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Home My WebLink About04-0424 PETITION FOR PROBATE and GRANT OF LETTERS Estate of Ollie Rebe(c.~ b 1\ ,'.s No. -2l-64- Lf':l4 also known as To: Register of Wills for the County of G.. ",.b.er/ ~'" cl in the Commonwealth of Pennsylvania , Deceased. Social Security No. 2 L <a- - 0 I - 4- 0 I Cj The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut 0 r in the last will of the above decedent, dated f4 pn lIS I 2 P9 3 and codicil(s) dated IV u .\ t: named ,19_ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in C U WI. ber h -tv last family or principal residence at ~ r'dLke ,),+ (list street, number and muncipality) Decendent, then 'b f( years of <\ge, die at \o\e.SS \itl\~' 00 (V, J4\ f' r-. c 'bv Except as follows, decedent did not marry, was not divorced and did not ave a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: IV / ,-\ Decendent at death owned property with estimated values as follows: $' '2. t D) 000 (If domiciled in Pa.) All personal property $ AJ . "t Ii; (If not domiciled in Pa.) Personal property in Pennsylvania $ 1'\1 V ~l ~ (If not domiciled in Pa.) Personal property in County $ N (J 1\ t: Value of real estate in Pennsylvania $ N 0 VI e situated as follows: WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters +,,~~""\ p", +~~ r, ,... theron. (testamentary; ad mistration c.t.~~ ~dminist2on d.b.n<q.~i.) s~p ~ '" ~ ~ '\' '" -...J () ~3~' .~,.n~ UP ~ '" ... t:.::'" -g.g JlIlia.~\ I'v\\L"~~1 l)e.Lod~ '" 'Z f.t g r ~Lk...ev' Ct 3~ b 0 '" '- MH~ ~... I (S v,'5, r A- I v)I(J S 0 30 :;j c:: Ol) Cii ~ Lv C' .- \.~~ 1'-'" OATH OF PERSONAL REPRESENTATIVE COMMONWEAL ~H OF PENNSY~ VANIA l ss COUNTY OF '" \ \V"Y\~(< \CLvld 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 we.ll and truly administe,r the estate aj;rding to law. ~ ~'(~'-iD Sworn to or affir"?ed and subscribed { , QAJ ""... l \, ~ ," ~ bef me this ""- ~ day of ~_ ~ '0, ~ i ~ r Estate of No. 2\ -0-\ -4')..4 ~~ ~bQ~0Q ~ r~ , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW l i{V1-i P ::'x') ~,L/ Jw_. io coosideration of the petition on the reverse side hereof, satisfactory proof hav~n~~e~ presented before me, IT IS DECREED that the instrument(s) date~ I~ ~c)()"\ described therein be admitted to probate and filed of record as the last will of and Letters ~~~(ltf\ are hereby granted to ~\.'r" '" ' \ C: ""a. -e\ ~\Oo.(~ FEES P b t L t Et $2/0 - 00 ro a e, et ers,. c.......... Short Certificates(2) . . . . . . . . .. $ lo - 00 U ~\l ~- ~ $ C, .c"G ~._""--'><"-"'" ~ . \~ . . . . ..J~j $Ic .co . TOTAL _ $2Qc:. aD Filed " .Y-. .-. .:$9 .-. ~. ?9~ . . . . . . . . . . . . . . ~~G.J:l"'oo ~"~ Register of Wi~ ~-. . A TIORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE 1f1('."."U'." R~\' 0/"" This 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. ,i '<...J ~ . ~..., ./-- ,o,~ ,~,,/ Local RegIstrar Fee for this certificate, $2.00 ~; 0' '1 a3~ . :',.. No. '~R X I"". '1".... ...r "~'''!' ,"'-", APR 292004 ;..; '. M ~ate .,.., ~..., -'-J ;.l cr ZI-04 --4~LJ > _8 Lv CI "0 ',J H105, 143 Rev. 2187 ~ NT COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH NT IK NAME OF DECEDENT (FiB!, Middlo, loot) 1. Ollie Rebecca Whiteaker AGE (losl Birthdoy) SEX 2. Female STATE FilE NUMBER SOCIAL SECURITY NUMBER ~228 01 4019 DATE OF DEATH (Month, Doy. Yoar) 4. April 26, 2004 . ., 88 COUNTY OF DEATH YIS. BIRTHPLACE (City ond 51010 0< Fo<olgn Coontry) HOSP , ........ 0 ERlOu_.O 7.Abington, VA ... FACILITY NAME (II nol instilution, give streel and number) OOAO ~"I'f)O - American Indian, Black, W1ite, et (Specify) / white 11L Mana er 11b. Education DECEDENT'S MAiliNG ADDRESS (StroBl, Cilyrrown, Slole, Zip Code) DECEDENT'S 100 Mount Allen Drive ~~~~~NCE 18. Mechanicsburg, PA 17055 ~'::'~l:;:)ns FATHER'S NAME (FilSl, Middle, lest) 18. Charles Alexander Whiteaker INFORMANT'S NAME (TypelPrinl) 200. Dorothy A. DeLoach METHOD OF 015 SinON . Donation 0 Buriel 0 Cremation ~omovallrom Slete 0 . 210. Other (SpedIy) . 51 i REOFFU C NSEEO, ON TI :0.5 DECEDENT EVER IN U.S. ARMED FORCES? YesO NolXI 12. MARITAL STATUS. MOlTied. NeV~~~s~~ed. 14. Widow SURVIVING SPOUSE (lfwile,gille maideo name) 17L Slalo PA Did decedenl livain 8 township? i7e. 0 Yes, decedent Dved in 17d. 0 ~~hi~=7~i= of TTppo"" A'1on lwp 17b. Countv Cumberland cityJboro MOTHER'S NAME (Firsl, Middle, Maiden Surname) ~ Ollie Riddle INFORMANT'S MAILING ADDRESS (Stroel, l?tylTown, Slate, Zip Codo) 2~. 6 Bracken Court, Mechanicsburg, PA 17050 PLACE OF DISPO.sITlON. No~ of Cemtlory. Cl8m~I~'}' I.OCA TlON . Cityrr own, Slole. Zip Code o<OIherPloce cremat10n ::;OC1ety ! 21<. Pennsylvania Crematory 21d. Harrisburg, PA 17109 NAMEANDADDRESSOFFACILlT'Cremation So<;iJ:!ty of PA 22<.4100 Jonestown Road Harr1sbur PA 17109 LICENSE NUMBER ClATE SIGNED (Month. Day, Vear) 23b. 23<:. WAS CASE REFERRED TO A MEDICAL EXAMINER /CORONER? 28. Yos S j L No 0 . Approximato PART II: 0Ih0r significanl condition. contributing 10 death. but : interval betwee not resutting in (he under1ying cause given in PART I : onset and death a. Sequentially Usl conditions I b. if any, leading to invnediate . couse. Enter UNDERLYING CAUSE (Disease or injury c. that initialed eventl resulting on death) LAST d. WAS AN AUTOPSY ~RE AUTOPSY FINDINGS PERFORMED? AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH? OUETO( AS A CONSEQ NeE OF): Vo. 0 No ~ Accidenl MANNER OF DEATH tJ o o DATE OF INJURV (Month, Day, Year) TIME OF INJURV INJURY AT I'IKJRK? DESCRIBE HOW iNJURY OCCURRED Natural Homicide Pending Investigation Could nol be deleonined o o 301. 3Gb. M. o PLACE OF INJURY ~ Al home, farin, street, factory, office building, etc. (Specify) 30.. Yes 0 No 0 30<:. vosO No 00 Suicide ~v~ /1/1 34. 2... 21b. CERTIFIER (Check only one) .~:~':F=GJ=~~~l~~~C:~~3~=.c:: &e:~:=(:r=r~x~a~.h:~~~~.~~~~~~.~~~~~.i.t~.~~).................. 0 21. .P:OO:~~:'~I:'G~N=:'~:~t~~~~~ ~~~=~~~.~~hd':t~Z~ut~.;;(~):: ::~~.r I. .t.ted...................... 0 .MEDICAL EXAMINERlCORONER ~:::rb::I:::.:~~~I.~~~~~ ~~.~~ ~~~~~.~~~~~.~: !~.~~ ~~I.~~.~: .~~~~~ .~~.~~~. ~.t. ~~~. ~~~:. ~~~:. ~~~ .~~.~~:. ~~~ .~~~. ~~ .~~ ~~.~~.~~.~~ .~~~.. 0 310. REGISTRAR'S SIGNATURE AND NUMBER " LAST WILL AND TESTAMENT OF d -C:. ~....., .AI ff:; " Ollie Rebecca Ellis I..:) I, Ollie Rebecca Ellis, of Mechanicsburg, P A, declare this to be my Last Will and Testament hereby revoking all prior Wills and Codicils. ARTICLES I. I am widowed and have two children who are now living, whose names are Dorothy E. DeLoach and Robert E. Ellis, Jr., and one deceased child, Betty Jo Ellis. All references in this Will to "my children" include only Dorothy E. DeLoach and Robert E. Ellis, Jr.. I have intentionally made no provision in this Will for Tina S. Thorpe, of Carlisle, P A, in that I have made gifts to her before my death because I wanted to see her enjoy the gifts while I was living. II. The expenses of my last illness and funeral shall be paid from the funds of my estate. III. I give all of the remainder of my estate to my children, in equal shares. Page 1 of 4 IV. In the event my daughter, Dorothy E. DeLoach fails to survive me by thirty days, I give her share to my son-in-law, Javan Michael DeLoach. In the event both Dorothy E. DeLoach and J avan Michael DeLoach predecease me, I give her share to Rebecca Celene DeLoach, of Ashville, North Carolina, and Javan Michael DeLoach, Jr., of Fairfax, Virginia, in equal shares. V. In the event my son, Robert E. Ellis, Jr. fails to survive me by thirty days, I give his share to his spouse living at the time of my death, provided she survives me by thirty days. In the event Robert E. Ellis, Jr. is unmarried at the time of my death and he has failed to survive me by thirty days, I give his share to my daughter, Dorothy E. DeLoach. In the event my son, his spouse, and Dorothy E. DeLoach fail to survive me, my son's share shall be distributed as set forth in Article IV, herein. VI. All taxes and interest and penalties thereon payable by reason of my death with respect to property comprising my gross taxable estate, whether or not passing under this Will, shall be paid from the principal of my residuary estate. VII. I appoint my son-in-law, Javan Michael DeLoach, as Executor ofthis, my Last Will and Testament. If Javan Michael DeLoach is unable or unwilling to act or continue as Executor for any reason whatsoever, I appoint Robert E. Ellis, Jr., successor Executor. No fiduciary acting hereunder shall be required to post bond or enter security in any jurisdiction. Page 2 of 4 /' IN WITNE~S WHEREOF, I, Ollie Rebecca Ellis, hereunto set my hand and seal this 12...-.- day of ~, 2003, to this my Last Will and Testament which consists of four typewritten pages. ~~ ~~-- Ollie Rebecca Ellis , t"' JlL4__ 1/~L Witness SIGNED, SEALED, PUBLISHED AND DECLARED, by Ollie Rebecca Ellis, the Testator above named, as and for the Testator's Last Will and Testament, and in the presence of us, who, at the Testator's request, in the Testator's presence and in the presence of each other have subscribed our names as witnesses. If J/iL {fft J-J'-( C? h v. 7 . P,1 Address w*, J)rlM6.j I!arrf~ fA Address COMMONWEAL TH OF PENNSYLVANIA ) : ss.: COUNTY OF DAUPHIN ) I, Ollie Rebecca Ellis, Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed this instrument as my Last Will, that I signed it willingly and that I signed it as my free and voluntary act for the purposes therein contained. (J~ /1e~ cf~( Ollie Rebecca Ellis Sworn or affirmed to and aCknowl~dfed before me by Ollie Rebecca Ellis, the Testator, this i" day of ---.!l..r J-t ,2003. Page 3 of 4 NOTARIAL SEAL d2.DY GOlDRING, Notary Public M C ot ~rrlsburg. Dauphin Co.. PA y ommission Expires Noy. 03, 2005 \ C':\~ ~ N'ot~ry Pub i c COMMONWEALTH OF PENNSYLVANIA ) ss.: COUNTY OF DAUPHIN ) WE, \;J;(f IAr'\. L 41 ~....r , and , the witnesses whose names are signed to the attached or foregoing . strument, being duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as the Testator's Last Will; that the Testator signed willingly and that the Testator executed it as the Testator's free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight ofthe Testator signed the Will as witnesses; and that to the best of our knowledge, the Testator was at that time Eighteen or more years of age, of sound mind and under no constraint or undue influence. ~!lAM 1~___ Witness c1I~CL J;;r~~ Witness ([ Sworn or affirmed to and subscribed before me by W l\\\~ L. MG.r , and C'1L~~ ~ witnesses, this ~ day of JJpr-; I 2003. NOTARIAL SEAL JODY GOLDRING. Notary Public City of Harrisburg. Dauphin Co., PA I My Commission Expires Nov. 03, 2005 ~~i~~ Page 4 of 4 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: E 11,',.$ 0 ( I " e R ~.I, ~ cc a , Date of Death: z. (. Op r. I '2.. 00+ Will No. 2. () D 4 - 0 0 4- 2. 4- Admin. No. fA "'0 2.1 -19+- O+L4 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 ~ Address ~Obec't ~. E-11t5f Jr ....011 ~t"er (t'PS-r c.rete, Lel>sbu~, ~L 3+1+B Doro+"'~ A. \)e.Lo~) to gt"~c..he~ c.+, Mec.t\C~"t~ burg f rA I,)D50 Tl~a. $. Thorf~) ID ~. Le-ror+ I)".) Uf-I. sit, if) J'lD/3 K~b~Ct~ C.e'e~e "De.Loac.iJ of; 6,f"C..~ Sf; ASkeVltt~, ~c 2...8"~o/ J"e"e~ 1"\. 1)e.Lo~~, :r...., (OO(q l"aklIVlQr c.~J t=""~I"'r~i) vA Z'2..03Z. Notice has now been given to all persons entitled thereto under Rule 5.6(a) except jVpV\~ Date: "2. 5 Me~ 200+ Signature ~ )Y\. De. ~ Name 'J"'all~V\ t\I\, 1)~ Lo ~c.h Lil Address b b re.-c..kell'\ L+ :~: M ec..~~J\' cshvt', I /A 1'10 SO Telephone (1''1) b q') - S 5 33 "-0 C....: ;- ~ 9 Capacity: ~ Personal Representative .. "1. ,- .... ....,.; 'lo.._ _Counsel for personal representative 0- REV.'SCOEXi5.00: REV-1500 . COMMONWEALTH OF . . PENNSYLVANIA . DEPARTMENT OF REVENUE DEPT 280601 "< . HARRISBURG, PA 17128-l1601 INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z W C w U w C DECEDENTS NAME (LAST. FIRST. AND MIDDLE INITIAL) ELLIS, Ollie R. DATE OF DEATH (MM~DD~YEAR) 04/26/2004 DATE OF BIRTH (MM.DD.YEAR) 03/29/1916 (IF APPliCABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST. AND MIDDLE INITIAL) w ~~(/) u"'''' w"u ",00 u"'~ .... .. .. [!] 1. Original Return o 4. Limited Estate o 6. Decedent Died Testate (At!ac~ copy {}f Will) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise {date o'dcath a1er 12-12-(12) o 7. Decedent Maintained a living Trust (Aliacr copy {}'Trw~t) o 10. Spousal Poverty Credit (uille ofeeatll ~JeIWeel' 12-31-91 and 1-1--95) F\I\E NUMBER 2!.L-OLi COIJ'HYCODE. YEAR o I-.( J.i_ NUMBER SOCIAL SECURITY NUMBER 228-01-4019 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Return ld,l~l of CC"~~', fJnO!" to 12.13.82i o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (A:"'c~schOJ 0- Z W o z 2 Ul w '" '" o u 'l:Il!$"'SECTION!MUS1"I3S:COMplEtEb,All CORRESPONDENCE ANll eO!il1;l1l ',~'rJ\X!IilI"_A1[,. NAME COMPLETE MAiliNG ADDRESS Javan M. Deloach ___~___~ Javan M. Deloach FIRM NAME (I' Applicilble) 6 Bracken Court Mechanicsburg, PA 17050-2374 (1) 0.00 ------- 197 501:i>.0 (2) cg :IJ I == ~'J G':- O~;:: ,e- (3) ct.' Vl (4) O:QO CT1 -0 (5) 4,333.~ - .r:- (6) 5,017$2 -0 w Ogl) .j:;. (7) -.J ------.---.---- TELEPHONE NUMBER.... (717) 697-5533 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule DJ z o ~ -l ::> l- e:: <C u w 0::: 5. Cash, Bank. Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Sclledule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G orL) 8. Total Gross Assets (total Lines 1-7) 9. FUlleral Expenses &Administrative Costs (Schedule H) (9) 10. Debts of Decedent. Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total DeductIons (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmentai 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) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ I-' ::> l1. ::i: o U >< ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) , .0 (15) 198,168.78 X.o 45 (16) 16. Amount of Line 14 taxable atlirleal rale 17. Amount of Line 14 taxable at sibling rate '.12 (17) 18. Amount of Line 14 taxable at collateral rate , .15 (18) 19. Tax Due 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE !lURE ,.0 AN ER ALL QUESTIONS ON RiW~ii: lit!!!!!, I'fPREClltEel(,MiI!i liI""li (8) 1,07195 7,216.45 (11) (12) (13) 206,853.18 8,B84.40 198,!~87~_~ 0.00 (14) 198.168.78 8,91~_~~ (19) 8,917.BO REV-1S03 EX, (6-98)~~~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF ELLIS, Ollie R. FILE NUMBER All property joIntly-owned with rIght of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION Bond Fund of America Class A 4,825.808 shares VALUE AT DATE OF DEATH 64,472 79 2. Investment Company of America Fund Class A 2,134.239 shares 61,25266 3. New Perspective Fund Class A 2,945.921 shares 71,76263 4. CitiGroup CitiBank Deposit Program 13.64 TOTAL (Also enter on line 2, Recapitulation) $ (If more space IS needed, Insert additional sheets of the same size) 197,50172 illlllllll Beginning value net of Total income Asset appreciation Total value as of Total return 111III11111111 4/3012004_( exel.acer .i nq 11II1111111 11111I111111 1111111111111111111111 200,010.16 266.79 (2,845.23) $ 197.501.72 1$ 2.67U41 Unrealized Jlaln or Gainlloss summary Realized gain or (lOSs) lossl 20,052.14 Thi 5 period $ 272.33 This year 756.02 L T $ 0.00 ST Not applicable $ Portfolio summary Beginning total value (excl. acer. int.) Net security depositS/Withdrawals Net cash deposits/withdrawals deposits/withdrawals This period $ 205,970.16 0.00 (5,890.00) This year $ 210,272.99 0.00 (12.540.00) 191,732.99 1,323.95 (1,555.22) $ 197,501.72 1$ 23127) Earnings summary Other dividends Total Taxable $ 266.79 $ 266.79 $ 0.00 $ 0.00 ! $ This Taxable 1,323.95 1,323.95 ! 0.00 $ 0.00 YO" Non-taxable aoangb~.nce $13.84 A free credit balance in any securities account may be paid to you on demand. Although properly accounted for on our books and records, these funds may be used for our business purposes. Account value Bank Deposit Mutual funds Programs"-principal This period Non-taxable Last period $ 13.64 This $ ~ Cash, money fund, bank deposits .01 Opening lNdance Securities bought and other subtractions I Securities sold and other additions Withdrawals DIvidends credited P8riod S 13.64 (822.82) 6,448.03 (5,890.00) 266.79 12,540.00) yea, This Citigroup Global Markets Inc., member NYSE, NASD, and other principal exchanges. Smith Barney is a division and service mark of Citigroup Global Markets Inc. and its affiliates and is used and registered throughout the world. CITIGROUP and the Umbrella Device are trademarks and service marks ot Citicorp or Its affiliates and are used and registered throughout the world Citigroup Global Markets Inc. is a member of the Securities Investor Protection Corporation (SIPC). This Your Financial Consultant FRED PEGGS P.O. BOX 12057 11 N 3RD ST'2ND FL HARRISBURG PA 17101 717.780-1778 Emall: tred.l.peggs@smithbarney.com www.smithbarney.com 72400403506843000001272 304121AE01 OLLIE R. ELLIS 6 BRACKEN COURT MECHANICSBURG PA 1711S11-2374 YCKr BrokerlDealer is CITIGROUP GLOBAL MKTS INC. Branch: 800.237.1700 Ref: ??oo1272 ??oo8569 SMITH BARNEY_ cltlgroupJ PCAF0015A Client Statement March 29 April 30, 2004 Account number 724-06843-11 Pogo 10'5 035 IIII ~m IIIIII~I ~II ~ III~ III 1m 11111 II~I 1IIIIII1 IIIII~IIIII ,988.388 86.019 61.831 2,134239 Total PlWChases Reinvestments to date Reinvestments to date T04laled Cost YS. Cwrent Value 52.420.80 2,033.47 1,699.51 56,153.71 28.39 23.639 27.488 28.311 28.70 28.70 28.70 ,774.55 11,252." 75.04 5,ll1l1." LT ST .111 1,1".80 57,1108.36 2,468.75 .,511.56 '35.28 ,986.389 Number or shares ',279.871 .,279.871 297.846 248.491 '.125." INVESTMENT COMPANY OF AMERICA FD CLASS A Reinvestments to date Reinvestments to date Tax-based Cost us. CWrent Value Total Pwchases VI. arrent Value FWMI Value IncnaselDecrease 06/26/02 52,420.80 3.33<1.22 11.7....7 N,73U. Cost $ 5<1,738.99 N,73U. 3,727.28 Description BOND FUND OF AMERICA ClASS A Total Pwchases DatI!! ~ 08126102 28.39 Share cost $ 12.79 12,71 12.522 1U17 12'- 28.70 3.36 13.36 13.36 13.38 Cumrtt E,rice $ 57.009.36 Cumnt vatUII $ 57.178..0 57.178,40 3.978.55 3,319.801 "','72.71 "','72.71 .,sa8.se (1'.381 2,17U2 LT 1.735.80 1.735.80 '.715 3,lMO.2I $ 2..39..1 U38,41 2.s.29 LT ST Unrealized gail\l(loss) LT Net Value lnero"" Decrease Yield Anticipated income (annualized) Mutual funds Yield is the current distribution annualized, divided by the func1's net asset value at the end of the statement period. Distributions may consist of income. capital gains or tire return of capital. Distributions and current dividend for funds not sponsorecl by us are based upon information provided by an outside vendor and are not verified by us. "Tax-Based Cost vs. CUmlnt Value'" is being provided for information purposes only. "CaM Dlst,ibutions (since incepUony when shown may not reflect all distributions receiVed in cash due to but not limited to the following: investments made prior to 111189, asset transfers, recent activity and certain adjustments made in your account "Total Purchase. va. Cu,.,..nt Value" is provided to assist you In comparing your "Total purchases", excluding reinvested alstributJons, with the current value of the fund's shar" In your account "Fund Value Increase/Deer.a.." reflects the difference between your total purchases ana the current value of the fUMS shares, plus cash distributions since inception. Principal 13.... Bank Deposit Program- Balances are FDIC insurecl up to $100.000 per institution, subject to combined Description CITlBANK NA BANK DEPOSIT PROGRAM total of aft your deposits, inCludIng those outskle this account Cu~ Accrued value Interut $ 13." AI% Annualized % .....m Anticipated inCOfM (annualized) _ $." Generally, the price of securities in this section are obtained from from iOUS quotation services. whose prices are based either on the Closing prices, the mean betwe8n the bid and asking price, or a matrix based on interest rates for similar securities (pricing may r8f1ect round Jot/odd lot differentials). Where prices are not available from quotation services, we may use such prices whiCh, In our judgment may best reflect the market prices of the securities. In either case, we do not guarantee the accuracy of such prices. These prices should not be considered firm bids or offers, and may be subject to fluctuations in market conditions. If a more current valuation ;s necessary, please contact your Financi" Consultant PI...e note: unrealized gainl(lDSs} is being calculated for informational purpO$es only and shoukt not be used for tax preparation without the assistance of your tax advisor. Ret ??oo1272 00008570 SMITH BARNEY_ cltlgroupJ OWE R. EW$ Client Statement March 29 - April 30, 2004 Account number 124-06'43-11 Page 2 af5 1135 - SMITH BARNEY_ cltlgroupJ Client Statement Page3of5 Ref: CKJOO1272 00008571 March 29 - April 30, 2004 - - OWE R. EWS Account number 724-06'43-11 035 , Mutual funds continued Net V_ Number Oat. Sha,.. Current CUmlnt Unrealized I......HI AntICipated of shares Description acquired Cost cost price value gain/(lass) Decrease Yied income (annualiZed) INVESTMEI ,RICA FD CLASS - T__ ... CIn1 . 1 52'-." 1 11.2S2_ '.,831_ - _V_ ..- .,831- - 2,891.088 NEW PERSI lYE FUN! IA 06126102 58,371.07 20.19 24.36 70,426.90 12,055.83 LT - 2.181'- T_P_ _,37'Im 20.1. 24.31 70'-_ 12'-.&1 - 33.131 Retnvestme ) date 595.03 17.959 20.36 807.07 212.CU LT - 21.702 Relnvestme > date 517.59 23.lU9 204.36 528.66 11.07 ST - 2,_.821 Ta"""" I ...CUrre , -.-- 20.182 71,1112.13 12,278.M .721 521.02 T__ ... CIn1 . _,37'1.07 71,782.13 13,381.5. . 13"'.51 - _V_ .asoIDoa ~I::i;;;;;;=~;;' @iMHHb/ liltJ ll~l'=;l,!;'ll'~;;!lll;lil=~:~==ll;ll;l;l''''llf:=il;;: ";':"::-"~-'::~:--:-:-:- -:.,.:__.._.n.: := ~;~~.;if~ ';';';:::'::;':::' ("'_,'.:1')':"."'''' '-:-:-:"-..;.;..- Y:':: 1M> ?i!";''::tiMHiliW:@WmWIMWl:f:jJJ...Mi& - il~lli,iiil:~iil:II:IIII~i1:=lil!i'!lllri:!!1I=llillIII ::-::::::-::-::::::,:-:-:-:-:-:-:: 1!!lit".r~::'.:::I:MWM' :~,;::::;:::;,~,.,-- . lm~ un... :"<.:." ,:.: '~:~;'. - :':::::::'::::"":::::'::':;::::::::::::::,::;::::,C!;';:::;:-, .':':':~::g::~::: :-:::.::::::;_:::::-:-:-:-:-:-:.:,: ..--.-,-.-"...-....'.". --'-:',-,-'---;-;_.,-----,--------'--.-,-----.-.------..-.." 8'~f0tidt :,:,:,:::;,;';:;::;:;::,:::;:.-.- c_.-.-.'.-__.-.-.-.-.-.-,-.-.-,-,._.'__,_._,.-,...,,_,_:.._._,_':_.___._______;__.__'_____, ."->,,~,.,,_,,_,,v:,_ ..,'_v_,~,':,'y_,~,_>,","'_>,0:<,", .,-.,.,..,."'--.---,.- -----,---,-,-----'--,-,-----... ..___.,_',-----'--'.. _",m-,------,--. :....--,-.;.-.-.-----,-,-.-.,.,-.,...._.,-,_..._-'-'_...<..------'-.---' ...,...-...-- '....,.....--.'... '.' _n___'__'_'________..__.___ .-. ...=..mMw~..', '.oW' __..____._,'._,..-.._._._..._'...._._._._._._'_'_. _.," '._'.'_._'__.__,---'-- __________',nWM'_._ ..!flff';:':: :.:::::i!~Ir;:::::~5ffi :fiI'iiliigiJ~ lif$lii I nvestment activity Oat. Activity Description Quantity Price Amount - 03I31/CU Reinvest BOND FUND OF AMERICA CLASS A $ 27-.32 REVERSAL PENDING REINVEST - - 03I31/CU Reinvest BOND FUND OF AMERICA CLASS A -273.15 WITHDRAWAL, PENDING REINVEST RECORD 01/2S1CU PAY O2I25JCU - - - 03I31/CU Reinvest BOND FUND OF AMERICA CLASS A -19.965 13.70 0.00 REV REINVEST SHS FOR 03l25/CU - - REINVESTED AMOUNT 127-.32 - O3I3l1CU Reinvest BOND FUND OF AMERICA CLASS A 20.011 13.65 0.00 REINVESTUENT SHS FOR 02125/04 REINVESTED AMOUNT 1273.15 - - - 04I061CU Reinvest BOND FUND OF AU ERICA CLASS A 281.71 REVERSAL PENDING REINVEST Igl~~1 HIIII ~IIIIIII~ I.IIIII~ III ~.IIII W HI I 1111 SMITH Client Statement Page 4 0'5 Ret ??oo1272 ??oo8572 March 29 - April 30, 2004 OWE R. EWS Account number 724-06843-11 035 Investment activity continued Oat. Activity Description Quantity Price Amount 04I06J04 Reinvest BOND FUND OF AMERICA ClASS A $ '274.32 WITHDRAWAL. PENDING REINVEST RECORD 02125/04 PAY 03125104 04106I04 Reinvest BOND FUND OF AMERICA ClASS A -20.638 13.65 0.00 REV REINVEST SHS FOR 02125104 REINVESTED AMOUNT $281.71 04I06J04 Reinvest BOND FUND OF AMERICA ClASS A 19.965 13.74 0.00 REINVESTMENT SHS FOR 03125104 REINVESTED AMOUNT $274.32 04126104 Sold BOND FUND OF AMERICA ClASS A -439.224 13.41 S,890.OO CONFIRM /ISOOO41120040!l979 04126104 Reinvest BOND FUND OF AMERICA ClASS A -275.35 WITHDRAWAL. PENDING REINVEST 04126104 Reinvest BOND FUND OF AMERICA ClASS A 20.549 13.40 0.00 , REINVESTMijNT SHS FOR 04/25104 REINVESTEDoAMOUNT $275.35 Total saariU.s,.......t..nd oilier subtractions $ .822.82 Total securities sold and other adcItions $ &,448.03 Withdrawals 0.1e Description Reference no. Amount Date Description RlIference no. Amount 04127104 CHECK 0724111413 5,180.00 BY HARRISBURG PA. TO MESSIAH VILlAGE ",,";_A , l1Titii!~t~i%!ii~~l!iiii!#?<i!i!iA :t.li~,~i@ilillJf~.*~4il:i@~i~ 1'=1;111 - " '-~-"-' JAR$jijG$l:)er: ::\H~~~#"6~(#yplk,'~l)ijt.;-:'-"'- ~-,-_'._,_.__ '". '_,' s,__'__,'_____" v __'_".__'_._.' _'_~..'_ __'.__',".'_ -";'-:'-;-:-:-:-:-'-:-:-:-::'>>'-:- -,',-.'- .-.-...--."......... ~.-.'< .'-'-~-- ,"- ..--. ---"'-"--'--'-"'-":'-: '-":-":-:,'--';::;:-:'--;::':::::'::'::::-;::'--;-'-:-" - '-:'--;-~.- ""'-"-'-' ,. Other dividends Oat. Oeser! pilon Comment Taxable Non-taxable Amount 03131/04 BOND FUND OF AMERICA ClASS A REV DIV ON 5225.1450 SHS $ ,274.32 $ -274.32 03131/04 BOND FUND OF AMERICA ClASS A CASH DIV ON 5204.5070 SHS 273.15 273.15 - RECORD 01/25/04 PAY 02/25/04 REV DIV ON 5204.5070 SHS - 04106104 BOND FUND OF AMERICA ClASS A .281.71 -281.71 04/06104 BOND FUND OF AMERICA ClASS A , 5225.1450 SHS 274.32 274.32 5104 PAY 03125104 , S244.483O SHS - 275.35 Ilmlllll ~IIIIIIIIIIIIIIIII~ IIIIIIIIIII~IIII ~IIIIIIIIIII ~~ IW II1I1111 11~llIm UIIIIIWIIIIII ~ 11111 Information regarding commissions and Charges will be made avaifable to you promptly upon request Please advise us of any materiaf change in your financial objectives or financial situation. AI/ checks written and deposited to your account must be made payable to Smith Barney. If you believe your statement ;s not co,rect, you must contact us within ten (10) days. Complaints and incorrect statement issues may be directed to the Manager of the branch servicing your account (see page 1 of statement for address and phone number) or Citigroup Gfobal Markets Inc.. Attention: Compfiance Department, 77 Water Street, 19th Floor, New York, NY 10005 11111111111 1111111111111111111111111111 1111111 Message: Introducing the Smith Barn., Platinum Se/ect@ MasterCard@ Designed with our clients in mind, the new Smith Barney Platinum Se/ect@ MasterCard@ credit card offers you the ability to choose whether you want to be rewarded for your spending with cash back or Travel & Rewards points. Select the cash back Program and earn up to 1% cash back deposited directly into an eligible Smith Barney brokerage account at year~end. No annual fee. Or, select the Travel & Rewards Program and earn points toward airline tickets, home improvement and shopping certificates, electronics, sporting goods and more. An annual fee applies. For more information or to request an application, speak to your Smith Barney Financial Consultant You can also find information about the card by logging onto smithbarney.com/cards This offer is not valid for Smith Barney clients with non-U.S. addresses, and a credit card account cannot be opened pursuant to this offer in the name of a business. Original trade date 06128/02 04121104 Sold Quantity 439.224 PurchaH price S 12.79 Sale price S 13.41 Cost basis S 5,617.67 Proceeds S 5,890.00 Realized gain or (loss) S 272.33 L T Closing trade date Realized gain or loss Please note, this malerial is being prepared for informational purposes only and should not be used for tax preparation without the assistance of your tax advisor. Trades are allocated the FIFO (first in-first-out) method. Day traders should therefore not rely on this section for day trading results. Your reinvestment activity has been summarized. Single lines have been designated to distinguish Short-term (Sf) or Long-term (LT) information. Detailed information will be available at year-end in your 1099 Year-end summary. using Ref: ??oo1272 00008573 SMITH BARNEY_ cltlgroupJ OWE R. EWS Client Statement March 29 - April 30, 2004 Account number 724-06843-11 035 Page 5 of 5 REV~1508 EX, (6~98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ELLIS, Ollie R. FILE NUMBER ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Plain gold wedding band 40,00 2. Philips COIOf TV Model 20PT633R 145.00 3. 2 Folding Chairs, Lifetime brand 38.00 4. 6 Cotton Pajamas 12.00 5. 2 Pairs Slacks 10.00 6. 12 Blouses 24.00 7. 4 Knit Cardigans 12.00 8. Raincoat 1000 9. Wind breaker 5.00 10. Winter coat 15.00 11. 2 pairs sneakers 6.00 12. Dress shoes 8.00 13. Sweater and hat set 20.00 14. 2 Sweat suits 10.00 15. Dress suit 12.00 16. Dress 5,00 17. Purse 2.00 18. 12 T-shirts 6.00 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F, Note: Value of clothing derived from comparison with like items at Goodwill Store. 19. Care First Medical Insurance Reimbursements (See attached bank statement) 3,788 84 20. Messiah Village refund 165.00 (If more space is needed, insert additional sheets of the same size) TOTAL (Also enter on line 5, Recapitulation) $ 4,33384 Back to Reaular Version You may sort your account register by date, 10, or amount by clicking on the appropriate column heading. Account: CHECKING/ll Account details from 04/26/2004 to 08/31/2004 follow the Summary Information table below. Current Account Information Current Balance Available Balance Amount of Last Deposit Year to Date Dividends As Of 09/09/2004 09/09/2004 08/31/2004 09/09/2004 Balance $4.685.16 $4,685.16 $0.94 $7.20 Summary Information Rate 0.250 Prior Year Dividends $19.68 DateD IdD Description AmountC Fee Balance 08/31/2004 DIVIDEND: Share Dividend $0.94 $4,783.84 08/20/2004 Share Deposit $611.93 $4,782.90 07/31/2004 DIVIDEND: Share Dividend $0.94 $4,170.97 07/27/2004 l1'Z SHARE DRAFT # 179: -$295.00 $4,170.03 07/06/2004 Share Deposit $25.53 $4,465.03 06/30/2004 DIVIDEND: Share Dividend $0.63 $4,439.50 06/29/2004 Share Deposit $102.19 $4,438.87 06/16/2004 Office Transaction $3.184.75 $4,336.68 06/11/2004 1ZQ SHARE DRAFT # 176: '$25.52 $1,151.93 06/09/2004 lZ!l. SHARE DRAFT # 178: -$770.12 $1,177.45 06/09/2004 ill SHARE DRAFT # 177: -$450.00 $1,947.57 06/02/2004 ~ SHARE DRAFT # 175: '$119.35 $2,397.57 05/31/2004 DIVIDEND: Share Dividend $0.54 $2,516.92 OS/25/2004 Office Transaction $67.29 $2,516.38 05/11/2004 ill SHARE DRAFT # 173: -$10.17 $2,449.09 05/06/2004 1H SHARE DRAFT # 174: -$16.29 $2,459.26 05/04/2004 122 SHARE DRAFT # 169: -$945.95 $2,475.55 05/03/2004 Share Deposit $29.44 $3,421.S0 04/30/2004 DIVIDEND: Share Dividend $0.71 $3,392.06 04/30/2004 III SHARE DRAFT # 172: -$42.19 $3,391.35 04/30/2004 ill SHARE DRAFT # 170: '$10.78 $3,433.54 04/29/2004 1Zl SHARE DRAFT # 171: -$53.40 $3,444.32 Savings federally insured by NCUA. Equal Opportunity Lender. Back to Reaular Version REV.1509 EX- IB.98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF ELLIS, Ollie R. FILE NUMBER 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. Dorothy A Deloach 6 Bracken Court Mechanicsburg, PA 17050-2374 Daughter B Javan M. Deloach 6 Bracken Court Mechanicsburg, PA 17050-2374 Son in law C JOINTLY.OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANKACCQUNTNUM8ER OR SIMILAR DATE OF DEATH DECO.S VALUE OF NUMBER TENANT JOlNT IDENTIFYING NUMBER. ATTACH DEeo FOR JOINTLY-HELD REAL ESTATE VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1 A, 06/13/2002 Members 1st Federal Credit Union, Account 219219.11 3,497.72 33 1,16593 B. 06/1312002 Members 1st Federal Credit Union, Account 219219~O 211.68 33 70.56 06/1312002 Members 1st Federal Credit Union, Account 219219~5 6,093.28 33 2,03113 2. A 05/0112002 Series HH Savings Bonds (See attached copies) 3,500.00 50 1,75000 TOTAL (Also enter on line 6, Recapilulation) $ 5,01762 (~more space is needed, insert additional sheets of the same size) Back to Reaular Version You may sort your account register by date, ID, or amount by clicking on the appropriate column heading. Account: CHECKING/ll Account details from 04/01/2004 to 04/30/2004 follow the Summary Information table below. Current Account Information Current Balance Available Balance Amount of Last Deposit Year to Date Dividends As Of 09/14/2004 09/14/2004 04/30/2004 09/14/2004 Balance $4,668.16 $4,668.16 $0.71 $7.20 Summary Information Rate Prior Year Dividends Ide Description DIVIDEND: Share Dividend 0.250 $19.68 AmountC Fee Balance $0.71 $3,392.06 -$42.19 $3,391.35 -$10.78 $3,433.54 -$53.40 $3,444.32 '$3.48 $3.497.72 '$16.27 $3,501.20 $962.00 $3,517.47 DateD 04/30/ 2004 04/30/ 2004 04/30/ 2004 04/29/ 2004 04/10/ 2004 04/03/ 2004 04/02/ 2004 1ll SHARE DRAFT # 172: ill SHARE DRAFT # 170: III SHARE DRAFT # 171: ill SHARE DRAFT # 167: JJill SHARE DRAFT # 168: US TREASURY 303 ~ - sac SEC: Automatic Withdrawal/Deposit Savings federally insured by NCUA. Equal OppDrtunity Lender. Back to Reaular Version Back to Reaular Version You may sort your account register by date, 10, or amount by clicking on the appropriate column heading. Account: SAVINGS/OO Account details from 04/26/2004 to 08/31/2004 follow the Summary Information table below. Current Account Information Current aalance Available aalance Amount of La.t Deposit Year to Date Dividends Rate Prior Year Dividends Summary Information DateC 08/31/2004 07/31/2004 06/30/2004 05/31/2004 04/30/2004 IdCl Description DIVIDEND: Share Dividend DIVIDEND: Share Dividend DIVIDEND: Share Dividend DIVIDEND: Share Dividend DIVIDEND: Share Dividend Savings federally insured by NCUA. Back to Reaular Version As Of 09/01/2004 09/01/2004 08/31/2004 09/01/2004 1.000 $1.02 Amount[] Fee $0.18 $0.18 $0.17 $0.18 $0.17 Balance $212.56 $187.56 $0.18 $1.38 Balance $212.56 $212.38 $212.20 $212.03 $211.85 Equal Opportunity Lender. Back to Reaular Version You may sort your account register by date, ID, or amount by clicking on the appropriate column heading. Account: INVESTMENT SVGS/MMA/OS Account details from 04/26/2004 to 08/31/2004 follow the Summary Information table below. Current Account Information Current Balance Available Balance Amount of Last Deposit Year to Date Dividends Rate Prior Year Dividends Summary Information DateC 08/31/2004 07/31/2004 06/30/2004 05/31/2004 04/30/2004 Ide Description DIVIDEND: Share Dividend DIVIDEND: Share Dividend DIVIDEND: Share Dividend DIVIDEND: Share Dividend DIVIDEND: Share Dividend Savings federally insured by NCUA. Back to Reaular Version As Of 09/01/2004 09/01/2004 08/31/2004 09/01/2004 0.000 $147.27 Amountc Fee $5.66 $5.65 $5.01 $5.18 $5.00 Balance $6,114.78 $6,114.78 $5.66 $52.86 Balance $6,114.78 $6,109.12 $6,103.47 $6,098.46 $6,093.28 Equal Opportunity Lender. ml"f." ; It "a .1' 1"1111."7'" REV-1511 EX+ 112-ee:w COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ELLIS, Ollie R. FILE NUMBER Debts 01 decedent mUlt be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Burial Vault, purchased from Cremation Society of Pennsylvania Engraved gravestone, purchased from Campbell Funeral Home, Abingdon, Virginia 295.00 481.95 2. 8. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representatlve(s) Social Security Nurnber(s)/EIN Number of Personal Representalive(s) StreelAddress City Slate lip Yea~s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's. attach explall8.tion) Claimant SlreetAddress City State Zip Relationship of Claimant to Decedent 4. Probate Fees 295.00 5. Accountant's Fees 6. Tax Return Pre parer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space IS needed, Insert additional sheets of the same size) 1,07195 .\1L\lBl.lh 1" ONU;\;I': V~ Accounts View Account DeQiil. Order Sta.......nt WIthd,.w by Check Export Account Infonution Tnn..cUon Search VISA History Loan Application Mortgage Application Online Service. Planning Tools Personal Profile PriVlcy Policy Security Tenn. & Conditions Site Map 1#. . ChAclIrTY'lgAS The Images you requested may take a few minutes to download. If the Images do not appear within several minutes, please contact the Call Center at (800) 895~2699. Representatives are available to assist you Monday through Friday. from lam to 7pm, and Saturday 8am to lpm. Click on the Image to view a larger version. Back to Hi!;torv rff GLUE L ELLIS J.YA."f"'D~ DOIlOtIfI'A.HLOACII , IltM:UM COURT lGCILVIICUUao.PA I'II!O ...~79 77!~~:~;'>~;::::l-~~ r~~;~ N~.h~Dr~iJP<I~ ---- 'fh ;" '*-~ l ,,# ; - ~,...' I ~ "-~ '~~1'~a1 ~ti~il~"~ '03JO(l()O.Co F'RB-PlflLR7'~3/~- O'fT"J6J8 TRCtJ628 Pl-U t::: I' I n I ! - L: '! !.' "', .1. \ ,,, V r~IX>>36O< n: o ~ .HEJ:.ft: eatu; ~.. l} ~ C Rk"f> Ii ILl.." 0 ....,..... - Im:D r: _' ';D ':' ~z~o c~::.a :~nqJ -,,...-,... ~:: .!..;~-O '1 ~"..{) -." 'f..I) <,j~;~';<) <.1"Iti l~~J '. u ri'~ ~ -1; 1 .~ !.( qi . . ! : I I ,I,' Back to Hlstorv Savings federally Insured by NCUA. Equal Opportunity Lender. Campbell Funeral Home, Inc. 250 East Main Street P.O. Box 948 Abingdon, VA 24212-0948 Ph: 1-276-628-2131 Fax: 1-276-628-1205 www.campbell-funealhome.com PAID Monument Order Sold to: Michael DeLoach 6 Bracken Court Mechanicsburg, PA 17050-2374 Date: September 9, 2004 Phone: 1-717-697-5533 Cemetery: Whiteaker Cemetery Sold By: /Marty White Description ************************************************************************ 18 X 24 Granite Marker Custom Layout $459.00 VA sales Tax $22.95 Total Marker Cost --------------------------------------$481.95 Robert Earl Ellis 1915 2002 Ollie Whiteaker Ellis 1916 - 2004 After complete approval, please sign below indicating the proof of the layout and the acceptance of the amount listed above. Please note that all markers are custom ordered and any changes will result in additional cost to the signing agent. We require 50% deposit prior to order or layout being produced. Confirmation by Phone/Credit Card 09/09/04 Thank You For Your Trust In Our Funeral Horne RECEIPT FOR PAYMENT * DUPLICATE * ------------------- ------------------- Cumberland County - Register Of Wills Hanover and High StreeE Carlisle, PA 17013 Rece~pt Date: Rece+pt Time: ReceJ.pt No. : 4/30/2004 15:20:43 1036459 ELLIS OLLIE REBECCA Estate File No. : Paid By Remarks: 2004-00424 JAVAN M DELOACH JA ------------------------ Receipt Distribution -----------_____________ Fee/Tax Description Payment Amount Payee Name PETITION FOR PROBA EXTRA PAGES SHORT CERTIFICATE JCP FEE Cash Total Received.... ..... 270.00 9.00 6.00 10.00 ---------------- $295.00 $295.00 CUMBERLAND COUNTY GENERAL FU CUMBERLAND COUNTY GENERAL FU CUMBERLAND COUNTY GENERAL FU BUREAU OF RECEIPTS & CNTR M. 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 Messiah Village (See attached statement) 4,77500 Note: On the attached statement, the payment of $5890.00 that was credited on May 6, 2004 was made II from the sale of the decedenls mutual fund stocks. That sale was made on the afternoon of April 26, 2004 prior to the death of the decedent later that same day, and is included in the value of the mutual fund listed on Schedule B. 2. Venzon final phone bill. 16.29 3. Unpaid medical expenses (See copies of attached checks) 2,82116 TOTAL (Also enter on line 10, Recapitulation) $ (If more space IS needed, insert additional sheets of the same size) 7,61245 ~ e.ssiah S tat e ill e n t ~ L-...........c::;;a.E!!5: 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 DOROTHY A DELOACH 6 BRACKEN CT MECHANICSBURG, PA 17050 QUeSTIONS? CALL: (717) 697-4666 ReSIDeNi NUMBER DAie 110304 05/31/2004 RESIDENTrSI Mrs. OLLIE R. ELLIS TOTAL AMOUNT DUE $0.00 DATE DUE 06130/2004 $ DATE DESCRIPTION UNIT CHARGES CReDITS BALANCE Balance Forward 10,665.00 05/0612004 PAYMENT RECEIVED - THANK YOU!!! 5,890.00 4,775.00 05/0612004 PAYMENT RECEIVED - THANK YOU!!! 4,940.00 -165.00 *** Nursinl( Care *** 0513112004 REFUND 1 165.00 0.00 Refund overpymnt on acct; MV ck #79747 RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 110304 0.00 0.00 0.00 0.00 0.00 $0.00 RESIDENT NAME Mrs. OLLIE R. ELLIS A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! Fonn PS.o1 "" Uyou have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! l\IEl\IBEHS 1" ONLINE View Accovnts View Account Details Order Statement Withdraw by Check Export Account Information Transaction Search VISA History Loan Application Mortgage Application Online Services Planning Tools Personal Profile Privacy Policy Security Terms & Conditions Site Map 1#. . Check ImQgm The images you requested may take a few minutes to download. If the images do not appear within several minutes, please contaq the Call Center at (800) 895-2699. Representatives are available to assist you Monday through Friday, from 7am to 7pm, and Saturday 8am to Ipm. Click on the image to view a larger version. Back to Historv ~OLlJlLEU" ' ..".. J7' ~:~yD~~M:H~';J~'':'f'i 1 ., O:;'EC/2?fN~.J/'0 ~ ili 8AACKEN COliJlT _,. MI'.cHANICSBURQ, PA IlmO ~:,~14~... I$~ ~~~~-~--""'"nlll"" M.~.t}.mcar OO~. riJwJ/J. .;tG) tk -:=7i77~..t-,M1/l~</tI9r g: "j. ':/U3a//~1l: /Ia/lHIH~ Ol?~ tOOOOOOI&/qt .-'.~'""""'-",,,,, , . FLEET ,49QJi'!Ugeamu ~ ((~~~1if i 49889 '. I , ! I , I I I I I [' ! '" CONSCUD RTN. FONV >0219li'24<16.'<#630137507S' FLEET ERNK 4~~OO 458 1457 05/04/04 5 . IE ~C.7 77 ". 744 vtRlZOti COlt I >O~t90244A<44E"". ~P6f,i75siifi;NSOLID RTtI. oot~.' S\lC.-1Sa"~kiPl t) 122926779 Back to Historv Savings federally insured by NCUA, Equal Opportunity Lender. ME~1BERS IS! ONLINE View Accounts View Account Details Order Statement Withdraw by Check Export Account Information Transaction Search VISA History Loan Application Mortgage Application Online Service. Planning Tools Personal Profile Privacy Policy Security Terms & Conditions Site Map 1#. . ChAd ImQgR.~ The Images you requested may take a few minutes to download. If the images do not appear within several minutes, please contact the Call Center at (800) 895-2699. Representatives are available to assist you Monday through Friday, from 7am to 7pm, and Saturday Sam to lpm. Click on the image to view a larger version. Back to History ..."..........--.....--.----......-."..- OI.I.It;a. rUlli rY1A.VA.'Il M. DE1.04CR DOItOTRY A. DELOACII 'IRACJCENCOuar lolECHANK:sauao, PA 17050 rJl.:~..jJL,hn1'A,;. ~ . 1$J.q.i>.~ ~ ,.'.. }J~,-j"~"v4;f"1:,'f;" I /M~......1ll '" M~h~r, : :=;:i;';;71I-M-tllYtj9 K:h/1~ A f"\+..J , .: 13 B8 11~ I.: 118 Ilq IIH" 0 I&q "'OOOOOq~ Sqs,o ~ .} y,.j 169 o.~.J":;: ~A; ,..;;J( --.. '. HI Z :,:j I i i i i i , I I , $rml<:aq!e~!1<<143Wf!tEFQ$'rr QtllV. FtC.l.lltlS ~;!'tv; t~ fJ"'l'i;otf'A. :l8693S 1 " , ' 00:.l''';'Q-:-''.''', C~034~~~ 'm~lwql~'J9 I:.;l\;~~ 27{i(j5474B7 882[1512495 "d r., I . , Back to History Savings federally insured by NCUA. Equal Opportunity Lender. MEi\IBERS IS! ONLINE View AccounL<; View Account Details Order Statement Withdraw by Check Export Account Information Transaction Search VISA History loan Application Mortgage Application Online Services Planning Tools Personal Profile Privacy Policy Security Terms & Conditions Site Map 1#. . Ch~k ImQges The images you requested may take a few minutes to download. If the images do not appear within several minutes, please contact the Call Center at (800) 895-2699. Representatives are available to assist you Monday through Friday, from 7am to 7pm, and Saturday Barn to lpm. Click on the image to view a larger version. Back to History rfffA~:"~~ ~ 170 DOROTHY A.. DELOACH o.u~';;J) (ltA./ J.::JiY'd 6 BRACkfN awar -.m'1 MEOtAlflCSBVRG.'^ 17U:50 1!l..~~~/?Ll";"6 'i P..1AJ':..D"..(j>)..!'1.d,Pt'I$~ .1~" 1" ~""""'-'-----~-----',,"l'" til!€ Ms:Y.1.h~r ~:;; tl32"~_ (i),'UlolJtf-A r'i\,A." M_ .: Il B8 I I~ l': I l8 I lHlq l" 0 l?0 ...000000 lO?8... 0- .~,~.~,__ ~. oiJ7'j~5;-J~'f'~,! C\2nS43740 ,0429200 .,' I roJ? El6 f'9 031~o FRB_PHI~/28/COO4 'ENT=1OS9 TJi>C::1OS9 Pt"'tl ",; , C" ~ >03J?01~' I !~ ~~~~~~ifJ I ~ '.<: o1:~ao" .. -', .~.. n..-iQ', ",1 ':"'" i ' c .:J .c".g' i, . & ,,!l.I:<1' ? '_'1'~ g~~~!! c.:= c ~~ga~, ,.:.l... .. ".!2;;;-2-<1 ':"" a:~ I ,;: ~g! I c~; 0 ! i [ if ...' 'j' ~, i Back to Historv Savings federally insured by NCUA. Equal Opportunity Lender. J\lEi\1BEHS IS! ONLINE View Accounts View Account Details Order Statement Withdraw by Check Export ACcount Information Transaction Search VISA History Loan Application Mortgage Application Online Services Planning Tools Personal Profile Privacy Policy Security Tenns & Conditions Site Map 1#. Ch~k ImagR.~ . The images you requested may take a few minutes to download. If the images do not appear within several minutes, please contact the Call Center at (800) 895-2699. Representatives are available to assist you Monday through Friday, from 7am to 7pm, and Saturday 8am to lpm. Click on the image to view a larger version. Back to Historv ~?1i~ DORotHY A.DELOACH ....:/;,-(){'" J .::rrr.f 1 71 6BRACKafcotJftT ___.~ MECHANICSBtJII:O, PA 1105l'l ~:rI1V'/'>A,:"i 10,)//18 l$ffi,33%J .1~.rl'" .I -fJf-rY'----^---~~,... lil .., M~4L .~'J!Jr ~....... --- ,..,~~~$I//)::t/)~ 1:23B8H~11: ~18Ilq~lH~ ._'--... :OJ#6~~^'"^: _ :04C'8EOO.t ';,' ().')JOClO04Q. F1i'B-PHILA. ," :E"T~oe5l r~C~C876,pt=JJ fJ~~l~13 "QJ 150013"<>4 ~3f)0293t179 : I !'i[ ! J., '~f!~ i "...~ 'nl~ ~ ~!'l,! . ~~ , , I .' . ~ , . .';' Back to History Savings federally insured by NCUA. Equal Opportunity Lender. \11 \!Il1 H" I' O'\L1\<I: Accounts Home ~?--~ V~W ~~~,.~. VIow__ Order ...._. _awby_ e__ - T__ VISA ItIawy .....~ MortpgI '\ilpn nUn """""- -IIIIT_ -- Privocy ""'Icy SocurIIy T...... & Conditions SIle,.... Accounts Home 1#. . Transfer Funds Contact u. Help Log Out C~k Im~ The Images you requested may take a few minutes to download. If the Images do not appear within several minutes, please contact the Call Center at (800) 895-2699. Representatives are available to assist you Monday through Frtday, from 7am to 7pm, and Saturday Barn to lpm. Click on the Image to view a larger verslQn~ Back to Hlstorv Front of Check: .......LIWI "O"'y"".... -.cLOM:II ~ ~&~7.. ~"~I'I1...AL<; I$~ . f~_811i1 r -=....~ G\ --1'nJl~ 1IJt,j!>'5f ~I ITOIl~i~lA 4>"1- Il/HUH..'.: lIall~lIU" auz "OODOOOloll~" ---... _-'(,. f/f.;J..:uvJ-72 - Back of Check: .-. ~ ')' ,. : I I- ,(,I I.~I. '=-. . ",1,/ .J I I .~.. ',~, it!il'''''' .,,.. M '" :i--id.oci .Ii "I~i .: , .,~. I:; . ,',..,., '. DiIlI,\ f'll :<r 270059252&' ~i i '<I' I: 'i.: J I~I ! "~I! " " ?;: . ~ , ,; ~j. Back to Hlstorv Savings federally Insured by NCUA. Equal OpportunIty lender. Transfer Funds Contact Us Help Log Out ME~1BEHS 1" ONLINE View Accounts View Account Details Order Statement Wtthdraw by Check Export Account Information Transaction Search VISA History Loan Application Mortgage Application Online Services Planning Tools Personal Profile Privacy POlicy Security Terms & Conditions Site Map 1#. . Check ImagAS The images you requested may take a few minutes to download. If the images do not appear within several minutes, please contact the Call Center at (800) 895-2699. Representatives are available to assist you Monday through Friday, from 7am to 7pm, and Saturday Barn to lpm. Click on the image to view a larger version. Back to Historv OUlIt.. EU.TS ~J4Y4."iM.DELO"CH DOROTHY.... DELOACH 6 BltACKENCOVU 1omOt.oOo1OlBURG,PA 111:&1 ... 29 (JfJn(!,;{Ooj173 , _'l ~:'''''i1J7?~ .b-Arht 1,,,"1"";'" l$lLP..2lJr...J ~/~~~~-......Iil!€; MSfAm~r ;;;;;";';4U"Aq~ fi:::b.IIfJjJ'tti,G:l,~d . l:nlian~ll: 2Ia21~1l~1~ Oln ~DODDOOIOIU ._,-..~,..... :I7J059.i'92~':" )5fOi?OOot ~:tR~:"'PHJLA _ 03100004ffiol'~IEk-ll EHT"'0907 TRC=Q917 PL=OO . , oo~~~~':! ::'>~~~'l"I:-C:;, (''If}......~......f..,., <"..lIth,;< ,llll"'",f-llCW," C\ I ,. I? I :~ ! --.~ f_ , -1 -, ) i? "!! ( - ..~ .~ -.~ ~ . - .2 ,. ~<l """i~ "'"' .-....("";'3~ ~i;i:;i~ ~~5:..~5i. ,.A....J.l 31 I ~ ..... - ~ i'i-I '.: I I "" I : ! ' Back to Historv Savings federally insured by NCUA. Equal Opportunity Lender. i\lBlBERS 1" ONLINE View Accounts View Account Details Order Statement Withdraw by Check Export ACcount Information Transaction Search VISA History Loan Application Mortgage Application Online Services Planning Tools Personal Profile Privacy Policy Security Terms & Conditions Site Map 1#. . ChQ(':!c ImngAS The images you requested may take a few minutes to download. If the images do not appear within several minutes, please contact the Call Center at (800) 895-2699. Representatives are available to assist you Monday through Friday, from 7am to 7pm, and Saturday Barn to lpm. Click on the image to view a larger version. Back to Historv OWIla. EWS rffJAoV4N",. DELOACH DOROTHY '" DELOACH 6 BItACUNCOVJtT MEOfANICSBOitG, I'AI'/O>> .; 175 ..., ..:i.4I71?:r<'{)t) ......- ~~~'~^~::f,~"~~1'= ~ MmlQm1r ::it-'c.fI'I3.4 fD,1J,w(j.,4.C\. A-g,~ . 1:,B~lail"ll: ~~BU'Hll:il'" Ol,?5 t"OOODOUcUS... ._,..._,...,,-,~ - !;. N ~ \ii, I I I '. or ~ I I i ~ I ~Cl i I i; I ...N i':i:~ J ~ i ii! ' (f1QoOSC i qr':l;~li ' lat~~,-I~ I 32C;E~509~i56 !.,<< ! i I I j , Back to Hlstorv Savings federally insured by NCUA. Equal Opportunity Lender, \11 \1 HI 1<'- I ' ()"\" I 1.....1 Accounts Home ~ ~ VIow__ 0nI0r_ _..c_ -- L.L.....A... -- ....- LoIIn~1Iton ~\:rnllll. ..-- "'"'- T_ -- ....... - ......., T..- & CondItions 1110 Map ,-. . Tr.n"', Fund. Con~ct u. Help Log Out Check Imogf!!: The Images you requested mlY lake a few minutes to download. If the Images do not appear within several minutes, plea.. contact the Call Center at (800) 895,2699. Representatives are available to assist you Mondav through Frldey, from 711m to 7pm, and Saturday 80m to Ipm. Click on the Image to view II larger version. Back to Hlstorv Front of Check: ~OLIJI"IWI __ J 178 ==.r:.:~ - /O'W .:Jr.rw- ., '.... 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Representatives are available to assist you Monday through Friday, from lam to 7pm, and Saturday 8am to lpm. Click on the image to view a larger version. Back to Historv . __ __.__u____.__ __.___. _" ___~.__. .._" , ~, ~r':-V~~~~ACH ~ !178 DOIW'tHY 4. Of'Ul.\CR D.ol~ J J L/'I" ~ /)/) 68K"CXf.NCOtJRT _'1 MECHAJro'lClWItG,PAI'lO!O ~:t-PjA^inrAJ/./l -, ,-,.-J$[ijZ~J , -' . J.:J- " . " , . - . ~, '. Sh~ - J n;..A,." el' J)J LIf'4{j d ft5i)-:,:,--o..u- m ~ J.._ r' . '. MftRa~m . ::'S"7/i'IlI- DIWl o.'4n<Jjtf4. 0" A-".1.... .:nI381IH.: 11811HIQI" 0178 0"00000710110" --.--- i , I , ! ,.. HI I ~ i , I ! i , I I I I I >>'.U;Sl.~<<t~~f.crlVlc'.i.[FOSIT 'o;tly..RtfJJUJ"~: ~ , .. ~ (lC ,~t:triirA, .' 4,:::tt~,.. 00.... ,""'.......,-. C\F..JlOJ4~"3 5?lleleool~t'9' ~~. ...:~ i . Wtl/94 ~~-0~~?~=!7:1~~- , 87206'72597 Back to Historv Savings federally insured by NCUA. Equal Opportunity Lender. :-'11 \11\1 HS I" ONLINE \-. . View AcCQunts View Account o.t.lla Ord... Sta"lMnt WIthdraw by Check Export Account Informlltion Tran.action Search VISA History LOIIn Application Mortgage Application Online Servlc.. Planning Tools Personal Proll" Privacy Policy Security Term. & Conditions Sit8Map ChACk 1rTV'1gFl~ The images you requested may take a few minutes to download. If the images do not appear within several minutes, please contact the Call Center at (800) 895-2699. Representatives are available to assist you Monday through FrIday, from 7am to 7pm, and Saturday 821m to lpm. Click on the image to view a larger version. Back to Hlstorv OWl:'" EWI ~J"'YANM.D&L04C. OO.OTffYA.Dl:LOA(II ,UACUMCOU&T ~.a.I'AlllM ,yyJ 180 .....Jr. (J, '8 ,;>. -..... 7.~~:.J,_~ LL~-=~~::~~ ~G!r "~~~~ _ U)'~n.JJ(J ,4, ~ A...~/ . l:n'J.u",~ UBBqUq~.. alBa IDonaDOnOO,f ~~"o._.r'-.,' : f'03.T'OOOJ-~,""', J.'Hlt:I!la9l!l"A, .. 91 7.71t+4-43'~11 ::: ...-..-..G'!ii.'EW:JW6IPl/.lte.N1ol: It'! ;l...t~S"'l~~~ ~- "N-417,lO'iffi", ~~~~3 :>909l!OO4 ENT=4171 TRC.41~i PlatS " I , " (' I ~ I I lD ." ;= ;~ m 0 '0 1m ~I~ I.. ~;=i - i ~ FI~ () I L Back to Hlstorv Savings federally insured by NeUA. Equal Opportunity Lender. \ 11 \11\ I I{" 1 ' ()'\, I I'\, I Account'S H()m~ ~ ~ --- 0Idw_ _bye.... I!xporl- ~.__....6... T__ -- LNn "'ww--. ,......... .PP""'--" <lnlIne_ _T_ -- -- - T_ & CondItions ... MIp Check ImogA!l 1#. . Log Out The Images you requested may take a few minutes to downlOlld. If the Images do not appear within several minutes, please contact the Call Center at (800) 895-2699. Representatives are lVallabte to assist you Monday through Friday, from 'am to 7pm, and Saturday Sam to lpm. Transfer 'uncla Contact U. Help Front o' Chock: Click on the Image to view a larger version. Back to Hllitorv 1- ~=l=..c. oral ti.~J!!!~ .. ...2t.nll8'~n .-. -M._ - ~'J~~ I ..... e II r '. :,:,:.:..-- _OHI..; ~tJ'il4 (i).,~ .4.tJ:),~~J. CZJ.J.ZZ~.C z..z.qz.q.. D... ~DDDDOq.'.~ ..ck "Chock: , ._.__._~: J. "', , -. - ~ ~.~l ~ : ; '!t~~~ -:-"-'8 ~;.. t -~at~~ \ ~ _ ' .....a u:Ja I ....q)\j. .. . I ., 0- : .26~Q1631~S:5lt9798167 I "!l ii, -. I I I" if' I : ! , . bl~ i ~ i'" I .11 ! ~~ , 1&1 i ~i II ! I ,. ~ . I ! Back to Hlstorv Savings federally Insured by NeUA. Equal Opportunity Lender. Tranafer Pundt Contact u. Help Log Out REV-1513 EX,,{9"()O) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF ELLIS, Ollie R FILE NUMBER 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 outright spousel distributions, and transfers under Sec. 9116(0) (1.211 1. Dorothy A, DeLoach, 6 Bracken Ct., Mechanicsburg, PA 17050,2374 Daughter 102,986.28 2. Robert E. Ellis, Jr., 4011 River Crest Circte, Leesburg, FL 34748 Son 96,330.79 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON. TAXABLE DISTRIBUTIONS ON LINE 13 OF REV.1500 COVER SHEET $ 0,00 (If more space is needed, insert additioJlaI sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG. PA 17128-0601 REV-1162 EX(1,-96l RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT DELOACH JAVAN MICHAEL 6 BRACKEN CT MECHANICSBURG, PA 17050 n______ fold ESTATE INFORMATION: SSN: 228-01 -4019 FILE NUMBER: 2104-0424 DECEDENT NAME: ELLIS OLLIE REBECCA DATE OF PAYMENT: 09/14/2004 POSTMARK DATE: 09/14/2004 COUNTY: CUMBERLAND DATE OF DEATH: 04/26/2004 NO. CD 004382 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $8,917.60 I I I I I I I I TOTAL AMOUNT PAID: $8,917.60 REMARKS: CHECK# 1460 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS ~~''''; _ R""~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX JAVAN M DELOACH 6 BRACKEN CT MECHANICSBURG 'O!~ DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-08-2004 ELLIS 04-26-2004 21 04-0424 CUMBERLAND 101 I"' -- ~, .\ n ....'~"") .l:; .LL . REY-1547 EX AFP 101-05) OLLIE R p~. 17050 Allount Rellitted t~\ n 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=i5'4-j-E3f-AFP--foY:03Y-Noi'-icE--oF-iNHEifiTAifcE-i'AX-APPRA-isEi"-ENT~--ALi-oWAi,rcE-ifR-------------- --- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF ELLIS OLLIE R FILE NO. 21 04-0424 ACN 101 DATE 11-08-2004 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. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 197.501.72 .00 .00 4.333.84 5.017.62 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage 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) 1,071.95 7.216.45 (11) (12) (13) (14) NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 206,853.18 8.288 40 198,564.78 .00 198,564.78 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 16. Allount of Line 14 taxable at Lineal/Class A rate 17. Allount of Line 14 at Sibling rate 18. Allount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: (15) .00 X 00 = .00 (16) 198,564.78 X 045 = 8,935.41 (17) .00 X 12 = .00 (18) .00 X 15 = .00 (19)= 8,935.41 l+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 09-14-2004 CD004382 .00 8,917.60 PAYMENT MUST BE MADE BY 01-26-2005*. TOTAL TAX CREDIT 8,917 .60 BALANCE OF TAX DUE 17 .81 INTEREST AND PEN. .00 TOTAL DUE 17.81 · IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. ~ IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE - ') A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) - RESERVATION: Estates of decedents dying on or before December lZ, 198Z -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. PURPOSE OF NOTICE: To fulfill the requirements of Section Z140 of the Inheritance and Estate Tax Act, Act Z3 of ZOOO. (7Z P.S. Section 9140). PAYMENT: Detach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side. --Make check or money order payable to: REGISTER OF MILLS, AGENT REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-13l3). Applications are available at the Office of the Register of Wills, any of the Z3 Revenue District Offices, or by calling the special Z4-hour answering service for forms ordering: l-800-36Z-Z050; services for taxpayers with special hearing and I or speaking needs: l-800-447-30Z0 (TT only). OBJECTIONS: Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. Z8l0Zl, Harrisburg, PA l7lZ8-l0Zl, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. Z8060l, Harrisburg, PA l7lZ8-060l Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-150l) for an explanation of administratively correctable errors. DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%) discount of the tax paid is allowed. PENALTY: The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of six (6%) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January 1, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through Z004 are: Interest Daily Interest Daily Interest Rate Factor Year Rate Factor Year Rate ~ -:ooom Im-199l ~ ~ mil ---gr- 16% .000438 199Z 9% .000Z47 ZOOZ 6% 11% .000301 1993-1994 7% .00019Z Z003 5% 13% .000356 1995-1998 9% .000Z47 Z004 4% 10% .000Z74 1999 n .00019Z 10% .000Z74 ZOOO n .00019Z Year mz 1983 1984 1985 1986 1987 Daily Factor . "OOiiZ7tT' .000164 .000137 .OOOUO --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUKBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT DELOACH JAVAN MICHAEL 6 BRACKEN CT MECHANICSBURG, PA 17050 __nn fold ESTATE INFORMATION: SSN: 228-01-4019 FILE NUMBER: 2104-0424 DECEDENT NAME: ELLIS OLLIE REBECCA DATE OF PAYMENT: 11/30/2004 POSTMARK DATE: 11/29/2004 COUNTY: CUMBERLAND DATE OF DEATH: 04/26/2004 NO. CD 004678 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $17.81 I I I I I I I I TOTAL AMOUNT PAID: $17.81 REMARKS: CHECK#1433 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS C H Z C >11I ....::) >-Z UlIII Z> ZIII III'" II. IL ILO o I- :Z:Z 1-11I ....:E CI- III'" :l:C ZII. 011I :EA :E o U W U ~~ "'I- o ....... 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(,.I :I:i: .:..1 (..1 ".) .:~.l ooo:;u Q)~C<1> ::l. <1> 3 ce. -. 0'" en ~O<1>(j) <1> 0 -, -, - C- \J::I-~9. )>g-Q.~ ~Co= -...IenOm O<1>C ~(J)a W.o-< Co ~ 0 <1> C ::I- ::T o C en <1> /~ ... ... ... 1I~,,':ti,.s' .,,,,,, ~, '1','\',':)1 ~,' 1 I~ J:;' \ II'III\!\'':> 'I~: i~ \' 'I' '\'111 ',1','\1 '\ i I 1\ ", i ~ N ;5 I () g rN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 005447 SMITH PAULA G 1260 HILLSIDE DRIVE MECHANICSBURG, PA 17055 ____n__ fold ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $5,000.00 ESTATE INFORMATION: SSN: 169-05-1453 FILE NUMBER: 2105-0424 DECEDENT NAME: GORDON CHARLES 0 DATE OF PAYMENT: 06/17/2005 POSTMARK DATE: 06/1 7/2005 COUNTY: CUMBERLAND DATE OF DEATH: 04/14/2005 TOTAL AMOUNT PAID: $5,000.00 REMARKS: CHECK# 518 SEAL INITIALS: CCP RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 3/07/2006 DELOACH JAVAN MICHAEL 6 BRACKEN CT MECHANICSBURG, PA 17050 RE: Estate of ELLIS OLLIE REBECCA File Number: 2004-00424 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO, 11 for decedents dying on or after July 1, 1992, the personal representative or his counsell within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 4/26/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, ,~~~ Glenda Farner s~rasba~- Clerk of the Orphans' Court cc: File Counsel ~/f( STATUS REPORT UNDER RULE 6.12 Name of Decedent: 0 ii, e R eheccc ~ l (, .$ Date of Death: 4, 2" I 20<<1+ Will No.: 2..00 4- ~ 004- 2.. 4- Admin. No.: 'Z.' - \0 4- - c 4- 2.+ 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 IB No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No lID b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Y es ~ No 0 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: 'IApr2oo& ~(;Vvl. m.t:). ~ SigdJture :Jav'an M.1)t!Lo4Ch Name <0 Br~c::.ltlf\. C+-. M12ch ~V\,c.S ~\rr~ r PA 1'1 oS 0 Address 'll'l, "q~'SS33 Telephone No. Capacity: ~ Personal Representative o Counsel for personal representative k]//'J0 ~" / /'