HomeMy WebLinkAbout01-0332
PETITION FOR PROBATE and GRANT OF LETTERS
Estate 01])D he....) J T D"vo' J4 No. o'2.J - 0 J -, ::S3::U
also known as To:
Deceased.
Social Security No. / OJ ~ -) ~ - L> 'LJ>5"
Re~ister of Wills for the
County of CnMRF.RT ,ANn in the
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age Rr older an the executY" : )(
in the last will of the above decedent, dated ftv;}.'2 4) ')
and codicil(s) dated
named
,19~
(state relevant circllmstances, e.g. renunciation, death of executor, etc.)
. I?ecendent was d?miciled. at .death i? l0 ir"r' b.u- ).:; h d fiounty, Pennsylvania, with
h \ <;. last fa.mily or pnnclpal residence at . I '-I 1 tJ ~ h. \,+0 h r. ) ~/,.,::
(Y\.-e...c-~~; c-rh"-{.~ ; tPA / (o S:S-(HAMPnF.N 'T'T.JP pE'r Gloria Ferron II 8-2002)
(list street, number and muncipality)
'00
Decendent, then 0
at
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
~fter execution of.Jh~.wi~p.rfered. for pro~ate; was nor the victim o.f a kil 'ng and was neve adi4dicated J' '0/0
mcompetent: Ji/CJ!.Jva...( -\-'L d ,'hc...D~ I l' L o. f L.a )
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: .) ") !A..Jot.:> dc...r-e... +-
e..c.. b<..tJ-
years of age, died
!tPlri) }
.~ 2..00-<
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WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters
/dministration c.I.a.; administration d.b.n.c.l.a.)
;emn~~f~~
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i,c>S'S
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA I s~
COUNTY OF CUMBERLAND J ~
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 _ ly a9min~~tate according to law.
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Sworn to or af~med and subscribed { ~ {., ~
before me this 4 day of ~
APRIL' 2002 ~ I::l
~&.'~""J~ _ - ~
CLEWIS' Register ~
11 - 5;"'} - J d-
No. DlJ- O/-r-?'~J}.J
Estate of
DONALD J DAVIS
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW APRIL 4, 2002 xi&x-, 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 R-?4-1 qq()
described therein be admitted to probate and filed of record as the last will of
DONALD J DAVIS
and Letters 'T'R~'T'AMRN"rARV
are hereby granted to GLORIA I FERRON AND CHERYL M STERNER
'"1'ih~ (!. I~J1J.t.. P (- f? CL _ ~~/~
MAR C LEWI~egister of Wills
FEES
Probate, Letters, Etc. .........
Short Certificates( )..........
~ ~+9-. P.Clg~? ..
JCP
$ 235.00
$
$
$
TOTAL _ $ 261.00
Filed 'l'.;,[~ ~t-~'~~??~' . . . . ~. '4 . 02" .. .. .. ..
mal eu 0 exec on "t- -
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AITORNEY (Sup. Ct. l.D. No.)
ADDRESS
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This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local ~egistrar. The original certificate will be forwarded to the State Vital Records Office for permanent~tJ.ling.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
~.JUd./'?&-I;'~
Local Registrar .
Fee for this certificate, $2.00
p
8203746
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Date
HI05. t43Aev. 2187
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
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NAME OF DECEDENT (fit$!. Middle.las)
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LAST WILL AND TESTAMENT
OF
DONALD J . DAVIS
21-0\-332.
I, DONALD J. DAVIS of Hampden Township, Cumberland County, Pennsyl-
vania, declare this to be my Last will and Testament, hereby revoking
any will previously made by me.
I - I direct the payment of all my just debts and funeral
expenses out of my estate as soon as may be practical after my death.
II - I devise and bequeath all of my estate of whatever nature
and wherever situate unto my three sisters, Gloria I. Ferron, Claire E.
Marsh and Byrle K. stevens, the share of a deceased sister to be paid to
her issue per stirpes.
III - I appoint my sister, Gloria I. Ferron, and my niece,
Cheryl M. sterner, Executrices of this, my Last will and Testament.
Neither of my personal representatives shall be required to post bond in
this or any jurisdiction.
IN WITNESS WHEREOF,
1:1-
the c:;; 71" day of
I have hereunto
~CJf~
#
set my hand and seal on this
, 1990.
u~A~~
(SEAL)
ARNOLD & SLlKE, AITORNEYS-AT-LAW, 2109 MARKET STREET, CAMP HILL, PA 17011
"
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, .
signed, sealed, published and declared by DONALD J. DAVIS, Testator
therein named, on this and one (1) other sheet of paper as and for his
Last Will and Testament, in our presence, who, in his presence, at his
request, and in the presence of each other, have hereunto subscribed our
names as attesting witnesses.
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Name
di(~
- . ~<<,;{L/~-,
/ Name
~/{~8,
Address
heWEt<Aogq~~
ress
ARNOLD & SLlKE, ATTORNEYS-AT-LAW, 2109 MARKET STREET, CAMP HILL, PA 17011
'.. ,
~ 100.... . t . ...
COMMONWEALTH OF PENNSYLVANIA)
: 55.
COUNTY
OF
CUMBERLAND)
WE, the undersigned, the testator and the witnesses,
respectively, whose names are signed to the foregoing instrument, being :
first duly sworn, do hereby declare to the undersigned authority that !
the testator signed and executed the instrument as his Last will and i
Testament and that he signed willingly (or willingly directed another to i
sign for him), and that he executed it as his free will and voluntary I
act for the purposes therein expressed, and that each of the witnesses, I
in the presence and hearing of the testator signed the will as witnesses
and that to the best of their knowledge the testator was at that time
eighteen years of age or older, of sound mind, and under no constraint
or undue influence.
j)-~J/)-~
~estator
*p~
. .. Witness
~L/~
and
of
Subscribed, sworn to and acknowledged before me by the te9~or,
subscr~d and sworn to before me by both v"itnesses, this ~~ day
~ ~ , 1990.
{/ ~~q;-e.<<4~:
Notary Public
NOTARIAL SE.AL
THELMA S. McCAUSLIN, Notary Public
Camp HHi. PA Cumber,and County
Wy Commj~sicn Expires July 3, 1992
,\P'l()l.D R. ,<';1 ,''':F. YITOPl'nY<"'-\1 !'\\\.,'IP'l\C\P1....,'! ',II~I'T r,\\fI'IlllI..I',\ linll
JERRY R. DUFFIE
RICHARD W. STEWART
C. ROY WEIDNER. JR.
EDMUND G. MYERS
DAVID W. DELUCE
RALPH H. WRIGHT, JR.
DAVID J. LANZA
MARK C. DUFFIE
KEIRSTEN WALSH DAVIDSON
MICHAEL J. CASSIDY
LAW OFFICES
JOHNSON, DUFFIE, STEWART & WEIDNER
A Professional Corporation
301 MARKET STREET
P. O. BOX 109
LEMOYNE. PENNSYLVANIA 17043-0109
WEBSITE: www.jdsw.com
HORACE A. IOHNSON
OF COUNSEL
TELEPHONE 717-761-4540
FACSIMILE 717-761-3015
E-MAIL mail@jdsw.com
WRITER'S EXT. NO. 15
E.MAIL dwd@jdsw.com
March 26, 2001
Clerk
Orphans' Court Division
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013
Re: Petition for Guardian
Estate of Donald J. Davis
Dear Sir or Madam:
Enclosed herewith please find the original and three (3) copies of a Petition for a
Guardian in the above-captioned matter. Also enclosed herewith is a check in the amount of
$32.00 to cover the cost of filing this Petition. Please forward this Petition to the Court
Administrator so that he may forward it to a Judge for entry of an Order scheduling a hearing as
soon as possible. When the Order has been signed and a Citation issued by your office, please
call me or my assistant, Kristee Myers, so that we may pickup the documents for service. Your
prompt attention to this matter shall be appreciated.
Very truly yours,
DWD:kkm:14664
Enclosures
cc: Holy Spirit Hospital (wlo encl.)
I .
MAR 2 8 200{;/'
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. .21.0 I -3.3~ ORPHANS' COURT
ESTATE OF DONALD J. DAVIS
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE DONALD J. DAVIS TO BE INCAPACITATED
AND TO APPOINT GUARDIANS FOR HIS PERSON AND HIS ESTATE
PRELIMINARY DECREE
AND NOW, this cJ..1'R.... day of ~ ~ , 2001, upon consideration of the
annexed Petition, it is ORDERED AND DECREED that a hearing on this matter is set for the 01 J I'rV'day of
ACi ~ ' 2001, in Courtroom No. _'? , at ~ " J d P .M,
at the umberland County Courthouse, 1 Courthouse Square, Carlisle, Pennsylvania, and that a Citation be
issued to Donald J. Davis commanding him to show cause why he cannot appear at the aforementioned
hearing pursuant to the Petition of Holy Spirit Hospital to have Donald J. Davis adjudicated an incapacitated
person and to have plenary guardians appointed for his person and his estate. Notice of the hearing shall
be given to Donald J. Davis in accordance with 20 P.S. 9 5511 (a) not less than twenty (20) days prior to the
hearing.
I' ,
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, I'. ,f '; (~L
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. \...2.J -01- d32....0RPHANS' COURT
ESTATE OF DONALD J. DAVIS
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE DONALD J. DAVIS TO BE INCAPACITATED
AND TO APPOINT GUARDIANS FOR HIS PERSON AND HIS ESTATE
FINAL DECREE
AND NOW; this '- ~y of · ( , 2001, upon consideration of the
Petition of Holy Spirit Hospital and following a haring, it is ORDERED AND DECREED that Donald J. Davis
is adjudicated an incapacitated person and that Gloria I. Ferron and Cheryl C. Sterner are appointed as
plenary guardians of his person and his property; and no bond shall be required of the guardians named
herein; and that said guardians are hereby authorized to make decisions on his behalf concerning his
medical care and treatment including admission to nursing homes, personal care facilities, hospitals and
other health care providers as well as to consent to and authorize his medical treatment; and the guardians
are authorized to sell and convey all of his real property, including that property located at 479 Wood crest
Drive, Mechanicsburg, Cumberland County, Pennsylvania; and the guardians herein appointed are further
authorized to make future payments of both income and principal for his care and maintenance as may be
necessary including the payment of legal fees, and court costs affiliated with obtaining this guardianship and
all matters related thereto.
J.
~.--
_-.:J
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. ORPHANS' COURT
ESTATE OF DONALD J. DAVIS
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE DONALD J. DAVIS TO BE INCAPACITATED
AND TO APPOINT GUARDIANS FOR HIS PERSON AND HIS ESTATE
TO THE HONORABLE, THE JUDGES OF SAID COURT:
The Petition of Holy Spirit respectfully represents that:
1. Your Petitioner, Holy Spirit Hospital of the Sisters of Christian Charity ("Holy Spirit Hospital")
is an acute care hospital located at 503 North 21st Street, Camp Hill, Cumberland County, Pennsylvania
17011-2288.
2. Donald J. Davis is a 79 year old incapacitated male, born on August 7, 1921. He has never
been married and has no children. His current residence address is 479 Wood crest Drive, Mechanicsburg,
Pennsylvania 17055, a single family residence owned by him.
3. Donald J. Davis was brought to the emergency room at Holy Spirit Hospital on March 7, 2001
and admitted as a patient. He was brought to the Hospital by an ambulance at the request of his sister after
falling in the shower and he was unable to pick himself up. This was the second time in the last six months
where he had been admitted to the Hospital as a result of a similar episode.
4. According to his treating physician, Richard Lock, M.D., the patient suffers from Diabetes,
high blood pressure and vascular dementia from multiple mini strokes.
5. Donald J. Davis resides alone and has had significant problems managing at home without
the assistance of his family, the Office of Aging and other in-home service providers. He was a patient at
Health South Acute Rehab and left the facility against medical advice on November 13, 2000. A home
health care agency began assisting him until December 1, 2000, when it discharged him from their services
due to his non-compliance and failure to take his medications at which time a protective services referral
was made at the Cumberland County Office of Aging.
6. During his current admission to Holy Spirit Hospital, both his treating physician, Dr. Richard
Lock and a consulting psychiatrist, Dr. David Petkash, have determined that he lacks the capacity to make
medical and financial decisions for himself and is in need of a guardian.
7. Donald J. Davis' treating physician, Dr. Richard Lock, has recommended that he be placed in
a supervised setting with 24-hour care, such as an assisted living center. While he is now ambulatory,
Donald J. Davis needs constant assistance in handling his affairs of daily living and cannot be left alone.
8. Donald J. Davis is an incapacitated adult person who needs a court appointed guardian for
his person and his property.
9. It is believed that Donald J. Davis has a monthly income of approximately $2,000.00, real
property where his home is located which is worth more than $200,000.00, and various investments, the
exact amount of which is uncertain.
10. Donald J. Davis executed a general Power of Attorney on August 24, 1990 appointing his
sister, Gloria I. Ferron as his attorney-in-fact, and designating his niece, Cheryl C. Sterner as his alternate
attorney-in-fact. Both have been providing assistance to Donald J. Davis, including the handling of his
financial affairs.
11. Based upon information from his family, it is believed that Donald J. Davis has executed a
Will designating Gloria I. Ferron as his Executrix, and his niece, Cheryl C. Sterner, as the alternate
Executrix.
12. Your Petitioner, Holy Spirit Hospital, is a creditor of Donald J. Davis, and has standing to
bring this action.
13. The Cumberland County Office of Aging who has been providing certain services to Donald J.
Davis has also indicated that he is appropriate for placement in some form of assisted living care.
14. Donald J. Davis refuses to follow the recommendations of his treating physician and the
Office of Aging, and desires to return to his home which your Petitioner does not believe is a safe and
appropriate living arrangement for him because he cannot manage his own affairs, his health will deteriorate,
and his life will be endangered.
15. In order to assist Gloria I. Ferron and Cheryl C. Sterner in the handling of Donald J. Davis'
affairs, a guardian over his person and his property needs to be appointed.
16. Gloria I. Ferron and Cheryl C. Sterner have both indicated their willingness to act as co-
guardians of the person and property of Donald J. Davis. Attached hereto as Exhibit "A" are consents to
being appointed guardian signed by Gloria I. Ferron and Cheryl C. Sterner.
WHEREFORE, your Petitioner prays that a Citation be issued to Donald J. Davis to show cause why
he should not be adjudged to be incapacitated and plenary guardians for his estate and person be
appointed, and that the Court schedule a hearing on this Petition.
Date4Zfe /0 I
avid . Del e
Attorney 1.0. #41687
301 Market Street
P.O. Box 109
lemoyne, PA 17043-0109
Telephone (717) 761-4540
Attorneys for Holy Spirit Hospital
: 144622
VERIFICA TION
I, Susan S. Zeigler, ACSW LSW, Director of Social Services of Holy Spirit Hospital of the Sisters of
Christian Charity, verify that the statements made in the foregoing Petition are true and correct to the best of
my knowledge, information and belief. I understand that false statements herein are made subject to the
penalties of 18 Pa.C.S. 94904 relating to unsworn falsification to authorities.
Dated:
a/d-o#1
/ r
031~3/20'01 10:54 FAX 717 761 3015
JDS&W
III 008/009
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. ORPHANS' COURT
ESTATE OF DONALD J. DAVIS
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE DONALD J. DAVIS TO BE INCAPACITATED
AND TO APPOINT GUARDIANS FOR HIS PERSON AND HIS ESTATE
ACCEPTANCE BY PROPOSED GUARDIAN
Gloria I. Ferron, hereby agrees to aeeept the appointment of plenary guardian of the person and
estate of Donald J. Davis, if he is adjudged to be an incapacitated person by the Cumberland County
Orphans' Court.
.4 ..."7
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Dated: 2/=)3/0/
.
03{~3/20~1 10:55 FAX 717 761 3015
.
JDS&W
III 009/009
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. ORPHANS' COURT
ESTATE OF DONALD J. DAVIS
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE DONALD J. DAVIS TO BE INCAPACITATED
AND TO APPOINT OUARDIANS FOR HIS PERSON AND HIS ESTATE
ACCEPTANCE BY PROPOSED GUARDIAN
Cheryl C. Sterner, hereby agrees to accept the appointment of plenary guardian of the person and
estate of Donald J. Davis, if he is adjudged to be an incapacitated person by the Cumberland County
Orphans' Court.
~C~
ryJ . Stemer
Dated: 7/d{ 3/0 I
/ /
-. , ' -
IN RE:
ESTATE OF DONALD J. DAVIS
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY. PENNSYLVANIA
NC"'cH -332.. ORPHANS' COURT
IMPORTANT NOTICE
CITATION WITH NO TICE
A petition has been filed with this Court to have you declared an Incapacitated Person. If the Court
finds you to be an Incapacitated Person, your rights will be affected. including our right to manage money
and property and to make decisions. A copy of the petition which has been filed by
HOLY SPIRIT HOSPITAL is attached.
You are hereby ordered to appear at a hearing to be held in Court Room No. 3 . Cumberland
County Courthouse, Carlisle, Pennsylvania. on APRIL 25 , 2001 ,at 2: 30 P.M. to
tell the Court why it should not find you to be an Incapacitated Person and appoint a Guardian to act on
your behalf.
To be an Incapacitated Person means that you are not able to receive and effectively
evaluate information and communicate decisions and that you are unable to manage your
money and/or other property. or to make necessary decisions about where you will live,
what medical care you will get. or how your money will be spent.
At the hearing. you have the right to appear. to be represented by an attorney, and
to request a jury trial. If you do not have an attorney. you have the right to request the
Court to appoint an attorney to represent you and to have the attorney's fees paid for you
if. you cannot afford to pay them yourself. You also have the right to request that the Court
order that an independent evaluation be conducted as to your alleged incapacity.
If the Court decides that you are an Incapacitated Person, the Court may appoint a
Guardian for you. based on the nature of any condition or disability and your capacity to
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make and communicate decisions. The Guardian will be of your person and/or your money
and other property and will have either limited or full powers to act for you.
If the court finds you are totally incapacitated, your legal rights will be affected and
you will not be able to make a contract or gift of your money or other property. If the court
finds that you are partially incapacitated, your legal rights will also be limited as directed
by the Court.
If you do not appear at the hearing (either in person or by an attorney representing you) the court
will still hold the hearing in your absence and may appoint the Guardian requested.
By:
DATED: If/Jfr/L iF; ;JOO/
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. 21-01-332 ORPHANS' COURT
ESTATE OF DONALD J. DAVIS
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE DONALD J. DAVIS TO BE INCAPACITATED
AND TO APPOINT GUARDIANS FOR HIS PERSON AND HIS ESTATE
AFFIDA vir OF DA VID ~ DeLUCE
COMMONWEALTH OF PENNSYLVANIA
ss:
COUNTY OF CUMBERLAND
DAVID W. DeLUCE, being duly sworn according to law, upon his oath, deposes and says:
1. I am counsel for Petitioner Holy Spirit Hospital in the above matter.
2. On the 9th day of April, 2001, I personally served upon Donald J. Davis at Country Meadows,
Dementia Unit, 4837 Trindle Road, Mechanicsburg, Pennsylvania 17055, and read to him, the Petition to
adjudicate him to be incompetent and to appoint a guardian for his person and his estate, the Citation issued
pursuant thereto by the Clerk of the Orphans' Court, an e relimin e sche ing a hearing.
:144622-9
Notarial Seal
lemoKrlstee K Myers, Notary Public
yne BolO, CUmberland County
My Commission Expires Dec. 2, 2002
Member, Pennsylvania Association ot Notaries
;, ~ '.. '" 'l".
HSH SOCIAL SERVICES
Fax:717-972-4138
Mar 16 '01 17:46
P.04
. . - -, - ..., ....r-'
G~ POIIq 01' A.'P~~J
I, DOHALe J. DAV7S of Mechanicsburq, Cumberland County, Pennsylvania,
hereby appoint my sister, GLORIA I. FERRON, (hereinafter referred to as
limy attorney") my attorney, and I intend that my attorney may transact
all my business for me and in my name and stead manaqe all my property
and affairs as completely as I myself miqht do if personally present,
including but not limited to, exercising the following powers:
1. IXAeQtlon of Contract~. To enter into, perform, modify,
extend, cancel, compromise, enforce, o~ othe~ise act with respect to
any contract of any sort whatsoever, including but not limited to,
leases and mort94qes, and to pay any money or to transfer title and
possession to any real or personal property ~hat may be required to be
paid or transferred by any contract or in the perfor.mance of any Obliga-
tion entered into Qr incurred by me or on my behalf.
2. Investmen~. To invAst in all forms of real and personal
property without any restriction whatsoever as to the kind at invest-
ment, including but not limited to, United States Treasury Bonds which
are redeemable at par in payment of federal estate taxes.
3. ReQist~atiqn of PrQpe~tx. ~o hold property unregistered or
in the name of a nominee.
4. Personal Property. To buy or sell at public or private sale
tor cash or credit or partly tor each, exchange, pledge, leas., give or
acquire options tor sales or exchanqes or leases, or by any other means
whatsoever to acquire, dispose of, repair, alter or manaqe tangible or
intangible personal property or any interest therein: and, without
limitation, with respect to any securities, to comply with any securi- . i
ties laws or regulations, to eXGcute indemnity agreements, to purchase I
insurance and to pay commissions or discounta required by any underwrit- I
inq.
... -l PETITIONER'S
j -i' EXHl81T
4i~/OJ 7A1L.1
ARNOLD Ie SLU~E. ATTOllllltU'AN.AW, flOl MAAKlT naU,T. ::AM' "IU. ,.~ IJOll
HSH SOCIAL SERVICES
Fax:717-972-4138
Mar 16 '01
17:47
P.05
~. 8eal Promlltty. '1'0 buy Qr ..11 at: Ilublic ot' pr!va1:. 8ale for
cash or credit or partly tor each, exchanq., mortqaqe, encunber, lease
for any period of ~1.., i1ve or acquire op~ion. tor .ale., purchases,
exchan9.. o~ l.a..s, dedicate/ or by any othar ..an8 wh4tsoe~.r to
I acquire or dispose at ~eal property or anY intereat therein: to parti-
. ticn and subdivide real property: to Danag. real property ~ 1:0 repair, I
~ alter, erect, or tea~ dc~n any structure or part ther.of~ and to file
.uch plans, applica~lons, or other documents in connect:ion therewi~h and ~
do such other act. .s .ar bB requested ~y any qovernment or ether auth- '
or1ty naving or purporting to have jurisdiction.
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6. ~8~u~tt:i.R. To vat. 1n parlon or ~y proxy at any ...ting,
to join in any =erger, rA0r9ani2atlon, votin9-~ru.t plan or other con-
cert.d action at security holders, to ~a~. payment:. in connection ~h8re-
with, and in general ~Q exerei.. all ri9h~s ot . .ecurity holder.
1. Insurance. To procure, alter, extend or cancel insurance
agalnet any and all ~isks affecting proper~y and peraonl, and aqainst
liability, da~age or claim of any sQr~; and to .xe~cis. any nan-
fortel~ur8 provision. of lite insura~c. palici...
8. ~. TO harz-oW Illoney 1n 8uch amounts feu: such periodS and \
upOn such ~eraa 8S .Y attorney Shall de.m proper and to eecure Ilny loan
by the .~rtqaqe or plQdge of eny property/ and t specifically authorize
bY a~~orn.y ~o ~rrow waney and to pledqe property as col1a~.ral eor the
pU~pQ.. ot purchasing united S~at.S ~~e..ury Bond. which are red.eaable I.
at pa~ in payaen~ af tederal ..t:a~. taxe..
9. bnk ~rmoun~.. To dqn ch8ckl!l, drart. and ather InetrullLBn1:s I
or otherwi.e ~aka v1thdrlvals fro~.any checking, ..v1nis, ~ran.ac~lon or i
other dlil~it account in 'fly nCURQ, alld to ol\4or.. check. payatlle to lne .
and receive tbe proceeds thereof in cash O~ otherwise, to open and cloa.
~heck1ni, s.vlng., transaction or oth~r deposit accounts in .y name; to
purch... and ~ed.em .avinga c8rtiricate./ c.rti~ica~.B of deposit or
.i_Liar i~.t:rUA.nt8 i~ my ~e: ~o execute and deliver receipts tor any
~~ds ~i~drawn or certificate. ~ede..ed: an4 1:0 do all acea regard1nq
any oheckinq account, eavinq. account, ..vinQa certlricat., eert1ticate
0' ~epo.i~ or Atmila~ 1nstrumen~ which I now have or ..y herearter
acquire, the 8am. .. I could do if personally present. Any tinanclal
inst1tu~1on ..Y continue to rely on ~hi. pawer ot attQrney until it
receives written notice troM .. tha~ this power of a~torney ie r.vo~8d
or actual notice ot my de&~ and 5ha~1 be indemnified end held harmless
by .. an~ my e.~ate, personal ~.pr...ntati~.. and heirs a9_1net any
liability or 10.., incl~inq lawyers' te.., co.~. of suit and claima of
third parties, which it might incur by relying on this power .fter -
te~ln.~ion or r.vQca~ion bu~ b.~~re !t r.ceive. 'UCft notic., or at any
~ime beeaU.8 ot wronqful acts, o~i..lon. or repre..nt.~ion. of my
a~tarne1. v1th r..pect to ~anlactionB covered by this power ot a~tor-
ney. My attorney ahall be subject to w~a~.v.r b~ rules and requla..
tion. I would be 'UbjAct to.
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Al,NOUlIo SL:ll. ATT:;).Nln~H,"W.JI" MAlLU1' IlUP. 0;;..... "'u., P. ,'.!I
HSH SOCIAL SERVICES
Fax:717-972-4138
Mar 16 '01
17:47
P.06
10. Sa~. D.9a8i~ Rexa., TO have access to and control over ~he
con"ten't's ot any safe deposit box rented by 'IDe, to rent aate deposit
boxes in ay name, to close out and .~.Qut. and deliver receipts tor safe
deposit DOxes in ay name, and to do all acts reqarding any safe deposit
bcx which I now have or may hGr..tter acquirQ. the sa.e a. I could do if
per80nally pre.e~r provided that ~ attorney ehall not deposit or keep
in any ~uch safe deposit any property in Which my attorney. have a
Feraonal inter.at. Any ~inancial institution may continue to rely on
this power ot attorney until it receiv.. writ~.n notice from me that
this power at attorney is r.~ked or actual notioe of .y death and ahall
be indemniti~ and held harml... b~ ~. and .y ..tate, pereonal represen-
tatives and heirs a9ains~ any liability or 10._, inCluding lawyers t.es.
coste at suit and claim. ot tb~rd partl.~, which it miqbt incur by
relylng on this power after terminaeion or revocation but beto~. it
receive. .uch notice, or at any time becau.. ot wrongful acts, omissions
or representation. ot .Y attQ~n.Y8 with respect to transactions covered
by this pOwer of a~torn.y. MY attorney shall be subject to whatever
bank ~l.. and ~ula~1on8 I WOUld be subject to.
11. rlAeaipu.aM ~;rovlll of A~QWlts. .To receive.. payJIlilnt 01:
any kin~, including . bequ"~, devise, qift or other transfer af real or
pe~.onal p~party to me in .y own r1qht or aa a fiduciary tor anotber,
and to 91v8 ~ul.l receipt and acquittance therefor, or .. 1:'eftmdlnq bond
therefor, to approve accounts ot any bUsin..., estate, trust, partner-
ship or other tr.neaation whatsoever 1n which I may have any interest of
any nature whatsoever. and to enter into any eo.promise and releane in
reqarcl tbereta.
12. "~ro'llh.. Ilnd Arbit:'t'at;~9n of Claillls. To cOlllpro.iee ot'
arbitrate any claim in vhloh I may be in any m.nn.~ interested, and for
that purpose to .n~.r into aqreemGnts to compromise or arbitrate, and
either throuqh coun..l or o~herwl.. to carry on 8uch c~prQml.. or
arbitration and pertorn or .nfarca any awar4 entered in arbitration.
13. lnAtitui:.ion Ilnd 0.1:10" .o.f C'1Il i '11'I1:. . ':ta il"lStitute, prOd....
cu~.. ~.f.nd. oompro~i.e, or othervi.. dispose of, and to appear lor me
in, any proc.~inQ. at law or 1n equity or otherwise before any tribunal
for the entorc...nt or tor the dsfen.. of any claim, either 1l10n. or in
conjunction with other persona, relatinq to me or to any property ot
mine or any other pereon, and to retain, discharqe and subet!tute eoun~
.01 and authori.e appearanoe af .ueh counsel to be enterod rar .. in any
SUch ac~ion or procaedinq.
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"I1(OI.D .. SUIE, 'TTQ_"t~S..t.LA", "., "~"""IT"U". C....ICIIJ.. ... :/0..
HSH SOCIAL SERVICES
Fax:717-972-4138
Mar 16 '01
17:48
P.07
14. ~. To prep.re, execute and file in .1 name and On my
behalf any return. report, prQtes~, .pplica~ion for correction ot
a.8ess8d valua~ion or real or ether property, appeal, bri.!, claim tor
refund, or peti~ion, lncludin9 petition to the United states Tax Court,
in connection ~itb any tax imposed or purported to be i.posed by any
9ov.rnm.n~, au~or1~y or Bgency, O~ Claimed, levied or ......84 by any
govern.ent, authority or aqency and to pay any such tax and to obtain
any extension of time tor any of tbQ toreqoinq: to @xecute waivers of
r..trictione on tbe ass...ment and collection of deficiency in any tax:
to eK8cute 010s1n9 aqr....nts And all other docum.nts, instru.ent~ and
papers r.l.~inq to any ~ax liability of mine at any sort; to institute
and carryon either throuqh counselor otherwi.. any proaaedinq in
connection wi~ eont..tinq any such tax or ~o recover any tax p.id, or
to re.ist any claim for additional tax or any proposed .ssess~.nt Or
1.vy thereof, and to .nt.~ into any aqre..ents or stipUlations for
c~pro.is. or other adj~tm.nt Qr disposition of any tax.
t5. nisclalm8r. TO execute, deliver ~nd tile for r.eord di.-
claimers Of any part or ell ot any prope~y. ~ower or int.~8st passing
ta or for .. under any will, deed ot t~~t or atherwi...
~&. Cr.a~iftn qt Tru~~. To cr.ate . reVOcable tru.t for my
benefit under the terMS ot which (i) my attorney or anyone or mere
Dt~er persons or corpor.tions with fiduciary ~rs selected by .y
attorn.y i. n.sed 88 the trustee or trust..., e1i) durinq .Y li~.t1~e
the entire net income and .. Duch of ~e principal 8. I or .Y a~torney
directa Or ~y trust.. thinks desirable ahall be paid to =e or as I or my ;
attorney direct, and. (i 11) upon lilY d..~ <cbe prinoipal and any undis-,
trib~ted income shall b. payable ~o the executor or administrator or my ;
e8tate, ana to transfer property to the truat.. or trust.es thereunder. I
I
17. bplOYM.m of cth.U. TO elllploy acoountant., .~t:orn.ylS- I
at-law, inv..t~nt counael, custodian., agents, .ervanc~1 and others, to!
delegate to the., to reaove thu,t.o appoint o~. 1n their places, and:
to pay th.. euob re.unera<cion .. my attgrney shall d... prOper.
18. ~ACUtion ot QOaU..nt~. To ex.cut., 4.1i~Gr, tile ~or ,
record, cancel, >>odify, ender.., acquire or ~lapo.. er any lna~rument, 1
1neludinq but hftt. limited to, stock and bond power., vehicle reqistra- I
t.ion., financing statements and. t"81ated tilinq doc;aUllenta, l"Gports of any :
sort to any qove~nt, authority or aqency. a. required Or p.~itted by I
la", <le.ds with or wi ~out .cov.nant. or warrant.i.., and any Qthat' docu- I
.ent appropriate tor carryinq out any ot ~n. tor.qoinq powers.
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AII.~OU).. IUItE, 'nG."'n..'.lAw, II" lIuUTnan.,. CAW''''L!. PA I""
HSH SOCIAL SERVICES
Fax:717 972-4138
Mar 16 '01
17:48
P.08
19. tiSla1th (!Bt'.... 'to arrange fOS' .y entrance to and ca~. at any
hOG. ,.., , nur.1n. hOOO, ...l<h con'''' ..n..l...... ...., ...1re....
...., or o1odl" inot1tut1on, and to orrang. tor, con.... '0, ..1v. .nd
e.~~nat. any and all ..dical and lur9ioa1 procedures on .Y behalf,
including the administration of druqa. and to pay all bills far my care.
20. WI.[lA%'t-l. 'fo 40 ell t:h~ng. lthich vrJ attorney ahall de..
prope~ 1n ardQr to carry ou~ any of the toregoin; enu..rated pOwer.,
which shall be canstrued in the broadest possible .ann.l'. The de.c~ip-
tive needin9s ot thie 9.ne~.1 power of attarney are inserted tor con-
venience only and anall not bA 4eeaQd to affect the ~.ninq or construc-
~ion of any ot th. provi.ions hereof ar to limit in any way the con-
.~ruction thereof in the broadeat po.Albie .anner.
2l. &vbatl~ut~on. If MY attorney-in-fact ~d abOye .n.l~ be
or beCo" unable or unwilling to .erve ar "to continue to ..rve. then I
appoint 1n her at.a4 or as her successor, .Y niece. c~.ryl H. sterner.
Subject to t~. foraqoinv, 1 author!E. ~y .~torney-in-tact to appoin~ a
sub~titute o~ &ucca..or to act as attorney-in-fact vlth the 8ame powers
as though named by m. in ~ni. Power of Attorney.
~2. Rati~~c.~ion. I herebY ratifY and conti~ all that my
at~rn.Y or the subatitut. or .u~.titut.. therefor _ball laWfUllY do or
caUBe to be ~on. by virtue heteo!.
23. lfOfelrt: p~~ Diaabfl- i ~. Tnt- power of attorney ahall not
be affectad by ay 4i..bility.
24. ggyernina t.aW. This pover ot attorney shall ))Ii qo....rn.4 by
an4 interprete4 1n accordance with pennsylvania law.
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HSH SOCIAL SERVICES
Fax:717 972 4138
Mar 16 '01
17:49
P.09
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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
WALTERS, MURREL R. III
54 EAST MAIN STREET
MECHANICSBURG, PA 17055
___h_h fold
ESTATE INFORMATION: SSN: 192-12-0785
FILE NUMBER: 2101-0332
DECEDENT NAME: DA VIS DONALD J
DATE OF PAYMENT: OS/28/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 04/01/2002
ACN
ASSESSMENT
CONTROL
NUMBER
101
TOTAL AMOUNT PAID:
REMARKS: MURREL R WALTERS III ESQUIRE
CHECK#1022
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
REV-1162 EXI11-96)
NO. CD 001219
AMOUNT
--------
I $99,382.84
I
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$99,382.84
MARY C. LEWIS
REGISTER OF WILLS
i ,."
/-'J. #~ _1/
/ ~" ,
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
'02 JU,--9
MURREl R WALTERS III ESQ
54 EAST MAIN STREET ,
MECHANICSBURG PA~~tJ855
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
07-08-2002
DAVIS
04-01-2002
21 01-0332
CUMBERLAND
101
. .",
i ./.;1 f
'*
(}
;../
REY-1547 EX AFP (DI-DU
DONALD
J
Allount Rellitted
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:is4--rEX--AFP--foY--02Y-Nor'"icE--oF-YNHEifiTAifcE-rAi-APjiRA-isEi'-ENT~-Ai:i-oWAifcE-ifR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF DAVIS DONALD J FILE NO. 21 02-0332 ACN 101 DATE 07-08-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Hortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E)
6. Jointly ONned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
184.175.25
.00
.00
.00
707.273.21
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Hisc. Expenses (Schedule H)
10. Debts/Hortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
18,586.24
1.082.85
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll Nith your
tax paYllent.
891,448.46
]9.669 09
871,779.37
.00
871,779.37
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
.00 X 00 = .00
.00 X 045 = .00
871 ,779.37 X 12 = 104,613.52
.00 X 15 = .00
(19)= 104,613.52
TAX CREDITS:
KICI.IC~t'1 (+J AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
05-28-2002 CDOO1219 5,230.68 99,382.84
TOTAL TAX CREDIT 104,613.52
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
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'iij [J Complete items 1 and/or 2 for additional services.
CII Complete items 3, 4a, and 4b.
t 0 Print your name and address on the reverse of this form so that we can return this
> card to you.
l!! [J Attach this form to the front of the mailpiece, or on the back if space does not
CII permit.
::: 0 Write 'Return Receipt Requested' on the mailplece below the article number.
c: 0 The Return Receipt will show to whom the article was delivered and the date
o delivered.
a: 3. Article Addressed to:
~ CLAIRE E MARSH
E 2441 BFADFDRD DRIVE
o
U YORK PA 17402
SENDER:
I also wish to receive the follow-
ing services (for an extra fee):
1. D Addressee's Address
2. D Restricted Delivery
4a. Article Number
70000600002555361165
4b. Service Type
D Registered
D Express Mail
D Return Receipt for Merchandise
~ertified
D Insured
DCOD
7. Date of Delivery
5. Received By: (Print Name)
~~\,~rv\ ~\.),-~ c\r
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PS Form 3811 , December 1994
8. Addressee's Address quested and
fee is paid)
102595-99-6-0223 Domestic Return Receipt
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CII Complete items 3, 4a, and 4b.
l!! [J Print your name and address on the reverse of this form so that we can return this
~ card to you. .
l!! 0 Attach this form to the front of the mailpiece, or on the back if space does not
GlilIlrmit.
~ CWrite 'Return Receipt Requested' on the mailpiece below the article number.
~ [J The Return Receipt will show to whom the article was delivered and the date
o delivered.
a: 3. Article Addressed to:
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SENDER:
I also wish to receive the follow-
ing services (for an extra fee):
1. D Addressee's Address
2. D Restricted Delivery
BYRLE K STEVENS
38 BUT'IDNWOOD AVENUE
WILKES BARRE PA 18702
.
4a. Article Number
70000600002555361158
4b. Service Type
D Registered
D Express Mail.
D Return Rece,ipt for Merchandise
~ertified
D Insured
DCOD
7. Date of Delive~PR 1 S 2001
8. Addressee's Address (Only if requested and
fee is paid)
,102595-99-8-0223 Domestic Return Receipt
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PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF
THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY
UNTIL COMPLETION
STATUS REPORT UNDER RULE 6.12
6L
tl)C-
Estate No.:
DONALD J. DAVIS
4/1/02
I
21-01-00332
Name of Decedent:
Date of Death:
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:
Yes_X_ No
2. If the answer is No, state when the personal representative reasonably believes that the
administration will be complete
(date)
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_X_
B. The separate Orphans' Court No. (if any) for the personal representative's
account is: (Not Applicable in Dauphin County)
C.t Did the personal representative state an account informally to the parties in
interest: Yes _X_ No
D.
Copies of receipts, releases, joinders and approvals of fo al or informal
accounts may be filed with the Clerk of the Orphans' ourt and may be
attached to this report.
Date: April 30, 2004
;,~
(L i:J
: ,.....
/I
MURREL R. WALTERS, III, ESQUIRE
54 East Main Street
Mechanicsburg, P A 17055
717-697-4650
[7: :','
[-A\!I.I t7!tapacity:
Personal Representative
_X_ Counsel for Personal Representative
REV-1500EX+(6-00)
'*
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
('~
OFFICIAL USE ONLY
S~I
IJ-
REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
\\
FILE NUMBER
2 1 - 0 1 3 32
""'Ccilji:jry"'COOE ---YEAR- - - N"liMeER--
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
DAVIS DONALD J.
DATE OF DEATH (MM-DD-Year)
SOCIAL SECURITY NUMBER
DATE OF BIRTH (MM-Do.Year)
192-12-0785
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
04/01/2002 08/07/1921
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST. AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
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[RI1. Original Return
D 4. limited Estate
[R] 6. Decedent Died Testate (Attach copy of Will)
D 9. litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a living Trust (AUachcopyofTrust)
D 10. Spousal Poverty Credit (date ofdealh belween 12-31.91 and 1-1-95}
o 3. Remainder Return (dateoldealhprioflo 12-13-82)
D 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach SchO)
THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
MURREL R. WALTERS 111 ESQ
FIRM NAME (If Applicable)
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54 EAST MAIN STREET
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TELEPHONE NUMBER
717/697-4650
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
MECHANICSBURG
PA 17055
.',p OFFICIAL.USE ONLY
18';':;';;.25 G
~-...)
(1)
(2)
(3)
(4)
(5)
\~
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Joinly 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 (Iotal Lines 9 & 10)
12. Net Value of Estate (line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
707,273.21
(6)
(7)
(9)
(8) 891,448.46
18,586.24
1,082.85
(10)
(11)
(12)
(13)
19,669.09
871,779.37
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
871,779.37
15. Amount of line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amountofline 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
X _(15)
X _(16)
871,779.37 X .12 (17) 104,613.52
X .15 (18)
(19) 104,613.52
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedenfs omplete ress:
S.REET ADDRESS
479 WOODCREST DRIVE
CITY I STATE I ZIP
MECHANICSBURG PA 17050
C Add
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
104,613.52
5.230.68
Total Credits (A + 8 + C)
(2)
5,230.68
3. InteresUPenalty if applicable
D.lnterest
E. Penalty
T otallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund (4)
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. (5A)
8. Enter the total of Line 5 + 5A. This is the 8ALANCE DUE, (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
99,382.84
99,382.84
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ........................................................................... 0 IZI
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 IZI
c. retain a reversionary interest; or ...................................................................................................... 0 [&J
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 IZI
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ......................................................... ..... ................................ 0 IZI
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 IZI
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .............. .......................... ............................................................... 0 IZI
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 that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct
and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATUR F PE ON R P ISLE FOR FILING RET RN DATE
5/23/02
A
PA 17055
DATE
5123/02
ADDRESS
PA 17055
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)l.
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 (aJ (1.1) (ii)l.
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)1.
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)(l)).
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.
"'.,~'''.('"''(.*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
R ID T
ESTATE OF FILE NUMBER
DAVIS DONALD J. 21 01 332
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
sUlVivorship must be disclosed on Schedule F.
SCHEDULE A
REAL ESTATE
ITEM
NUMBER
1.
DESCRIPTION
RESIDENCE SITUATE AT 479 WOODCREST DRIVE, MECHANICSBURG, PA
NET SALE PRICE
VALUE AT DATE
OF DEATH
184,175.25
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
184.175.25
. 2502-0265 ..-.-
A. B. TYPE OF LOAN:
U.S. DEPARTMENT OF HOUSING 8< URBAN DEVELOPMENT 10FHA 2.DFmHA 3. [j9CONV. UNINS. 4.DVA 5.DcONV.1NS.
6. ~I~!;,~'!,MBER T7 ~2:N NUMBER:
SETTLEMENT STATEMENT 8. MORTGAGE INS CASE NUMBER
C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.
Items marked "[POC)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals.
10 3198 (SADlER.PFDISADLER/12)
D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER
Michael W. Sadler Estate of Donald J. Davis Wells Fargo Home Mortgage, Inc
Diane K. Sadler P. O. Box 5910
3861 Eastview Drive Sprlngfleld.OH 45501-591O
Orefield, PA 18069
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 23-2015480 1. SETTLEMENT DATE:
479 Woodcrest Drive Residential Commercial Abstract. Inc.
Mechanlcsburg, PA 17050 April 11. 2002
PLACE OF SETTLEMENT
3631 North Front Street
Harrisburg, PA 17110
J. SUMMARY OF BORROWER'S TRANSACTION K. SU MARY OF SEL ER' TRAN ACTION
101. Contract Sales Price I 206.000.00 401. Contract Sales Price I 206,000.00
102. Personal Prooertv I 402. Personal Pronertv I
103. Settlement Charnes to Borrower (Line 1400) I 8,290.40 403. I
104. I 404. I
105. I 405. I
I
100. C\tvrTown Taxes to I 406. CitvrTown Taxes to .
107. Countv Taxes 04/12/02 to 01/01/03 I 426.23 407. Countv Taxes 04/12/02 to 01/01/03 ; 426.23
108. School Tax 04/12/02 to 07/01/02 I 484.37 408. School Tax 04/12/02 to 07/01/02 I 484.37
109. Aor. Mav June Sewer 04/12/02 to 07/01/02 i 86.15 409. Apr. May June Sewer 04/12/02 to 07/01/02 I 86.15
110. ! 410. ,
11,. 411. I
112. 412. I
120. GROSS AMOUNT DUE FROM BORROWER 215.287.15 420. GROSS AMOUNT DUE TO SELLER I 206,996.75
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER:
201. Deoosit or earnest mOney I 2.000.00 501. Excess Oeoosit (See Instructionsl T
202. Princioal Amount of New Loan(s) . 140,000.00 502. Settlement Charnes to Seller tLine 1400) I 39.541.50
203. ExistinQ loan(s taken subiect to I 503. Existinq loanis' taken subiect to I
204. Direct Bill Amount I 5,664.00 504. Payoff of first Mortgage
',205. I 505. Payoff of second Mortnane
206. I 506.
207. 507. (Qeoasit disb. as oroceeds)
208. , 508. I
209. Seller Assist/Camet Allowance r 8.000.00 509. Sener Assist/Caroet Allowance I 8,000.00
Ad'ustments For Items Un aid B Seller Ad"ustments For Items Un aidB eller
210. CitvrTown Taxes to I 510. Cit'lfTown Taxes to I
211. County Taxes to i 511. County Taxes to I
212. School Tax to 512. Schoal Tax to
213. . c- 513. ;
1214. 514. I
'215. , 515. ,
;216. , 516. i
.217. 517.
218. 518. I
219. : 519.
220. TOTAL PAID BY/FOR BORROWER 155.664.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 47,54150
300. CASH AT ETTLEMENT FROMITO BORROWER: 600 CASH AT SETTLEMENT TO/FROM SELLER:
301. Gross Amount Due From Borrower (Line 120) 215.287.15 601. GrosS Amount Due To Seller (Line 420 206.996.75
302. Less Amount Paid By/Far Borrower (Line 220) ( 155.664.00) 602. LesS Reductions Due Seller (Line 520) ( 47.54150
303. CASH ( X FROM) ( TO) BORROWER 59.623.15 603. CASH ( X TO) ( FROM) SELLER 159.455.25
OMS NO
-.
HUD+1 (3-86) RESPA, HB4305.2
Paae2
L. SETTLEMENT CHARGES
700. TOTAL COMMISSION Based on Price < "" ". <0 , nn PAID FROM PAID FROM
Division of Commission (Jine 700) as Follows: BORROWER'S SELLER'S
701. $ 6.205.00 to Re/!'v1ax Realty Associates FUNDS AT FUNDS AT
702. S 6.101.00 \0 Prudential Thompson Wood SETTLEMENT SETTLEMENT
703. Commission Paid at Settlement 12.306.00
704. Processino Ser/!ce Fee \0 Rei Max Realtv Associates 250.00
800. ITeMs PAYA8LE I E TI N WITH Ir.AN
801. Loan Ori ination Fee 1.0000 % to Wells Far 0 Home Mortoaoe, lnc 1.400.00
802. Loan Discount % to
803. Appraisal Fee to Lenders Service, Inc. 325.00
804. Credit Report to Rels Reporting SV 15.00
805. Lender's Inspection Fee to
806. Martaaae Ins. ADD. Fee to
807. Processing Fee to Wells Fargo Home Mortgage. Inc 100.00
B08 Flood Zone Determination Fee to Wells Fargo Home Mortgage, Inc 16.00
809.
810.
811.
9 O. ITEMS RE ut o BY j)Ci>i'nB~PAIO IN AOVA
901. Interest From 04/11/02 to 05/01/02 @ $ 23.970000/day ( 20 days %) 479.40
902. Mortqa e Insurance Premium for months to
903. Hazard Insurance Premium for 1.0~ars to Erie Insurance PQC $400.00b
904.
905.
1000 "eseRVFS DEP WI E 0
1001. Hazard Insurance 4.000 months $ 33.33 Der month 133.32
"'IOQ2. Mortnaoe Insurance months $ ..aer month
1003. Citv/Town Taxes months $ aer month
1004. County Taxes 4.000 months $ 51.00 oer month 204.00
1005. School Tax 11.000 months @ $ 187.92 per month 2.067.12
1006. months (ffi $ 'ner month
1007. months (n) .'t, ner month
1008. Aooreaate Adiustment months rill $ ner month .421.69
o . IT HAR"~'-
1101. Settlement or Closina Fee to
1102. Abstract or Title Search to
1103. Title Examination to
1104. Title Insurance Binder to
1105. Document Prenaration to
1106. Notarv Fees to Residential Commercial Abstract, Inc. 10.00
1107. Attorney's Fees to
fincludes above item numbers:
1108. Title Insurance to Residential Commercial Abstract Inc. 1 388.75
(includes above item numbers.11 0"'1 i 1 02 "'1104 )
1109. Lender's Coverage $ 140.000.00
1110. Owner's Coverage $ 206.000.00
1111. Endorsements 100 300 8.1 to Residential Commercial Abstract, Inc. 150.00
1112. Courier Fees to Residential Commercial Abstract, Inc. 15.50
1113. Closing Protection Letter to Old Republic National Title Ins. Co. 35.00
1200 GOV E T 01 F C"A""~S
1201. Recording Fees: Deed $ 27.50; Mortgage $ 60.50; Releases $ 88.00
1202. Citv/Countv Tax/Stamns: Deed 2,060.00. Mortaaoe 2.060.00
1203. State TaxJStamns: Revenue Slam s 2.060.00: Martoao. 2.060.00
1204.
1205.
13 .AOO IONA' ~~T IiAI>G
1301 Survev to
1302. Pest Insoection to HomeSpec PQC $35.00b
1303. Aor. Mav & June Sewer to Hampden Twn. Authoritv 98.00
1304. Obtainina Deed CODV to Re/Max Realtv Associates 7.50
1305. See addit'j disb. exhibit to 225.00 24,820.00
1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section K 8,290.40 39,541.50
By signing page 1 of this statement, the signatories acknowledge receipt of a completed copy of page 2 of this two page statement.
Q1-
"'--.
1
Certified to be a true copy.
Residential Commercial Abstract, lnG.
Settlement Agent
(SADLER 1 SADLER 112)
ADDITIONAL DISBURSEMENTS EXHIBIT ~
Borrower: Michael W. Sadler
Diane K. Sadler
Seller: Estate of Donald J. Davis
Lender: Wells Fargo Home Mortgage, Inc
Settlement Agent: Residential Commercial Abstract, Inc.
(717)901-8926
Place of Settlement: 3631 North Front Street
Harrisburg, PA 17110
Settlement Date: April 11, 2002
Property Location: 479 Woodcrest Drive
Mechanicsburg, PA 17050
PAYEE/DESCRIPTION
NOTE/REF NO
BORROWER
SELLER
HomeSpec
Home Inspection
Prudential Thompson Wood
Transaction Fee
Caldwell & Kearns Escrow Agent
Inheritance Tax Reserve
Wells Fargo Real Estate Tax Services
Tax Service Fee
Re/Max Realty Associates
Deed Preparation
265.00
POC $265.00b
125.00
24,720.00
100.00
100.00
Total Additional Disbursements shown on Line 1305
$
225.00
$
24,820.00
( SADLER.PFD/SADLER/12)
ACKNOWLEDGMENT OF RECEIPT OF SETTLEMENT STATEMENT l
Borrower: Michael W. Sadler
Diane K. Sadler
Seller: Estate of Donald J. Davis
Lender: Wells Fargo Home Mortgage, Inc
Settlement Agent: Residential Commercial Abstract, Inc.
(717)901-8926
Place of Settlement: 3631 North Front Street
Harrisburg, PA 17110
Settlement Date: April 11, 2002
Property Location: 479 Woodcrest Drive
Mechanicsburg, PA 17050
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and
accurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certify
that I have received a copy of the HUD-1 Settlement Statement~ -)"Y).~~ I Co(--':
~~~ /' ~
7(~1 ~~Ie<< ituili~ sta e 0
r!>iane f. Sadler I
To the best of my knowledge, the HUD-1 Settlement Statement which I have prepared is a true and accurate account of
the funds which were received and have been or will be disbursed by t e undersigned as part of the settlement of this
transaction. ! u
Re:>i'dential Commercial Abstract, Inc,
Settlement Agent
WARN ING: It is a crime to knowingly make false statements to the United States on this or any similar form. Penalties
upon conviction can include a fine and imprisonment. For details see: Title 18 U,S, Code Section 1001 and Section
1010,
HUD.1 (3...aS) RESPA. HB43052
'''"os,,'',.;.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
DAVIS DONALD J
FILE NUMBER
21 01
332
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. CLAREMONT HOME 4,632.50
RESIDENTIAL CARE REFUND
2 COMCAST 32.00
CABLE TV REFUND
3 COUNTRY MEADOWS 1,929.25
RESIDENTIAL CARE REFUND
4 AMERICAN EXPRESS 51,435.14
ANNUITY 930040299743004
5 AMERICAN EXPRESS 604,499.92
IMA ACCOUNT 000138387014021
6 AMERICAN EXPRESS 1,317.53
MUTUAL FUND 011336035859002
7 WAYPOINT BANK 40,064.41
CHECKING 3100002100
8 WAYPOINT BANK 3,362.46
IRA 523011232
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
707.273.21
~l Way~qi!lt
LOOK FOR US, WE'LL GET YOU THERE.
05/03/2002
MURREL WALTERS III
54 E MAIN ST
MECHANICSBURGPA 17055-3851
The information which you requested on the account(s) of DONALD J DAVIS
(Social Security Number 192-12-0785) is/are as follows:
Balance at Date of
Death
Account Ownership SOLE
Name of Joint
Owner, if any
Date Ownership
Was Established
Account Number
Class of Account
Date Opened
Principal Balance
Accrued Interest
Account Number
Class of Account
Date Opened
Principal Balance
Accrued Interest
Balance at Date of
Death
Account Ownership
Name of Joint
Owner, if any
Date Ownership
Was Established
Additional
Information
Requested
3100002100
CHECKJNG
02/07/97
40063.20
1.21
40064.4 I
523011232
IRA
07/11/86
3359.47
2.99
3362.46
SOLE
ESTATE-BEN
07/11/86
PLEASE COMPLETE W-9
~relY, ~~
KAi~1i!'6~
SENIOR SERVICES REP,
P.O, Box 1711, HARRISBURG, PENNSYLVANIA 17105-1711
Toll Free 1-866-WAYPOINT (I-B66-929-7646) , IN YORK AREA 717/815-4500 . www.waypointbank.com
}-
,-
f'
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IDS LIfE 1lSURANCl! COMPAN'f
I\IURICAN ~S PU_
AMERICAN EXPRES8 CERTIfICATE COMPANY
IlMERlCAN!Xl'RESI BROKEMGIl
70100 AllP FlMncIoI c.""",
IIln.......II..IiIN 55474
May $, 2002
MATnIlJW AI.ANTAYLOR
PINE RUILDINUllUITE 201
1006 LENKER STRI!I!T
MI,;('HANICSRURG. PA 17050-2440
~tMA TIHEW ALAN TAYl.OR:
Thank you for YOIIr n:c.:ul inqully regilding DONAtD 1 DAVIS's acc:o\lll18. l'hcse an: the
values of the OCCOUllll as of 04/0 112002.
Muhl.1 Fuds
ACWUnl NlJI1Ibtr
011336035859002
Anaaides . P\IIlt 1985
Total Value
51317'33
# orsharel
1317.200
Allie! ValDe Per SlUlre
- 1.000
ACGOunl Nwnbor
93004029974 3004
IM^
1'1>1.1 Value'
$51435,14
Account Nurnbc-r
0001381&7014'021
ToIDl V llIue
$60449!l.9i
A ~>}\ is mclucled wilh Ibis \cIIer ilia! rq_ each aecurilY bcId in 1110 IMA accOUllI.
The dale of dcalh vl1lues provided lIfO for eaIa'~ lax pwpotes and an: DOl a value 10 be paid.
ACCOUDls may be S\lbjel!110 """"'el Jluctnation .. tovorned by e:1Cb prock",.,
W" appnxlate \he """M\U1Iityto be or.etVk:eto yolL PIClllO eootnClIIS llyn" Iulvo any
qlleslion..
Sincerely,
lC\\D Kurn-Reg is
Dealh SClIlc""",,. Proccuing Team
70310 AXP 11lnmci:>1 C,,01tClr
MilWllpoli." MN SS474
1UlB- 723-8476 I!ulur 14162
Insut8n:oand onnv!tios 81e
i,OIlllIl by IDS Ute 1nSIIr8llCll
t~nr, llII Maricon ExPf&lS
CDlll(JOt1y.M>criCDD~
8rDiDmM ISClftMdoiI by__
r'l'wl=inRilII JldvilIntI hie,
1Immc.n Expma n_ilIl
Adv....tnc, Mrtrtw~
Amartcon ~811 Compony i.
,"",r."o "DIll AlO8Im !xC"",
F1noncIOI1llM8Or,1..... 011111. nol
obtOl.8rllealer.
RE""""'(('''~.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
DAVIS DONALD J
FILE NUMBER
21
01
332
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. NEILL FUNERAL HOME, CAMP HILL, PA 4,756.60
2 "DK CATERING POST FUNERAL LUNCHEON 221.81
3 ROLLING GREEN CEMETARY CRYPT OPENING 670.00
4 FUNERAL CLOTHING 389.00
B. ADMINISTRATIVE COSTS:
1. Personal RepresentaUve's Commissions
Name of Personal Representative (s) GLORIA I. FERRON 3,000.00
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address 141 WINSTON DRIVE
City MECHANICSBURG State PA Zip 17055
Yea~s) Commission Paid: 2002
2. Attorney Fees MURREL R. WALTERS III ESQ 3,600.00
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 REGISTER OF WILLS CUMBERLAND COUNTY 650.00
5. Accountant's Fees GEORGE BRADNEY 150.00
6. Tax Return Preparer's Fees
7. ESTATE NOTICE PUBLICATION 93.83
8 ESTATE NOTICE PUBLICATION 75.00
TOTAL (Also enter on line 9, Recapitulation) $ 18586.24
(If more space is needed, insert additional sheets of the same size)
Continuation of REV.1500 Inheritance Tax Return Resident Decedent
DAVIS, DONALD J.
21
01
332
Paqe 1
Schedule H - Funeral Expenses & Administrative Costs - 81
ITEM
NUMBER DESCRIPTION AMOUNT
B. ADMINISTRATIVE COSTS:
Personal Representative's Commissions
2 Name of Personal Representative (s) CHERYL M. STERNER 5,000.00
Social Security Number(s) I EIN Number of Personal Representative{s) 178409872
Street Address 99 HARRISON DRIVE
City NEW CUMBERLAND State PA Zip 17070
Yea~s) Commission Paid: 2002
SUBTOTAL SCHEDULE H.B1 5,000.00
"""""",..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
DAVIS DONALD J.
FILE NUMBER
21 01
332
Include un reimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1.
DEPARTMENT OF VETERANS AFFAIRS
MEDICINE
29.00
2
PPL
ELECTRIC
193.31
3
WEST SHORE EMS
MEDICAL
73.35
4
PINNACLE HEALTH
HOSPITALIZATION
91.00
5
MATTHEW TAYLOR
FINANCIAL ADVICE
196.19
6
HARPER MYERS
REMOVAL OF FUEL TANK
500.00
TOTAL (Also enter on line 10. Recapitulation) $
(If more space IS needed, Insert additional sheets of the same size)
1.082.85
RE~_1513EX:I.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
nAVI" no ?1 01 qq?
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include ou(right spousal distributions, and transfers under
Sec. 9116 lal 11.2)]
1. GLORIA I. FERRON SISTER 1/3
141 WINSTON DRIVE
MECHANICSBURG, PA 17055
2 CLAIRE E. MARSH SISTER 1/3
2441 BRADFORD DRIVE
YORK, PA 17402
3 BYRLE K. STEVENS SISTER 1/3
28 BUTTONWOOD AVE
WILKES-BARRE, PA 18702
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
1.
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)
PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF
THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY
UNTIL COMPLETION
STATUS REPORT UNDER RULE 6.12
Name of Decedent: DONALD J. DAVIS
Date of Death: 4/1/02
Estate No.: 21-0~-00332
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:
State whether administration of the estate is complete:
Yes __.X No
If the answer is No, state when the personal representative reasonably believes that the
administration will be complete
(date)
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 X
Bo
Date: April 30, 2004
Do
The separate Orphans' Court No. (if any) for the personal representative's
account is: (Not Applicable in Dauphin County)
Did the personal representative state an account informally to the parties in
interest: Yes __X__ No
Copies of receipts, releases, joinders and approvals offo~//al or informal
accounts may be filed with the Clerk of the Orphans' 'Q6urt and may be
attached to this report. / . ~
MURREL R. WALTERS, III, ESQUIRE
'~"t_it:v,.3 54 East Main Street
:: D Mechanicsburg, PA 17055
717-697-4650
f- l[t!d P~.apacity:
Personal Representative
X
__ Counsel for Personal Representative
`c~
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: DONALD J. DAMS
Date of Death: April 1, 2002
Will No. 2001-00332 No. 21-01-0332
To the Register:
I certify that notice of (beneficial interest) estate administration 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 May 2, 2002.
Name Address
Gloria J. Ferron 141 Winston Drive
Mechanicsburg, PA 17055
Claire E. Marsh 2441 Bradford Drive
York, PA 17402
Byrle K. Stevens 38 Buttonwood Avenue
Wilkes-Barre, PA 18702
Notice has now been given to all persons entitled there under e 5. except:: None
Date: May 2, 2002
Murrel R. alters, III, Esquire
54 East Main Street
Mechanicsburg, PA 17055
(717) 697-4650
Capacity: Personal Representative
X Counsel for personal representative
1--