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Home My WebLink About03-0760 CHARLES E. SHIELDS, HI A TTORNE Y-A T-LA W 6 CLOUSER ROAD !~ ~,~:~ ~ ~ Corner ofTrindle and Clouser Roads i MECHANICSBURG, PA 17055 GEORGE M. HOUCK TELEPHONE (717) 766-0209 (1912-1991) '0'~ ?i~¥-3 ~3,1~ :~ FAX (717) 795-7473 April 30, 2004 Ann Capozzi Register of Wills Cumberland County Courthouse 1 Court House Square Carlisle, PA 17013 Re: Ada Mae Mummert Estate Dear Ann: Please find enclosed the following checks for the estate ofMs. Mummert. Check No. //1002 in the amount of $3,330.29 for inheritance tax, check no. #100 in the amount of $155.00 for additional probate and check no. #99 in the amount of $15.00 for filing. Also, please find enclosed two copies of the inheritance tax returns. Thank you. Very truly yours, Charles E. Shields III Attorney-At-Law CES:cas enclosures ~ COMMONWEALTH OF REV-1500 PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 2 060 , INHERITANCE TAX RETURN HARRISBURG, PA 17128-0601 RESIDENT DECEDENT cou,T CO , DECEDENTS NAME (~ST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER DATE OF DEATH (MM-DD-Y~R) DATE OF BIRTH (MM-DD-YEAR) THIS R~URN MUST BE FILED IN DUPLICATE WITH T (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~I, Onginal Return ~ 2. Supplemen~l Return ~ 3. Remainder Return (date of ~eat~ p,or to 12-13-82) ~ 4. Limited Estate ~ 4a. Future Interest Compromise (date of dea~ a,er ~2-12~2) ~ 5. Federal Estate Tax Return Required ~ 6. Decedent Died Tes~te (A~ ~py of Will) ~ 7. Decedent Maintained a Living Trust (A~ch ~py of Trust) ~ 8. Total Number of Safe Deposit Boxes ~ 9, Litigation Proceeds Received ~ 10. Spousal Pove~ Credit (date of death ~en 12-3~-9~ and ~-~-95) ~ 11. Election to ~x under Sec. 9113(A)(A~ach ,,~HIS~¢~ MU~QMP~T~ CORRESPp~DENCE A ID CONE~IAL T~.IN~ORMATION SHOULD BE DIRECTED T( NAME~~~ ~ ~ ~/~ ~ COMPL~E MAILING ADDRESS TELEPHONE NUMBER ~~/~S~/~ :~ ~ ~F~IAL USE ONLY 1. Real Esate (Schedule A) (1) ~ 2, Stocks and Bonds (Schedule B) (2) 3. Closely Held Co~oration, PaAnemhip or Sot~Propdetomhip (3) 4. Mo~gages & Notes Revivable (Schedule D) (4) 5. Cash, Bank Deposits & Mis~llaneous Personal Pmpe~ (5) / /~ 7 ~ - ~ ~ ;~-- (Schedule E) ,~ , 6. Jointly Owned Prope~ (Schedule F) (6) ~ Separate Billing Requested 7. Inter-Vivos Transfem & Miscellaneous Non-Probate Prope~ (7) (Schedule G or L) 9. Funeral Expenses & Administrative Cos~ (Schedule H) (9) ~ / ~ ~ ~. &/ 10. Debts of Decedent, Mo~gage Liabilities, & Liens (Schedule I) (10) ~ ~ ~ ~. ~Z 11. Total Deductions (total Lines 9 & 10) (11) ~1 7~ ~- ~ 12. Net Value of Ssate (Line 8 minus Line 11) (12) ~ 7~ ~ · ~ 13. Charitable and Govemmental BequestESec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to T~ (Line 12 minus Line 13) (14) ¢7~ ~, ~ SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE ~TES 15. Amount of Line 14 taxable at the spousal tax rote, or transfers under Se~. 9116 (a)(1.2) ~ x .00 (15) 17. Amount of Line 14 taxable at sibling rote x .12 (17) 18. Amount of Line 14 taxable at collateral rate x .15 (18) > > BE SURE TO ANSWER ALL QUESTIONS. ON REVERSE ~IDE AND ~HECK MATH < < REV*- 1503 EX · ~ SCHEDULE B COMMONW~LTH O~PENNS~LV^N,^STOCKS & BONDS RESIDENT DECEDENT All property jointly-owned with right of survivorship must be disclosed on Schedule F, ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 2, Recapitulation) (If more space is needed, insert additional sheets of the same size) Wacnov~a Securities. LLS ~,",, Retail investment Group / "-"~ :"'!..-:~, i:, ,';.. ~'~'- NC1164 401 South Tryon Street Charlotte, NC 28288 WAOI-IOXZ-~,. ~ CT. YP,_LLCJ.~S September 29, 2003 Charles E. Shields, Attorney At Law 6 Clouser Road Mechanicsburg, PA 17055 RE: 59218259 Dear Charles E. Sh/elds, I I I: We recently received your request regarding the date of death valuation for the account(s) o£ Ada Mae Mummert. As of the date of death, the balance in this account was zero. Therefore, a date of death value is not available. If you have any questions regarding this matter of if you need further assistance, please contact an Estate Processing Specialist at 866-874-2717. Sincerely, Richard Shirm Estate Processing Specialist Wachovia Securities *First Union National Bank and Wachovia Bank, N.A. merged effective April 1, 2002, and the combined bank is now Wachovia Bank, N.A. First Union is a registered trademark of Wachovia Corporation. Securities and Insurance Products: I Not Insured By FDIC Or Any MAY LOSE VALUE I Not A Deposit Of Or Guaranteed By ] Federal Government Agency [ A Bank Or Any Bank Affiliate Brokerage services offered through Wachovia Securities, LLC, a registered broker-dealer and a separate, non-hank affiliate of Wachovia Corporation. Member NYSE and SIPC. BKDJ1495552130 59218259 .~.,,.E×.,..~ ~ SCHEDULE 'E COMMONWEALTH OF PENNSYLVANIA CASH. BANK DEPOSITS, & MISC. ,ES,~NT DECEDE~ PERSONAL PROPERTY ESTATE OF P ~/~//3'~.~' ~ ~, ~ ~ FILE NUMBER In~u~e the Dm~eos of Ii,gabon and ~e aate ~e premeds were ~ived by ~e ~a~. All pm~ ~intiy~ed ~h the right of suw~omhi 3 must be disclosed on Sc~ea,i ITEM VALUE AT DAT~ NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) x~ArACI-IOVI2k Re£erence ID: 712736 Wachovia Ban[: N.A. Balance Confirmation Services P O Box 40025 Roanoke~ VA 24022-7313 September 29, 2003 CHARLES E SHIELDS III ATTORNEY AT LAW 6 CLOUSER ROAD CORNER OF TRINDLE AND CLOUSER ROADS MECHANICSBURG, PA 17055 SUBJECT: Verification / Confirmation of Account and Balance Information provided for: Customer: ~,KI)A M MUIVI1VIERT (SSN# 181-01-7860) Date of Death: September 11, 2003 Deposit Account Information Account Account Date of Death Average Date Maturity Interest Accrued YTD Date Type Number Balance Balance* Opened Date Rate Interest Interest Paid Closed CHECKING 1010041725663 $14,036.52 2/8/2002 $0.32 $2.42 9/19/2003 LEGAL TITLE: ADA MAE MUMMERT PATRICIA A. LIPPERT, POA CLOSING BALANCE: $i3987.14 CHECKING 1010041725676 $86,472.54 2/8/2002 $59.00 5;762.80 9/19/2003 LEGAL TiTLE: ADA MAE MUMMERT PATRICIA A. LIPPERT, POA CLOSING BALANCE: $86544.82 * Due to system limitations, we can only provide a twelve month average balance on depository accounts. 0000 000514 ~ACI-I Reference D: 712736 CAI', BROKERAGE and SELF-DIRECTED IRA ACCOUNTS HAVE BEEN CONVERTED TO WACHOVIA SECURITIES. YOUR REQUEST HAS BEEN FORWARDED FOR PROCESSING and WILL BE Mi[LED UNDER SEPARATE cOXrER. FOR QUESTIONS REGARDING CAP, BROKERAGE, or SELF-DIRECTED IRA ACCOUNTS PLEASE CALL WACltOVIA SECURITIES at 1o866-874-2717. * Date of death balance does not include accrued interest. ' If date of death occurrs on a weekend or a holiday, date of death balance does not include any transactions that were j~uha s, omad,e during that time period. Servicenter Associate Phone: (540)56%7323 cbc; js 0000 000614 EV-1511 EX~ ft2-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & ~NHERrrANC~ TAX RETURN ADMINISTRATIVE RESIDENT DECEDENT ESTATE OF FILE NUMBER Del~ts of decedent must be reported on Schedule ITEI~.; NUBILE:: DESCRiPTiON AMOUNT A. FUNERAL EXPENSES: , B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) /,9~1: ~'/,~/a¢ ,ag'. //,~'~"~ ~- Social Security Number(s)/EIN NumUer of Personal Representative(s) ~ ~ -- ~ ~-- ~ Street Address ~/~ ~. ~~ City ~ ~~ ~ ~ State ~ Zip Year(s) Commission Paid: ~ ~ 2, A~orney Fees ~~ ~ ~/~ ~ 3. Family Exemption: (If decedent's address is not the same as claimant's, a~ach explanation) Claimant ~ ~/~/~ ~. ~/~ ~ Street Address ~/~ ~. ~0 ~ ~W~ City ~~/~~6 State ~ Zip / 7~ Relationship of Claimant to Decedent 5. Accountant's Fees 3~.oo Tax ~tum P~epa~Ps Fe TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) t~/ 417~Jonestown Road · Harrisburg, Pennsylvania 17108 .eceived from-~'~'~-~ ~. ,~~, -~ ' t~ )~ , ~ ~ ' ~, . ~-.~..~.~., __., ~¢~ ?cod&o,: ;L~' /~.~. ~, ~L~:.,'~:, ,¢~.~.~..,;~. ~L'~'~.~L Dollars ~ LAST BALANCE ~ ~'., ~, , -,, ,. Payment ~-.,.~;. '~ ' '~ ¢.5~, ~¢~ BALANCE $ · Date ~ -/~-¢:~ By .~ 3-50/3t0 9 3 ~,, " / Dare ' C)~D~o~ -' ~ . ~ - - 1- ' ~/ --___.7 ~ ~ .~~ - Wachovia~nk, N.A. ~ _ ~~ . AC.H RIT 031000503 / ~ '" . · _______. ...................................................................... - ~ ~%.~;~,~,. ~,- SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, ~.--_s~o~,~? ~-::~ MORTGAGE LIABILITIES, & LIENS ESTAT~ OF FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER DEscRIPTION AMOUNT TOTAL (Also enter on line 10, Recapitulation $ Z 'g//l~ff, ]2. (If more space is needed, insert additional sheets of the same size) ~%MPDEN TOWNSHIP AMBII/~ANCE INVOICE 4~: 0300591 230 SOL~H SPORTING HI/~L 'P~h%D MECHANICSBURG, PA 17055 DATE: 03/04/2004 (717) 761-5343 TAX # 23-6050136 PATIENT: ADA MUMMERT BILL 'TO: ADA MUMMERT 310 E PORTLAND ~ MECHANICSBURG, PA 17055 ACCOUNT %: 18107860 CONTROL #: 0300591 DATE OF SERa-/CE: 04/t5/2003 PATIENT PICKED UP: RESIDENCE PATIENT TAKEN TO: HARRISBURG DESCRIPTIO:: DI~IT COST QT~. ~OI~T DIIE-- 2003 BLS BASE RATE A0429 275.00 1.0 275.00 2003 MILEAGE CHARGE AO425 5.00 9.0 45.00 OXYGEN AND SUPPLIES A0422 25.00 1.0 25.00 Comments: THIS IS YOU~ FIRST NOTICE. SUBTOTAL 345.00 BALANCE IS DuE'WITHIN 30 DAYS AMOU/TT PLEASE WRITE THE INVOICE NUMBER ON YOUR CHECK PAID 245.00 THANK YOU THANK YOU. TOTAL '~""~100.~_ 00 i:. i!iiii::::i:iSi i/;~fi:~;~i~!:iiiii?: :?~i ?:~ ~i~ ~i i ~ i~. :~ ........ :. ...... For Account Information, Please C_ddl (71 ? ) 230-3? I ? !:::!3.:ACCOU!][:::~O: ................. ~33279 ........ ' :: :":': :: ':: :': ':':: Statement .of/1 ccount 10/03/03 Transaction Date Description Amount PREVIOUS BALANCE 5,752. 09/30/03 HEDICARE DTSCOUNT 701 HEDICARE i70.C Estimated Insurance Due: .00 ' Total Patient Credits: Account Balance: 5,51~2.12 CUSTOMER SERVICE HOURS MON-WED-FRI 7:00AM TO 4:00PM TUES-THUR 7:00AM TO 6:00PM CALL 717-230-3717 LOCAL OR 1-800-603-6064 OUT OF AREA Please deach and return with your p~menl For Hospital Urea OnlyAcomunt Number: ADM DT: 060503 233279 ?!~ :?i/.~:i::5;582;12:::. Patient Name: " ' IDue' PINNACLE HEALTH HOSPITALS DSH DT: 082903 P.O. BOX 2353 MUMMERT ,ADA I 10/17/1 HARRISBURG, PA 17105 HOSP SVC: SSN [] ¥irm [] Manercard [] Di ...... [] American '-----------------E~r, ~,ai'd Number:. tExp. DaLe: ADDRESS SERVICE REOUESTED DX CD: V66.5 Signature: IAmount Paid: Make Check Payable To PINNACLE HEALTH HOSPITALS ' - h,,llh,,llh,,,l,h,hl,,,Ih,,lh,l,l,,h,h,,liil,,,,lh,i 0003.3.765 3. AT 0.292 oz I,,,llh,,h,,lllh,,,l,h,,hh,lh,hh,,Ih,hh.lh,hhl 233279 PINNACLE HEALTH HOSPITALS ADA MUMMERT P.O. BOX 2353 310 E PORTLAND ST HARRISBURG, PA 17105-2353 MECHANICSBURG PA 17055-3354 ] Please check this box if your address or insurance information has changed and record the changes on the back o[ this statement ~ ~ Pinnacle Health Hospitals p.o..ox :as3 !!iiiii!ii~~h~!ii~i!!iii iiii!iill ! !ii!iii i Account lnform-tion, PIc~c C~I U17)230-~19 Statement of Account 10/2~/03 7r~sa~ion Date Description Amount PREVIOUS BALANCE 1,676.00 09/03/03 21 AL~UTEROL .08~ 3 (CO-PAY) ~.D0 09/D~/03 1 PUHP/PDLE--P~CK fi .20 Estimated Insurance Due: .OD Total Patient Credits: Account Balance: !,686.20 YOUR ACCOUNT IS PAST DUE! PLEASE PAY IMMEDIATELY OR CALL 1-800~603-$064. IF PAYMENT HAS BEEN SENT, PLEASE DISREGARD. CUSTOMER SERVICE HOURS MON-WED-FRI 7:00AM TO 4:00PM TUES-THUR 7:00AM TO 6:00PM CALL 717-230-3717 LOCAL OR 1-800-603-6064 OUT OF AREA ............................................. Ple~ale OIItach and rmturn w th For Hompital UIm Only Account Nunlber. i~i~iiii~ii:~! · ^DM DT: 090203 maas '~tient Name: PINNACLE ItEALTH HOSPITALS DSH DT: 090503 P.O. BOX 2353 MUMMERT ,ADA 1 ~ 107103 HARRISBURG~ PA 17105 Card. Nu.sb~:~. ~,xp. Date: ADDRESS SERVICE REQUESTED DX CD: V66.5 Sigrsatum: ~z~mOUnt Make Check Payable To PINNACLE HEALTH HOSPITALS : - - h,,llh,,llh,,,hh,hh,,ll,,,li,,hh,l,,h,,lllh,,,Ih,I ooolo232 1 AT o.2~2 0Z h,,llh,,h,,lllh,,,hh,,hh,lh,hh,,Ih,hh,,Ih,hhl 233335, PINNACLE HEALTH HOSPITALS ADA MUMMERT P.O. BOX 2355 310 E PORTLAND ST HARRISBURG, PA 17105-2353 MECHANICSBURG PA 17055-3356 ] Please check this box If your address or insurance information has changed and record the changes on the back of this statement HARRISBURG, PA 17105 ................................................... For Account Information, Please Call {717)230-3717 iStatement of..Account 09/.17/03 Trmmaction Date Description Amount ...................... PREVIOUS BALANCE ..... . o~ 07/25/03 1 VISIT LEVEL 3 E 9gZB3 305.01 07/25/03 I ABD 1V 76000 138.01 07/25/03 i ABD 1V 76000 13B.OI 07/25/03 I FLUOROSCOPY UP TO I H076000 237.0( ..... DB/DB/'03 ...... 5¥SGE~-'$ENZ'OR BLUE'L' '"B'6'9 'I~E ...... 525.5; DB/Z7/D3 P~T-C~C 65 SPEC D69 K~E Z6g.qt Estimated Insurance Due: .00 - Total Patient Credits: Account Balance: CUSTOMER SERVICE HOURS MON-WED-FRI 7:00AM TO 4:00PM TUES-THUR 7:00AM TO 6:00PM CALL 717-230-3717 LOCAL OR 1-800-603-6064 OUT OF AREA Please G&~ch and return with lpg_ur o_e~ment ADM DT: 072503 240022156 Pati~t Name; PINNACLE HEALTH HOSPIT~S DSH DT: *NONE* P.O. BOX 2353 MUMMERT ,ADA r 10/0110~ H~RISBURG, PA 17105 HOSP SVC: CER ~ Visa ~ M~te~ ~ Dis~er ~ ~e.~n ~, ~ Numbe~ /~- Date: ADDRESS SERVI~E REQUESTED DX CD: V55.1 signature: Amount Paid: Mak~ Check Payable To PINNACLE HEALTH HOSPITALS ' ~-'~ h,,llh,,llh,,,hh,hh,,Ih,,lh,hh,h,h,,lilh,,,lh,I 2400221~ P~NNACLE HEALTH HOSPITALS A~A HUHHERT P,O, ~OX ~10 E PDRTLAN~ ST HARR~S~URG~ PA NECHANICSBURG PA 17055-555fi ] Please check this box if your address or insurance information has changed and record the changes on /he back of this statement . Statement of A ccount 09/29/03 Tr~a~ion Date D~crigtion; ~ Amount PREVIOUS ~ALANCE .00 07/25/D3 1 SNF SUB PRDB FDCUSEO P99~11 ~8.00 08/D5/03 SYSGEN 5ENIOR~BLUE C B69 KHE 38.00- 08/07/D~ KHP DISCOUNT ~69 KME S8.00 D8/OT/O~ KHP DISCOUNT ~69 KHE 28.00- Estimated Insurance Due: .[}0 Total Patient Credits: Account Ba!a_~cc: { 1 {}.{}O.~J CUSTOMER SERVICE HOURS MON-WED-FRI 7:00AM TO 4:00PM TUES-THUR 7:00AM TO 6:00PM CALL 717-230-3717 LOCAL OR 1-800-603-6064 OUT OF AREA Please all)tach and tatum wi_th_ ~Lour pal/mere SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF 'FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARi NUMBEF NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE ,f. TAXABLE DISTRIBUTIONS (include oumght spousal distributions) ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHE! !'1. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. 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) LAST WII.L AND TESTAMENT OF ADA MAE MUMMERT I, ADA MAE MUMMERT, an unremarried widow, of the Borough of Mecbanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and tmderstanding} do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and fi~neral expenses as soon after my decease as the same can convenienlly be done. 2. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, I give, devise and bequealh as follows: a.) One-half (1/2) to my daughl:er, PATRICIA M. LIPPERT, per stiles. b.) One-fourlh (1/4) Io my granddaughter, ttEATHER LINN MUMMERT. c.) One-fourlh (1/4) to my grandson, MICHAEL WILLIAM MUMMERT. If either, or both, of my grandchildren predecease me and he or she is survived by childreu, Iben his or her children shall take his or her share. If one of my said grandchildren predeceases me and is not survived by children, Ihen his or her share shall go to my other grandchild or bis or bet children as the case may be. If both of my grandchildren predecease me and neither is survived by children, then their shares shall go to my said daughter, PATRICIA M. LIPPERT, per s!i_rpes. I nominate, constitute and appoint my daughter, PATRICIA M. LIPPERT to be the Executrix or' this my Last Will and Testament. In the event that she should predecease me or for any reason be unwilling or unable to act as such Executrix, I nominate, constitute and appoint nay son-in-law, MARLIN L. LIPPERT, Jr, to be Executor in her place and stead. In the event that he should predecease me or for any reason be unwilling or unable to act as such Executor, I nominate, constitute and annoint mv m'an&tam, hmr I:IF. ATt~'F.D T IMM ~AIlhtllX/l'lZ;l>'l' IN WITNESS WHEREOF, I have hereunto set my hand and seal this _,.z-~27~ day of ___ ~'~i~-~ _, A.D. 1998. ADA MAE lvlUMMERT Signed, sealed, published and declared by the above-named ADA MAE MUMMERT as and for her I~ast Will and Testament, in lhe presence of us, who at her request and in her presence, and in Ihe pregence of each other, have hereunto subscribed our names as witnesses. PETITION FOR PROBATE and GRANT OF LETTERS Estate of ffJg~4t /~'~ /J~l/I////E~dT- No. ~t-- 03'~ ~O also known as ~ ~~ ~ To: Register of Wills for the Deceased. County of ~~D in the Social Security No. /~/ - 0/- 7~0 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execulN~ named in the last will of the above decedent, dated ~a~ 2~ , 19~$ and codicil(s) dated (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ~4,~/3'~',q'Z,,~,q,'.~ County, Pennsylvania, with last f~mily or principal residence at ~/o ~aa~ ~/a~d ~ee~ ~ee~m~s~ (hst street, number and muncipality) Decendem, then ~ years of age, died ~, I/ ,~o~, Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ . ff~ ~. aa (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: WHEREFORE, petitioner(s) respectfully reauest(s) the probate of the last will and codicil(s) presented herewith and the grant of letters (testamerffary; administration c.t.a.; administration d.b.n.c.t.a.) theron. x OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 3 COUNTY OF ~Ltml~F4d~/.b f 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 and truly administer the estate according to law. Sworn to or affirm_,~ and subscribed ~ ~i~'~~~, ..~9~2~'~ .~Z~ ) ~ No. 1- 03- Estate Of (] c~ ffYb~ /')0~~~ _a,'~..ad,~/73,~ Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW ,~ ~_,~,~a h..t_n_ / &, ~2oo& ~l~ .., in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated 10 -~9c/- ! ~q~ described therei, I~ be admitted to probate and filed of record as the last will of and Letters "~~~-~ are hereby granted to i'~ED~Tt C~_~_-. ~ ~ FEES Probate, Letters, Etc .......... $~O.C~ ~ ~~~. Short Certificates( ) .......... $ ~ .GO AWO~NSY (Sup. Ct. ~.D. No.) $ I o · oO ADD,SS TOTAL $/0~. oO 7/7- Filed .... ~. ~ .l.~/. ~ E ?~ ................ , PHONE REGISTER OF WILLS OF P~~/~,~,~2 COUNTY OATH OF SUBSCRIBING WITNESS ~ a su~s~in~ %mess to the ~11 pr~ent~ herewith, ~ being d~y qu~fi~ ~ecor~ng to law, ~os~s) ~d sa~s) that ~ ~ ~~ present ~d saw the testat r/x , si~ the s~e ~d that ~ si~ ~ a ~tn~s at the r~uest of t~tat~k in ~ pr~ence and (in the pr~ence of each other) (in the presence of the o~er subs~bing ~tn~s(~)). me_t~s ~ day of ~~ ~ ~g/~s ~= ' (N~e) j~'~.' ~ ~-~ ' ~O . (Ad. ess) ~.5~-/ (Addr~) ~GIsT~R OF WI~s OF COUNT~ OAT~ OF NON-sU~sc~IN~ WITNess a subscriber hereto, (each) being duly q ified according to depose(s) and sa s tha~ ~ ~ familiar wi --.. Y( ) - _ th the'si4mature o~ ... ..~ , testat ~x~f (one of the sub'Se~ing witnesses to)~th~ will presented herew'~i~l and that ~ ~ '~ codlml '%',believes the signature once w' ' ' · - ~ v~ ~~s m the handwrItIng °f Sworn to or affirmed and subscribed be'f~ ~. me,lit'---,,, day of~ '"" ...... ~ (Name/ REGISTER OF WILLS ~ COUNTY OATH OF SUBSC~~~~.~ ( ) a subscripted herewith, (each) being duly ualified each law, depots) and say(s) that - ~ ........ x,,,~,o q ~o ~ si,,~ed as a wi ~_ (marne) - _ (Name) ,~-~' (Addre~) :_I~EGISTER OF WILLS OF C ~ ~ s~_:~;_0 COUNTY O~ATH OF NON-SUBSCRIBING WITNESS O~h.) a subscriber hereto,-(.e~eb) being duly qualified according to law, depose(s) and say(s) tha~ testat r~'~, of ~ ;~e ~,_,b_~c~-.'n~ ~-~:~.~:,,~ ~,) the will presented herewith and that. ._?H~- codicil believes the ~ignature on the will is in the handv, q-iting of to the best of ~ knowledge and belief. Sworn to or affirmed and subscribed before × ' ' ' (Name/ (Address) This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as I,ocal Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 9507616 $£P 1 2 Z003 No. Date COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS CERTIFICATE OF DEATH / ~ ~arrlsburg ~arrlsburg ~ospttal ~m.~. m~ ~ White idowed 310 East Portland Street ,~..~,,. Penns lvania _~ ,,~.~.~~ ................ ,,.Mechanicsburg, PA 17055 erland let '~"~ Mrs. Patricia A. Lippert Ida Mo~er ~,~ c,~,~ "*~,.-s~,.~ 310 E. Portland Street, Mechanicsburg PA 17055 9-15-2003 ~odla~ Memorial Gardens PA 17109 rman-Au : O0 A 9-11-2003 L~ca~ ~E ~ LAST WILL _AND TESTAMENT OF ADA ~MAE ~RT I, ADA MAE MUMMERT, an unremarried widow, of the Borough of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, I give, devise and bequeath as follows: a.) One-half (1/2) to my daughter, PATRICIA M. LIPPERT, ~. b.) One-fourth (1/4) to my granddaughter, HEATHER LINN MUMMERT. c.) One-fourth (1/4) to my grandson, MICHAEL WILLIAM MUMMERT. If either, or both, of my grandchildren predecease me and he or she is survived by children, then his or her children shall take his or her share. If one of my said grandchildren predeceases me and is not survived by children, then his or her share shall go to my other grandchild or his or her children as the case may be. If both of my grandchildren predecease me and neither is survived by children, then their shares shall go to my said daughter, PATRICIA M. LIPPERT, ~. I nominate, constitute and appoint my daughter, PATRICIA M. LIPPERT to be the Executrix of this my Last Will and Testament. In the event that she should predecease me or for any reason be unwilling or unable to act as such Executrix, I nominate, constitute and appoint my son-in-law, MARLIN L. LIPPERT, Jr, to be Executor in her place and stead. In the event that he should predecease me or for any reason be unwilling or unable to act as such Executor, I nominate, constitute and aoooint IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ day of ~~~i~$a~_~, A.D. 1998. ~EAL) Signed, sealed, published and declared by the above-named ADA MAE MUMMERT as and for her Last Will and Testament, in the presence of us, who at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. LAST ~UT~AND TESTAMENT OF ADA MAE MUMMERT CHARLES E. SHIELDS III A'CI'ORNEY-AT-LAW 6 CIouser Road MECHANICSBURG, PA 17055 CERTIFICATI_ _ ON OF N_____~ICE U~NDER RULE 5~.6 a Name of Decedent: ADA MAE MUMMERT, aka ADA MUMMERT Date of Death: September 11, 2003 Admin. No. 21-03-00760 Will 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 September 25, 2003: Name _Addres_s Patricia M. Lippert 310 E. Portland Street, Mechanicsburg, PA 17055 Heather L. Mummert 338 N. Mill Road, Hamsburg, PA 17112 Michael Wm. Mummert 338 N. Mill Road, Harrisburg, PA 17112 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: September 25, 2003 CHAR~F~ E. SHIELDS, III 6 Clouser Road Mechanicsburg, PA 17055 Telephone: (717) 766-0209-.-.: Counsel for Personal Repre~ntativ ,e~_.~, COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE REV-1162 EX(11-96) BUREAU OF INDIVIDUAL TAXES DEPT. 2806O1 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 003888 SHIELDS CHARLES E III 6 CLOUSER ROAD MECHANICSBURG, PA 17055 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold 101 J 83,330.29 ESTATE INFORMATION: SSN: 181-01-7860 FILE NUMBER: 2103-0760 DECEDENT NAME: MUMMERT ADA MAE DATE OF PAYMENT: 05/03/2004 POSTMARK DATE: 05/01/2004 COUNTY: CUMBERLAND DATE OF DEATH: 09/1 1/2003 TOTAL AMOUNT PAID: $3,330.29 REMARKS: PATRICIA A LIPPERT CHECK//1002 INITIALS: AC SEAL RECEIVED BY.' GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONNEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280&01 ~RRISBURG, PA ]7128-060] NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE 06-21-2004 ESTATE OF MUMMERT ADA M DATE OF DEATH 09-11-2005 FILE NUMBER 2I 05-0760 COUNTY CUMBERLAND CHARLES E SHIELDS III ACN 101 6 CLOUSER RD I Amount Remitted MECHANICSBURG PA 17055 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA I7015 CUT ALONG THIS LINE ~- RETAIN LONER PORTION FOR YOUR RECORDS ~-: [ ~- ' ~- -~ ~- -[ ~i~-~ ~3- -~ ~'~ ~- ~-~ - ~-~ ~-f ~-g - kX~- ~-6 ~'~ ~-~ ~- -~[~-~ ~-g - ~- ................. DISALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MUMMERT ADA M FILE NO. 21 05-0760 ACM 101 DATE 06-21-200~ TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN ~. Real Estate CSchedule A} ([) .00 NOTE: To insure proper 2. Stocks and Bonds CSchedule B) C2) .00 credit to your account, 5. Closely Held Stock/Partnership Interest CSchedule C) C$) .00 submit the upper port/on ~. Mortgages/Notes Receivable CSchedule D) C~) .00 of thls form with your 5. Cash/Bank Deposits~Misc. Personal Property CSchedule E) C5) 100/756.58 tax payment. &. Jointly Owned Property CSchedule F) C&) .00 7. Transfers CSchedule G) C7) .00 8. Total Assets C8) 100,756.58 APPROVED DEDUCTIONS AND EXEMPTIONS: 19,5~6.61 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 11. Total Deductions C11) 12. Net Value of Tax Return C12) 7~,006.~5 15. Charitable/Governmental Bequests; Non-elected 9115 Trusts CSchedule J) (iS) .00 14. Net Value of Estate Sub3ect to Tax Cl4) 74,006.45 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 w111 reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: u OO~ O0 15. Amount of L/ne Lq at Spousal rate C/5) · X ~:~- ' 16. Amount of Line lq taxable at Llneal/Class A rate C[6) 7~,006.~5 x 0~5 = 5,550.29 17. Amount of Line 1~ at Sibling rate C17) .00 x 12~ = .00 18. Amount of Line tq taxable at Collateral/Class B rate C18) .00 X I5'~ = .00 19. Principal Tax Due C1~)9= 5,550.29 TAX CREDITS PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID i~I DATE NUMBER INTEREST/PEN PAID C-) 05-01-200~ CD005888 .00 5,530.29 TOTAL TAX CREDIT I 5,550.29 BALANCE OF TAX DUEl .00 INTEREST AND PEN. .00 TOTAL DUE .00 ~ IF PAID AFTER DATE INDICATED, SEE REVERSE C IF TOTAL DUE IS LESS THAN $I, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR}, YOU MAY BE DUE-~ A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.} RESERVATION= Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class 8 (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Xnheritance Taxes at the lawful Class B (collateral) rate on any such future interest. PURPOSE OF NOTICE= To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 25 of 2000. (72 P.S. Section 9140). PAYHENT= Detach the top portion of this Notice and submit with your payment to the Register of Nills printed on the reverse side. --Hake check or money order payable to= REFUND (CR)= A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an '°Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications are available at the Office of the Register of Wills, ar~ of the 25 Revenue District Offices, or by calling the special 2q-hour answering service for forms ordering= 1-800-562-2050~ services for taxpayers with special hearing and / or speaking needs= 1-800-447-5020 (TT only). OBJECTIONS= 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 (&O) days of receipt of this Notice by= --written protest to the PA Department of Revenue~ Board of Appeals, Dept. 281021, Harrisburg, PA 17128-~02], OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. AONIN- 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. 280601~ Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. DISCOUNT= If any tax due is paid within three (5) calendar months after the decedent's death, a five percent (51) discount of the tax paid is allowed. PENALTY= The 151 tax amnesty non-participation penalty Js computed on the total of the tax and interest assessed, and not paid before JanuamJ 18, 1996~ the first day after the end of the tax amnesty period. This non-participation penalty Js 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= 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 which became delinquent before January 1, 1982 bear interest at the rate of six (61) percent per annum calculated at a daily rate of .0001~4. All taxes which became delinquent on and after Januar~ 1~ 1982 will bear interest at a rate which ~ill vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2004 are= Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor ~ 20~ .000548 ~'~'~-1991 11~ .000501 ~-~ ~ .000247 1985 16~ .000458 [992 9~ .0002~7 2002 6~ .0001~ 1984 11~ .000501 1995-1994 7~ .000192 2005 51 .000157 1985 15~ .000556 1995-1998 9~ .000247 2004 4~ .000110 1986 10~ .000274 1999 7~ .000192 1987 lOX .000274 2000 71 .000192 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELTN~UENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment, If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. STATUS REPORT UNDER RULE 6.12 Name of Decedent: Ada M. Mummert Date of Death: 09-11-2003 Will No. Admin. No. 21-03-0760 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~hether 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: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes__ No . b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative s~a.te an account informally to the parties in ' · YeseS. No [nterest~ d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. Signature Charles E. Shields, III, Escf~gre Name (Please type or print) ,~,..{ ~ i ~ ~.~ ~.~t ~ 6 Clouser Road, Mechanicsburg, PA 17055 , . %~) Address .[ 717 I 766-0209 ~'. [[\J 9t 83§ ~0. Tel. No. .... ~ Capacity: Personal Representative ]~' ..... X Counsel for personal ( MAH: rmf/AM3 ) representative