HomeMy WebLinkAbout03-0483Register of Wills of C berland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of Helen A. Clark
also known as
William C. Clark , Deceased
Petitioner(s), who is/are 18 years of age or older, apply(les) for:
Social Security No. 166-12 - 1942
(COMPLETE 'A' or 'B' BELOW:)
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut or
the Decedent, dated 05/06/87 and codicil(s) dated Non. e
named in the last Will of
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
[] B. Grant of Letters of Administration
(c.t.a.; d.b.n.c.t.a; pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and
heirs:
Name
Residence 3
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cu-mberland County, Pennsylvania with his/her last family
or principalresidenceat 846 Anthony Drive , Hampden Township
(list street, number, and municipality)
Decedent, then 81 years of age, died 05/31 , 03,at Holy Spirit Hospital, Camp Hill, PA
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property
(If not domiciled in PA) Personal property in Pennsylvania
(If not domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
(Location)
50,000.00
160,000.00
situated as follows: 846 Anthony Drive, Mechanicsburg, Hampden Township, PA
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of
letters in the a~iate form to the undersigned:
~ _Signature ~rinted name and residence
___C. Clark
3117 King St., Alexandria,
VA 22302
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems, inc.
Form RW-1 (1991)
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true
and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of
the Decedent, Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed ~./~ C. ~
before me this/c~ day cf
For the Register
William C. Clark
NO,
Estate of Helen A. Clark Deceased
Social Security No: 166- 12- 1942 Date of Death: 05/31/03
AND NOW, ~----~///~j..~ /~/ '~J ,r~°L~;iderati°n
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters ~-~ Testamentary ~ Of Administration !'i: ' ~_ ? ,
(c.t.a.; d.b.n.c.ta.; pendente lit~!,durante al:~ntia; durante mino~itate~
are hereby granted to William C. Clark
in the above estate and that the instrument(s) dated 05/06/87
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters ...........
Short Certificate(s) .....
Renu nciation ........
$ Attorney: David J. Lenox
Affidavits ( ) ....
Extra Pages ( ) ....
I.D. No: 29078
The Wiley Group
Address: One S. Baltimore St.
Codicil ........... $
Dillsbur~, PA 17019
JCP Fee .......... $
Telephone: 717/432 - 9666
Inventory .......... $
Other ........... $ /~"~, 0 4'~')
TOTAL ......... $ C:~4:~D,,. ~'"J)
Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, inc.
Form RW-1 (1991)
Form S-3006
EXECUTORS BOND
County of Cumberland , Peunsylv/mia.
~,state of Hden A. Clark } No of
lat~ of Helen A. Clark deceased
KNOW ALL ~ l~ ~ PRF.~ That wo Willian C, Clark
as Principal, and The Ohio Casualty Insu~n~ Company . a co.or.on of~e Sram of Ohlo , ~i an~odzct to
become sole su~W In ~e Comm~weal~ ofPe~sylvanla, ~e held and ~ly bound uaw ~e Commonweal~ of Pc~sylv~ia, for
· e ~o of~osc iut~e~ted tn ~ estate, in ~e sum of One H~d ~o~d ~ n~c~ ( $ _100t000'
Dollar, to be paid to the ~id Commonw~Ith, to which ps~en~ well and ~ly ~o be made, we do bind o~lves, jointly and
severally, for and in ~e whole, our h~[~, executo~, adm~is~to~, successom and asstgns, and eaoh and eve~ of ~em, fimly by
these presents.
Soal~ with our seals and dated 6-11~3
TIIE CONDITION OF THIS OBLIGATION I8, That if the above bounden
William C. Clark
Stat= of Pennsylvania
County of Cumberland
Executor or any of them, shell well and truly administm the estate
according to law, this obligation, shall be void as to those who shall $o administer the estate; but otherwise, it ~h~ll remain in force.
Sealed and delivered in the presence of: ~/, (Se~l)
The Ohio Cas~l~surance Com_~¢.~ any
I, William C, Clark
do sol¢~mlly swear that. as the Executor
or,he esr. ate of Helen A. Clark
deceased, I
will well and l~uIy administ~' the es~a~e of said decedent, accordinE to law,
Sworn and subscribed before mc
llkts day of
A.D. and leners of admir~Jstradon granted
u~lto
CERTIFIED COPY OF POWER OF ATTORNEY
THE OHIO CASUALTY INSURANCE COMPANY
WEST AMERICAN INSURANCE COMPANY
No. 35-931
Know Ail Men by These Presents: That THE OHIO CASUALTY INSURANCE COMPANY, an Ohio Corporation, and VfEST AMERICAN INSURANCE
COMPANY, an Indiana Corporation, in pursuance of authority granted by Axticle VI, Section 7 of the By-Laws of The Ohio Casualty Insurance Company and Article VI,
Section 1 of West American Insurance Company, do hereby nominate, constitute and appoint: John J. Richardson, Jr. or Lisa B. Richardson of Dillsburg, Pennsylvania its
true and lawful agent (s) and attorney (s)-in-fact, to make, execute, seal and deliver for and on its behalf as surety, and as its act and deed any and all BONDS,
UNDERTAKINGS, and RECOGNIZANCES, not exceeding in any single instance ONE MILLION ($I,000,000.00) DOLLARS, excluding, however, any bond(s) or
underIaking(s) guaranteeing the payment of notes and interest thereon
And the execution of such bonds or undcrIakings in pursuance of these presents, shall be as binding upon said Companies, as fully and amply, to all intents and proposes, as if
they had been duly executed and acknowledged by the regularly elected officers of the Companies at their administrative offices in Hamilton, Ohio, in their own proper persons.
The authority granted hereunder supersedes any previous authority heretofore granted the above named attorney(s)-in-fact.
In WITNESS WHEREOF, the undersigned officer of the said The Ohio Casualty Insurance Company and West American Insurance Company has
hereunto subscribed his name and affixed the Corporate Seal of each Company this 7th day of November, 2001.
STATE OF OI~O,
COUNTY OF BUTLER
Sam Lawrence, Assistant Secretary
On this 7th day of November, 2001 before the subscriber, a Notary Public of the State of Ohio, in and for the County of Butler, duly commissioned and qualified, came Sam
Lawrence, Assistant Secretary of THE OI-HO CASUALTY INSURANCE COMPANY and WEST AMERICAN INSURANCE COMPANY, to me personally known to be the
individual and officer described in, and who executed the preceding inslrument, and he acknowledged the execution of the same, and being by me duly sworn deposeth and salth,
that he is the officer of the Companies aforesaid, and that the seals affixed to the preceding instrument are the Corporate Seals of said Companies, and the said Corporate Seals
and his signature as officer were duly affixed and subscribed to the said insmunent by the authority and direction of the said Corporations.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my Official Seal at the City of Hamiltun, State of Ohio, the day and year first above written.
Notary Public in and for County of Butler, State of Ohio
My Commission expires August 6, 2002.
This power of attorney is granted under and by authority of Article VI, Section 7 of the By-Laws of The Ohio Casualty Insurance Company and Article VI, Section I of West
American Insurance Company, extracts from which read:
Article VI, Section 7. APPOINTMENT OF ATTORNEYS-IN-FACT, ETC. "The chairman of the board, the president, any vice-president, the secretary or any assistant
secretary of each of these Companies shall be and is hereby vested with full power and authority to appoint attorneys-in-fact for the purpose of signing the name of the
Companies as surety to, and to execute, at~ach the corporate seal, acknowledge and deliver any and all bonds, recognizances, stipulations, undertakings or other instruments of
suretyship and policies of insurance to be given in favor of any individual, firm, corporation, or the official representative thereof or to any county or state or any
or boards of county or state, or the United States of America, or to any other political subdivision." , , official board
Article VI, Section 1. APPOINTMENT OF RESIDENT OFFICERS. '"fhe Chairman of the Board, the President, any Vice President, a Secretary or any Assistant Secretary
shall be and is hereby vested with full power and authority to appoint attorneys in fact for the purpose of signing the name of the corporation as surety or guarantor, and to
execute, attach the corporate seal, acknowledge and deliver any and all bonds, recognizances, stipulations, undertakings or other instruments of surety-ship or guarantee, and
policies of insurance to be given in favor of an individual, firm, corporation, or the official representative thereof, or to any county or state, or any official board or boards of any
county or state, or the United States of America, or to any other political subdivision."
This instrument is signed and sealed by facsimile as authorized by the following Resolution adopted by the respective directors of the Companies (adopted May 27, 1970-The
Ohio Casualty Insurance Company; adopted April 24, 1980-West American Insurance Company):
"RESOLVED that the signature of any officer of the Company authorized by the By-Laws to appoint attorneys in fact, the signature of the Secretary or any Assistant
Secretary certifying to the correctness of any copy of a power of attorney and the seal of the Company may be affixed by facsimile to any power of attorney or copy thereof
issued on behalf of the Company. Such signatures and seal are hereby adopted by the Company as original signatures and seal, to be valid and binding upon the Company with
the same force and effect as though manually affixed."
CERTIFICATE
I, the undersigned Assistant Secretary of The Ohio Casualty Insurance Company and West American Insurance Company, do hereby certify that the foregoing power of attorney,
the referenced By-Laws of the Companies and the above Resolution of their Boards of Directors are tree and correct copies and are in full force and effect on this date.
IN WITNESS WHEREOF, I have hereunto set my hand and the seals of the Companies this _ ./~ '~ _ day of ~'~--~-,~..,d[ ~
Assistant Secretary
S-4300
'03 JUN 12 P1:48
'03 .JUf~I 12 P1:49
WILL
I, HELEN A. CLARK, of the Township of Hampden, County
of Cumberland, Commonwealth of Pennsylvania, declare this to
be my Last Will and Testament and revoke any and all prior
Wills and Codicils made by me.
ITEM I: I direct my Executor hereinafter named to
pay all my just debts, funeral and burial expenses as soon
after my decease as practicable, as well as all death taxes,
whether state or federal, which may be assessed against my
estate, as part of the costs of administration.
ITEM II: I give, devise and bequeath my entire
estate of whatever nature and wherever situate at the time
of my death to my husband, RAY CLARK, provided he shall
survive me by at least sixty days.
ITEM III: My husband, RAY CLARK, and I are now joint
owners of a residence in Cumberland County, Pennsylvania,
which is our usual home. If, however, my husband survives
me and at my death our usual home is held in any manner
which will not result in passage of full title to him by
operation of law, I devise my entire interest in said home
to him. If he does not survive me, then said property shall
pass under Item IV hereof.
ITEM IV: Should my husband predecease me or die on
or before the sixtieth day following my death, I give and
bequeath my entire estate to my son, WILLIAM C. CLARK, of
Alexandria, Virginia, per stirpes.
ITEM V: No interest of any beneficiary of my
estate, either in income or principal, shall be subject to
anticipation or to pledge, assignment, sale or transfer in
any manner, nor shall my beneficiary have any power in any
manner to charge or encumber his or her interest, either in
income or principal, nor shall the interest of any
beneficiary be liable or subject in any manner while in the
possession of the Executor for the liability arising from
his or her debts, contracts, torts or other engagements of
any type.
ITEM VI: All death taxes (not income taxes) that
may be assessed in consequence of my death, of whatever
nature and by whatever jurisdiction imposed, shall be
considered a part of the expense of the administration of my
estate, and my Executor shall have the absolute power in his
discretion to pay the same at once whether or not the law
under which they are imposed permits the postponement of
payment of all or part of them to a later date.
ITEM VII: I direct and empower my Executor to sell
any and all real estate of which I die seized, at such time
and upon such terms as he may deem best, and to deliver good
and sufficient deeds therefor to the purchaser(s) thereof.
ITEM VIII: If my husband and I should die under such
circumstances that it cannot be determined which of us died
first, he shall be deemed to have predeceased me for all
purposes hereunder.
ITEM IX: In addition to the powers granted by law, my
Executor shall have the following powers which shall be
exercisable without leave of Court and shall continue until
distribution is actually made:
A. To retain any or all property, real
or personal, owned by me at my death, and to
invest in all forms of property without being
confined to legal investments;
B. To sell at public or private sale
for cash or credit, or partly for each, to
exchange, or to lease for any period of
times, any or all property, real or personal,
and to give options for sales, exchanges, or
leases;
C. To borrow from or to sell to anyone,
including the Trustee under my Trust
Agreement referred to above, even if the
fiduciary involved is on both sides of a
given transaction;
D. To execute and deliver any deeds,
leases, assignments or other instruments as
may be necessary to carry out the provisions
hereof;
E. To compromise claims;
F. To distribute in cash or kind, or
partly each; and
G. To make a partial distribution at
such time or times as is expedient to carry
out the objections of this Will and the
aforesaid Trust Agreement.
ITEM X: Should any person entitled to a share of my
estate be under the age of twenty-five years at the time for
distribution to him or her, I devise and bequeath the share
of such person to Sovran Bank, N.A., or its successor, of
Alexandria, Virginia, IN TRUST, to hold, manage, invest and
reinvest the corpus or principal and use and apply the
income or principal, or so much thereof as in the Trustee's
discretion, may be necessary or appropriate for their
support, maintenance and education until they respectively
attain the age of twenty-five years when such share or
shares so held shall be distributed to him or her
absolutely.
ITEM XI: I nominate, constitute and appoint my
husband, RAY CLARK, Executor of this my Last Will and
Testament. Should my husband fail to qualify or cease to
act as Executor, I appoint my son, WILLIAM C. CLARK, of
Alexandria, Virginia, Executor of this my Last Will and
Testament. Should my son fail to qualify or cease to act as
Executor, I appoint FULTON BANK, or its successor, of
Harrisburg, Pennsylvania, Executor, of this my Last Will and
Testament.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal this /~ day of ~z/ , 1987, at the end hereof,
composed in all of six pages, including the self-proving
attestation clause and signatures of witnesses.
HELEN A. CLARK
( SEAL )
COMMONWEALTH OF PENNSYLVANIA:
: SS:
COUNTY OF :
We, HELEN A. CLARK, the Testatrix and
Dn~ ?.. ~nv~r and h~ ~ ~==~r , the
witnesses, whose names are signed to-th~ ~A~-~oregoing
instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed, sealed,
published, acknowledged, and declared the instrument as her
Last Will and Testament; and that he signed willingly and
that she executed it as her free and voluntary act for the
purposes therein expressed; and that each of the witnesses
in the joint presence of each other and in the presence and
hearing of the Testatrix, signed the instrument as witness
to his Last Will and Testament; and that to the best of
their knowledge the Testatrix was at the time eiqhteen years
of age or older, was of sound and disposing mind~ memory and
understanding, and was under no constraint or undue
influence.
HELEN A CLARK, Test trix
uum-N ~. ~'~D~:{{,, / -----W-l=L,r~ss---~.
Subscribed, sworn to and acknowledged before me, the
undersigned officer, by HELEN A. CLARK, the Testatrix,
and subscribed and sworn to before me by
DONN L. SNYDER and DIANE E. GRISSINGER
and witnesses, in the presence of each other, this 6th
day of May , ~~ ~~ --
Y ~ommissioh Expi~ss l'~:;w_rnb~r 21, 1981
J'Jarrisbur& PA D~phm County
LAST
WILL AND TESTAMENT
OF
HELEN A. CLARK
LAW O F'F'IC E..6
DONN L. SNYDER
212 LoCt~T STREET
P 0 Box 741
HARRISBURG. PA 17108
71-Z-233-117~3
CERTIFICATION OF NOTICE UNDER RULE 5.6 (a)
Name of Decedent: Helen A. Clark
Date of Death: May 31, 2003
Estate Number: 21-03-0483
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
June 26, 2003:
Name Address
William C. Clark 3117 King St., Alexandria, VA 22302
Notice has now been given to all persons entitled thereto under Rule 5.6 (a) except N/A.
Date: June 26,2003 ~'c~ ~. ~/~-~
' Signatur~
Name: David J. Lenox, Esquire
Address: One S. Baltimore St.
Dillsburg, PA 17019
Telephone: (717) 432-9666
Capacity: Counsel for personal Rep.
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 003049
LENOX DAVID J ESQ
305 ROBIN HOOD RD
DILLSBURG, PA 17019
........ fold
ESTATE INFORMATION: SSN: 166-12-1942
FILE NUMBER: 2103-0483
DECEDENT NAME: CLARK HELEN A
DATE OF PAYMENT: 09/23/2003
POSTMARK DATE: 09/20/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 05/31/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $709.50
REMARKS:
TOTAL AMOUNT PAID:
DAVID LENOX ESQUIRE
$709.50
SEAL
CHECK# 1423
INITIALS: VZ
RECEIVED BY.'
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
COMMON~VEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-06{31
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
~=ILE NUMBER
21 03 00483
COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
Clark, Helen A. 166-12-1942
DATE OF DEATH (MM-DO-YEAR) DATE OF BIRTH (MM-DD-YEAR)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
05/3 1/2003 01/22/1922 REGISTER OF WILLS
SOCIAL SECURITY NUMBER
APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
[]
[]
[]
[]
12-31-91 and 1-1-95
~AME
David J Lenox
1. Original Return [] 2. Supplemental Retum [] 3, Remainder Return (date of death prior to 12-13-82)
4. Limited Estate [] 4a. Future Interest Compromise (date of death after [] 5. Federal Estate Tax Return Required
12-12-82)
6. Decedent Died Testate (Attach copy [] 7. Decedent Maintained a Living Trust (Attach 8. Total Nurnber of Safe Deposit Boxes
of Will) copy of Trust)
9. Litigation Proceeds Received [] 10. Spousal Poverty Credit (date of death between [] 11. Election to tax under Sec. 9113(A) (Attach $ch O)
COMPLETE MAILING ADDRESS
:IRM NAME (If applicable)
The Wiley Group
rELEPHONE NUMBER
717/432-9666
1 S. Baltimore Street
Dillsburg, PA 17019
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 Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
[] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
179,900.00'
-0-
None
None
27,130.18
37,465.39
21,810.82
58,077.81
5,327.43
13. Charitable and Governmental Bequests/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)
OFFICIAL USE ONLY
(8)
266,306.39
63,405.24
202,901.15
202,901.15
(11)
(12)
(13)
(14)
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 .00 (15)
16,Amount of Line 14 taxable at lineal rate
202,901.15 x .045 (18)
9,130.55
9,130.55
17.Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
x .12 (17)
x .15 (18)
(19)
20. []
Copyright 2000 form software only The Lackner Group, Inc. Form REV-tS00 EX (Rev. 6-00)
Decedent's Complete Address:
ISTR~i~r ADDRESS
CITY Mechanicsburg
846 Anthony Drive
STATE PA ]ZIP 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
8,000.00 421.05
Interest/Penalty if applicable D. Interest
E. Penalty
9,130.55
Total Credits (A + B + C) (2)
Total Interest/Penalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page I Line 20 to request a refund
5. If Line I + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
8,421.05
0.00
709.50
709.50
(5A)
(5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ............................................................................ [--] ~
b. retain the 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? ...................................................................................................................... [] []
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 perjur~, 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 an_y~k~owledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
William C. Clark
~x~/~ ~, ~ 3117 kip-g St'
Alexandria, VA 22302
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
DATE
SIGNATURE OF PREPARER OTHER~JqAN REPRESENTATIVE ADDRESS DATE
David J Lenox ~ / //' / / /
~ / Y ~ / 1 S. Baltimore Street c~,/~,,/~ _
Dillsburg, Pa 17019 7. ~'~/U~.~
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. {}9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116
1.2) [72 P.S. §9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedenrs 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.
WILL
I, HELEN A. CLARK, of the Township of Hampden, County
of Cumberland, Commonwealth of Pennsylvania, declare this to
be my Last Will and Testament and revoke any and all prior
Wills and Codicils made by me.
ITEM I: I direct my Executor hereinafter named to
pay all my just debts, funeral and burial expenses as soon
after my decease as practicable, as well as all death taxes,
whether state or federal, which may be assessed against my
estate, as part of the costs of administration.
ITEM II: I give, devise and bequeath my entire
estate of whatever nature and wherever situate at the time
of my death to my husband, RAY CLARK, provided he shall
survive me by at least sixty days.
ITEM III: My husband, RAY CLARK, and I are now joint
owners of a residence in Cumberland County, Pennsylvania,
which is our usual home. If, however, my husband, survives
me and at my death our usual home is held in any manner
which will not result in passage of full title to him by
operation of law, I devise my entire interest in said home
to him. If he does not survive me, then said property shall.
pass under Item IV .hereof.
ITEM IV: Should my husband predecease me or die on
or before the sixtieth day following my death, I give and
bequeath my entire estate to my son, WILLIAM C. CLARK, of
Alexandria, Virginia, per stirpes.
ITEM V: No interest of any beneficiary of my
estate, either in income or principal, shall be subject to
anticipation or to pledge, assignment, sale or transfer in
any manner, nor shall my beneficiary have any power in any
manner to charge or encumber his or her interest, either in
income or principal, nor shall the interest of any
beneficiary be liable or subject in any manner while in the
possession of the Executor for the liability arising from
his or her debts, contracts~ torts or other engagements of
any type.
ITEM VI: All death taxes (not income taxes) that
may be assessed in consequence of my death, of whatever
nature and by whatever jurisdiction imposed, shall be
considered a part of 'the expense of the administration of my
estate, and my Executor shall have the absolute power in his
discretion to pay the same at once whether or not the law
under which they are imposed permits the postponement of
payment of all or part of them to a later date.
ITEM VII: I direct and empower my Executor to sell
any and all real estate of which I die seized, at such time
and upon such terms as he may deem best, and to deliver good
and sufficient deeds therefor to the purchaser(s) thereof.
ITEM VIIi: If my husband and i should die under such
circumstances that it cannot be determined which of us died
first, he shall be deemed to have predeceased me for all
purposes hereunder.
ITEM IX: In addition to the powers granted by law, my
Executor shall have the following powers which shall be
exercisable without leave of Court and shall continue until
distribution is actually made:
A. To retain any or all property, real
or personal, owned by me at my death, and to
invest in all forms of property without being
confined to legal investments;
B. To sell at public or private sale
for cash or credit, or partly for each, to
exchange, or to lease for any period of
times, any or all property, real or personal,
and to give options for sales, exchanges, or
leases~
C. To borrow from or to sell to anyone,
including the Trustee under my Trust
Agreement referred to above, even if the
fiduciary involved is on both sides of a
given transaction;
D. To execute and deliver any deeds,
leases, assignments or other instruments as
may be necessary to carry out the provisions
hereof;
E. To compromise claims;
F. To distribute in cash or kind, or
partly each; and
G. To make a partial distribution at
such time or times as is expedient to carry
out the objections of this Will and the
aforesaid Trust Agreement°
ITEM X: Should any person entitled to a share of my
estate be under the age of twenty-five years at the time for
distribution to him or her, I devise and bequeath the share
of such person to Sovran Bank, N.A., or its successor, of
Alexandria, Virginia, iN TRUST, to hold, manage, invest and
reinvest the corpus or principal and use and apply the
income or principal, or so much thereof as in the Trustee~s
discretion, may be necessary or appropriate for their
support, maintenance and education until they respectively
attain the age of twenty-five years when such share or
shares so held shall be distributed to him or her
absolutely.
ITEM
I nominate, constitute and appoint my
husband, PAY CLARK~ Executor of this my Last Will and
Testament. Should my husband fail to qualify or cease to
act as Executor, I appoint my son, WILLIAM C. CLARK~ of
Alexandria, Virginia, Executor of this my Last Will and
Testament. Should my son fail to qualify or cease to act as
Executor, I appoint FULTON BANK, or its successor~ of
Harrisburg, Pennsylvania, Executor, of this my Last Will and
Testament.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal this ~ day of ~x/ , 1987, at the end hereof,
composed in all of six pagesf including the self-proving
attestation clause and signatures of witnesses.
HELEN A. CLARK
(SEAL)
CO~D4ONWEALTH OF PENNSYLVANIA:
: SS:
COUNTY OF :
We, HELEN A~ CLARK, the Testatrix and
D~n~ l._ gnvH~r and . n~=~= E a~==~=r , the
Witnesses, wKose names are signed to-the
instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed, sealed,
published, acknowledged, and declared the instrument as her
Last Will and Testament; and that he signed willingly and
that she executed it.as her free and voluntary act for the
purposes therein expressed; and that each of the witnesses
in the joint presence of each other and in the presence and
hearing of the Testatrix, signed the instrument as witness
to his Last Will and Testament; and that to the best of
their knowledge the Testatrix was at the time eighteen years
of age or older, was of sound and disposing mind, memory and
understanding, and was under no constraint or undue
influence.
HELEN A~ CLARK, Testatrix
DIANE E. I ' [~7Witnes~
Subscribed, sworn to and acknowledged before me, the
undersigned officer, by HELEN A. CLARK, the Testatrix,
and subscribed and sworn to before me by
DONN Lo SNYDER and DIANE E. GRISSINGER
and witnesses,
in the presence of each other, this 6th
day of May ~ ~-A ~
,~ SCHEDULE A
REAL ESTATE
COMMONWEAL'IH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clark, Helen A. FILE NUMBER
21 - 03 - 00483
All real prope .r~y owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price
at which propert~ would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having
reasonable_knowledge of the relevant facts. Real property which is jointly-owned with right of survivorshi must b
schedule r. p e disclosed on
ITEM
NUMBER DESCRIPTION
!
2
Sale of real estate - 846 Anthony Drive, Mec.hanicsburg, Cumberland County, PA:
TOTAL (Also enter on Line l, Recapitulation)
VALUE AT DATE Of
DEATH
179,900.00
179,900.00
09/0~/~003 08:gg FAX 717671~?i8 T.A. OF HBG
002/'003
A. U.S. DEPARTMENT OF HOUSING AND O'R~AN DEVELOPMgNT
~ETTLEMENT ~TATEM ENT
T.A, of Harrisburg, LLP
4775 Linglcstown R. oad
HarrisbUrg, ?~aasylvaaia 17112
717.~71~71~ ~: 717-~V1-~71~
HARI25-2336
'-~-. J~OTE: Thi~ ~orm i~ fi~rn~sh~d ~o ~e you a s~t of o~mni s~tl~ cos~. ~mo~ p~d gO ~d by Ibc $~l~t ~mt ~e sh~n.
E~ S~r: W~am C, ~ Executor of~c E~atc ofHet~ A. Cl~k
846 A~ony Ddve
G. Propmy: H~pdm Tow~hJp
Lot 40, F~ Pl~ No. 2, Pa~ of g~on E, Deiml~ M~or, Book 32, Page I0 Dauph~ C0~,
J, 8umma~ of ~o~ow~r's Tram~ou ] ~ Samm~ of Sell~'s Transa*fion
10fi.~ [ Town T~ 406. ClW ~ T~ Tins
County / F~th Taxes Stp 2, 2003 thru Dec 3 I,--
107. 2003 127. tt0
108. ~ahool Taxes Sop 2, 2003 llu'a Jun 30 2004 1,251.79
109, Scv, m'/T_r~.hJ~ep2.,2003~t~'-uS_e~30~2003 .31,21
12___~0..Gross &mooing Due f~om Borrower: . 185,817,93
,,,~100. A,motult. s Paid,,.b,y or ia'Behalf, of Borrower:
-20l' D~sit / Em'nest M °n.~-Z 4,000.0(
202. Pri~i'~fI~u~ Leas . 6.0.000.0(
203.
205.
206.
210. Cit~ /Town Ta.x~
2l 1, C0tmty/P._~ish Taxe~'
212. School T~es
220. To~I Paid by / for Borrower:
64,000.00
300. Cash:~t..S. etdemeai~o,n:Fral~drr~wer:, .,
301. Gross AmOunt dU~ from Bolro-wc:r (lino 120) ] g5.81'7.93
302. I_~ss ~olmt
303. Cash From Borrower:
64,000.00.
$121,817.95
marked
179300,00
County/Parish Taxes Stp 2, 2003 thru Dec 31 --
407. 2003 ' 127.80
4.08_. 8choolT~x~$~.2,~2003thruJu,~0,2004 ' '
409. Se.werfPrnsh $~a~ 2~ 200~ th~ Sep 30;2003 31.21
4_20. Gross Amount Due to Seller:
500. Redueflbus:iu..A~u, ount D'ud
502. S~tlem.e~t ~KCS to So~ (Li~.~ 4~
504. Payoff ofFi~t Mo~ m Wa~o~t B~k
506. P~e Mon~Mo~go
510. GW/Tom T~
-~12. SchOOl T~
~20, Total R~flo~s ia Amour Due
181,710.80
14~04_8..43
17,462.74
32~111.17
.600, Ca,h ~t'8 ettllunea~ti~ 2.~om ~ller~.
601. Gro~.'A~no-u~ ~ duo m Sellat. 01ae 420) ]III,H ] 0}80
· 602. L~s R-~lu~ttons Amount due .qeller_(line 5205 32,11 l. 17
603. Cash To Seller:
$149,199.63
1 hay, ¢~ruthlly rt-v/~w~d 0ne I-IUD- l Sm'llemml Sla~mmi ~md t~ thc ~ ol"my lmowl~gc ~md belief, il. is a irue md accustom ~a~cnt of all re~cipm and
disbm'~em~u made ou my ~coo~mt or by me m ~ li'ao~action, l flu'ther cra-lily that I have receiv~fl a =opy oFHUD- I SaUlcment 8memmg.
C~rl L. MO,er -- Seller:
William C. Clark, Ex~umr of thc E~t~ta o f H=I~ A. ~larl{
Bor~owe~. Carol K.
The HI-/D- 1 Serllem~t S~a~mmmt which I have p~d is a Ir~c a~d a~curale account of ~11~ tramaofion. I hw~ cau*~l or will cause thc fun~ m b~ disbursed
ill n~ordanc~ with lht~ s~tamlmr. ·
S~'tl~mmt Agent: Date: Stpt~nbm-2, 2003
K. aye E.K. opc *'" FileNo.: HAR125.Z.336
TA K322759
WARD'IN'G; It i, a erim~ to knowingly make £al~ nat,=mm'~ts tn ~he UMmd Stat~ on thi~ or any other ~hnilar form, Pmaltim upon conviction
include ~ finn or imprisonment For d*t~ih ~: Titln 1 It U.S. Code Section 100 ! and Section 1010.
['IUD - 1 May 2002
Se. ptemb~r 2, 2003 9:15 AM OMB NO. 2502-026J
R~SPA hlmdbook 4305.2
09/02/~003 08~37 FAX 717~71~715 T.A. OF HB6
' Scffi~ment D.,e:ScpV;~mber2,2003
Lo Settlemen~ Charge~
700. T~al s'al~'s / Brokei't.sTCd~iralmsid~: ' ,' . . "..
Based.un'i~.lee
Di~siou ~ ~ommission ~ f011ows,
' 701.5,422.00 to
~. 5,372.00 tO
7~. O~
, ,'{
.705. Tn~.$acdon/Proc~aing Fee to RF_~M AX Ruaky A~o~iates
706- ?roceSSi.n.g F~:c tO ~ ~R~al_._~fessiouals __
800. Item~ Payable ,iu Cnnnz~flofi wi~ l.~'a',ffm..
801. Loan Ori~Snatlon Fao to Counllvr~eBank/Hm'rlaburst
802. Loma Discount to Commerce BankYli, lmburg: N.A.
_~03. Apprmsd Fe~ to Eliot D, Goldsteln
804. Credit F, eport to [2omnm'~ Bang/Hatfisbazg, N~A. --
805. Lendees In~p. ection F~. __
806, Mortgage haaur .an. o~ Application
807. Assump_.tlon Fee
808. T~x Service C. onu'act Fcc
809. Flood Cm'tifiea0on zo Cou-aueme Bank/Harrisburg, N.A. __
.gl0. DocumcntPr _*~3radou to ~omra*r¢oBanldltarrisbu_rlt, N,3.
811. Unden'weitin/[ Fee,to Comm.-ce B~,bur~,
812. Coufi~"Fe~ ~
90'0.. Items R .~l.nlred .by Lelud'er.t~ be,Pakl'iu ,~vli~¢e: .
901. la.Lea'est from S~.2, 2003 to Oct l, 2003
902. Mortg~ In~artmge Premium
903. Ha:mrd lasuranc~ Premlmu
904. Flo~:l Insurance Pr,anium
.1._~000. Re,era'e, Depdsil~d ~lth'L. edder:'j '.. "
1001. H~ ~ranco ... '~
1003- ei~ Frop~m ~ '
1004. County Pro~ T~ ~
1005. Sch~l T~
,il'00, Titl~Ch~g~s: ,,' , ," :",, · : ~ .. ,' ......
1101, S*~r or Clo~m~ F~_ .. ' 'ql_
_[102_ A~ot or ~tlp $~ck ~'
1104, ~tl~ ~s~ce B~d~
t 105. Docnra,:nt PreEarmSoa
1106. N.o~ Fern to Kay3 ~ ..Kope
1107. Aeomey Fees
(Mclud~ above tteau umnber$;
¥108. Title Insurance 1o T,A- of Harrisbm'g,
(includes above its
1109- Lmadmr's CovmragE_ _ 60,000.00 Pd~k Pram'urn
1110. Own~s Gov.em._~ 17~,900.00 I~ l~:mium
l 11 h Eudorsem~uts: 100,..30.0: 8.1 t~ ;r.A. o£Hm, HsburF. ~ '--
1 i 12, Closin. g. Servi¢~ Lc. mx to
1113. Ovmmi h~ T_A_ Tttl~ln~unmem Co.mpimy
1200;'~veram~t Rc~r~g..and T~er Chgrges: '
1201. E*~rding Fe~: D~ 41.50 M~gage .....
1202. Ci~/~m~/s~pr D~ J.,7~%00 Mon~.
1202. ~e t~s~ps; -. D~ 1.799.00. Monga~
1,258.75
o.00 _..
0.00
13__._.0.0. Additi6nal ~htl e m 6&,t. Ch~/xg~s: [ :.
1301. $urvqS__' ' ....
1303, Home W~m~ ro ~
13~-2003 Sch~IT~ to K~ W,
1400', Td~'Skffi~efit Charg~ ~fi~ On ~ 105, $ecfiafi ~ 'and ~e 502, $~'c~on
~003/003
Number: HAR125-2336
TA K322759
Paid from Paid from
Borrower's Seller'S
Funds Funds
at: at
Settlement Settlement
__ !.0,794.00
123.00
-- 125.00 I
300.00
15.00
150.00
245.00
18.00 12.00
1,258.75
150.00_
35,00
99.00
1 ~799..00
1,799~00
395,00
.!~507.93
HUD-I May 2002 OMB No, 2502-0265
Si:pt~rnber 2, 2003 9:15 ~ II_ESPA handbook 4305.2
COMMONV~.ALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clark, Helen A.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21 - 03 - 00483
Include the proceeds of litigation and the date the proceeds were received by the estate, All property jointly-owned with the right of
survivomhlp must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
VALUE AT DATE OF
DEATH
2
3
4
5
6
7
8
9
10
11
Misc. Personal Property:
Waypoint Bank Checking #2222030213:
Penn Treaty Refund:
HGS Admin Refund:
Sale of 1999 Buick Sdn:
Waypoint Bank Certificate #7100033025:
Waypoint Bank Certificate #8000045155:
5,053.00
2,617.70
707.62
37.10
6,375.00
11,107.91
1,231.85
TOTAL (Also enter on Line $, Recapitulation) 27,130.18
APPRAISAL FOR THE ESTATE OF HELEN CLARK
ITEM AMOUNT
KENMORE WASHER t75.00
KENMORE DRYER 150.00
KNICKKNACKS SHELF 20.00
BENCH 45.00
HAMPER 35.00
ELECTRIC CHAJNSAW 15.00
CRAFTSMAN TABLE SAW 55.00
BLACK & DECKER SAW ' 7,00
JIGSAW ' 5.00
RAKE
METAL SHELVES 25.0(
!PLATE COLLECTION
EDGER
· 150.0C
7.00
8.0(
WEEDEATERS
CHIPPER SHREDDER 35.00;
CHIPPER 25.00
WALLPICTURE
NORITAKE BOWLS 35.00
HAND TOOLS
WALL CLOCK 35.00
OAK TABLE 16(3
OAK CHAIRS 4 @ $10.00 EACH 40.00
STAND TABLE 30,00
SHELF 5,00
PICTURES
MICROWAVE 'I .............
MSC DISHES - CUPS - KITCHEN iTEMS
MSC PICTUF
COFFEE TABLE
RECLINER
25.00
15,00
ODD CHAIR
WD STOOL
COUNTRY STYLE SOFA
35.00
60.00
75.00
25,0(
15.0(
i 100.00
LG END TABLES 2 @ $50.00 EACH '-i'
100.00
TABLE LIGHTS 3 ¢___.. $10.00 '?, 30.00
FLOOR MODEL TV
150,00
LG WD BOOKSHELVES_2__~ $75.00 EACH
FLOOR LIGHT
25.00
KNICK KNACKS 100.00
WALL PICTURE 2 @ $50.00 EACH 100.00
5 PC WICKER SET
KIRBY SWEEPER 75.00
CROCKS q'
75.00
JUG LIGHTS 2 @ $30.00 EACH 60.~
JUG 30.1
WD FRAME CHAIRS 3 @ $15.00
WD SHELF W/BASKETS
BATHROOM WALL SHELF
SOL BED
CHEST OF ERS
NIGHT STAND
45.00
35.00
35.00
50.00
10.00
APPRAISAL FOR THE ESTATE OF HELEN CLARK
ROCKER
, 35.00
WALL PICTURES 4 @ $15.00 EACH i 60.00
LIGHTS
.................................................. 35 00
DINING ROOM SUITE
350.00
MARBLE STAND i 25.(~
MARBLE STAND i ................
SOFA
75.00
ODD CHAIRS 2 @ $25.00 EACH :~ 50.00
FLOOR LIGHT i 10.00
SMALL CHEST i 75.00
TABLE LIGHTS ', 10.00
STAND TABLE ¢ ~
WD STOOL
7.00
COFFEE TABLE ~ 30.00
~-~-~TAN~5 .................................................
15.0~
ROUND END TABLE__ ....................................... u 25.00
......................................................... 35.00
FLOOR LIGHT .............. -~ ...........................................................
....................................................... 3.00
CURIO CABINET
MSC WD PIECES
............................................. ' 20.00
WALL MIRROR
25.00
AREA RUG
HOWARD MILLER GRANDFATHER ~LOCK i 325,00
WD BENCH W/CUSHIONS
.................................................. ; 50.oo
PICTURE
DOLL ~ 7.OO
SGL BED 35 00
! ~-O-~-~-E-~H E S q? ...................................................... i ....................................... .... -
WD CUPBOARD ; 75.00
....................................... i 15.oo
FILE CABINET ................... i ....... ~ ..................................... ~(~
TV STAND
SM TV 15.~
, 3.00
CAST IRON i 7.00
ADJUSTABLE BED
~ 175.00:
DRESSER W/MIRROR i ......... ~5.'00
3 DRAWER STAND 50.00
CHEST OF DRAW~-S-- .................................... -~- ...............
80,00
SEWING MACHINE
STOOL
10.00
NIGHT STAND t5.00
TABLE LIGHTS 2 @ :$10.00 20.00
PICTURE 20.00
QUILT RACK ---- 7.00
PHONE STAND 35.00
ODD CHAIR 10.00
TOTAL 51053.00
8/11/2003
THE WILEY OKOUP
1 S BALTIMORE ST
DILLSBURG PA 17019
The informmion which you requested on-the account(s) of HELEN A CLARK
(Social Security Number 166121942 ) i~(are as follows:
Account Number 2222030213
Class of'Account CHECKING
Date Opened 030183
Principal Balance 2617.70
Balance at Dale of 2617.70
Death
^ceount Ownership SOLE
Name of Joint
Owner., if any
Date Ownership 030183
Wa,,; E,~tabli.~hed
Account N~Lmber
C]ass of Account
Date Opened
Principal Balance
Accrued Interest
Balance at Date of
Demh
Account Ownership
Name of Joint
Owner, if any
Date Ovmemhip
Was Established
6000010159
CERTIFICATE
020300
11446.63
11.67
11458.30
3100013022 3106103332 3134096317 3181527140
CEKTIFICATE CHECKINO RE'I'I]~EM'~.NT RETIREMENT
041699 020783 011486 110896
I1937.47 45524.38 6665.71 1696.11
25.27 6.55 30,24 2,97
11962.69 45530.93 6695.95 1699.08
JTO YTO
WILLIAM C WILL1A2VIC
CLARK CLARK
041699 020783
7100033025 8000045J55
CERTIFICATE CERTIFICATE
t03102 113098
11092.51 1229.93
15.40 1.92
11107.91 1231.85
3195527409
RETIREMENT
020397
835.64
.92
836,56
SOLE SOLE SOLE
YI'O SOLE SOLE
WILLIAM C
CLARK
020300 103 102 I 13098
011486 110896 020397
Additional
'l'n£ormatioa
Requestect
SENIOR SERVICES REP.
P.O. Box 171 I, HARRt~BUR6. PeNN~YIS~NIA 17105-1711
TOll F~{~ I.~-WAYI~OiNT (I-~5~-~)-~71B4t~) · IN YORK AR6A 717/815-4S00 · www. wagpotntbank.cem
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
Clark, Helen A. FILE NUMBER
21 - 03 - 00483
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. William C. Clark 846 Anthony Drive son
Mechanicsburg, PA 17055
JOINTLY OWNED PROPERTY:
ITEM
NUMBER
1
2
3
4
5
7
8
9
l0
ll
12
13
14
15
]6
LETTER I DATE
FOR JOINT MADE
TENANT JOINT
A. 02/0?/1983
A. 02/03/2000
A. 08/31/1983
A. 10/26/1983
A. 12/21/1982
A. 02/15/1983
A. ~ 04/12/1983
A. 06/07/1983
A. 12/06/2083
A. 10/11/1983
A. 08/16/1983
A. 01/31/1984!
A. 03/27/1984
05/22/1984
A. 07/17/1984
A.
DESCRIPTION OF PROPERTY ~'
estate · J y- d real4VALUE OF ASSET
Waypoint Bank Certificate #3100013022: I 11,962.~
Waypoint Bank Checking #3106103332:
Waypoint Bank Certificate #6000010159:
US Savings Bond - LI 11158375EE:
US Savings Bond - L 112331144EE:
US Savings Bond - L117127444EE:
US Savings Bond - L 122576519EE:
US Savings Bond - L 123036213EE:
US Savings Bond - L123240001EE:
US Savings Bond - 056845434EE:
US Savings Bond - 056703033EE:
US Savings Bond - 05705816SEE:
US Savings Bond - 048776374EE:
US Savings Bond - 069763614EE:
US Savings Bond - 069802712EE:
Total of Continuation Schedule(s)
45,530.93
11,458.31~
100.8z
100.8z
96.22
94.3~
87.12
83.8C
165.12
165.12
165.12
160.41
158.0t
158.0~
153.20
% OF 1 DATE OF DEATH
DECD'S [ VALUE OF
INTEREST DECEDENT'S INTEREST
50%
50%
50%
IOO%i
100o/
5,981.35
22,765.47
5,729.15
100.84
100.84
100%
100%l
100%!
100°/~
100%I
100%I
96.22
94.32
87.12
83.80
165.12
165.12
100%
100%
100%
100%
100%
165.12
160.48
158.08
158.08
153.20
1,301.08
...... TOTAL (Also enter on line 6, Recapitulation i 37,465.39
SCHEDULE F
JOINTLY-OWNED PROPERTY
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clark, Helen A. FILE NUMBER
21 - 03 - 00483
If an asset was made joint within one year of the decedent'$ date of death, it must be reported on schedule G.
17
18
19
JOINTLY OWNED PROPERTY
DESCR ,T O. OF RO ERW
ITEM LETTER / ,D. ,AT~E._ )nclude name of financial institution and bank account number
NUMBER FORTENANT t Y~"'~JOINT/ ~,w,.,m,~ restate.Dr similar identiflfing number. Attach deed for jointly-held real
A/
09/11/1984t US Savings Bond - 0770853~
/
A. 11/06/1984 J US Savings Bond - 07720160SEE:
20
21
22
23
24
25
A.
A.
A.
A.
A.
A.
01/02/198~
02/26/1985
04/23/1985
06/18/1985
08/13/1985
12/03/1985
10/08/1985
US Savings Bond - 064415368EE:
US Savings Bond - 064458292EE:
US Savings Bond - 064549666EE:
US Savings Bond - 089062493EE:
US Savings Bond - 088784422EE:
US Savings Bond - 089034547EE:
US Savings Bond - 08923264EE:
DATE OF DEATH
150.881 100%]
146.281 100%
143.92 100%I
143.92t 100°/~
143.401 100%I
140.60 100%i
140.61 100%
140.6( 100%
DATE OF DEATH
VALUE OF
DECEDENTS INTEREST
150.88
150.88
146.28
143.92
143.92
143.40
140.60
140.60
140.60
Page 2 of Schedule F
'1/2003
THE WILEY OKOUP
1 S BALTIMORE ST
DILLSBU'RG PA 17019
The information which you requested on the account(s) of HELEN A CLARK
(Social Security Number 166121942 ) iv/are as follows:
Account Number 2222030213 3100013022 3106103332
Class of Account CHECKING CERTIFICATE CI'IECKINO
Da(e Opened 030183 041699 020783
Principal Balance 2617.70 11937.47 45524.38
Accrued Inter~st 25.22 6.55
Bal~ee at Date of 2617.70 11962.69 45530.93
Death
Account Ownership SOLE JTO JTO
Name of Joint WILLIAM C WILL1AM C
Owner, if any CLARK CLARK
Date Ownership 030183 041699 020783
Was Established
6000010159 7100033025 8000045'155
Account Number
CERTIFICATE CERTIFICATE CERTIFICATE
CJass of Account
020300 103 [02 I 13098
Date Opened
11446.63 11092.51 1229.93
Principal Balance
11.67 15.40 1.92
Accrued/nterest
11458.30 l 1107,91 1231.85
Balance at Date of
Death
yro SOLB SOLE
Account Owner,~hlp WILLIAM C
Name of Joint CLARK
Owner, if any
Date Ownership 020300 103 i 02 I 13098
Wa~ Established
3134096317 3181527140 3195527409
RETIILEMENT RETIREMENT RETIREMENT
011486 110896 020397
6665.71 1696. I 1 835.64
30.24 2.97 .92
6695.95 1699.011 836.56
SOLE SOLE SOLE
01 t486 I ~0896 020397
Additional
hfonnat/on
Requestecl
Sm', OR S aV C $
~-0. 8ox I7l !, HARRI~BUI~G. P~NN~Y%%~NIA i7105-1711
Toll Fr'e~ 1-866-WAvi~OINT (I-8~;6;-D~9-7646). IN YORK AR~_a~ ?l?/SIS-4SO0 · www. wat.~polntbank,com
l'~!l..Lta~. C C~RK 220-6~-7B08
SELIES EE
Li!!
166121:942 !
7~HE1-EN A CLARK 166--12,-19z42
i546 A.NTEION¥ DRt VE
~ECHA;S;IICSBURG PA 1705~
SERIES EE
CLARK 2,20-66-'?808
UT ;
;OCT 26 82; :
~ L~ ':: '~"' '~ '~ 44 EEi
WHICH IS THE FIRST DAY OF '
CLARK 166-12-19~+2 OCT t983
846 ANTHONY DR'!VE
MECHAN. tCSBuRG PA
t~61219~2
17055
220-66'-7808
EE
AT ?H£ MATURr'i'Y HEREOF WlLJ. PAY "~""~"~ .......... ~ '~~'~
.... ~ WHICH IS THE F~RST DAY OF
7;~E'LEN A CL~'RK
ANTHONY DR.I V~E
MECHAN[CSBURG PA 17055
OR W,I.LLIAN C CLARK 220--66--780.8
OCT' 11 '83 : ¢
EE
~HELEN 'A CLARK 166-12-19/+2
ANTHONY 9RI.¥F_ 166121942 1
MECHANICSBURG PA .[7055
WILLIAM C CL~RK 220-66-7808
ISSUE; DATE:
WHICH IS THE: F}RST DAY OF
........ . 1 83
~HELEN ~ CL~RK i66-12-1942 DEC Z9~3
846 ANTHGNY DRIVE
MECHANICSBUR. G PA 17055
OR NILLI.aM C CLARK 220-66-7808
;,JAN 31 84;
S RD S EE
.c~'~:: ';~ ~ ~ ~l
, ~ ~' ~-- ~ ' ~ t
~HELEN a CLARK 166-12-1942
846 ANTHONY CRIVE 1661.21~42 I
MECHAN tCSBURG p~ 17055
OR W[LLJA'M C CLaR~ 220-66-7808
SERIES EE
069
ISSUE DATI~
WHI'CH IS THE FIRST DAY OF
7,::, 3 6 -~ 4 E E
seams EE
HELEN a CLARK 166-12--1942
~46 AN'THO~'Y DR:!~.E
M~CH~N::[ C S BURG PA 17055
~66121942 I
WILLIA~ C CLAR~ 22~-66-78~8
'WHICH IS THE FIRST DAY OF
~HELEN A CLAR~ [66-t2-[942
8~ ANTHONY DRIVE 166121942
HEC:HANICS~URG PA 17055
OR WILLIA~ C EL.aRK 220-'66-'7808
84~ ~THCNY ~RtV~ 1.6~121942
sE ms EE
8~6 ANTHONY 'DRIVE 1661219~2
~E~HA .... ,
N ~,~ SBU~G P~ 17055 DT/'
OR ~ILLIA~ C CLAR'~ 22'0-66-7808 F
............................. ~ .... ., 08~ ,,e 232 EE~
SEKIES .... ~=~ ......
~HELEN a CLARK 166-12-19t2
8~6 AN~.HONY.DRIVE
MECHINtC$BURG PA 17055
166121942 t
OR WILLIAM C CLAR~ 220-66-7808
Redemption Date:
U,S. Savings Bond Transaction
Customer Copy
6112~2003
Issue Redemption Backup
Series Denomination Date Value Interest Withholding
EE $50,00 De / 1982 $96.22v/ $71.22 $0,00
EE $100.00 Se/ 1984 $~50.88~/ $100.88 $0.00
EE $100.00 No / 1984 $[46.28 ¥~ $96.28 $0,00
EE $[00.00 Jan / ~985 $143.92 v/ $93.92 $0.00
EE $100.00 Nar/ [985 $143.92v/ $93.92 $0,00
EE $[00.00 Ha / [98$ $143.40¥' $93,40 $0.00
EE $100.00 Jul/ [985 $140.60 ¥~ $90.60 $0.00
Total: 7 Bond(s) $965.22 $640.22 $0.00
The interest earned on Series EE bonds issued on or after January
1990 may be wholly or partially exempt from Federal income tax
under the provisions of the U.S. Savings Bond Education Benefit
Program. For further information concerning the benefits and
restrictions that apply, please contact the :Internal Revenue
Service.
Redemption Date:
U,S. Savings Bond Transaction
Customer Copy
6/12/2003
Series
Issue Redemption Backup
Denomination Date Value Interest Withholding
I EE $50.00 Au / 1982 $100.84 ,/~ $75.84 $0.00
2 EE $50.00 Feb / 1983 $94.32 ~/ $69.32 $0.00
3 EE $50.00 Apr / 1983 $87.12,~,/ $62.12 $0.00
4 EE $50.00 Ma / 1983 $83.80 r,~,' $58.80 $0.00
5 EE $100.00 Oct / 1983 $165.12 V~ $115.12 $0.00
6 EE $100.00 AU / 1984 $150.88 S/ $100.88 $0.00
7 EE $100.00 Oct / 1985 $140.60 X/' $90.60 $0.00
Total: 7 Bond(s) $822.68 $572.68 $0.00
The interest earned on Series EE bonds issued on or after ~lanuary
1990 may be wholly or partially exempt from Federal income tax
under the provisions of the U.S. Savings Bond Education Benefit
Program. For further information concerning the benefits and
restrictions that apply, please contact the ]:nternal Revenue
Service.
Redemption Date:
U.S. Savings Bond Transaction
Customer Copy
6/! 2/2003
Issue Redemption Backup
Series Denomination Date Value Interest Withholding
1 EE $50.00 Oct/ 1982 $100.84`/ $75.84 $0.00
2 EE $100,00 3un / 1984 $153,20~ $103.20 $0.00
3 EE $100.00 Apr/ 1984 $158.08 ~ $108.08 $0.00
4 EE $100.00 Feb/ 1984 $158.08v/ $108.08 $0.00
5 EE $100.00 De / 1983 $160.48~/ $110.48 $0.00
6 EE $100,00 3ul/i 1983 $165,12'/ $115.12 $0,00
7 EE $100.00' Se / 1983 $165.12 '/ $115.12 $0.00
8 EE $100.00 Au / 1985 $140.60 %/ $90.60 $0.00
Total: 8 Bond(s) $1,201.52 $826.52 $0.00
The interest earned on Series EE bonds issued on or after 3anuary
1990 may be wholly or partially exempt from Federal income tax
under the provisions of the U.S. Savings Bond Education Benefit
Program. For further information concerning the benefits and
restrictions that apply, please contact the ]Internal Revenue
Service.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
I FILE NUMBER
Clark, Helen A.
21 - 03 - 00483
This schedule must be completed and filed if the answer to any of questions I throu,qh~4 0n page_: is ]/es.
ITEM
NUMBER
l
2
3
4
DESCRIPTION OF PROPERTY
Include the name of the transferee, their mlationshlp to decedent and the date of transfer.
Attach a copy of the deed for real estate.
Waypoint Bank Retirement Account: #3134096317
Waypoint Bank Retirement Account #3181527140:
Waypoint Bank Retirement Account #3195527409:
MetLife Total Control Account #4030857901:
DATE OF DEATH
VALUE OF ASSET
6,695.95
1,699.08
836.5~
12,579.23
% OF
DECD'S
INTEREST
100%
100%
100%
100%
EXCLUSIOI~
(IF APPLICABLE
TAXABLE VALUE
6,695.95
1,699.08
835.56
12,579.23
M~Life and,Affiliates
Total Control Account
485-E US Highway 1 South 4th Floor
lseiin, NJ 08830
Te1:1-800-638-7283
July 29, 2003
David J Lenox, Esquire
1 South Baltimore Street
Dillsburg, PA 17019
Helen A Clark
TOTAL CONTROL ACCOUNT 4030857901
Dear Mr. Lenox:
! am responding to your request for the date of death balance regarding the above
account.
The balance in the above account was $12,579.23 on 05/31/03, which includes interest
earned orS 31.62.
If you have m~y further question, you may call our Customer Service Representatives
Monday through Friday 8:00 a.m. to 6:00 p.m. Eastern Time.
Sincerely,
' Pat McGowan
AUG-11-200~
1~:]0 FROM:WAYPOINT 7179097481 T0:943~04~6
W aup i n
P.2-2
8/11/2003
THE WILEY GROUP
1 S BALTIMORE ST
DILLSBURG PA 17019
The information which you requested on-the ~count(s) of HELEN A CLARK
(Social Security Number 166] 21942 ) isJare as follows:
Account Ntmlber 2222030213 3100013022 3106103332
Class of Account CHECKING Cb2KTIFICATE CI-IECKI'NO
Date Opened 030183 041699 020783
Principal Balance 2617.70 11937.47 45524.38
Accnled Interest 25.22 6.55
Balance at Date of 2617.70 11962,69 45530.93
Death
Aceoum Ownership SOLE JTO
Name of Join! WILLIAM C WILLIAM C
Owner., if any CLA R K CLARK
Date Ownership 030183 041699 020783
Was E~tabli~hcd
6000010159 7100033025 8000045'J 55
Account' Number
CERTIFICATE CERTIFICATE EK FIFICATE
C'~ ,
CJass of Account
020300 103102 113098
Date Opened
11446.63 ] 1092,51 1229,93
Principal Balance
'11,67 15.40 1.92
Accrued Interest
11458.30 11107,91 1231.85
Balance at Date of
Death
J'l'0 SOLE SOLE
Account Ownership WILLIAM C
Name of Joim CLARK
Owner, if any
Date Ownership 020300 103102 I 13098
Was Established
3134096317 3181527140 3195527409
RETIILEMENT RETIREMENT RETIREMENT
011486 110896 020397
6665.71 1696.1 ! 835.64
30,24 2,97 .92
6695.95 1699.08 836~56
SOLE SOLE SOLE
011486 '110896 020397
Additioaal
Iafotnmtioa
Requested
WAT~ L/~ c~_~.~k
SENIOR SERVICES REP,
PO. Box 171 I, HAI~Iqle~I~Ug~L D~NN.~NIA 17105-1711
Toll Free 1-866-WAYPOINT (I-SE;6;-9~9-76;a6) - IN YORK AIaEA 717/81S-4SO0 · w1/vw, wagpolntbank, com
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
4
5
6
El.
1.
Clark, Helen A.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
FUNERAL EXPENSES:
1 Neill Funeral Home:
2 Good Shepard Church:
3 Organist:
Soloist:
Good Shephard Church (meal):
Flowers:
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
2
DESCRIPTION
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State Zip
Year(s) Commission paid "
Attorney's Fees Wiley, Lenox, Colgan, & Marzzacco, P.C.:
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
FILE NUMBER
21 - 03 - 00483
Street Address
C~ty
Relationship of Claimant to Decedent
Probate Fees Register of Wills:
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
Cumberland Law Journal (advertise):
The Sentinel (advertise):
State Zip
AMOUNT
7,475.30
100.00
100.00
75.00
200.00
50.00
12,376.36 -
355.00
75.00
102.11
Total of Continuation Schedule(s) 37,169.04
TOTAL (Also enter on line 9, Recapitulation)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
~H
4
5
6
7
8
9
10
11
12
Clark, Helen A.
Filing Fee:
Sellers costs on sale of real estate:
The Dillsburg Agency (Executor's bond):
Personal Property Appraisal fee:
Plumbing repair:
US Postal Service:
All Smart Movers:
US Treasury (CSRS refund):
US Treasury (CSRS refund):
Wittington Mowing:
FILE NUMBER
21 03-00483
25.00
32,111.17
368.00
100.00
1154.00
14.80
850.00
1,201.07
1,765.00
580.00
Page 2 of Schedule H
CONINIONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Clark, Helen A.
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
FILE NUMBER
21 - 03 - 00483
Include unmimbumed medical expenses.
ITEM
NUMBER
1
2
3
4
5
6
7
Mary Baxter (cleaning)
Holy Spirit Hospital:
Sewer bill:
Kelly Home Services:
Verizon:
Waypoint Bank (mortgage payments):
PP&L:
DESCRIPTION
AMOUNT
500.00
840.00
99.00
1,371.75
108.47
1,544.79
863.42
TOTAL (Also enter on Line 10, Recapitulation) 5.,327.43
REV-1513 EX+ (9-00) ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
Clark, Helen A.
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
William C. Clark
3117 King St.
Alexandria, VA 22303
FILE NUMBER
21 - 03 - 00483
RELATIONSHIP TO
DECEDENT
Do ~.i,~m~.s) __
~on
IA. SPOUSAL DISTRIBUT ONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
lb. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
AMOUNT OR SHARE
OF ESTATE
one hundred percent.
Register of Wills of Cumberland County, Pennsylvania
INVENTORY'
Estate of Clark, Helen A.
also known as
No. 21 -03- 00483
Date of Death 5/31/2003
, Deceased Social Security No. ]66-12-1942
William C. Clark
The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory
include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania
of said Decadent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the
Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that
which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true
and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904
relating to unsworn falsification to authorities.
Attorney:
I.D. No.:
Address:
Telephone:
Personal Representative
David J Lenox Signature:
William C. Clark __ , ,~ /
29078 Signature: ___~,~__~,.~_.~ ~ ......
Signature:
1 S. Baltimore Street
Dillsburg, Pa 17019
Address: 3117 king St.
Alexandria, VA 22302
717/432-9666
Telephone: 703-578-3740
Dated:
Misc. Personal Property:
5,053.00
Waypoint Bank Checking #2222030213:
Penn Treaty l~ftmd: 2,617.70
707.62
HGS Admirv~Refund:
~q 37.10
Sale of 1999'Buick Sdn:
'2_.
-' ~ 6,375.00
Waypoint B~fik Certificate #7100033025:
'~ 11,107.91
Total Personal Property $25,898.3~
(Attach additional sheets if necessary) Total Personal Property and Real Estate
Register of Wills of Cumberland County, Pennsylvania
Estate of Clark, Helen A.
also known as
INVENTORY
continued
, Deceased
No. 21-03-00483
Date of Death 5/31/2003
Social Security No. 166-12-1942
Real Estate
Sale of real estate - 846 Anthony Drive, Mechanicsburg, Cumberland County, PA:
179,900.00
Total Real Estate
$179,900.00
2
Name of Decedent:
Date of Death:
Will No. ,?1-05
STATUS REPORT UNDER RULE 6.12
Admin. No.
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with
respect to completion of the ad ,rn, inistration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes ~ No
2. If the answer is No, state when the personal representative reasonably believes that the
administration will be complete:
If the answer to No. I is Yes, state the following: '
a. Did the personal representative file a final account with the Court?
Yes No ~
b. The separate Orphans' Coud No. (if any) for the personal representative's account is:
c. Did the personal representative state an account informally to the parties in
interest? Yes ,.,." No
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts
may be filed with the Clerk of the Orphans' Court and may be attached to this repod.
Date:
Name (Please type dr prin~
Address ~, ~s~ ¢~ I~ o ~
Tel. No. ~
Capacity:
Personal Representative
Counsel for personal
representative
Jan M. Wiley
David J. Lenox
Timothy J. Colgan
Christopher J. Marzzacco
August 29, 2003
THE XVILEY GROUP
Attorneys at Law
Wiley, Lenox, Colgan & Marzzacco, P.C.
David E. Hershey
Diana Woodside
Bradley A. Winnick
Jennifer U Frechette
Stephanie L. Mihalko
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013
In Re: Estate of Helen A. Clark
Number 21-03-0483
Dear Register:
Enclosed please find a check from the Estate of Helen A. Clark in the mount of $8,000 for
prepayment of inheritance tax.
Please return a receipt to my office in the envelope provided.
Thank you for your assistance.
Sincerely,
DJL/sdg
encl.
cc. William C. Clark
1 South Baltimore Street · Dillsburg, PA 17019 · Phone: (71 7) 432-9666 · (800) 682-4250 · Fax: (717) 432-0426
Offices in Harrisburg · York · Carbondale
www. wileygrouplaw, com
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 O0296O
THE WILEY GROUP
C/O DAVID J LENOX
ONE SOUTH BALTIMORE STREET
DILLSBURG, PA 17019
........ fold
ESTATE INFORMATION: SSN: 166-12-1942
FILE NUMBER: 2103-0483
DECEDENT NAME: CLARK HELEN A
DATE OF PAYMENT: 08/29/2003
POSTMARK DATE: 08/29/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 05/31/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $8,000.00
TOTAL AMOUNT PAID:
$8,000.00
REMARKS: WILLIAM C CLARK C/O THE WILEY
GROUP,TAX PAY HAND DELIVERED
SEAL
CHECK# 111
INITIALS: SK
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
TO:
THE WILEY GROUP
Attorneys At Law
I S. Baltimore Street
Dillsburg, PA 17019
REGISTER OF WILLs
CUMBERLAND CO. COURTHOUSE
ONE COURTHousE SQUARE
CARLISLE, PA 17013
BUREAU OF INDIVIDUAL TAXES
/NHER/TANCE TAX DTYTSZON
DEPT. 280601
HARRISBURG, PA 17128-060!
DAVID J LENOX
NZLEY GROUP
I S BALTIMORE ST
DILLSBURG
CONNONNEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLO#ANCE OR DZSALLONANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE 11-10-2003
ESTATE OF CLARK
DATE OF DEATH 05-31-2003
FILE NUMBER 21 03-0q83
~.':COUNTY CUHBERLAND
ACN 101
Amoun~ Remitted
REV-1647 EX &FP (OZ-OS)
HELEN A
PA'1'7019 '
MAKE CHECK PAYADLE AND REHZT PAYMENT TO:
REGISTER OF ~ILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
REV 1547 EX AFP (01 03) NOTICE OF INHERITANCE TAX APPRAZSEMEN~'~C-~O#A~ OR
ESTATE OF CLARK DZSALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
HELEN AFZLE NO. 21 03-0q83
ACN 101 DATE 11-10-2003
TAX RETURN NAS: (X) ACCEPTED AS FTLED
RESERVATION CONCERNING FUTURE ~NTEREST - SEE REVERSE
( ) CHANGED
APPRAISED VALUE OF RETURN ~ASED ON: ORIGINAL RETURN
1. RaaZ Estate (Schedule A) (1)..
E. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
fi. Nortgages/No~as Receivable (Schedule D) (~)
5. Cash/Bank Deposits/Misc. Personal Proper~y (Schedule E) (5)
6. Jointly O~nad Propar~y (Schedule F) (6).
7. Transfers (Schedule G)
8. Total Asse~s (7).
APPROVED DEDUCTZONS AND EXEMPTIONS:
9. Funeral Expansas/Adm. Costs/Misc. Expanses (Schedule H) (9)
10. Debts/Hortgage Liabilities/Liens (Schedule Z) (10)
11. To,al Deductions
12. Nat Value of Tax Return
179z900.00
.00
.00
.00
27~130.18
37zq65.39
21~810.82
58,077.81
5,327.q3
(11) _
NOTE: To insure proper
credit to your account,
submit the upper port/on
of this fore with your
~ax payment.
266,306.39
~;3.~05.~q
202,901.15
ZF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDZT[ONAL ZNTEREST.
CD0030q9
DISCOUNT (+)
ZNTEREST/PEN PAZD (-)
qZ1.05
.00
AMOUNT PAID
8,000.00
709~
TOTAL TAX CREDZT ~-
· ALANCE OF TAX DUEJ
ZNTEREST AND PEN. I
TOTAL DUE /
9,130.55
.00
.oo
.o0
IF TOTAL DUE TS LESS THAN $1, NO PAYMENT TS RE~UTRED.
ZF TOTAL DUE *rs REFLECTED AS A "CRED*rT' (CR}, YOU NAY BE DUE
REFUND. SEE REVERSE S*rDE OF TH*rS FORM FOR *rNSTRUCT*rONS. }
TAX CREDITS:
PAYHENT
DATE
08-29-2003
09-20-2003
RECE/P1
NUMBER
CD002960
(12)
13. Charitable/Governmental Bequests; Non-aZactad 9115 Trusts (Schedule J) (15) .00
lq. Net Value of Estate Subject to Tax
(xq) 202,901.15
NOTE: Zf an assessment was issued Previously, lines 14, 15 and/or 16, 17, 18 and 19
refZect f/gures that /nclude the total of ALL returns assessed to date.
ASSESSHENT OF TAX:
15. Amoun~ of Line lq at Spousal ra~a (15) .00 X O0 = .00
16. Amount of Line lq ~axable at Lineal/Class A rata (16) 202,901.15 X Oq5 = 9,130.55
17. Amount of Line lq at Sibling re~a (17) .00 X 12 = .00
18. Amount of Line lq taxable at Collateral/Class B rata (18) O0 X 15
19. Principal Tax Due ' ' = .00
(19)= 9,130.55
RESERVATION= Estates of decadents dying on er before Da(ember 1Z, 1981 -- 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 Colaon#ealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the laeful Class B (collateral) rata on any such future interest.
PURPOSE OF
NOTICE: To ~u[fil! the requirements of Section ZlqO of the Inheritance and Estate Tax Act) Act 15 of ZOO0. (TZ P.S.
Section 9140).
pAYMENT: Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side.
--Hake check or money order payable to: REG/GTER OF N/ELS, AGENT
REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may bo requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1515}. Applications are available at the Office
of the Register of Nills, any of the 15 Revenue District Offices, or by calling tho special Z4-hour
answering service for fores ordering: 1-BO0-561-ZOSO; services for taxpayers with special hearing and / or
speaking needs: 1-800-q~7-5010 (TT only).
OBJECTIONS: Any party in interest not satisfied with the appraisement, allowance) or disalloaance 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. ZBIOZ1, Harrisburg, PA iT1ZB-IOZ1, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
ADMIN-
ISTRATIVE
CORRECTIONS: 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. lB0601) Harrisburg, PA 17118-0601
Phone (717) 787-6505. Sea page 5 of tho booklet "Instructions for Inheritance Tax Return for a Resident
Decadent" (REV-IS01) for an explanation of administratively correctable errors.
DISCOUNT: If any tax due is paid within three (3) calendar months after the dacedant's death, a five percent (SX) discount of
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 and of the tax amnesty period. This non-participation
pana11LV is appealable in the same manner and in the the same tiaa period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST: 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 be(aaa delinquent before January 1, 1981 bear interest at the rata of
six (6Z) percent per annum calculated at a daily rate of .00016~. AIL taxes which became delinquent on end after
January 1, 1981 will bear interest et a rate which ail1 vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1981 through Z005 ara:
Interest Daily Znterest Daily Daily
Factor
Year Rate Factor Yaa.~r Rata
1982 ZOZ .OOOS~S 1987 9Z
1983 161 .O00~SB 1988-1991 ZZZ
198~ 11X .000301 1991 9Z
1985 132 .000356 199~-199q 7Z
1986 lOX .O00Z7~ 1995-1998 9X
--Interest is calculated as follows:
Interest
Factor Year Rate
.O00Zq7 1999 ?Z .000191
.000501 2000 81 .000119
.0002~7 2001 9Z .O00Zq7
.000192 ZOOZ 6Z .00016q
.0002~7 2003 51 .000137
XNTEREST = BALANCE OF TAX UNPATD X NUNBER OF DAYS DELI'NQUENT X DAXLY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen ilS) days
beyond the date of the assessment. If payment is made after the interest computation date sheen on the
Notice, additional interest must be calculatad.
REV-15OO EX + (6*00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
2 t -0 0
COUNTY CODE YEAR
0 4 8 3
NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL
KAUFFMAN; PAUL J.
DATE OF DEATH (MM-DD-Year) I DATE OF BIRTH (MM-DD-Year)
O4112/2OO0 I Ol110/1 920
(IF APPLICABLE) SURVIVING SPOUSES NAME (LAST, FIRST, AND MIDDLE INITIAL)
KAUFFMAN; MARIE E.
SOCIALSECURITYNUMBER
t 8 4 - I 2 - 4 9 8 6
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
t 7 9- I 2- 4 I I 6
r~l, Original Return
r~4. Limited Estate
[-~6. Decedent Died Testate (Attach copyofwiiD
r-'] 9. Litigation Proceeds Received
r-~2. Supplemental Return
O4a. Future Interest Compromise (date of beath alter 12.12-82)
D7. Decedent Maintained a Living Trust (Attac~ copyof Trust)
[~]10, Spousal Poverty Credit (date o! dea~ between 12-31-91 and 1-1-95)
D3. Remainder Return (dateofdeath pdorto 12.13-82)
O5. Federal Estate Tax Return Required
__ 8. Total Number of Safe Deposit Boxes
'--]11. Election to tax under Sec. 9113(A) (A~ach Sch O)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
COMPLETE MAILING ADDRESS
NAME
MURREL R. WALTERS III ESQ
FIRM NAME (If Applicable)
TELEPHONE NUMBER
717/6974650
54 EAST MAIN STREET
MECHANICSBURG
PA 17055
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Pa~ership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
[] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Line.~ 1-7)
9. Funeral Expenses & AdministralJve 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. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
20;000.00
OFFICIAL USE ONLY
(8)
20;000.00
3;875.00
(11)
3~875.00
16,125.00
(12)
(13)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
t6;125.00
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 91~16 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
16;125.00 X 0 (15)
X ~ (16)
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at coilateral rate
X .12 (17)
X .15 (18)
19. Tax Due
20. []
(19)
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent.'s Complete Address:
STREETADDRESS
90 WINTER LANE
CITY
ENOLA
STATE
PA
IZIP
17025
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Interest/Penalty if applicable
D. Interest
E. Penalty
5o
(1)
Total Credits ( A + B + C ) (2)
Total Interest/Penalty ( D + E )
(3)
If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page I Line 20 to request a refund (4)
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B: Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
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 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? ....................................................................................................... [] []
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 pedury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is tie, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
ADDRESS MARIE E. KAUFFMAN / ~/~'///
ADDRESS MURREL I~. WALTERS III ESQ
54 EAST MAIN STREET~ MECHANICSBURG
DATE
PA "17025
PA t7055
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 exem0t a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX + (1-9;~. ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF ~ FILE NUMBER
KAUFFMAN. PAUl. ,,J.
Include the proceeds of liUgation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. NATHAN & LEWIS SECURITIES 20~000.00
CERTIFICATE OF DEPOSIT
TOTAL (Also enter on line 5, Recapitulation) $
20~000.00
(If more space is needed, insert additional sheets of the same size)
REV-151'~EX* (1-97} ,~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
KAUFFMAN. PAUL ,.I,
Debts of decedent must be reported on Schedule I.
FILE NUMBER
O0
0483
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
Bo
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Pemonal Representative (s)
Social Secudty Number(s) / EIN Number of Personal Representative(s)
Street Address
City State
Year(s) Commission Paid:
Attomey Fees MURREL R. WALTERS III ESQ
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant MARIE E. KAUFFMAN
Zip
Street Address 90 WINTER LANE
City ENOLA State PA Zip 17025
Relationship of Claimant to Decedent WIFE
Probate Fees REGISTER OF WILLS
~ CUMBERLAND COUNTY
Accountant's Fees
Tax Return Preparer's Fees
TOTAL (Also enter on line 9. Recapitulation) $
300.00
3,500.00
75.00
3~875.00
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (g-nm
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
KAUFFMAN, PAUl. ,,I.
NUMBER
I.
1.
1.
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outfight spousal distributions, and transfers under
Sec. 9116 (a)(1.2)]
MARIE E. KAUFFMAN
90 WINTER LANE
ENOLA~ PA 17025
FILE NUMBER
21 917 04~3
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
SURVIVING SPOUSE
lOO%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)