000 Linglestown Road, Suite 303
Harrisburg PA 17110
ADDRESS
717 5404332
PHONE
REGISTER OF WILLS OF COUNTY
OATH OF SUBSCRIBING WITNESS
(each) a
law, depose(s) and
the testat ., sign the
request of testat in h
other subscribing witness(es)).
Sworn to or affirmed and
me this
codicil
to the will presented herewith,
before
day of
19.__
duly qualified according to
__ present and saw
signed as a witness at the
(in the presence of each other) (in the presence of the
(Name)
Register
(Address)
REGISTER OF WILLS OF (q.~k~0~_,~, ~(
COUNTY
OATH OF NON-SUBSCRIBING WITNESS
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
~ ~/3 familiar with the signature of ~4e~.~ ~9-~ ~ /~"~c~_~ ,
codicil ~
testato~, ~- of (one of the subscribing witnesses to) the ~ presented herewith and
codicil
that ,-~ Cc~..~_,~o believegthe signature on the will is in the handwriting of
to the best of ,-~t~ ~_ knowlec{ge angbelief.
Sworn to or affirmed and subscribed before
me tvs ~L~ day of
- ~ ~-.C~.~ ~L~e~ister
(Address)
(Name)
(Address)
REGISTER ~ WILLS OF . COUNTY
OATi~OF SU }S( ~ ~NESS
~ codicil~ "~,.~
request of testat ~~~~Mhe presence of ~ch ~(in the presence r
~t~r subscribing with% ~ ~-
~n to or ~firmed ~d s~d ~r~ ~ . ~
Ndr s ,
~ ~ (Nam~
~ ~ ~ (Address~
REGISTER OF WILLS OF ~, L~.A~,_~L- COUNTY
OATH OF NON-SUBSCRIBING WITNESS
(each) a subscrilYer hereto, (each) being duly qualified according to law, depose(s) and say(s) that
..~ ,x~ familiar with the signature of ~r~ ~ /~A~ ,
codicil a
testat~t_.J~, of (one of the subscribing witnesses to) the ~ presented herewith and
codicil
that ._~c ¢_)oy0~ believe~ the signature on the will is in the handwriting of
U
to the best of J~.o knowledge and belief.
Sworn to or affirmed and subscribed before
me t~. J ~ "~l,q dayof
(Address)
(Name)
(Address)
his is to certify that the information here given is correcdy 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.
Fee for this certificate, $2.00 ~
~,,,,,~ Local Registrar
No. ~ Date
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~,,3 ~e~ ~a? COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF DEATH
,. Helen P.. Kelly ,.Female ,. 194 --12 --6589
~70~ ~ ~e RESIOE~E
~ ~=1~ PA 17070 <~'"~ ~=1~ ~
'" '~.~m ,,,~ ~ ~ ~rl~, PA 17070
~ ~id Kelly ~ 6~ S~te ~d, ~st ~, PA 1~
~ ~ G ~,b. ~ 22, ~3 [~,~z~ ~rz~ ~ {:,,. 1~72
~ ^ I - 03 -3q- J-
LAST WILL AND TESTAMENT
OF
HELEN E. KELLY
KNOW ALL MEN BY THESE PRESENTS, That I, HELEN E. KELLY, of the
Borough of New Cumberland, County of Cumberland, and Commonwealth of Pennsylvania,
do make, publish, and declare this instrument to be my Last Will and Testament, hereby
revoking and making void any and all former Wills by me at any time heretofore made.
It is my wish that my son Daniel E. Kelly be given the opportunity to live in my home
independently and that the house be not sold unless and until it be determined in the
exercise of good and reasonable consideration and judgment that he is unable to live
independently. Then in that event, sale of said property will be at the discretion of both Ann
M. Wilson and David M. Kelly.
FIRST: I direct the Executor hereof to pay all my just debts, funeral expenses and
costs of administration as soon as conveniently may be done after my death. I further
direct the Executor hereof to pay all inheritance, estate, transfer and succession taxes
which may be levied or assessed upon any property which is included as part of my gross
estate for the purpose of any such tax.
SECOND:I give, devise and bequeath unto my husband, EDWARD M. KELLY, rest,
residue and remainder of my estate, realty and personalty, howsoever designated
wheresoever situate provided that he is living on the thirtieth (30th) day after the date of my
death.
-1-
THIRD: If my said husband, EDWARD M. KELLY, does not survive me or does not
survive by the said period of thirty (30) days, then in that event, I give, devise and bequeath
all the rest, residue and remainder of my estate in equal shares, share and share alike, to
my Children ANN M. WILSON, and DAVID M. KELLY, perstirpes.
FOURTH: I appoint my husband, EDWARD M. KELLY, to be Executor of this my
Last Will and Testament. I do hereby give to the Executor hereof full power, discretion and
authority at any time or times to sell, at private or public sale, mortgage, lease, pledge,
exchange or otherwise deal with or dispose of the property comprising my estate as
deemed best, to settle and compound any and all claims in favor of or against my estate as
deemed best and, for any of the foregoing purposes, to make, execute and deliver any and
all deeds, mortgages, contracts, leases, bills of sale or other instruments necessary or
desirable therefor.
FIFTH: In the event my husband, EDWARD M. KELLY, fails or refuses for any
reason to serve as Executor of this my Last Will and Testament, then in that event I appoint
ANN M. WILSON as Executrix of this my Last Will and Testament.
LASTLY: I direct that no fiduciary appointed by this, my Last Will and Testament,
shall be required to give bond and that if, notwithstanding this direction, any bond is
required by any 'law, statute or rule of court, no surety shall be required thereon.
IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and
Testament, consisting of three (3) typewritten pages on the margin of which (except this
-2-
page) I have affixed my initials this 18th day of May, A.D. 2000.
Signed, sealed, published and declared by Helen E. Kelly, the above-named
Testatrix, as and for her Last Will and Testament, in the presence of us and each of us,
who at her request, and in her presence, and in the presence of each other, have hereunto
subscribed our names as attesting witnesses.
~)~'than Byerly
-3-
County of Cumberland
Commonwealth of Pennsylvania
ACKNOWLEDGMENT AND AFFIDAVIT
We, Helen E. Kelly, the testatrix, and the undersigned witnesses to the Will, the
attached or foregoing instrument, having been qualified according to law do depose and
say:
(a)that I, the testatrix, do hereby acknowledge that I signed the instrument as my
Will, that I signed it willingly and as my free and voluntary act for the
purposes therein expressed; and
(b)that
we, the witnesses, were present and saw the testatrix sign the instrument as
her last Will, that she signed it willingly and as her free and voluntary act for
purposes therein expressed; that each of us in the hearing and sight of the
testatrix signed the Will as a witness and that to the best of our knowledge
the testatrix was at that time 18 or more years of age, of sound mind and
under no constraint or undue influence.
Sworn to or affirmed before me by Helen E. Kelly, testatrix, and Nathan Byerly and
Amy Knauer, witnesses, this 18th day of May, 2000.
Helen E. Kelly
By: David W. Knauer
Amy KnauerL..j''
Attorney I.D. #21582
-4-
David W. Knauer. P.C.
Attorneys-at. Law
41 I-A East Main Street
Mechanicsbur~ PA 17055
(717) 795-7790
BUREAU OF INDIVIDUAL TAXES
THHERTTANCE TAX DZVTSTOH
DEPT. ?.60601
HARRTSBURG, PA 17128-0601
ANN NILSON
119 CRICKET LN
CAHP HILL
COHHONHEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAZSENENT, ALLO#ANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSNENT OF TAX
'0~ FEB 13 73:28
DATE 02-16-2006
ESTATE OF KELLY
DATE OF DEATH 05-18-2005
FILE NUNBER 21 05-0562
COUNTY CUHBERLAND
ACN 101
I Amount Remitted
HELEN E
HAKE CHECK PAYABLE AND RENZT PAYHENT TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THZS LZNE ~ RETAIN LOHER PORTION FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLONANCE OR DZSALLO#ANCE OF DEDUCTZONS AND ASSESSHENT OF TAX
ESTATE OF KELLY HELEN E FZLE NO. 21 05-0562 ACN 101 DATE 02-16-2006
TAX RETURN NAS: ( ) ACCEPTED AS FILED (X) CHANGED SEE ATTACHED NOTICE
RESERVATZON CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00
4. Mortgages/Notes Receivable (Schedule D) (4) .00
E. Cash/Bank Daposits/N/sc. Personal Property (Schedule E) (5) 201226.00
6. JointZy Owned Property (Schedule F) (6) .00
7. Transfers (Schedule G) (7) .00
8. Total Assets
APPROVED DEDUCTIONS AND EXEHPTZONS:
9. Funeral Expenses/Ada. Costs/N/sc. Expenses (Schedule H) (9)
10. Debts/Mortgage L/ab/1/t/as/L/ans (Schedule Z) (10) 91;610.00
11. Total Deduct/ons (11)
12. Net Value of Tax Return (12)
152z500. O0
.00
(8)
16,862.00
NOTE: To insure proper
cred/t to your account,
submit the upper port/on
of th/s form w/th your
tax payment.
172,726.00
66,276.00
15.
14.
NOTE:
Char/table/governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15)
Nat Value of Estate Sub~ect to Tax (14)
:If an assessment ~as lssued previously, 11nes 14, 15 and/or 16, 17,
.00
66,276.00
18 and 19 ~ill
re~lect figures that include the total of ALL returns assessed to date.
ASSESSHENT OF TAX:
15. Amount of L/ne 14 et Spousal rate
16. Amount of L/ne 14 taxable et L/heal/Class A rata
17. Aeount of L/ne 14 at Sibl/ng rate
18. Amount of L/ne 14 taxable at Collateral/Class B rata
19. Pr/ncipal Tax Due
TAX CREDITS:
PAYNENT RECEIPT DTSCOUNT
DATE NUHBER INTEREST/PEN PAID (-
06-19-2005 CDOOZ710 .00
12-06-2005 CD003316 . O0
(is) .00 x O0 = .00
(16) 66,276.00 x 065= 2,982.33
(17) .00 x 12 = .00
(18) .00 x 15 = .00
(19)= 2,982.$$
AHOUNT pAID
900.00
1,521.00
TOTAL TAX CREDIT
BALANCE OF TAX DUE
~NTEREST AND PEN.
TOTAL DUE
2,621.00
INTEREST IS CHARGED THROUGH O$-OZ-ZO06
AT THE RATES APPLICABLE AS OUTLINED ON THE
REVERSE SIDE OF THIS FORH
IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
561.$$
6.83
566.16
( IF TOTAL DUE ZS LESS THAN $1, NO PAYNENT IS REQUIRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR)~ YOU NAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORN FOR ZNSTRUCTZONS.)'~
RESERVATION:
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMIN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 11, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life or for years, the Coaaonmealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
To fulfill the requirements of Section ZlqO of the Inheritance and Estate Tax Act, Act Z3 of ZOO0. (72 P.S.
Section 91q0).
Detach the top portion of this Notice and submit with your payment to the Register of #ills printed on the reverse side.
--Hake check or money order payable to: REGISTER OF N/LLS, AGENT
A refund of a tax credit, which was not requested on the Tax Return, amy be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-151$}. Applications are available at the Office
of the Register of Hills, any of the 25 Revenue District Offices, or by calling the special Z4-hour
answering service for forms ordering: 1-800-561-Z050; services for taxpayers with special hearing and / or
speaking needs: 1-800-447-5010 iTT only).
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 181011, Harrisburg, PA 17118-1011, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 180601, Harrisburg, PA 17118-0601
Phone (?17) 787-6SOS. See page S of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-1SOi} for an explanation of administratively correctable errors.
If any tax due is paid within three ($) calendar months after the decedent's death, a five percent (5Z) discount of
the tax paid is allowed.
The 151 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning aith 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 1, 1982 bear interest at the rate of
six (61) percent per annum calculated at a daily rate of .000164. All taxes ahich became delinquent on and after
January l, 1982 wiII bear interest at a rate ahich ail1 vary from calendar year to caIendar year mith that rate
announced by the PA Department of Revenue. The appIicabIe interest rates for 1982 through 2003 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1981 lOX .000548 1987 91 .000247 1999 71 .000191
1983 161 .000438 1988-1991 111 .000301 2000 81 .000219
1984 111 .000301 1991 91 .000247 2001 9Z .000147
1985 131 .000356 1993-1994 7Z .000192 ZOOZ 61 .000164
1986 101 .000174 1995-1998 91 .000247 Z003 SZ .000137
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID
X NUNBER 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 data shown on the
Not/ce, additional interest must be calculated.
~EV-1470 EX (6-88)
INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME FILE NUMBER
Helen E Kelly 2103-0342
REVIEWED BY ACN
Deborah Washington 101
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
I 3 Inheritance tax escrow is not an allowable deduction against the taxable estate.
Row Page 1
Name of Decedent:
Date of Death: ~ /~- /~) ~
Will No. _~_/-- ~,~-- (~ q &
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Admin. No.
To the Register:
I certify that notice of (beneficial interest) estate adnfinistration required by Rule 5.6(a) of i~,~anl~C~rt Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on :
Name Address
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: L.,~/
9t:6~ Et ~4B~' E0.
Signature
Name
Address
Telephone q f-~
Capacity: __ Personal Representative
Counsel for personal representative
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD 002710
WILSON ANN M
119 CRICKET LANE
CAMP HILL, PA 17011
fold
ESTATE INFORMATION: SSN: 194-12-6589
FILE NUMBER: 2103-0342
DECEDENT NAME: KELLY HELEN E
DATE OF PAYMENT: 06/19/2003
POSTMARK DATE: 06/1 9/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 03/1 8/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $900.00
TOTAL AMOUNT PAID:
$900.00
REMARKS: ANN WILSON
SEAL
CHECK# 117
INITIALS: SK
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-11 62 EX(11-96)
CD 003316
WILSON ANN M
119 CRICKET LANE
CAMP HILL, PA 17011
........ fold
ESTATE INFORMATION: SSN: 194-12-6589
FILE NUMBER: 2103-0342
DECEDENT NAME: KELLY HELEN E
DATE OF PAYMENT: 12/08/2003
POSTMARK DATE: 1 2/04/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 03/18/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $1,521.00
TOTAL AMOUNT PAID'
$1,521.00
REMARKS:
SEAL
CHECK//1 31
INITIALS: AC
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
REV-1500 EX (6-00~
i COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500 J
INHERITANCE TAX RETURN /
RESIDENT DECEDENT mcou. cODE
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DECEDENT'S NAME (LAS, T, FIRST, AND MIDPLE INITIAL)
DATE OF DEATH (MM-I~D-yEA~ ' DATE OF BIRTH (MM-DD-YEAR)
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, A-ND' MIDDLE INITIAL)
[-'~ 1. Original Return /Y/~] 2. Supplemental Return
[] 4. Limited Estate [~ 4a. Future Interest Compromise (date of death after 12-12-82)
~--]6. Decedent Died Testate (Attach copy of Will)[] 7. Decedent Maintained a Living Trust (Altach copy of Trust)
[~ 9. Litigation Proceeds Received [] 10, Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
SOCIAL SECURITY NUMBER
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOClALSECURITYNUMBER
] 3. Remainder Return (date of dealh prier to 12-13-82)
['~5, Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
[~11. Election to tax under Sec. 9113(A) (Attach Sch O)
NAME b0ils0n,
FIRM NAME (IfApplicable)
TELEPHONE NUMBER
COMPLETE MAILING ADDRESS
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Properly (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
~] Separate Bitling Requested
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)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13.
14.
(8)
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
(11)
(12)
(13)
(14)
6 q,
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2) x .0 __ (15)
16. Amount of Line 14 taxable at lineal rate --5--q)(~5) x.0 ~ (16)
17. Amount of Line 14 taxable at sibling rate x .12 (17)
18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
Decedent's Complete Address:
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
c. ,sco.t c. o
3. Interest/Penalty if applicable C~
D. Interest
STATE
E. Penalty
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
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 + 5A. This is the BALANCE BUE.
Total Credits ( A + B + C ) (2)
Total Interest/Penalty ( D + E ) (3)
(4)
(5)
(5A)
(5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
F~ "'I I Ill
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred; .......................................................................................... []
b. retain the right 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? ........................................................................................................................ []
BLOCKS
No
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 true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
DATE
SIGNATURE OF PERSON RE,gPON,giBLE FC~F/I~LIN,,~. R~E.~. N
r,,'
SIGNATURE OF PREPARER OTHER THAN'REPRESENTATIVE .... ~ 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 RS. §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 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 decedent's siblings is 12% [72 RS. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decadent, whether by blood or adoption.
REV- 500 EX (6-00}
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
· DEPT. 280601
HARRISBURG, PA 17128-0601
,REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
COUNTYCODE YEAR
DECEDENTS NAME (LAS,T, FIRST, AND MIDpLE INITIAL)
Weien
DATE OF DEATH (MM-I~D-yEA~r ' DATE OF BIRTH (MM-DD-YEAR)
,:3 I
(IF APPLICABLE) SURVIVING SPOUSE'8 NAME (LAST, FIRST, ~N~ MIDDLE INITIAL)
~1. Original Return /~/~ 2. Supplemental Return
~ 4. Limit~ Estate ~ 4a. Future Inlerast Compromise (date of death a,er 12-12-82)
6. Decedent Died Testate (A~ ~y o~ wi,) ~ 7. Deceden~ Maintained a Living Trusl (AUa~ ~py of Trusl)
~ 9. Litigation Proceeds Re~ived ~ 10. Spousal Povedy Credit (dale of death ~een 12-31-91 a~ 1-1-95)
SOCIAL SECURITY NUMBER
NUMBER
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
] 3. Remainder Return (dale of death priorto t2-13-82)
I-'--]5. Federal Estate Tax Return Required
8. Total Number of Safe Deposil Boxes
r-'-] 11. Election to tax under Sec. 9113(A) (Attach Sch O)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CON ,FIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Iici O_.rl'cK + tan
TELEPHQNE NUMBER
1. Real Estate (Schedule A) (1)
'2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnemhip or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, B~nk Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
[~] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (?)
(Schedule G or L)
Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedenl, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequesls/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
0i- I:.iCIAI. LISE-
(11)il "/,
(13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2) x .0 __ (15)
16. Amount of Line14 taxable at lineal rate ..~J"'IjS5j x.0 ~) (16)
17. Amount of Line 14 taxable at sibling rate x .12 (I7)
18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
20. ~]
> > BE SURE TO ANSWER ALL QUESTIONS ON 'REVERSE SIDE AND RECHECK MATH < <
Deceder~t's Complete Address:
CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
¢.
Discount
,I
7
D. Interest
E. Penalty
Total InteresFPenalty ( D + E )
(1)
If Line 2 is greater than Line 1 + Line 3, enler the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
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 Credits ( A + B + C ) (2)
(3)
(4)
(5)
(5A)
(5B)
z,P I-ZO 70
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 right to d~signate 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 properly within one year of death
without receiving adequate consideration? .............................................................................................................. []
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. []
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .............................. : ......................................................................................... []
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS.PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined Ihis return, includ ng accompanying schedu es 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
SIGNATURE OF PERSON RE,gFONSt6LE FQR FILING RE.TilRN
ADDRESS
SIGNATURE OF PREPARER OTHER THAN'REPRESENTATIVE 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 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 RS. §9116(a)(1.2)].
The lax rate imposed on the net value of transfers to or for the use of the decedent's lineai 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 decodenrs 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-1502EX + (1 97) ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATEOF . i . / . . , / ,~ FILENUMBER
All real pr'op'erty owned solely or as a tenant in common must he rel~orted a~'fair market value. Fair market value is defined as the p~'-ce at whic'~ prop~'rty would be exchanged
between a willing buyer and a willing seller, neither being compelled to buy or sell, both h~ving reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of
survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
170 1 £ [t
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 1, Recapitulation) $ I ~--'~l 5 ~ D
(If more space is needed, insert additional sheets of the same size)
REV-~508 EX + (1-97) ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MlSC,
PERSONAL PROPERTY
Include the proceeds of litigation and the date the proceeds were received ~ the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
Z? ~o
TOTAL (Also enter on line 5, Recapitulation)
6
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12 99)~,,~&
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
ITEM
NUMBER
5.
6.
7.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Debts ~f decedent must be reported on Schedule
DESCRIPTION
FUNERAL EXPENSES:
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
Year(s) Commission Paid:
Attorney Fees //"~O/q/~//~
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Zip
Street Address
City State
Relationship of Claimant to Decedent
__ Zip
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
TOTAL (Also enter on line 9, Recapitulation
(If more space is needed, insert additional sheets of the same size)
AMOUNT
%$5?
COMMONWEALTH OF PENNSYLVANIA
iNHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGELIABILITIES,&LIENS
Include unreimbursed medical expenses.
FILE NUMBER
ITEM
NUMBER
DESCRIPTION
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
AMOUNT
6th & W. Market Sts.
POTTSVILLE, PA 17901
Phone 570-622-7888
Fax 570-628-1995
O SCHLITZER-ALLEN-PUGH
William C. Pugh, Supervisor
FUNERAL HOME, INC. Gregory Achenbach, F.D.
"AT GARFIELD SQUARE"
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
FU.ERAL SERV,CES FOR: .'/ Date o, Death
TYPE OF SERVICE ARRANGED:
[] At Need r~- Burial [] Direct Disposition
Account// "~/) ir./~' t/'
. -L) Date of Service. '-4 ' .',,',- ~
I
Graveside Service [] Shipping Remains
I I [] I
[] Pre Need [] Cremation [] Funeral Service [] Memorial Service [] Receiving of Remains
[] Pre Need/At Need [] Other J~/Funeral/Graveside [] Memorial/Graveside
FUNERAL SERVICES: Charges are only for those items that are used. If We are required by law to use any items, we will explain the reasons in writing below. The
goods and services shown are those we provide for our clients. You may choose only those items you desire. Your director will adjust, cross out or note as not
applicable (N/A) any items that you decline.
Consult the General Price List
for a detailed description of the following items.
BURIAL CASKET SELECTED ........................................... $_ ~.~{; '~. /j i ~:)(:]
LifeSymbol Option No Exua Charge
CREMATION CASKET OR CONTAINER SELECTED .................. $ '~
OUTER BURIAL CONTAINER SELECTED .............................. $ .. ~
In most areas of the country, no state or local law makes you buy a container to
surround the casket in the grave. However, many cemeteries ask that you have such a
container so that the ground will not sink in. Either a burial vault or a graveliner will
satisfy these requirements.
REQUIREMENT OF CEMETERY: The funeral director assumes no liability
for gravesite cave-in or sinking if no outer burial container is used.
An outer burial container ff'ris nCQUIRE~, ~ .......
(Cemetery Name)
ADDITIONAL GOODS & SERVICES ........................................
$ ..:['-~ .3-'/ Custom Printed Guest Register
$ ~/,'~- ~;)':' Memorial Folders or Prayer Cards (per 100)
$-. Acknowledgement Cards (25 per box)
~,..'l
$ ~i '.-~ -, Hairdresser
Temporary Grave Marker
Crucifix
Clothing
Name Plate for exterior of casket
Custom Cap Panel
Custom Engraving of Casket or Cremation merchandise
$ - Refrigeration per day, after 24 hours in lieu of embalming
~ ~ Cremation
CASH ADVANCES AND ACCOMMODATION ITEMS ..........................
CREMATION MERCHANDISE SELECTED .................................. $_ ~
Warranty Disclaimer
The only warranty on the merchandise sold by us is the express written warranty, if
any. provided by the manufacturer of such merchandise. We make no warranty,
expressed or implied, with respect to merchandise. A manufacturer's warranty, if any,
will be provided to you.
BASIC SERV,CES OF FUNERAL DIRECTOR & STAFF ................. $ /~ J?5 (jO_
TRANSFER OF REMAINS TO FUNERAL HOME .......................... $.' ~5. OLf'?
EMBALMING ........................................................................ $ 7/';. ~i C~¢~)
If you selected a funeral service which requires embalming, such as
funeral with a viewing, you may have to pay for embalming. You do not
have to pay for embalming you did not approve if you selected
arrangements such as direct cremation or immediate burial. If we charge
for embalming we will explain why below.
EMBALMING IS REQUIRED IF YOU:
El' Selected a service with a viewing
[] Arranged for shipment by common carrier
[] Selected arrangements that require us to hold the remains for more
than 24 hours provided no refrigeration is available or a hermetically
sealed container is not used and provided that embalming does not conflict
with religious beliefs or medical examination.
rq'~Nas Granted
Relationship: L?-~/[~
Time: ,/~" '~3 DAM
ORAL PERMISSION TO EMBALM the above named decedent
[] Was Refused
[] In Person [] By Phone
OTHER PREPARATION OF REMAINS ..................................... $..
STAFF AND USE OF FACILITIES FOR FUNERAL SERVICE,
MEMORIAL SERVICE OR SERVICE AT A LOCATION OTHER
THAN FUNERAL HOME REQUIRING TRANSFER ........................
This includes visitation or viewing one hour prior to service.
$_
STAFF & USE OF FACILITIES FOR VISITATION OR VIEWING
OTHER THAN ONE HOUR PRIOR TO FUNERAL OR MEMORIAL
SERVICE .................................................... :. ....................
~TAFF FOR GRAVESIDE SERVICE & ACCESSORIES
NEEDED ........................................................................
/Iotor equ pment rates sted be ow apply to a 25 mile radius
rom the funeral home. Add $1.50 per loaded mile after the $--
irst 25 miles for each vehicle requested.
IEARSE TO FINAL DISPOSITION ............................................ $.
;ERVICE VAN Icircle use) .................................................. $ /I~') (.G S-
May be elected and used for disposition of flowers, "
transfer to crematory, cemetery, anatomical gift registry,
airport or other.
AMILY TRANSPORTATION ...................................................... $ .- $ __
For your convenience we will order and handle payment of the following items. Any
omission of any item by the supplier of these services shall be the sole responsibility of
the supplier. The funeral director is relieved of any liability therefore by acting as your
agent. Certain charges may be estimated.
$ /'/? ~i~ (.~) Certified copies o f death certificate
$ //)..,.4¢.: Local Newspapers
~ Cemeter~ Equipment from Vault Company (tent, greens, lowering device)
TOTAL CASH SALE PR?CE OF ITEMS SELECTED ,~ ~ VD 0_4
LESS DEPOSIT RECEIVE'D ON ACCOUNT ...................................... $ ;'~ .': (, :~, :-.'., ).,
, BALANCE DUE FUNERAL HOME $(," ~' ' /- '/()
TERMS OF PAYMENT
Deduct $ if paid in full at time of arrangement
METHOD OF PAYMENT
rlCash rlCheck [] Visa [] Mastercard [] Discover
rllnsurance Assignment of a Verifiable Policy
I-IOther
PAYMENT SHALL BE MADE BY (date). (time)
Provisions for payment are due at time of arrangements or eot later than 24 hours prior to
service. In the event of default by Purchaser(si, Purchaser{s) hereby authorize(s) and agree(si
to the subsequent cancellation of service by Seller and further agree{s) to pay a penalty.
commencing from the first day after the date of service, at a rate of 18% per annum {1.5%
per month or fraction thereof) on any balance not paid within 30 days from date of service.._j
AGREEMENT
It is understood that the total'charges shown above may be estimated and reflect only that
agreed upon at the time of this arrangement. Any additional items of service and/or
merchandise ordered or required after the time of this arrangement shall be considered part
of this agreement and the cost wil be reflected on the final statement wh ch we will provide
to you no ater than 5 days from the date of service.
OTHER ITEMS OF COST THAT MUST BE PAID BY PURCHASER PRIOR
TO SERVICE DATE - Please make checks payable to:
$-- Cemetery:_
$-- Clergy:
Organist:
Sexton:
Shipping:_.
Other:
FLOWERS TO BE ORDERED ON BEHALF OF BUYER: Florist where Buyer has an
. account
Florist will add Pennsylvania Sales Tax to order beldw.
Casket Spray of Flowers
On the Card:
[] Ledge Piece [] Hinge Spray
On the Card:
Suggestions:
Satin Pillow with Roses (# of Roses .
On the Card:
[] Cross [] Heart
Other:
On the Card:
~UTHORIZATIONS: I or We authorize and ratify prior consent to the fun '
o. I or We represent ourselves as the person(si hay n the res .... eral d~rector to take possession of the body give care to and carr
o su I ' . g ponsloH~ty to arran e for th .... y out the arrangements hereto s ecifl
Pp y the service and or merchandise as listed ahnv. ~- .-.-,, .... g .e final disposition of the above named d.,-.d..t ~-- - ~ - p 'ed and agreed
,ayment of the cost of the services and ~r .... .__-~T:~-~ ~o w~.,, as. any ;?](ht~onal services and or merchandise ordered nr r~~'-'~: ~ Ho.hereby g?nt authority to the funeral director
~ ,,, a.ul~e omereo ano rOvlded ursuant u a/tel fee time of this arrangement I or We guarantee
.... P P to the above TERMS OF PAY~f' .... .
I (WE}, THE BUYER(SI, HEREBY AGREE THAT IN CONSIDERATION OF T
,., ~ONTRA .T 8FTWFF~ R YF~I~I A~B g~ ...... ~nlo oCr~Ub/ N IHE AGRcCnncn,* ~ ............ LLY AND JO NTLY
- - , , --- .~ [v~t~ uc~c~v ~ ~cc~o, T,~ n~ ~,.,~m vvlm~ bELLEH. N ACCORDAN E WITH TM~ T~ane
A. U.S DEPARTMENT OF HOUSING and URBAN DEVELOPMENT
SETTLEMENT STATEMENT
Phone:
SECURED LAND
TRANSFERS, INC.
5006 East Trindle Road
Suite 203
Mechanicsburg, PA 17055
(717) 591-8500 FAX: (717) 591-8506
OMB No. 2502-0265
TITLEPRO
Laserprinl
B. TYPE OFLOAN
1. J FHA 2. I ] FMHA 3..~ I CONV. UNINS.
4. IVA 5.[ ICONV. INS.
6. FILE~NUMBER: I 7. LOAN NUMBER:
505102 549484301
8. MORT. INS. CASE NO.:
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 the closing; they are shown here for informational purposes and are not included in the totals.
D. NAME AND ADDRESS OF BORIfOWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER:
Richard C. Keck]er
Donna J. Kecklez
G. PRQPERTY LOCATION:
1701 Warren Street
New Cumberland ~OROUGH
CUMBERLAND County
Estate of
Helen E. Kelly
H. SE~LEMENT AGENT:
Secured Land
GMAC Mortgage Corporation
P.O. Box 76
Camp Hill, PA 17011
Transfers, Inc.'
PLACE OF SE~LEMENT:
3915 Market Street, Camp Hill, PA 17011
J. SUMMARY OF BORROWER'S TRANSACTION:
152500 .--~
5649 .~-~-
10o GROSS AMOUNT DUE FROM BORROWER
101 Contract sales price
102 Personal property
to3. Settlement charges to borrower (line 1400)
104
105
Adjustments for items paid by seller in advance
lo6. City/Town ~ax I~
,07 Co~y ~a× 06/13/0
108 Assessments ,
,o9. School 66/13/0~
,0 Refuse:$35.60/~
,,, Swr:$~9.44/q ~n--d~ 0~~
112
66 . "0-~--'
6 . ~'~---
7.35
158590.40
12o GROSS AMOUNT DUE FROM BORROWER
200 AMOUNTS PAID BY OR IN BEHALF OF BORROWER
201. Deposit or earnest money 2 0 0 ~
202. Principal amount of new loan(s) 1 2 2 0 0 0 .-"~-b--0-'
203 Existing loan(s) taken subject to
I. SE'FrLEMENT DATE:
06/13/03
K. SUMMARY OF SELLER'S TRANSACTION:
4oQGROSS AMOUNT DUE TO SELLER
40t.Contract sales pr!ce
402 Personal property
403
404.
405.
Adjustments for items paid by seller in advance
406. Ci{y/Town tax to --
407 County tax 0 6 ~
408 Assessments {o --
409. School 0 6~
~~S_~_.'_.3_5~6_0 c~oen 6 30
4,,. ~wr:$39.
412.
152soo.--0'T0-~.
360 .-~
42o. GROSS AMOUNT DUE TO SELLER
soo REDUCTIONS IN AMOUNT DUE TO SELLER
66 .-'b-~
207
208 ._~
209.
Adjustments for ilems unpaid by seller
21o. City/Town tax to
211. County tax to
212. Assessments to
213. School tO
214. --
215
220 TOTAL PAID BY/FOR BORROWER
300. CASH AT SETTLEMENT FROM OR TO BORROWER
124000.00
3Ol. Gross amount due from bof rower (line 120) f 1 5 8 5 9-'-~'0-~"'~. ~ 0
302 Less amount paid by/for bo, rower (line 220) i 124000.-~
303. CASH (D(] FROM) ([ ] TO) BORROWER 34590.40
Buyer or Borrower's Signature
7.35
152940.42
5el.Excess deposit (see instructions)
so2 Settlement charges to seller (line 1400)
so3,Existing loan(s) taken subject to
so4.Payoff of First Mortgage Loan
Chase Manhattan Mortgag_____e:
s0sPayoff of Second Mortgage Loan
506.
S0?
509.
Adjustments for items unpaid b ' seller
[o
to
to
[o
510 City/Town
511 .County tax
512. Assessments
513. School
514.
515
516
517
518
519
s2o. ToTAL REDUCTION AMOUNT DUE SELLER
251,
74657.46
600 CASH AT SETTLEMENT TO OR FROM SELLER
6el.Gross amount due to seller (line 420) 15 2
6o2 Less re..__..~duction amount due seller (line 520) 9 91
6o3, CASH (IX] TO) ([ ] FROM) SELLER 53135.02
99805.40
. Seller's Signature
HUD- 1 Rev.
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
L. SETTLEMENT CHARGES 505102 SETTLEMENT STATEMENT
700. TOTALSALES/BROKER,S COMMiSSiON based on Prices '152500 .
Division of Commission (li.e 700) as follows: Total: $9,15 0 0 0
7o~. $ 4550. O0 to ·
7o2. $ 4600. O0 ~o
703. Commission paid at Settlement
704. Trans Fee
S00. ITEMs PAYABLE IN CONNFCTION WITH LOAN
80L Loan Origination Fee I .000 %
802. Loan Discount %
8o3. Appraisal Fee to
804. Credit Report to
805. Lenders Inspection Fee
106. Mortgage Insurance Appli¢ation Fee to
807. Assumption Fee
808 Doc Pre
'a× er-c ce
81o Flood Cert
81,. LfLnFldCrt
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE '
901. Interest from 06/1'~ 03 to06 30 03 @$ 18.38/day
02. Mortgage Insurance Premi~lm for mo. to
903. Hazard insurance Premium for
904.
)1 Fee
~000. RESERVEs DEPOSITED WITH LENDER FOR
IOOl. Hazard Insurance 3 mo. @ $
OD2. Mortgage Insurance mo. @ $
yrs. to
yrs, to
33 . 58 /mo.
/mo.
Realtor E~-- SETTLEMENT
ERA-NRT, Inc -
· 100.00
1003. City/Town tax
1004. County tax 5
IO05. Assessments
I006. School Tax 13
1007.
lUSt
1100. TITLE CHARGEs
r to f. Settlement or closing fee to
102. Abstract or title search to
103. Title examination to
1104. Title insurance binder tn
1105. Document preparation to
106. Notary fees to
mo, @ $ /mo.
mo. @ $ 54.54 /m~----~
mo. @ $ /mo.
mo.@$ 118.48 /mo.
mo. @ $ /mo.
mo @ $ /mo.
107. Attorney's fees
(includes above items No.:~
~R_e~It Associates
Cash
Mari~azen
1108. Title Insurance In
(includes above items No.:)
109. Lender's coverage $
fo. Owner's coverage $
~f12. Mail Fee
,ifs. Secured Land
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
'201. Recording fees: DeedS 39.50
202. City/county tax/stamps: Deed $
203. State tax/stamps: Deed $
204. IntTxEscrw
Secured Lan-~ransfers
end. ~_0_0, ~
122,000
152,500
Transfers
Mortgage $
1525 .~
1525.00 Mortgage
2os. Swr 4/5/6 -
300. ADDITIONAL SETTLEMENT CHARGES
]01. Survey lo
]02. Pest Inspection to
Io~3. Home Insp
~o4. Tax Cert
Secured La-~-~ran s f e r s'
New
Cumberland Borot
Bi er & Ti
Bi, er & Ti e]
260 O~
5.00
2 .o~-
OMB No. 2502-0265
Page
BORROWER'S SELLER'S
FUNDS AT FUNDS AT
Seller's New Address & Phone:
~illl,t;'~; (ur.l,~.~ ro)dk:<'~eW:zr~olnY ?oaokr :fl~ilc~%~,lcallioe~r¢lls01o he LIt lied Sial .... Ih ...... y .... lar IorDmal%enall ..... p ......... l ....... ~ ~onmeel, ~ ....
HUD-I Rev. 5/86
~r's Address & Phone:
05. Trans Fee ~Re ._ Realty Associates
Re/Ma i 4.
0~0. TOTAL SETTLEMENT CHARGES (enter on liees t03 and 502, Sections J and K) 125 .
564 251,
Parties agr,,~e lhal no liability is assumed by Selllemenl Agent for the at;curacy el informaliorl flJrrlished by olhers as shown on [he HUD-1 Selllerneel Slalemenl. Selllemenl Agonl hereby expressly
-~ervos I;'le righ ID deposit any amollnls ;ollecled Ior disbursement in an inleresl bearing accounl in a Federal¥ Insured inslilulion arid Io credil any interesl so earned to ils owe accounl as addilioaal
rnpensalion for ils services in I/lis Iransnclloe.
HUD CERTIFICATION OF BUYERS AND SELLERS
I have carefully reviewed Ihe HUD f Settlement Statement and to ~he best ot my knowledge and belief, it is a Irue and accurate statemenl et all receipts and disbursements
de on my account by me in this lransaction. I further certify that I have received a copy of [he HUD-1 Settlement Statement,
10.00
1273
108 .
1525
35.
2?5.
100 .
10.
454.
15.00
1525.
1372
39.
-285.
6th & W. Market Sts.
POTTSVILLE, PA 17901
Phone 570-622-7888
Fax 570-628-1995
OSCHLITZER-ALLEN-PUGH
FUNERAL HOME, INC.
"AT GARFIELD SQUARE"
William C. Pugh, Supervisor
Gregory Achenbach, F.D.
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
TYPE OF SERVICE ARRANGED:
[] At Need I ~Burial I [] Direct Disposition
[] Pre Need I [] Cremation I [] Funeral Service
Iq- Pre Need/At Need [] Other [~Funeral/Graveside
¥)
[] Graveside Service
[] Memorial Service
Account# "'
Date of Service
[] Shipping Remains
[] Receiving of Remains
[] Memoria)/Graveside
FUNERAL SERVICES: Charges are only for those items that are used. If we are required by law to use any items, we will explain the reasons in writing below. The
goods and services shown are those we provide for our clients. You may choose only those items you desire. Your director will adjust, cross out or note as not
applicable (N/A) any items that you decline.
Consult the General Price List ADDITIONAL
for a detailed description of the following items. ,
BURIAL CASKET SELECTED ........................................... ~ /!'~ '~'.~. i?~l $ __
.~ gl..) ,72
,,, :, ;14 /f;' r,, ,:lC
$
LifeSymbol Option No Extra Charge
CREMATION CASKET OR CONTAINER SELECTED ..................
OUTER BURIAL CONTAINER SELECTED ..............................
In most areas of the country, no state or local law makes you buy a container to
surround the casket in the grave. However, many cemeteries ask that you have such a
container so that the ground will not sink in. Either a burial vault or a graveliner wilt
satisfy these requirements.
REQUIREMENT OF CEMETERY: The funeral director assumes no liability
for gravesite cave4n or sinking if no outer burial container is used.
An outer buriaJ container r~l~S P~EQUIRED - [] IS NOT REQUIRED
By: _~,-c,/~l ;"z ~'.,~{[ /,::,%':A:.:/r/ ?/A~ E
(Cemetery Name)
CREMATION MERCHANDISE SELECTED .................................. 5 --"
GOODS & ,SERVICES ..............................................
__ Custom Printed Guest Register
Memorial Folders or Prayer Cards (per 100)
Acknowledgement Cards (25 per box)
Hairdresser
__ Temporary Grave Marker
Crucifix
__ Clothing
__ Name Plate for exterior of casket.
__ Custom Cap Panel.
__ Custom Engraving of Casket or Cremation merchandise
5 " Refrigeration per day, after 24 hours in lieu of embalming
~ ~' Cremation
CASH ADVANCES AND ACCOMMODATION ITEMS .......................... $
For your convenience we will order and handle payment of the following items. Any
omission of any item by the supplier of these services shall be the sole responsibility of
the supplier. The funeral director is relieved of any liability therefore by acting as your
9gent. Certain charges may be estimated.
5 /'~*) ~) ( ~ ) Certified copies of death certificate
5 /~'. ~ Local Newspapers
~/-5'/"7OOut-of4own Newspapers /'/~/~*.3/'~/~'A~(~' /'/,]~'/~',ft.~'/~
Warranty Disclaimer
The only warranty on the merchandise sold by us is the express written warranty, if
any, provided by the manufacturer of such merchandise. We make no warranty,
expressed or implied, with respect to merchandise. A manufacturer's warranty, if any,
will be provided to you.
BASIC SE.V,CES OF FU.ERAL D,.ECTOR STAFF ................. 5
!
TRANSFER OF REMAINS TO FUNERAL HOME ..........................
EMBALMING ........................................................................
If you selected a funeral service which requires embalming, such as '
funeral with a viewing, you may have to pay for embalming. You do not
have to pay for embalming you did not approve if you selected
arrangements such as direct cremation or immediate burial. If we charge
for embalming we will explain why below.
EMBALMING IS REQUIRED IF YOU:
r~l' Selected a service with a viewing
[] Arranged for shipment by common carrier
[] Selected arrangements that require us to hold the remains for more
than 24 hours provided no refrigeration is available or a hermetically
sealed container is not used and provided that embalming does not conflict
with religious beliefs or medical examination.
Cemetery Equipment from Vault Company (tent greens lowering device)
TOTAL CASH SA ,LE PR~ICE OF ITEMS SELECTED; .............. !:*i::;:!:ij,.{[~!~/*'~' o~
LESS DEPOSIT RECEIVE'D ON ACCOUNT ...................................... $ :~ ;' (' ~b' ?~ ~-
BALANCE DUE FUNERAL HOME ................................................ 5' t'{~O· ~.~)
TERMS OF PAYMENT
Deduct 5 if paid in full at time of arrangement
METHOD OF PAYMENT
[] Cash [] Check I-I Visa [] Mastercard [] Discover
[]Insurance Assignment of a Verifiable Policy
[]Other
PAYMENT SHALL BE MADE BY (date)_ .(time)
Provisions for payment are due at time of arrangements or not later than 24 hours prior to
service. In the event of default by Purchaser(sD, Purchaser(s) hereby authorize(s) and agree(s)
to the subsequent cancellation of service by Seller and further agree(s) to pay a penalty,
commencing from the first day after the date of service, at a rate of 18% per annum (1.5%
per month or fraction thereol) on any balance not paid within 30 days from date of service.
ORAL PERMISSION TO EMBALM the above named decedent
ITI:VVas Granted [] Was Refused
Relationship: 5'~'? r Date:
Time: -/~ :~' BAM ~M BInPerson BByPhone
OTHER PREPARATION OF REMAINS ..................................... 5 /i'l./~"~.
STAFF AND USE OF FACILITIES FOR FUNERAL SERVICE,
MEMORIAL SERVICE OR SERVICE AT A LOCATION OTHER
THAN FUNERAL HOME REQUIRING TRANSFER ........................ 5
This includes visitation or viewing one hour prior to service.
AGREEMENT
it is understood that the total charges shown above may be estimated and reflect only that
agreed upon at the time of this arrangement. Any additional items of service and/or
merchandise ordered or required after the time of this arrangement shall be considered part
of this agreement and the cost will be reflected on the final statement which we will provide
to you no later than 5 days from the date of service.
OTHER ITEMS OF COST THAT MUST BE PAID BY PURCHASER PRIOR
TO SERVICE DATE - Please make checks payable to:
5__ Cemetery:
$__ Clergy:
Organist:
Sexton:
Shipping:
Other:
STAFF & USE OF FACILITIES FOR VISITATION OR VIEWING
OTHER THAN ONE HOUR PRIOR TO FUNERAL OR MEMORIAL
SERVICE .............................................................................. $
STAFF FOR GRAVESlDE SERVICE & ACCESSORIES
AS NEEDED ...........................................................................
Motor equipment rates listed below apply to a 25 mile radius
from the funeral home. Add 51.50 per loaded mile after the
first 25 miles for each vehicle requested.
HEARSE TO FINAL DISPOSITION ............................................ $. ~ ~ ~i
SERVICE VAN (circle use) ...................................................... $
May be elected and used for disposition of flowers,
transfer to crematory, cemetery, anatomical gift registry,
airport or other.
FAMILY TRANSPORTATION ...................................................... $.
.3';:.3
FLOWERS TO BE ORDERED ON BEHALF OF BUYER: Florist where Buyer has an
account
Florist will add Pennsylvania Sales Tax to order beldw.
$.-- Casket Spray of Flowers
. On the Card:
5 [] Ledgc Piece [] Hinge Spray
On the Card:
Suggestions:
5 Satin Pillow with Roses (# of Roses
On the Card:
[] Cross [] Heart
$ Other:
On the Card:
AUTHORIZATIONS: I or We authorize and ratify prior consent to the funeral director to take possession of the body, give care to and carry out the arrangements hereto specified and agreed
to. I or We represent ourselves as the person(s) having the responsibility to arrange for the final disposition of the above named decedent, and do hereby grant authority to the funeral director
to supply the service and or merchandise as listed above as well as any additional services and or merchandise ordered or required after the time of this arrangement. I or We guarantee
payment of the cost of the services and or merchandise ordered and provided pursuant to the above TERMS OF PAYMENT.
I (WEI, THE BUYER{S}, HEREBY AGREE THAT IN CONSIDERATION OF THE GOODS AND/OR SERVICES TO BE DELIVERED, THAT BUYER(S) INDIVIDUALLY AND JOINTLY
IS (ARE) HEREBY OBLIGATED TO PAY ALL AMOUNTS OWING AND SHOULD BUYER(S) DEFAULT IN THE AGREEMENT WITH SELLER. IN A~;~:t")Rr)J~N~:g WITH TI-Il= Tl=mta(=
A. U.S DEPARTMENT OF HOUSING and URBAN DEVELOPMENT OMB No. 2502-0265
SETTLEMENT STATEMENT TITLEPRO
Lase,print
SECURED LAND
---- ------TRANSFERS, INC. B. type OF,OAN
5006 East Trindle Road t. l iL:HA 2. I ] FMHA 3.~]CONV. UNINS.
Suite 203 4.1 ]VA 5.1 ]CONV. INS.
Mechanicsburg, PA 17055 6. FILE NUMBER: I 7. LOAN NUMBER:
505102I 549484301
Phone: (717) 591-8500 FAX: (717) 591-8506 8. MORT. tNS. CASENO.:
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 the closing; they are shown here for informational purposes and are not included in the totals.
D. NAME AND ADDRESS OF BORftOWER: E. NAME AND ADDRESS OF SELLER: E NAME AND ADDRESS OF LENDER:
Richard C. Keck]er Estate of GMAC Mortgage Corporation
Donna J. Kecklez Helen E. Kelly
P.O. Box 76
Camp Hill, PA 17011
G. PROPERTY LOCATION: H. SETTLEMENT AGEI~T: I. SEI-FLEMENT DATE:
1701 Warren Street Secured Land Transfers, Inc. ' 06/13/03
New Cumberland ~2, OROUGH PLACE OFSETTLEMENT:
CUMBERLAND County 3915 Market Street, Camp Hill, PA 17011
J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION:
lOO GROSS AMOUNT DUE FROM BORROWER 4oo. GROSS AMOUNT DUE TO SELLER
lol Contract sales price 152500 . 00 401,Contract sates pr!ce 152500.00"
lo2 Personal property 402 Personal property
103 Settlement charges to borrower (line 1400) 5 6 4 9 . 9 8 403.
lO4. 404.
105. 405.
Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance
lO6. City/Town tax ~o 4o6City/Town tax to
lo7 County ia× 06/13/03to 12/31/03 360 . 40 4o7county tax 06/13/03to 12/31/03 360 . 40
1 o8. Assessments to 408. Assessments to
,og Schoot 06/13/03,o06/30/03 66.04 40, SchooZ 06/13/03to06/30/03 66.04
,0 Refuse:$35.G0/c~oend 6/30 6.63 4,0 Refuse:$35.G0/c~oend 6/30 6.63
,, Swr:$39.44/q end 6/30 7.35-'L]7[-S-~-~?$~3-9-i~lq--~~0 ............ ~.~
112 412
12o GROSS AMOUNT DUE FROM BORROWER 158590 .40 420. GROSS AMOUNT DUE TO SELLER 152940.42
20o AMOUNTS PAID BY OR IN BEHALF OF BORROWER 50o. REDUCTIONS IN AMOUNT DUE TO SELLER
2o). Deposit or earnest money 2 0 0 0. 0 0 5Ol Excess deposit (see instructions) I
202 Principal amount of new loan(s) 122000 . 00 5o2 Settlement charges to seller (line 1400) 25147 . 94
2o3. Existing loan(s) taken subject to 5o3.Existing loan(s) taken subject to
204. 504 Payoff of First Mortgage Loan
Chase Manhattan Mortgage; 74657.46
2o5 50sPayoff of Second Mortgage Loan
206 506,
207. 507
208. 5o,8,
209. 509.
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
210. City/Town tax to 510 City/Town tax to
211~ County tax to 511, County tax to
212 Assessments to 512Assessments to
213 School to 513. School tO
214 514.
215 515.
216 516.
217 517,
218 518.
219 519
22o TOTAL PAID BY/FOR BORROWER 124000 . 00 52o. TOTAL REDUCTION AMOUNT DUE SELLER 99805.40
30o. CASH AT SETTLEMENT FR()M OR TO BORROWER 6oo CASH AT SETTLEMENT TO OR FROM SELLER.
3ol. Gross amount due from bot'rower (line 120)il 1 5 8 5 9 0 . 4 0 6el.Gross ~mount due to seller (line 420) [ 1 5 2 9 4 0 .'4; 2
302. Less amount paid by/for bo, rower (line 220) I 1 2 4 0 0 0 . 0 0 6o2 Less reduction amount due seller (line 520)I 9 9 8 0 5 . 4 0
3o3. CASH([~] FROM) ([ ]TO) BORROWERI 34590.40 6o3.CASH (D(] TO) ([ ]FROM) SELLER I 53135.02
Buyer or Borrower's Signature
Seller's Signature
HUD-1 Rev. ~':.,(¢;
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
SETTLEMENT STATEMENT
OMB No. 2502-0265
page 2
L. SETTLEMENT CHARGES 505102
700. TOTAL SALES/BROKER'S COMMISSION based on Prices
'152500.00 6.0
Division of Commission (lille 700) as follows:
Total: $9,150.00
7o1.$ 4550.00 to
Jack Gaughen Realtor ERA
Re/Max Realty Associates
702.$ 4600.00 to
CommissionpaidatSettlement
Trans Fee
PAID FROM
BORROWER'S
FUNDS AT
SETTLEMENT
703. 9150.00
704. ERA-NRT, Inc. 100.00
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Origination Fee 1.000 % GMAC Mort ($1220 POC-L)
802. Loan Discount %
803. Appraisal Fee to
804. Credit Report to
805, Lenders Inspection Fee
8o6, Mortgage Insurance Appli( ation Fee to
8o7. Assumption Fee
808. Doc Prep 260.00
GMAC Mortgage Corporation
809. TaxService GMAC
810. Flood Cert GMAC
901.
902,
81~. LfLnFldCrt GIVlAC
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
Interest from 06/13/03 to06/30/03 e$
Mortgage Insurance Premi~lm for mo. to
903. Hazard Insurance Premium for yrs. to
904. yrs. to
905. Appl Fee
1000.
Mortgage
Mortgage
Mortgage
18.3 8/day
Corporation
Corporation
Corporation
GMAC Mort ($325 POC-B)
RESERVES DEPOSITED WITH LENDER FOR
Hazard Insurance 3 mo. @ $ 33 . 58 /mo.
1001.
1002. Mortgage Insurance mo. @ $ /mo.
003. City/Town tax mo. @ $ /mo.
004. County tax 5 mo. @ $ 5 4 . 5 4 /mo.
1005. Assessments mo. @ $ /mo.
~006. School Tax 13 mo.@$ 118.48 /mo.
1007. mo. @ $ /mo.
moa AggrAdj ust mo. @ $
/mo.
85.00
17.00
2.00
330.84[
100.74
272.70
1540.24
-285.29
100. TITLE CHARGES
10 I. Settlement or closing fee to
102. Abstract or title search to
103. Title examination to
104. Title insurance binder to
105. Document preparation to
Re/Max Realty Associates
Cash 10
Marielle F. Hazen
.00
106. Notary fees to
107. Attorney's fees to
(includes above items No.:)
Secured Land Transfers
I08. Title Insurance to
(includes above items No.:) end. 100, 300, 900
1109. Lender's coverages 122,000
1110. Owner's coverage $ 152, 500
Secured Land Transfers
I111.
112. Mail Fee
13.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
PAID FROM
SELLER'S
FUNDS AT
SETTLEMENT
100.00
10.00
454.50"
1201. Recording fees: DeedS 39.50 MortgageS 68.50 Misc.$ Ii 108.00I
1202. City/countytax/stamps: DeedS 1525 . 00Mortgages I 1525.00
I
1203. State tax/stamps: D,;ed $ 1 5 2 5.0 0 Mortgage $
1204. IntTxEscrw Secured Land Transfers
m05. Swr 4/5/6 New Cumberland Borough
1300. ADDITIONAL SETTLEMENT CHARGES
1301, Survey to
15.00
1525.00
13725.00.
39.44
1302. Pestlnspection to Biechler & Tillery
1303. Home Insp Biechler & Tillery
~304. Tax Cert Re/Max Realty Associates
,308. Trans Fee Re/Max Realty Associates
1400. TOTAL SETTLEMENT CHARGES (onler on lines 103 and 502, Seclions J and K)
35.00
Buyer or Borrower's S/gnalu~e
275.00
5649.98;
4.00
125.00
25147.94
Seller's Signalure
Buyer's Address & Phorle: Seller's New Address & Phone:
H,. HUD-l~(/St'ate~menl which I ,,av/~,d~,ared is. , ....... d .... .ral ....... t ol this transaction. I [ .... c:,Jsed .... ill cause Ih. lunds ,o be disbursed i ....... da.ce wilh ,his slalemerlL
WARNIN~il'i:}'I¢: cd.i~edf;~:j:~J~ 7~ :',~,l;%;'ftli:~r¢'¢01.o the Ur ed Stat .... h ..... y .imf, ...... Pen.allies up ...... ioli ...... include a Ii .... d ,mpri ...... ,. For deles see
tIUD-1 Rev. 5/86
Parlies agree Ihal no liabilily is assumed by Selllemenl Agerd lot lbo accuracy el inlormation hJrnished by others as shown on Ihe HUD-1 Selilemenl Slalement. Setllemeel Agonl hereby expressl'
reserves lbo righl Io deposit any amounls ;allotted Ic, r disbursement in an inleresl bearing accounl iea Federally insured inslitulion arid Io credil any inlerest so earned le ils own account as addilional
compensalion for its services in Ihis Irans;,clion,
HUD CERTIFICATION OF BUYERS AND SELLERS
I have c,~relully reviewed Ihe HUD 1 Settlement Statement and to the best el my knowledge and belief, it is a true and accurate statement of all receipls and disbursemenls
made on my account by me in this transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD'002710
WILSON ANN M
119 CRICKET LANE
CAMP HILL, PA 17011
....... fold
ESTATE INFORMATION: SSN:
FILE NUMBER: 2103 - 0342
DECED.ENT NAME: KELLY HELEN E
DATE OF PAYMENT: 06/19/2003
POSTMARK DATE: 06/19/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 03/18/2003
194-12-6589
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $900.00
REMARKS:
ANN WILSON
TOTAL AMOUNT PAID'
$900.00
SEAL
CHECK# 117
INITIALS: SK
RECEIVED BY.'
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
TAXPAYER
waup i.n t
P.O. Box 1711. Harrisburg. PEnnsglvania 17105-1711
Member FDIC;
STATEMENT DATE
3-25-03
HELEN E KELLY
OR EDWARD M KELLY
1701 WARREN ST
NEW CUMBERLAND PA 17070-1145
01/-993
WAYPOINT NOW OFFERS ONLINE HOME FINANCING COMPLETE
THE ENTIRE MORTGAGE .PROCESS ONLINE! GET STARTED TODAY
AT WWW.WAYPOINBANK,'COM OR CALL US TO FIND THE MORTGAGE
CENTER NEAREST YOU FOR MORE PERSONAL ATTENTION.
ACCOUNT TYPE OF ACCOUNT
700028998 FOCUS FIFTY
AVERAGE BALANCE
1 723.77
PREVIOUS BALANCE
DEPOSITS
WITHDRAWALS
CHARGES
'INTEREST
ENDING BALANCE
1,915 34
868 02
1,135 52
O0
.33
1,648.17
* ............ INTEREST SUMMARY ..............
INTEREST EARNED FROH 2/25/03 TO 3/25/03
DAYS IN PERIOD 28
INTEREST EARNED .33
ANNUAL PERCENTAGE YIELD EARNED .25 ~
INTEREST PAID THIS YEAR 1.22
INTEREST WITHHELD THIS YEAR .00
* ............. TRANSACTION SUMMARY ..............
DATE TRANSACTION DESCRIPTION
2/28 CHECK 1416
3/03 US TREASURY 312 CIVIL SERV
3/03 CHECK 1415
3/03 CHECK 1417
3/17 AAA LIFE INS CO INS, PREM.
3/25 INTEREST PAYMENT
DEPOSITS/ CHECKS/
CREDITS DEBITS
138.90
868.02
.33
BALANCE
1776.44
2644.46
872.19 1772.27
57.43 1714.84
67.00 1647,84 -
1648,17
.............. CHECKS PAID ...............
NO. DATE AMOUNT NO. DATE AMOUNT
1415 3-03 872,19 1417 3-03 57.43
1416 2-28 138.90
THANK YOU F. OR BANKING AT WAYPOINT BANK
CustomEr SErvicE Toll-FrEE 1-866-WAYPOINT (I-866-9;~9-7646) · In York ArEa 717/815-4500
June 19, 2003
Re: 1701 Warren Street (Subject Property)
New Cumberland, PA
Seller: Estate of Helen E. Kelly
Buyers: Richard C. Keckler and Donna J. Keckler
Settlement: June 13, 2003
Settlement Agent: Secured Land Transfers, Inc.
Agents: ReMax Realty Associates, Craig Wilson, Listing Agent
Jack Gaughen Realtor ERA, Paula Hershey, Selling Agent
Seller in above transaction, through Seller's Agent, erroneously represented that Subject
Property included a parcel of land located behind a neighboring property, shown on attached
drawing as an "adverse conveyance". In fact this parce.1 was not included in the ownership of the
Subject Property, but had been conveyed by a former owner to the former neighbor. Buyers
agree to'accept $4,000 in payment from the Seller for the error in representation of ownership of
the land parcel, and Buyers further agree to accept conveyance of 1701 Warren Street, New
Cumberland, PA as described in deed from Seller to Buyers. Buyers and Seller are entering into
this agreement of their own volition, intending to be bound by their signatures, and agreeing that
this is a fair and acceptable settlement of the issuel
Buyers and Seller and all Agents, associates, and employees of Agents agree to hold each other
harmless from any further liability, now known or not known, concerning the parcel of land
located behind the neighboring property and not included in the conveyance of Subject Property.
Witness
Buyer
Witness
Witness"
Buyer
~~e Bank Date: 06-18-2003
Harrisb~
~enate Ave
(~amp Hill PA 17001 . Acct: 0000000536027352
,60// We CHARGED your account and RETURNED to you the following item
CHECK NUMBER REA'SON AMOUNT
276666 PAYMENT STOPPED 53135.02
THE ESTATE OF HELEN E. KELLY
ANN MARIE WILSON EXE
119 CRICKET LANE
CAMP HILL PA-17011
Item Amount $ 53135.02
Return Check Fee $ 7.00.
FRBP~RETURN ITEMS
aOO3663t O3~iOOOC)40
40035531
Chk#277198 T#505102
SECURED LAND ?RANSFERS, INC.
Date Payee
6/19/03
Estate of
Helen E. Kelly
>03 t ?20 f 360<
COMHERCE BANK Nm
CHERRY HILL, ~-NJ
:? 2; ,.: _? .':o
Item
CHECK
Descr±p~±on
TOTAL
277198
Amount
$49,068.77
HCR*ManorCare
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
PRIVATE
STATEMENT
ROOM 148 - B
KELLY, HELEN 2126~1 09/12/02 03/18/03 05/21/2003
.......... ' ............... '"'"'"'"'"'" ................. ""::' ....... :':':':':':':':':':':':':~:':':':':':':'": ....................... ::::::::::::::::::::::::::::::::: :::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~:~`~``.:~:m:i.~:::::::~:[::~.:!~::!:!:~:1:`..!:.~i:~:~:~8!:~i:1[i~i![:ii~i:g~`:~i:[;~i::.``~.```::
01/01/03 BALANCE FORWARD $6,310.76
01/22/O 3
01/16/03
01/23/03
01/31/03
01/31/03
01/31/03
01/31/03
02/04/03
02/19/03
02/27/03
02/28/03
02/28/03
02/28/03
03/04/03
03/16/03
03/16/03
03/16/03
05/21/03
PAYMENT RECEIVED - THANK'YOU
PERM
HAIR COLOR
CABLE RENTAL
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
INSURANCE PREMIUM CREDIT
PAYMENT RECEIVED - THANK YOU
WASH AND SET
WASH AND SET
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
INSURANCE PREMIUM CREDIT
PAYMENT RECEIVED - THANK YOU
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
INSURANCE PREMIUM CREDIT
PAYMENT RECEIVED - THANK YOU
$36.00
$25.00
$5.00
$1,981.85
$9.00
$9.00
$1,981.85
$1,981.85
($8o.oo)
($58.70)
($205.46)
($2,000.00)
($58.70)
($205.46)
($825.00)
($58.70)
($205.46)
($8,642.83)
HCR*ManorCare
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
PRIVATE
STATEMENT
ROOM 140 - B
KELLY, EDWARD 21256 09/03/02 09/14/02 05/21/2003
02/04/03 PAYMENT RECEIVED - THANK YOU ($640.00)
09/30/02 PRIVATE PORTION $863.76
09/30/02 MEDICARE B PREMIUM CREDIT ($54.00)
04/09/03 PAYMENT RECEIVED - THANK YOU ($169.76)
Amount Due $0.00
BUREAU OF ZNDZVZDUAL TAXES
TNHER/TANCE TAX nTVTSZON
DEPT. ZSO60Z
HARRTSBURG PA 171Z8-0601
COHHONWEALTH OF PENNSYLVANXA
DEPARTHENT OF REVENUE
NOTZCE OF INHERZTANCE TAX
APPRAZSEHENT) ALLOWANCE OR DZSALLO#ANCE
OF DEDUCTZONS AND ASSESSHENT OF TAX
REV-1;~i7 EX AFP (01-OS)
ANN WZLSOH °0~, FEB 17 P12:46
1].9 CRTCKET LN
CAHP HTLL "-t.,~ PA '170],1
L.:~ ~., ,..' ~,? Oourt
Cumberi~nd Co., PA
DATE
ESTATE OF
DATE OF DEATH
FXLE NUHBER
COUNTY
ACN
02-16-2004
KELLY
0:5-18-200:5
21 0:5-0:542
CUH]~ERLAND
101
Amoun~ Remi~ed
HELEN
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGZSTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLZSLE) PA 1701:5
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD 003566
HAZEN MARIELLE F
2000 LINGELSTOWN ROAD
HARRISBURG, PA 17110
........ f01d
ESTATE INFORMATION: SSN: 194-12-6589
FILE NUMBER: 2103-0342
DECEDENT NAME: KELLY HELEN E
DATE OF PAYMENT: 02/1 7/2004
POSTMARK DATE: 02/14/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 03/18/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $566.16
;REMARKS:
TOTAL AMOUNT PAID:
RECEIVED OF ANN M WILSON
$566.16
SEAL
CHECK//135
INITIALS: MW
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
BUREAU OF INDIVIDUAL TAXES
TNHERTTANCE TAX DIVTSZON
DEPT. Z80601
HARRISBURG,, PA 171Z8-0601
COMMON#EALTH OF PENNSYLVAN'rA
DEPARTMENT OF REVENUE
ZNHERZTANCE TAX
STATEHENT OF ACCOUNT
REV-160? EX AFP C01-D3)
ANN NILSON
119 CRICKET LN
CAMP HILL
PA 17011
DATE 05-15-2004
ESTATE'OF KELLY
DATE OF DEATH 05-18-2005
FILE NUMBER 21 05-0542
UN CUMBERLAND
il::. Amoun'1' Rem'i'l:'l:ed I
HELEN
HAKE CHECK PAYABLE AND RENTT PAYMENT TO:
REGISTER OF HILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
NOTE: To insure proper credi~ ~o your account, submi~ ~he upper por~:/on of ~hAs form wi~:h your ~mx payment.
CUT ALONG THZS LINE ~ RETAIN LONER PORT/ON FOR YOUR RECORDS ~
REV-1607 EX AFP
(01-03)
~ ZNHERZTANCE TAX STATEMENT OF ACCOUNT ~
ESTATE OF KELLY HELEN E FZLE NO. 21 05-0542 ACN 101 DATE 05-15-2004
THZS STATEMENT TS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACH ZN THE NAMED ESTATE. SHONN BELON
ZSA SUNHARY OF THE PRINCIPAL TAX DUE, APPLZCATZON OF ALL PAYMENTS, THE CURRENT BALANCE, AND, ZF APPLZCABLE,
A PROJECTED INTEREST FZGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-16-2004
PRINCIPAL TAX DUE: ...........................................................................................................................................................................................................................
PAYMENTS (TAX CREDITS):
2,982.33
PAYMENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID
06-19-2005
12-04-2005
02-14-2004
CD002710
CD003316
.00
.00
900.00
1,521.00
566.16
IF PAKD AFTER THIS DATE, SEE REVERSE
SKDE FOR CALCULATKON OF ADDKTKONAL KNTEREST.
( ZF TOTAL DUE KS LESS THAN $1,
NO PAYMENT KS REQUKRED.
KF TOTAL DUE KS REFLECTED AS A "CRED[T" (CR),
YOU NAY BE DUE A REFUND. SEE REVERSE SKDE OF THKS FORM FOR KNSTRUCTKONS. )
BALANCE OF TAX DUE
INTEREST AND PEN. .00
TOTAL DUE 1.05CR
2,983.38
1.05CR
CD005566
3.78-
TOTAL TAX CREDIT
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 or money order payable to: REGISTER OF HILLS, AGENT.
-- If NON-RESIDENT DECEDENT make check or money order payable to: COMMONWEALTH OF PENNSYLVANIA.
REFUND (CA): 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-1315). Applications are available at
the Office of the Register of Nills, any of the Z5 Revenue District Offices or from the Department's Zq-hour
answering service far fores ordering: 1-BOO-36Z-ZO50~ services for taxpayers with special hearing and / or
speaking needs: 1-BOO-qq7-5020 (TT only).
REPLY TO:
guastions regarding errors contained on this notice should ba addressed to: PA Department of Revenue, Bureau
of Individual Taxes, ATTN: Post Assessment Reviam Unit, Dept. ZB06Ol, Harrisburg, PA 17IZB-060I, phone
(717) 787-6505.
DISCOUNT:
any tax due is paid within three (5) calendar months after the decedent's death, a five percent [SI} discount
the tax paid is alloaed.
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 beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes mhich became delinquent before January I, 19BI bear interest at the rate of
six (BZ) percent per annum calculated at a daily rate of .00016~. AX! taxes ahich became delinquent on and after
January I, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 198Z through 200~ are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1982 202 .O00Sq8 xg&~-1991 XlX .O00SOl 2001 9Z .O00Zq7
1965 162 .000q58 1992 92 .O00Zq7 ZOOZ 62 .O0016q
198q llZ .O00~Ol 1995-199q 7Z .O0019Z 2005 5X .000157
1985 13Z .000556 1995-1998 9Z .O00Zq7 ZOOq qX .000110
1986 102 .O0027~ 1999 72 .00019Z
1987 9Z .O00Zq7 ZOO0 8Z .000Z19
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPA'rD X NUI~BER OF DAYS DEL/NQUENT X DATLY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (lB) days
beyond tho date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be catculatad.
Name of Decedent:
Date of Death:
Will No.:
STATUS REPORT UNDER RULE 6.12
'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 w,~he/ISer administration of the estate is complete:
Yes ~ No [--]
2. If the answer is No, state when the personal representative reasonably believes
that the adrainistration will be complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal rep~sentative file a final account with the Court?
Yes _ No
b. The sep~ate Orphans' Court No. (i/any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the parties
in interest? Yes []~ No' [--]
Date:
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. ,..,4
Signature
Capacity:
Telephone No. ~
[~/~ersonal Representative
Counsel for personal representative
ESTATE SETTLEMENT AGREEMENT
RECEIPT AND RELEASE
THIS AGREEMENT, made this ~,t~, ~ day of~, 2004, by and among:
ANN MARIE WILSON, Executrix of the Estate of Helen E. Kelly,
*AND*
ANN MARIE WILSON and DAVID M. KELLY, beneficiaries by virtue
of the Last Will and Testament of Helen E. Kelly.
YEITNESSETH:
WHEREAS, Helen E. Kelly died testate on March 18, 2003, having first made
and published her Last Will and Testament dated ~.~/ ~ , ~, in which she
named
Ann Marie Wilson, Executrix. A true and correct copy of the said Will is attached hereto, made
a part hereof and marked Exhibit "A"; and
WHEREAS, on Dpcil I'/
granted in the Estate of Helen E. Kelly; and
,2003, Letters Testamentary were originally
WHEREAS, it is understood and agreed that all debts of the Estate of Helen E. Kelly be
paid from the Estate of Helen E. Kelly, and which arrangement has been approved by the two
aforementioned beneficiaries; and
WHEREAS, the Executrix has proceeded with the administration of said Estate and has
prepared the Inheritance Tax Retum and Inventory of Real and Personal Property with the
required Schedules attached thereto; and
WHEREAS, the parties hereto desire that the Executrix shall not be required to file
a formal accounting with the Orphans' Court of Cumberland County, Pennsylvania, and that the
net estate of the decedent shall be distributed without the necessity of filing said formal
accounting; and
WHEREAS, it is understood that in accordance with the First and Final Account,
attached hereto of each of the decedents, each beneficiary herein shall receive the sum of
~ ~F~.~ _,f'~, plus accmedinterest.
NOW, THEREFORE, the parties hereto intending to be legally bound hereby, mutually
agree as follows:
1. The parties hereto, and each of them agree and acknowledge that they have fully and
carefully examined the Inheritance Tax Return and Inventory of Real and Personal Property with
the required Schedules attached thereto and the Schedule of Distribution relating thereto, and
find them to be tree and correct, and acceptable to the parties hereto and each of them, and
further that each of them has received a copy of this Agreement and of the said Account and
Schedule of Distribution.
2
2. The parties hereto do hereby release, remise and forever discharge the Estate of Helen
E. Kelly, and Ann Marie Wilson, Executrix, of the Estate of Helen E. Kelly, Deceased, from all
manner of acts, suits, claims, accounts, accountings, debts, dues and demands whatsoever which
they or any of them or their legal representatives or assigns may at any time hereafter have,
against the Executrix, the said estate or the assets thereof, from, for, touching or concerning any
of the assets and property of the said estate and/or any claim or interest thereto or therein, and the
administration, management, collection, sale or distribution of any of the said assets and for or
on account of any money, interest income, assets or proceeds out of same, from the time of the
death of the said decedent to and including the date of this Agreement and Release.
3. This instrument is a Full and Final Estate Settlement Agreement by and among the
parties hereto, both Fiduciary and Individual, all of the same having been arrived at, concluded
and executed after a full and complete disclosure of the assets of the said Estate and the rights
of the parties therein and thereto and all of the parties hereto, and each of them, agrees to abide
by the terms hereof.
4. The parties hereto, and each of them, agree that they will at all times in the future and
whenever necessary, appropriate or convenient, make, execute and deliver to the said Executrix
and/or to the other party or persons, any and all instruments, documents, conveyances, deeds,
releases or other instruments of any kind necessary or convenient to carry out the intention of this
Agreement and/or to permit, assist and enable the Executrix to fulfill her duties with reference to
the said Estate and all of the assets thereof.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF~
ON THIS, the c~4 ~
)
: SS:
)
day o 2004, before me, a Notary Public, personally
appeared ANN MARIE WILSON, Executrix of the Estate of Helen E. Kelly known to me or
satisfactorily proven, to be the person whose name is subscribed to the foregoing Estate
Settlement Agreement Receipt and Release, and acknowledged that she executed same for the
purposes therein contained.
WITNESS my hand and seal the day and year aforesaid.
LORI L. POMNITZ, i'Jolarv Public
West IReadin~ Borough, Berks 0o.
My Commission Expires:
(SEAL)
5
LAST WILL AND TESTAMENT
OF
HELEN E. KELLY
KNOW ALL MEN BY THESE PRESENTS, That I, HELEN E. KELLY, of the
Borough of New Cumberland, County of Cumbertand, and Commonwealth of Pennsylvania,
do make, publish, and declare this instrument to be my Last Will and Testament, hereby
revoking and making void any and all former Wills by me at any time heretofore made.
it is my wish that my son Daniel E. Kelly be given the opportunity to live in my home
independently and that the house be not sold unless and until it be determined in the
exercise of good and reasonable consideration and judgment that he is unable to live
independently. Then in that event, sale of said property will be at the discretion of both Ann
M. Wilson and David M. Kelly.
FIRST: I direct the Executor hereof to pay all my just debts, funeral expenses and
costs of administration as soon as conveniently may be done after my death. I further
direct the Executor hereof to pay all inheritance, estate, transfer and succession taxes
which may be levied or assessed upon any property which is included as part of my gross
estate for the purpose of any such tax.
SECOND:I give, devise and bequeath unto my husband, EDWARD M. KELLY, rest,
residue and remainder of my estate, realty and personalty, howsoever designated
wheresoever situate provided that he is living on th.e thirtieth (30th) day after the date of my
death.
-1-
THIRD: If my said husband, EDWARD M. KELLY, does not survive me or does not
survive by the said period of thirty (30) days, then in that event, I give, devise and bequeath
all the rest, residue and remainder of my estate in equal shares, share and share alike, to
my Children ANN M. WILSON, and DAVID M. KELLY, per stirpes.
FOURTH: I appoint my husband, EDWARD M. KELLY, to be Executor of this my
Last VVill and Testament. I do hereby give to the Executor hereof full power, discretion and
authority at any time or times to sell, at pdvate or public sale, mortgage, lease, pledge,
exchange or otherwise deal with or dispose of the property comprising my estate as
deemed best, to settle and compound any and all claims in favor of or against my estate as
deemed best and, for any of the foregoing purposes, to make, execute and deliver any and
all deeds, mortgages, contracts, leases, bills of sale or other instruments necessary or
desirable therefor.
FIFTH: In the event my husband, EDWARD M. KELLY, fails or refuses for any
reason to serve as Executor of this my Last Will and Testament, then in that event I appoint
ANN M. WILSON as Executrix of this my Last Will and Testament.
LASTLY: I direct that no fiduciary appointed by this, my Last Will and Testament,
shall be required to give bond and that if, notwithstanding this direction, any bond is
required by any 'law, statute or rule of court, no surety shall be required thereon.
IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and
Testament, consisting of three (3) typewritten pages on the margin of which (except this
-2-
page) I have affixed my initials this 18th day of May, A.D. 2000.
Signed, sealed, published and declared by Helen E. Kelly, the above-named
Testatrix, as and for her Last Will and Testament, in the presence of us and each of us,
who at her request, and in her presence, and in the presence of each other, have hereunto
subscribed our names as attesting witnesses.
-3-
County of Cumberland
Commonwealth of Pennsylvania
ACKNOWLEDGMENT AND AFFIDAVIT
We, Helen E. Kelly, the testatrix, and the undersigned witnesses to the Will, the
attached or foregoing instrument, having been qualified according to law do depose and
say:
(a)that I, the testatrix, do hereby acknowledge that I signed the instrument as my
Will, that I signed it willingly and as my free and voluntary act for the
purposes therein expressed; and
(b)that
we, the witnesses, were present and saw the testatrix sign the instrument as
her last Will, that she signed it willingly and as her free and voluntary act for
purposes therein expressed; that each of us in the headng and sight of the
testatrix signed the Will as a witness and that to the best of our knowledge
the testatrix was at that time 18 or more years of age, of sound mind and
under no constraint or undue influence.
Swom to or affirmed before me by Helen E. Kelly, testatrix, and Nathan Byedy and
Amy Knauer, witnesses, this 18th day of May, 2000.
Helen E. Kelly
By: David W. Knauer
Amy Knauer~) ~
Attomey I.D. #21582
-4-
5. This Agreement constitutes the entire understanding among the parties hereto, and
each of them acknowledges that no representations or statements of any kind, written or oral,
have been made to them or any of them prior hereto by the Executrix or by any other person or
party upon their behalf.
6. This Agreement shall inure to the benefit of and shall be binding upon the parties
hereto, and each of them, their heirs, executors, administrators, successors and assigns.
7. This Agreement may be executed in multiple counterparts and, when as executed,
shall be binding upon all the parties, and their respective heirs, next-of-kin, personal
representatives and assigns.
IN WITNESS WHEREOF, the parties hereto have hereunto set their respective
h .ands and seals the day grid year first above written.
{~TlqES8 t ~-~ Ai~i~i~'I~/~iE{wlLS-OI~, ~e~U'~l~ix
AN:~"~E ~LS6N,~eneficia~
' 'OAWO LLY,/
(S~AL)
(StAL)
(SEAL)
4
ESTATE OF HELEN E. KELLY
ANN M. WILSON,
Executrix
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: NO. 2103-0342 .
PETITION FOR LEAVE TO WITHDRAW
AND NOW, comes Marielle F. Hazen, Esquire, of the Law Office of Marielle F. Hazen, to
petition this Honorable Court for Leave to Withdraw as counsel for the Executrix, and respectfully
represents:
1. On or about April 1,2003, Petitioner, Marielle F. Hazen, Esquire, of the Law Office
of Marielle F. Hazen, 2000 Linglestown Road, Suite 303, Harrisburg, Pennsylvania 17110, was
hired by Ann Wilson to act as attorney for the Estate of Helen E. Kelly.
2. Petitioner began the probate process, including but not limited to the probate petition
filing and consultation with the client regarding the sale of the decedent's house and advice to the
client with regard to the need for inheritance tax filing, notice to beneficiaries, advertising, and
opening of an estate account.
3. The Executrix advised Petitioner that she and her brother were going to handle the
estate on their own. Petitioner confirmed this with the Executrix by a letter dated August 4, 2003.
(Attached as Exhibit "A" is a copy of the correspondence dated August 4, 2003).
4. Because the Executrix advised the Petitioner that the Executrix wished to handle the
estate on her own, good cause exists under Rule 1.16(a)(3) of the Pennsylvania Rules of Professional
Conduct for Petitioner's withdrawal.
5. Withdrawal of counsel can be accomplished without material adverse effect to the
interest of the Executrix.
WHEREFORE, Petitioner requests that this Court grant Petitioner leave to withdraw her
appearance for the Executrix, Ann M. Wilson, in this action
Respectfully submitted,
~lVl~ar~e~l~' F. ~azen, Esquire
Attorney I.D. No. 68003
2000 Linglestown Road
Suite 303
Harrisburg, PA 17110
(717) 540-4332
ESTATE OF HELEN E. KELLY
ANN M. WILSON,
Executrix
· IN THE COURT OF COMMON PLEAS
· CUMBERLAND COUNTY, PENNSYLVANIA
'ORPHANS' COURT DIVISION
· NO. 2103-0342
CERTIFICATE OF SERVICE
I, Marielle F. Hazen, Esquire, certify that on -&L~.~ 3 ,2004, I served a
tree and correct copy of the within Petition for Leave t~ Withdraw on the parties named below,
by depositing same in the United States mail, first class, postage prepaid, addressed as follows:
Ann M. Wilson
119 Cricket Lane
Camp Hill, PA 17011
1/elar[e~le~F. I-]aze"l~, Esquire
Law Office of Marielle F. Hazen
2000 Linglestown Road
Suite 303
Harrisburg, PA 17110
(717) 540-4332
The Law Office of
E
Attorney at LaTM
Certified Elder Law Attorney by dte National EMer Law Foundation
2000 Linglestown Road
Suite 303
Harrisburg, PA 17110
(717) 540-4332
(717) 540-4313
www. hazenelderlaw, com
August 4, 2003
Ms. Ann M. Wilson
119 Cricket Lane
Camp Hill, PA 17011
Re: Estate Administration
Dear Ann:
I received your telephone message of July 29, 2003, in which you inquired as to
whether or not your mother has estate recovery issues. As I explained to you in our
meeting and also mentioned in my last letter to you, your mother does have estate
recovery issues because she received benefits from the Department of Public Welfare for
payment of long term care services.
The Department of Public Welfare does not contact you regarding these
payments, rather you are required to notify the Third Party Liability Unit of her passing,
and there is a procedure that must be followed so that the Department of Public Welfare's
claim is handled appropriately. It is very important that you address this matter in the
administration of your mother's estate.
You have previously indicated to me that your brother was going to handle this
estate. If you wish to retain me as legal couflsel to assist you in administering this estate,
I would need to be involved in all aspects. ! am concerned about being involved in just
answering questions from time to time because of the potential for errors to be made by
you in the estate administration. Please feel free to contact me if you want me to assist
you in moving forward with administering this estate. As I have previously mentioned to
you, it is very important that both the inheritance tax return and the estate recovery issues
be handled in a timely manner and that they be handled appropriately.
In your letter you also inquired regarding how to pursue the nursing homes'
actions in caring for your mother. You can contact the Pennsylvania Department of
Health to make a complaint against the facility for issues relating to your mother's care.
Should you decide you wish to pursue a private action against the nursing home, please
contact me and I will refer you to a litigation attorney.
Ann Wilson
August 4, 2003
Page 2
Again, please let me know if you want me to work with you in the administration
of your mother's estate. I plan to hold my file and take no further action on your behalf
unless I hear from-you.
Sincerely,
Marielle F. Hazen
MFH/jah
ESTATE OF HELEN E. KELLY
ANN M. WILSON,
Executrix
: 1N THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: NO. 2103-0342
ORDER ALLOWING WITHDRAWAL OF COUNSEl,
AND NOW, this ~'~ d~av of ~ , 2004, upon consideration of the
Petition for Leave to Withdraw in the above-captioned matter, it is hereby ORDERED and
DECREED that said Petition is GRANTED and that Petitioner, Marielle F. Hazen, Esquire, be
permitted to withdraw her appearance of record for the Executrix in the above matter.
CERTIFICATION OF NOTICE UNDER RULE §.6(a)
Name of Decedent: Helen E. Kelly
Date of Death: March 18, 2003
Will No. 2003-00342
Admin. No.
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
January 6, 2005
Nanle
Address
David Kelly, 638 West State Road, West Grove, PA 19390
Ann M. Wilson, Guardian of Daniel Kelly, 2270 Tonto Drive, Auburn, PA 17927
Notice has now been given to all persons entitled thereto under Rule 5. 6 (a) except
Not applicable
Date:
Signature
Name
Address
Lisa M. B. Woodburn, Esquire
4503 N. Front Street
Harrisburg, PA 17110
Telephone (717) 238-6791
Capacity:
Personal Representative
X Counsel for personal
representative
291214
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
WILSON ANN M
119 CRICKET LANE
CAMP HILL, PA 17011
-------- fold
ESTATE INFORMATION: SSN: 194-12-6589
FILE NUMBER: 2103-0342
DECEDENT NAME: KELL Y HELEN E
DA TE OF PAYMENT: 06/21/2007
POSTMARK DATE: 06/20/2007
COUNTY: CUMBERLAND
DATE OF DEATH: 03/18/2003
NO. CD 008313
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $476.58
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: RECEIPT TO ATTORNEY
CHECK# 7288161
SEAL
INITIALS: AJW
RECEIVED BY:
REGISTER OF WILLS
$476.58
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
--'
15056051058
REV-1500 EX (06-05)
PA Department or Revenue .
Bureau or Individual Taxes INHERITANCE TAX RETURN
PO BOX 280601
Hanisburg, PA 171~1 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
194-12-6589 I 03/18/2003
File Number
o~
D~~
I
Decedent's Last Name Suffix
IK~L~Y__ _ u____ ] 1__ _ J
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
IN/A
Spouse's Social Security Number
Date of Birth
I 01/05/1922
Decedent's First Name
HELEN
MI
I~
Suffix
II
Spouse's First Name
MI
I~
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
c:::> 1. Original Return c:::>
4. Umited Estate
c:::>
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
2. Supplemental Return
c:::>
c:::>
c:::> 4a. Future Interest Compromise (date of
death after 12-12-82)
c:::> 7. Decedent Maintained a Uving Trust
(Attach Copy of Trust)
c:::> 10. Spousal Poverty Credit (date of death c:::> 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - lHlS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONRDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number l"-.3
I Lisa Woodburn, Esquire (717) 238-67~O
.::;:.....
Firm Name (If Applicable)
I Angino & Rovner, P.C.
First line of address
~_ of Helen E. Kelly
Second line of address
1______________ ------------- - _________0____
4503 North Front Street
City or Post Office
I Harrisburg
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
c:::>
em
REGISTER
I SE oN5
::0 hi '"
r;::. _:JJ
<7' Cf>"?'-
000
00"'"
be
=:s
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____~_J
1
-
c.J1
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State ZIP Code
I EJ I ~!~1 ~-1?~=_
DATE FILED
___ ___ _ .J
Correspondent's e-mail address:
Under penalties or peljury, I declare that I have examined this retum, induding 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 infonnation of which preparer has any knowledge.
SIGNATUmERSON RflSPOJISIIJ9: FOR FILING RETURN DATE
~ f'L ~tt6>
ADDRESS '~L ')i\ II ~ A- I
~-wTcnlfV1>1 qWXJwU~ 'J~l~o-o--
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051058
15056051058
--'
q)
-.J
15056052059
REV-1500 EX
Decedenfs Name:
RECAPITULATION
HELEN
E KELLY
1. Real estate (Schedule A). .... . . . . . . . . . . . . . . . .. . . .. .. . .. .. .. .. .. .. . ... 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3.
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .. . . . . .. 5.
6. Jointly Owned Property (Schedule F) c::> Separate Billing Requested . . . . . .. 6.
7. Inter-VIVOS Transfers & Miscellaneous Non-Probate Property
(Schedule G) c::> Separate Billing Requested.. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . .. . . . . 10.
11. Total Deductions (total Lines 9 & 10). ........ . . . .... . . . . . .. .. . . .. ... . . . 11.
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) .. . . . . . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under See. 9116
(a)(1.2) X .0_
16. Amount of Line 14 taxable
at lineal rate X.O 45
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
0.00
10,590.70
0.00
0.00
19. TAX DUE. ..... . . . .. . ... . ..... .. . .. . ... .... . ... . ... . . . .. . ... .. .. . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052059
Side 2
15.
16.
17.
18.
Decedent's Social Security Number
.194-12-6589
I
I
10,590.70
10,590.70
10,590.70
10,590.70
c::>
15056052059
-.J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DDI
DECEDENrs NAME DECEDENrS SOCIAL SECURITY NUMBER
HELEN E KELLY 194-12-6589
STREET ADDRESS
1701 Warren Street
CITY I STATE I ZIP
New Cumberland PA 17070
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
476.58
Total Credits ( A + B + C ) (2)
3. InterestlPenalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Une 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.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(5)
(SA)
(5B)
476.58
A. Enter the interest on the tax due.
476.58
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;.......................................................................................... 0 iii
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 iii
c. retain a reversionary interest; or.......................................................................................................................... 0 [iJ
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [iJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 iii
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 iii
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 iii
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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 three (3) percent [72 P.S. 99116 (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 zero (0) percent
[72 P.S. 99116 (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 retum 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 zero (0) percent [72 P.S. 99116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use ofthe decedenfs siblings is twelve (12) percent [72 P.S. 99116(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-1508 EX+ (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
KELLY HELEN E
FILE NUMBER
21 030342
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
DESCRIPTION
from Survival Action, Cumberland County
VALUE AT DATE
OF DEATH
10,
of Common Pleas NO. 04-3065 Civil Term
""'5TJo7~'oO'7'
I
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
KELLY Helen E
FILE NUMBER
21 030342
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) RECENlNG PROPERTY
I TAXABLE DISTRIBUTIONS pnclude oubight spousal disbibutions, and transfers under
...._.._.____.._..._..._....__....___~!1~_~j~H.l,.?lL_.._._____. _. _....__... ._...._..... ........._.___
1 I David M. Kelly
;_..__..__._____.._.___._._..___..........__... ._._.....__... __...____~______._~_.... _._..__.__ __.__._____.___m__._.
12270 Tonto Drive
'Son
1638 W. State Road
i
l~~~~~~~~~._~.~~:~_._.. ...___.__....___..._.._...._...._..._...._........._....
i .~~-~_...~.~~...._-- . -'" _w~~..__~ ",......-...~.,....~._.. ~._~._._...-.~...~-._-~ -----..,..-"""-~-. .,_.T.~__....., ~_......~_.-...~=~,.. ~..
2.: iAnn E. Wilson
Daughter
IAubum, PA 17922
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE. ON REV-1500 COVER SHEET
n NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
." . .~__.._. __.. ,_, ,_.,,_ ._,_ ~_ .'___ ',._..",... _._*_,o__~. ......_
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- 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)
.~:l!2007 09:48
717-783-3467
INHERITANCE TAX
PAGE 02/02
5U~U OF INDIVIDUAL TAXES
INHERiTANCE TAX DIVISION
Po Box 280601
HARRlS8URG, PA 1712.8-0601
WEB ADDRESS www.state.Oi.us
. COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
March 19, 2007
Lisa M. B. Woodburn, Esq.
Angina & Rovner. PC
4503 N. Front St.
Harrisburg, PA 17110
Re: Estate of Helen E. Kelly
File Number: 2103-0342
Court Number: CCP Cumberland Co.; No. 04-3065
Dear Ms. Woodburn:
The Department of Revenue has received the Petition for Approval of Settlement Claim to
be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action.
It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the
proceeds paid to settle the actions.
Pursuant to the Petition, the 81-year-old-decedent died as a result of negligent care.
Decedent is surviv~d by her adult children.
Please be advised that, based upon these facts and for inheritance tax purposes only, this
Department has no objection to the proposed allocation of the net proceeds of this action, 80% to
the wrongful death claim and 20% to the survival claim. Proceeds of a survival action are an asset
included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax.
42 Pa. C.S.A. ~8302; 72 P.S. ~99106, 9107, Costs and fees must be deducted in the same
percentages as the proceeds are allocated. In re Estate of Merrvman, 669 A.2d 1059 (Pa.
Cmwlth. 1995). .
I trust that this Jetter is a sufficient representation of the Department's position on this
matter. As the Department has no objections to the Petition. an attorney from the Department of
Revenue wlll not be attending any hearing regarding it. Please contact me if you or the Court has
any questions or requires anything additional from this Bureau. Finally, the approval of this
allocation is limited to this estate and does not reflect the position that the Department may take in
any other proposed distribution of proceeds of a wrongful death/survival action.
_ Si~~reIY,
CJd.. ~'t~~.
Holly A. McClintock
Trust Valuation Specialist
Inheritance Tax Division
Bureau of Individual Taxes
PHONE: 717.787-1794 . FAX: 717-783-3467 . I;MAJL: hmcclintoc@5tate.ca.us
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ANGINa & ROVNER, P .C.
717/238-6791
FAX 717/238-5610
RICHARD C. ANGINO
NmJ. ROVNER
JOSEPH M. M:E1.ill.o
DAVID L LUTZ
MICHAEL E. KOSIK
RICHARD A. SADLOCK
L1S.A M. B. WOODBURN
DARYL E. CHRIsTOPHER
4503 NORTH FRONT STREET
HARRIsBURG, PA 17UCH799
WWW.ANGIND-ROVNER-COM
E-MAIL: LWOODBURN@ANGIND-ROVNER.COM
ANN WILSON. EXECUTRIX OF THE ESTATE OF HELEN KELLY v.
MANORCARE HEALm SERVICES. INC.. ET AL.
DISTRIBUTION SHEET
$115,000.00
TOTAL AMOUNT OF SETTLEMENT
DEDUCTIONS:
Attorney's Fee (30%)
Balance
$ 34,500.00
$ 80,500.00
Reimbursement of expenses paid by attorneys
to others for records, experts, etc.
Balance
$ 4,559.15
$ 75,940.85
$ 8,407.63
Escrow for reimbursement of Medicare lien
Balance
$ 67,533.22
Reimbursement of Dept. of Public Welfare lien
$ 14,579.71
BALANCE TO CLIENT PLUS ANY lNTEREST EARNED
WHILE HELD IN BANK ESCROW
$ 52,953.51
FlNAL DIVISION:
Attorney's Fee $34,500.00
Client's Balance $52,953.51
Reimbursement of Expenses $ 4,559.15
Escrow for Medicare Lien $ 8,407.63
Escrow for DPW Lien $14,579.71
This settlement/verdict may be taxable. We rec.ommend that you consult your ac.countant or tax attorney for the
calculation of your tax iiability and any deductions to whiCh you may be entitled.
WARRANTY
AND NOW, this --++-- day of ~.... L ' 2007, we acknowledge that we have read, understood,
approved and obtained a copy of this Distributi Sheet. We further acknowledge that the above balance constitutes my
total reimbursement for medical expenses, wage losses, pain and suffering and any other losses sustained or claims
resulting from our accident. We warrant that if there are any outstanding medical bills, child support arrearages or claims
other than as set forth above, they will be our responsibility; we further warrant that we will pay any outstanding Blue
Cross, Blue Shield, Public Assistance, MedicareIMedicaid, medical subrogation liens or any other liens and expenses not
o.17ed above. III J 'v / I!. .
fl~ ~'~f%IM
WI S ANN ~SON, Executrix of the Estate
. of Helen E. Kelly
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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
REV-1607 EX AFP (03-05)
?r.Cj II" "'0
.....UJ}: ....,l;'L t
Pf'~ '-i: 00
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
07-16-2007
KELL Y
03-18-2003
21 03-0342
CUMBERLAND
101
HELEN
E
ANN WILSON C! j''''
119 CRICKET LN
CAMP HILL PA 17011
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insu~e p~ope~ c~edit to YOu~ account, submit the uppe~ po~tion of this fo~m with you~ tax payment.
CUT ALONG THIS LINE
-+
RETAIN LOWER PORTION FOR YOUR RECORDS
+-
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
REV-1607 EX AFP (03-05)
*** INHERITANCE TAX STATEMENT OF ACCOUNT ***
ESTATE OF KELL Y
HELEN
E FILE NO. 21 03-0342
ACN 101
DATE 07-16-2007
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUE. APPLICATION OF ALL PAYMENTS. THE CURRENT BALANCE. AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-09-2004
PRINCIPAL TAX DUE: 2,982.33
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
06-19-2003 CD002710 .00 900.00
12-04-2003 CD003316 .00 1,521.00
02-14-2004 CD003566 3.78- 566.16
06-20-2007 CD008313 .00 476.58
TOTAL TAX CREDIT 3,459.96
BALANCE OF TAX DUE 477.63CR
INTEREST AND PEN. .00
* IF PAID AFTER THIS DATE. SEE REVERSE TOTAL DUE 477.63CR
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1.
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRl,
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. l
dJYl
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BUREAU OF INDIVIDUAL TJ)(i~"
INHERITANCE TAX DIVISION
PO BOX 2801i01
HARRISBURG PA 17128-01i01
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
" NOTICE OF INHERITANCE TAX
'-APf'RAISEMENT, ALLOWANCE OR DISALLOWANCE
. OF DEDUCTIONS AND ASSESSMENT OF TAX
'*'
REV-1547 EX AFP (01i-05)
DATE 08-13-2007
ESTATE OF KELL Y HELEN E
DATE OF DEATH 03-18-2003
FILE NUMBER 21 03-0342
COUNTY CUMBERLAND
ACN 501
APPEAL DATE: 10-12-2007
( See reverse side under Objections)
A.ount Re.ittedl 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 +-
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REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF KELLY HELEN E FILE NO. 21 03-0342 ACN 501 DATE 08-13-2007
t'\rn'" 'f~~""'n
L;JJ ;.,,):; LU
'[: 08
Cl-ERK 0=
ODPL.J;\'\!""" rl~1 'r'\-r
I II i I,'~\i '~ ,:::;, ....../\)1.. Ji '1 j
f'1!I ,'--"" ,. ,"
LISA WOODBUR-N\iiESQ.J..:,
ANGINO & ROVNER PC
4503 N FRONT STREET
HARRISBURG PA 17110-1799
TAX RETURN WAS: (X) ACCEPTED AS FILED
} CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: LITIGATION RETURN
1. Real Estate (Schedule A) (I)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
4. Mortgages/Notes Receivable (Schedule D) (4)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5)
Ii. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
.00
.00
.00
.00
10.590.70
.00
.00
(8)
NOTE: To insure proper
credit to your account.
submit the upper portion
of this form with your
tax payment.
10,590.70
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
.00
(9)
(0)
.00
Ol}
(2)
03}
(4)
.00
10,590.70
.00
10,590.70
NOTE:
If an assess.ent was issued previouslY, lines 14. 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. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
18. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TS:
OS)
06}
(7)
(8)
. DO X
10,590.70 X
.00 X
.00 X
00
045 =
12 =
15 =
(9)=
.00
476.58
.00
.00
476.58
N
DATE
06-20-2007
+)
PAID (-)
.00
AMOUNT PAID
476.58
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
476.58
.00
.00
.00
* IF PAID AFTER DATE INDICATED, 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" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
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