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Home My WebLink About04-0428PETITION FOR PROBATE and GRANT OF LETTERS No. O/-o4'r- also known as , Deceased. Social Security No. / T zzZ-.~ O ~'~f '~ ~ ('~ To: Register of Wills for the County of 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 execut/~_/'A in the last wilt of the above decedent, dated and codicil(s) dated in the named , 19.~ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ,A4-~c-bz~5~/TT'/4~-fi'/t4 t':~3, ~ County, Pennsylvania, with ~ last f~mily or principal residence at ~/~ (list street, number and muncipality) Decendent, then, ~ years of age, died at ~L~ ~ ~, ~t~ ~0~/~~~' // ' ' Except as {ollow~ decedent did not ~arry, was not divorced and did not have a child born or adopted after execution of t~ 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 (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: ~ ~Y~O ,oC-~ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) OATH OF' PERSONAL REPRESENTATIVE Sworn to or af_~,~ and subscrib~df before me this ~ COMMONWEALTH OF PENNSYLVANIA } ss COUNTY OF Thc petitioner(s) above-named swear(s) or affirm(s) that thc statements in the foregoing petition arc truc and correct to thc best of thc knowledge and belief of petitioner(s) and that as personal rcprescn- tativc(s) of thc above decedent petitioner(s) will well and truly administer the estate according to law. Estate Of No. ,Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated described therein be admit~ to probate and filed of record as the last will of and Letters L --/-~-_ ~7-~q/~x~7~xE 6/ ..,l,~, in consideration of the petition on FEES Probate, Letters, Etc .......... ~ ~_Shor~Ce~ificates( )...~ ...... $~ ~R.efiunc'iation ................ $. ,"c~ · ~-0 TOTAL $ ~/, ~ Filed .~~.. ~ ~ ............. ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. i105 143 Rev, 2/87 Fee for this certificate, $2.00 No. COMMONWEALTH OF PENNSYLVANIA ° DEPARTMENT OF HEALTH ° VITAL RECORDS CERTIFICATE OF DEATH STATE FILE NUMBER Local Registrar / A?R 1 4 2004 Date NAME OF DECEDENT (Fiat, Middle, Last) I SEX I SOCIAL SECURITY NUMBER I DATE OF DEATjrl (Month. Day, Year) 1Daniel. P. Erney 1.3Male I.a 174 -- 20 -- 7396 AGE(LRsIBi~lday) I UNDERIYEAR I UNDfiRIDAY I DATE OF BIRTH I BIRTHPLACE (City and IPLACEOFDEATHtCheckonlvone-seainsEucttonsonotharside} / ! ' I Months I Days I Houls I Minutes I (Month, Day, Year) I State or Fo~eigrt Cour~ I I-IO~iTAL:. I OTHER: ~'OUNW oF pEAT.' ' I clff. BORG, T~'~ OF DEATH I FACI£,~Y .~ME (. r~ ~.ti~on. ~e .~,~l'an~ n~m.) IWAS DECEDENT OF HISPANIC ORIGIN? I EACE- Amedcan Indian. Black, INnit., et, . I S I TW . No[] Ye, ~ea, spa<ely Cu~., (Specih,) . DEC/DENT'S USUAL OCCUPATIONI KIND OF BUSINESS I INDUSTRY IVVAS DECEDE~I' EVER INDECE[](~m' I _ .s....~. I ........... ~.~ (e~vekindofwo~doaedu~am~ I ~ · -- I US ARMED FORCES? I (SF~Clff°~e/hlghe~lgred~mml~ I NeVarMafT~I..~WIGOWeG, I ot_v,~d~:~o,~u.,~'ed) iMecnarllcsDuro i '_' ~ ..r-~ I E~m~.Ws.c,~d.~ I C~ege I Divorced(.Spedf_y) I ...~ ~,y~ i,~.aval s~pplv~efia~:es,~ ~o,, I,,. *~' I "~'"I-. ~arr~_e~I,,Thelma Swartz DECEDENT'S MAILING ADDRESS (Street City/To~vn State Zip Code)IDECEDENT'S ~. ...... P~ ~ u u ~' , "~ I RESIDENCE --~ ~t . t,.~echan~c~burg,P~ ~_70SS I~,~)a ,,,.~, Cumber~ana ,ow~,? ,,,.[~ .%~'~'='&~. FATHJ~ I~AME (First.~lidele, J.a,~t) __ MOTH~'S ~I4,ME Fif~L Middle, I~k:len.~lame) I~. UllVeT ~SCOr.'c ufirrle~ t~. uaEnerlne uortle~ INFORI~[T'S NAME (TyDe~Print) INFORMANT'S MAILING ADDRESS {Stre~ City/Town, State, ,Zip Code z0,. Tne.Lma'~. ~.rney 1=~.88~ Oak Oval, Mechan~csburg,PA 17055 METHOD OF DISPOSITION DATE OF DISPOSITION ~ PLACE OF DISPOSITION- Name of Cemetery, Crematory ~ LOCATION - City/Town, State. Zip Code I ~.~,~.1-1 .,~ IRIc,oma.onEl,~,~,,a~omst,aE]~ ~?~.0~I.~.o17 , 2004 . :~9 G~ee~ Mem. Park 31,. Camp H'111, PA 17011 I3,,.FO 012342-L I~%.tone&MurrayFH408 3rd St NewCumbe Pi of ~ knowledge, deet~ occurred at I~e time. date and place ~-!~,d LICENSE NUMBER IDATE SIGNED I (Mo~lh, Day, Year) ca. fy cause of deem. 23a. I 23b. 123c. Itihlas 24-2~ muat be completed by TIME OF DEATH D DEAD (Mooth, Day. Year) I WAS CASE REFERRED TO A MEDICAL EXAMINER/CORONER? be~.o~<.,de.th, I-. Y*' [] 23'. PART I: E~er ~4e e~ea~e., ~ e* cem~llcatkmi which c.u~d Iho a~.ih. ,, ApproximatePART I1: Othar mgnificam conditione conthbuting to death, but Lm ealy ~ ca~ o..ad~ ll,~. , interval behvear ~ot reaulting in the underlying cause given in PART t. -~"~""" o.~,~'~E~TBi, de~)CAUSE~(~thal a. ~ ~"Yr- ~ ~ ~o'O'~ : o~al and de~, D~ TO (O~ AS A CONSEOUENCE O~): If ~y, Medthg ID immediete ~ DI~ ?o (o~ AS A CORSEOUENCE OI9: ' =Busa. Entar UNDERLYtNG I CAUSE (Disel~a ~ injury c. ~t initiated events DUE TO (OR AS A CONSEQUENCE OF): ., rsEulting on death ) LAST d. WAS AN AUTOPSY ~ WERE AUTOPSY FINDINGS ~ MANNER OF DEATH I DATE OF INJURY ~ TIME OF INJURY I INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED I ICOMPLET'ONO~CAUSE IN'=al Et [ ~ PLACE OF INJURY - At home, farm, etroet, ~clory, office ~"~' (~,~) ~reet. City/To,,,~. State) 28a. 3~,. 2~. · CERTIFIER (Di~eck o~y o~e) SIGNAIUR E AND TITLE DE CERTIFIER '/o Ell bll~ m my anov~eage, deelh Doc[iliad due to ilia caulea(i) &nu mlnner ea itated. ................................................................ 3lb. LICENSE NUMBER DATE SIGNED {Mooth,.Day, Year) 'PRONOUNCING AND CERTIFYIN~ PNYSIClAN (Physician bo~ ixonouncing death aDd ceflifyin0 to cause of death) '.BDICAL EXAMINER/CORONER ,INtAefM~M~7A)NTDy~DDo~'RpErl/SI[S OF PERSON WHO COMPLETE D CAUSE OF DEATH //7 0 (./~I On tl~e beale of esemlnaUofl etld/or laveaflgaUon, In my opinion, dealt1 occun'ed at the time, date, and place, and due to the caueal(i) end ,..' ...... ............................................................................................................................................................ ",,. r iA , · DATE FILED (MGoth, Day. Year) t LAST ANI) TESTAMENT DAN/EL P. ERNEY I, DANIEL P. ERNEY, of UpperAIlen Township, Cumberland County?. Pennsylvania, do make, publish and declare this to be my Last Will and Testament, hGreby revoking all Wills and Codicils by me at any time made. ITEM 1: I direct that all Inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my estate or by any recipient of any property, shall be paid by the Executrix out of the property passing under ITEM IV of this Will, es an expense and cost of adminiMmtion of my estate. The Executrix shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this Will. ITEM Ih I direct the Executrix to pay my just debts and the expanses of my last illness and funeral expensss from the property passing under this Will as an expense and cost of ndminlatration of my estate. ITEM II1: In the event my Wife predeceases me, I make the following special bequests: (a) To my 8on, STEPHEN S. ERNEY, I bequeath my Norman Rockwell plate collection and antique brsss wall sconces: diamond (b) To my son, MICHAEL P. ERNEY, I bequeath the sum of One Thousand Doliare ($1,000.00) since I believe he may not enjoy any sentimental value of hms of pareonsl property which I have; and (c) To my daughter, SUSAN KAY ERNEY JONES, I bequeath THELMA G. ERNEY's engagement ting, Grandma 8wartz's diamond engagement ring, Grandma Midge Townsiay's engagement Hag, Grandma Swartz's cedar chest and the quiltad wall hanging and Amish counted cross stitch that Susan made. ITEM IV: I devise and bequeath all the residue and remainder of my estate to my spouse, THELMA G. ERNEY. In the event my spouee predecesses me, I devise and bequeath my estate as follows: (a) One-third (1/3) to my son, STEPHEN S. ERNEY, or, in the event my son predeceases me, I devise and bequeath his share to his issue, par atirpes; (b) One-third (1/3) to my son, MICHAEL P. ERNEY, or, in the event my son predeceases me, I devise and bequeath his share to his Issue, per stirpes; and (c) One-third (1/3) to my daughter, SUSAN K. ERNEY JONES, or in the event my daughter pr~Jeceam~ me, I devise and bequeath her share to her i~sue, par ~tirpas. In the event any beneficiary above precisceasee me and dies without issue, his or her share shall be paid equally to the other named beneflcisrisB. ITEM V: In the settlement of my estate, my Executrix shall pomi4es, among othere, the following powere: (a) To retain any inve.tmento I may have at my death, as long am the Executrix may deem it advisable to my eMate to do so; (b) To uell either at private or public .ale and upon such temm and conditions am the Executrix may deem advamgeoue to tho estate, any or aH real or pamonal proparty or inter(mt therein owned by the estate; (c) To pay all coMs, texe~, expens~ and clmrgm in connection with the administration of my estate; (d) To compromise controvemis~; and (e) To do all other ecte in the Executdx's judgment deemed nece~ary or desirable for the proper and advantageous management, investment and distribution of the estate. ITEM Vh Any parson who shall have died at the amine thne aa I shall have, or in a con. non dimmter with me, or under circumstances that the order of cleathe cannot be established by proof, or within thirty (30) days of my death, shall be deemed to have predeceased me. ITEM Vlh appo THELMA G. EPJ~EY, MY WIFE, to be the Executrix of my Esiate. In the event THELMA G. ERNEY cannot act or refumm to act a~ Executrix for any re. on, I nominate, con~titute and appoint my eld~t ~on, STEPHEN 8. ERNEY, ~ duty or obligation of filing any bond or other .ecutiry. IN WITNESS WHEREOF, I have hereunto set my hand and mi to this, my ~ Will and Te~tement. con~isting of this m.J the preceding page this DANIEL P. E (SEAL) ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA: :SS. COUNTY OF CUMBERLAND : I, DANIEL P. ERNEY, whose name is signed to the attached or foregoing Instrument, having been duly qualified according to law, do hereby acknowledge that I tigned ,nd executed the Instrument as my Last Will and Testament, that I signed it willingly, and that I signed it at my free and voluntary act for the purposes therein expre,sed. DANIEL P. ERNEY 'P Sworn to and subscribed before me this I Notarial Seal My Commill,~,ioR Expil'~: Jennifer R. Freeland, Notary Public Upper Allen Twp., Cumberland County (SE/M,) My Commission Expires Dec. 13, 2004 Member, Pennsylvania Association of Notaries We, the undemigned, hereby cerlJfy that the foregoing Will w~ signed, ~ealed, published and declined by the above-named DANIEL P. ERNEY ~ and for hi. Last WIH and Te~mnt, M tim ~ of each other, Imve hereunto ,mt our hand~ and mi. the day and year first above writl~n, and we ce~ify that at the time of the execution thereof, the ~aid DANIEL P. ERNEY wa~ of m~md mind and memory. AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA: : SS. COUNTY OF CUMBERLAND : to law, do depose and say' mat we were present and saw DANIEL P. ERNEY, mgn Bna execute the inatnmment am hi~ Last WIH and Testament; that DANIEL P. ERNEY ligned wilHngly and he executed MM Will as his free and voluntary act for the purposes therein exprmmed; that each of u~ in the hearing and sight of DAHIEL P. ERNEY signed the WIH es witnesses; and that to the best of our knowledge DANIEL P. ERNEY wis at ttmt time eighteen (t8) or more years of ~Kle, of sound mind and under no conatmint or undue influence. Swom to and subscribed before me this My CommAsion Expires: (SE~.) l- Notarial 8cai d~tlllifQr R,_Freeland, Notary Public I UI~P..~* AIIQn ~vp:~ C,umbe_dand County I My ~emmiaaion Expires uec. 13, 2004 I '~,~~,ri?,, ~'?n~ ~,~,soclation of Notaries Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717)240-6345 Date: 08/02/2004 ERNEY THELMA G 881 OAK OVAL MECHAiqICSBURG, PA 17055 RE: Estate of ERNEY D~NIEL P File Number: 2004-00428 Dear Sir/Madam: It has come to my attention that you have not filed the Certification of Notice Under Rule 5.7 (a) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.7, shall file with the Register of Wills or Clerk of the Orphans' Court his/her Certification of Notice. This filing will become delinquent on 08/13/2004 Your prompt attention to this matter will be appreciated. Thank You. cc: File Counsel Judge Sincerely, GLENDA FARNE~H Clerk of the Orphans' Court Name of Decedent: Date of Death: Will No. To the Register: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) //, Admin. No. ~-~_~,0 _Z~/"~CJz/t~ ~'' I cex~ify that notice of (beneficial in.rest) ~ 'on required by Rule 5.6(a) of.the Orpharbs' Court Rules was served on or mailed to the following beneficiaries Of the above-captioned estate on ~' ~tg~Tz : Name Address Notice has now been given to ail persons entitled thereto under Rule 5.6(a) except Date: Signature Name j.~.rr--,~ ~. Address 0~] ~ Capacity: ~ Personal Representative Counsel for personal representative REV-l000 EX (6-001 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 n~?0 REV-1500 :)\\( w .... ~~(I) C)"'''' w""u =<00 C)"'~ ,,"01 "" " ~ FILE NUMBER I I 2L-(} 'i COUNTY CODE YEAR INHERITANCE TAX RETURN RESIDENT DECEDENT 04;(~_ NUMBER I- Z W C W U W C DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) ~ I€/lJG SOCIAL SECURITY NUMBER 17~ - :;;<0 737ra THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER I? IEL DATE OF BIRTH (MM-DD-YEAR) .tj-/~"-dOO </ 9 -~- /y,??;? (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) EARE TH'Et..J.1 G. ~ 1. Original Return o 4. Limited Estate o 6. Decedent Oled Testate (Attach copy of Wili) o 9. litigation Proceeds Received o 2, Supplemental Return o 4a. Future Interest Compromise {date of death after 12-12-82) o 7, Decedent Maintained a Living Trust {Attach copy of Trust) o 10. Spousal POlJerty Credit \ciale 0\ ciea\h be\weffi'l 12-31-'>l1 and 1-H'15) 03, Remainder Return (dBteofdeath priorlo 12.13-82) o 5. Federal Estate Tax Return Required 8, Total Number of Safe Deposit Boxes o II Election to tax under Sec. 9113(A) {Attach Sch 0) .... Z W " Z o "" '" w "' '" o C) FIRM NAME (If Applicable) COMPLETE MAILING ADDRESS g &'/ ({JAI< Ot/;::JL #eeH/JIf//t!'Sl3u/2&~ A4 17't?..rs-- TELEPHONE NUMBER 7/7- Cf7-7SS/ 1. Real Estate (Schedule A) 2, Stocks and Bonds (Schedule B) (I) () (2) (J (3) 0 (4) 0 (5) 0 0 - ; (6) C,j (7) 0 (8) 0 (9) (10) z o !;: ...I ::::l l- ii: <( u w ct: 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Noles Rece'lvable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9 Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) (11) (12) (13) o 12. Net Value of Estate (Line 8 minus Line 11) 13 Charitable and Governmeng! Bequests/See 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) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o !;j: I-' ::::l ll. ~ o u >< ~ 15. Amount of line 14 taxable at the spousal tax 0 (') rate, or transfers under Sec. 9116 {a}{i .2) x.O_ (15) 16. Amount of Line 14 taxable at lineal rate x.O_ (16) 17. Amount of Line 14 taxable at sibling rate x .12 (17) 18 Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) 200 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT .!!i~il!'\'OM... Decedent's Complete Address: STREET ADORES CITY Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) Total Credits (A+ B + C) (2) 3. InteresYPenal1y it applicable D. Interest E. Penally TotallnteresVPenal1y ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) Zlij 1 CIS !!: 5. 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. (SA) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT r ..- ~"T ~ w~~...,... PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS No o o o o o o o IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, 1. Did decedent make a transfer and: 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? ................. .. ......w'"'"... 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? . ................ Ves ...0 .0 ......0 ....0 .....0 o .................0 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and comptele. Declaration of preparer other than the personal representative is based on all inlormation of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS r- [III III IIn ''VI 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. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (iill. The statute does not exemDt a transfer to a surviving spouse from tax, and the s1atutory 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. 99116(a)(1.2)]. The tax rafe imposed on the net value of transfers to or for the use of Ihe decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Decedent's Complete Address: STREET ADORES CITY ~ ZI/ 1'V'S"; Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InteresUPenalty if applicable D. Interest E. Penalty TotallnteresUPenalty ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. 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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (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 olthe property transferred;.......................................................................................... 0 0 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 0 c. retain a reversionary interest; or.......................................................................................................................... 0 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 0 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 pe~ury, I declare thai I havB examined this relum, including accompanying schedules and statements, and to the besl of my knowledge and belief, it is true, correct and complete. Declaralion of preparer other than Ihe personal representabve is based on all informalion of which preparerhas any knowledge. SIGNATURE OFjER~N RESPONS.IBLE FOR FILING ETURN ~/~. h ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS :t:&~;:~f1i;:~~}~~~;~'~'"@f~:Jff~~;~Jl~it.~~~'t1k"~_m::!~ml~itg~;~~;[Jl~*![Kit32i:i For dates of death on or after July 1, 1 994 and before January 1, 1995, the tax rate imposed on the nel value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the lax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (iI)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger al death to or for the use of a natural parent, an adoptive parent, or a slepparent of the child is 0% [72 P.S. 99116(2)(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. 99116(1.2) [72 P.S. 99116(a)(1)]. Thl? t~'.I r~tp imonsF!rl nn IhF! nAt vl1hJp. of tr::msfArs to or for thA IJSA nf the decedent's siblinas is 12% r72 P,S. ~9116(a)(1.3)]. A sibling is defined. under Section 9102. as an individual who h~s at least one parent in common with the decedent, whether by blood or adoption. . R'EV-1502 EX+ (6-98) .* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER All real property 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 property 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 survivorship must be disclosed on Schedule F. ITEM NUMBER I. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 1. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) . REV-1503 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER All property lointly~wned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER ,. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (1-97) , '. . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also en1er on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-l5ll5EX + (1-97) '* SCHEDULE C.1 CLOSEL Y.HELD CORPORATE STOCK INFORMATION REPORT COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER State State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year 1. Name of Corporation Address City 2. Federal Employer I.D. Number 3. Type of Business ZipCooe Product/Service 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restnctions pertaining to each ciass of stock. 5. Was the decedent employed by the Corporation? If yes, Position o Yes 0 No Annual Salary $ DYes 0 No Time Devoted to Business 6. Was the Corporation indebted to the decedent? If yes, provide amount 01 indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? 0 Yes 0 No a yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock 01 this company within one year pnorto death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Number of Shares Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. Consideration $ Date 9. Was there a written shareholders agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. DYes 0 No 10. Was the decedent's stock sold? DYes o No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? 0 Yes 0 No If yes, provide a breakdown of dlstlibutions received by the estate, inciuding dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C.l or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's stock. B. Comptete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the compiete addressles and estimated fair market value/s. if real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those deciared and unpaid. G. Any other information relating to the valuation of the decedent's stock. .REV-1506 .EX+ 19-0. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Partnership Address City 2. Federal Employer I.D. Number 3. Type of Business Date Business Commenced Business Reporting Year State Zip Code ProducVService 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Nel proceeds payable $ Owner 01 the policy . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Consideration $ Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 1 Q. Was there a written partnership agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. Date DYes 0 No 11. Was the decedent's partnership interest sold? If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? . . . . . . . . . . . . .. 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. DYes 0 No 13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule CM 1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (1-97) . '. . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ,ruOM""''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) RP/:'SOSEX+(M7) '*' SCHEDULE F JOINTL Y.OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF 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. B c. JOINTLY -OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY . %OF DATE OF DEATH ITEM FOR JOINT MADE Include name offlnancial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed forjoinUy-held realestale, VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL (A.lso enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) '~'';,"''''I''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON.PROBA TE PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDETHENMlEOFTKETRANSFEREE,THEIRRELATIONSHIPTODECEDENTANDTHE DATE OF TRANSFER DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH ACOPVOFTHEDEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IFAPPLICABL~). NUMBER 1. TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) . . ~,:'<l. . !" "" COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1, B, ADMINISTRATIVE COSTS: 1, Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State _ Zip Relationship of Claimant to Decedent 4, Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7, TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV:1512 EX+ (12-03) '*' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) _REV-151~ EX+ (9-00~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF D/l/UI FILE NUMBER C:UcJLj-o~ RELATIONSHIP TO DECEDENT Do Not List Trustee(s) NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (0) (1.2)] 1. -rlfeLMA- G. E12AJEf ?Jr;? I @4-K. Ot/J4L- ;tI cel-! /}I///CS 6t1R~ p/-J- 17t755~ CtIIP~ ~~ ~~ tp ,,1:.g.~k CUiL ~ rrin;C al~~ t-tJiU ~, -<2....4L . e AMOUNT OR SHARE OF ESTATE /00 t~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II 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 ,. TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REY-1500 COYER SHEET $ (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ 112-0. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV-1500 Cover Sheet ESTATE OF FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. o Will 0 Intervivos Deed of Trust 0 Other LIFE ESTATE INTEREST CALCULATION NAME(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF OEATH LIFE ESTATE IS PAYABLE o Life or o Term of Years o Lifeor o Term of Years o Life or o Term of Years o Life or o Term of Years o Life or o Term of Years - 1. Value of fund from which life estate is payable . . . . . . . ..... .$ 2. Actuarial factor per appropriate table ......................... Interest table rate - 0 3 1/2% 06% 0 10% 0 Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) .. ............. .$ ANNUITY INTEREST CALCULATION NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY 15 PAYABLE o Ufeer o Term of Years o Life or o Term of Years o Life or o Term of Years - o Life or o Term of Years 1. Value of fund from which annuity is payable . . ........ .$ 2. Check appropriate block below and enter corresponding (number) Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) o Monthly (12) o Other ( 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ............................. 5. Annuity Factor (see instructions) Interest table rate - 0 3 1/2% 0 6% 6. Adjustment Factor (see instructions) ... o 10% 0 Variable Rate % 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) 07-25-2005 ERNEY 04-11-2004 21 04-0428 CUMBERLAND 101 APPEAL DATE: 09-23-2005 ( See reverse side under Objections) Amount Remitted I I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE _ RETAIN LOWER PORTION FOR YOUR RECORDS _ REV: iSl,7 - Ei( AFP- '( 03:0S; - NOTicE-oF - iNHERiTANcE - TAi( APPRAisEMENT: - ALLOWANcE-OR - - - - - - - - - - - - - -- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DANIEL P FILE NO. 21 04-0428 ACN 101 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 11128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX ~~:~:i~~~L~::~~~E~~~~~A~~~:CE 2C~5..F..~:2 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN r" , I,. ':; "7 '-<. (- THELMA G ERNEY r 881 OAK OVAL MECHANICSBURG PA 17055 ESTATE OF ERNEY *' REY-lS47 EX AFP (06-05) DANIEL P TAX RETURN liAS: I X I ACCEPTED AS FILED I CHANGED DATE 07-25-2005 I~ an assessment was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will r~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Mount of Line 14 at Spousal rete US] 16. ~unt of Line 14 tax.ble at Lineal/Class A rat. (16) 17. ARount of Line 14 at Sibling rat. (17) 18. ~ount of Line 14 taxable at Collateral/Class Brat. (18) 19. Principal Tax Du. T . RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. R..1 Est.t. (Schedule A) 2. stocks and Bonds (Schedule 8) 3. Closely Held stock/Partnership Interest (Schedule C) 4. tIortgqBs/Notes Reeei vable (Schedule D) 5. C.shIBank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Ownod Property ISchedule FI 7. Transfers (Schedule S) 8 . Total Assets III (2) 131 I'll 151 161 171 .00 .00 .00 .00 .00 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/A~. Costs/Hisc. Expenses (Schedule H) (9) 10. Debt~ortgage Liabilities/Liens (Schedule I) (10) 11. Total Deduct10ns 12. Net V.lue of Tax Return 13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax .00 .00 1111 1121 1131 1141 NOTE: .00 .00 .00 .00 X 00 = X 045 = X 12 = X 15 = AHOUNT PAID DATE IlUIIIIER INTEREST/PEN PAID I-I ~ TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. NOTE: To insure proper credit to your account, sub.it the upper po~tion of this fo~. with your till( paynent. .00 00 .00 .00 .00 1191= .00 .00 .00 .00 .00 .00 .00 .00 .00 I IF TOTAL DUE IS LESS THAN $1, NO PAYIlENT IS REIlUIRED. IF TDTAL DUE IS REFLECTED AS A "CREDIT"' ICRI, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORK FDR INSTRUCTIONS.I Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 3/06/2006 ERNEY THELMA G 881 OAK OVAL MECHANICSBURG, PA 17055 RE: Estate of ERNEY DANIEL P File Number: 2004-00428 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 4/11/2006 please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, ~~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel ~~ . Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name ofDecedent: 08A.J IffL if E R IV EY / Date of Death: tf -//- a(7t7 L.-/ Estate No.: ,~tJoLf - Ot?1/-a~ Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes14 No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be con1plete: 3. lfthe answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No 0 r:-Y ~L€~...) ~ ,. b. The separate Orphans' Court No. (if any) for the personal representative's account is: d~71' L ~-r{.f- c. Did the personal representative state an account informally to the parties in interest? Yes 0 No 0 Atf'7J ~ C ~U~ . c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: 3- 9'~() (., Sig:::~'J:/,. / ~1/ /JlELHA G- EI2AJeV I Name %gl @fJK OtJlJl- ~ NE'MItAJ)CSI3t1~G; fJll /~OS.s- Address 7/7-697--785/ I:.:=) Telephone No. Capacity: ~Personal Representative - ("lJ I P €' o Counsel for personal representative 'fa