HomeMy WebLinkAbout03-0472 PETITION FOR PROBATE and GRANT OF LETTERS
es,ate os
To:
also known as
Deceased.
Social Security No. ~ ~ °c-O ~l - ~ I b ~ ._
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age.or older an the execut ri/t.
in the last wilt of the above decedent, dated ~ o, vc~ t ~ I q ~ ~
and codicil(s) dated Naat
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Register of Wills for the
County of
Commonwealth of Pennsylvania
in the
named
Decendent was domiciled at death in t~o ~,b¢*-I~,~o( County, Pennsylvania, with
h ~ ~, last family or principal residence at PO 0~¢~ ~,aat~ .T~54~
(list street, number and muncipality)
Decendent, then ~o years of are, died 0 5'I~~' ] Z.c~ '~ ,n~F9 ,
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $
(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: E7 II ~r~ (~oa~ i (~rl,~-~ ~ DA- ( h~o,~4~ ~ddle
WHEREFORE, petitioner(s) respectfully
presented herewith and the grant of letters
theron.
request(s) the probate of the last will and codicil(s)
(testamentary~'administration c.t.a.; administration d.b.n.c.t.a.)
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~ ss
COUNTY OF Cmnberland
Thc petitioner(s) above-named swear(s) or affirm(s) that the statements in thc foregoing petition are
truc and correct to thc best of thc knowledge and belief of petitioner(s) and that as personal reprcsen-
tative(s) of thc above decedent petitioner(s) will well and truly administer thc estate according to law.
Sworn to or affirmed and subscribed ~ "')~~ "'fi/" ~ ~ _ c~
f%efore me ~hi~ 4 t~ _ a~ o~ ~ ~ ~'
Donna M. O~to,lst D~putydReg' ~r L ' , f ~
21-2003-472
Estate Of, 0~ e. clo~st~- , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
June 9th
AND NOW
be .reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated. March ls~ 1985
described therein be admitted to probate and filed of record as the last will of
David F..Clous~r
and Letters T e s t amc n t a r ¥
areherebygrantedto Mary M. Campbell
~gx 2 0 O ~a consideration of the petition on
FEES
Probate, Letters, Etc .......... $. 200 o 00
Short Certificates(4 ) .......... $ 12.00
g~gamll~i~ro~iX...e.x._t..r.a., p.a. ~te. ss 3.00
Copies 2.50
JCP $
1U.UU
TOTAL $
Filed J. Ur~e..gth,
MAILED LETTERS TO ATTORNEY ON
~-9-03.
Register of Wills
Donna M. 'Otto,lst Deputy
A'I-TORNEY (Sup. Ct. I.D. No.)
,°.o, t~r z'~,~e,~ ~l,,~*t,;
ADD.SS
PHONE
LAW OFFICES
GERALD K. MORRI$ON
CENTER SQUARE, P.O. BOX 232
NEW BLOOMFIELD, PA 17068
TELEPHONE: 717-582-2300
FAX: 717-582-4220
June 5, 2003
Cumberland County Courthouse
Register of Wills Office
Hanover & High Street
Carlisle, PA 17013
RE: David E. Clouser Estate
To Whom It May Concern:
I enclose the Oath of Subscribing Witness form for the above-mentioned estate.
Please forward all documentation to my office, at your earliest convenience.
Thank you.
Very truly yours,
GKM:smb
Enc.
rrison, Esqmre
REGISTER OF WILLS OF S~
OATH OF SUBSCRIBING WITNE
codicil
(each) a subscribing witness to the will presented herewith, (eac~eing duly qualified according to
law, depose(s) and say(s) that ~ present and saw,
the testat , sign the same and that / _ .... signed as a witness at the
request of testat in h~ presence an~the presence of each other) (in the presence of the
other subscribing witness(es)). . /
Sworn to or affirmed and subscribed/heqore ....
me this /day of (Name)
/ ,9__. ....
Register ....
(Name)
21-2003-472
REGISTER OF WILLS OF ~k~A ~[/~LtUb COUNTY
OATU OF NON-SUBSCRIBING WITNESS
(each) a s er hereto, (each) being duly qualified according to law, deposeff)~and saygO that
~[- u~b familiar with the signature of ib/~'i~) ~-~. (! Lt')~,k',-~t~ ,
testat C)~_ of
(one ef the
that
to the best of ~ ~J knowledge and belief.
Sworn to or affirmed and subscribed before
me this 4th day of
, June ~ >i~[ ~2__~_, 0 3
Donna M.Otto,lst' Deputy
~ub?' ' ' ) the presented herewith and
believe~ the signature on the e handwriting of
(Name)
(Address)
21-2003-472
REGISTER OF WILLS OF C~,,~-I~.o[ .._ COUNTY
OATH OF SUBSCRIBING WITNESS
codicil
(each) a subscribing witness to th~~resented herewith, (each) being duly qualified according to
law, depose(s) and say(s) that ~x~- ~ o,_~ present and saw
the testat 0 c , sign the same and that % e_ signed as a witness at the
request of testat o,c- in h ~ presence and (in the presence of each other) (in the presence of the
other subscribing witness(es)).
Sworn to or affirme/:! and subscribed before
me this
day of
Register
(~Va~
(Address)
OF WILLS OF
tF NON-SUBSCRIBING Wl-
:OUNTY
(each) a subscriber hereto, (each) being duly to law, depose(s) and say(s) that
familiar with of .,
codicil
testat of (one of the subscribing~nesses to) the will presented herewith and
codicil
that / believes the signature on the w~handwriting of
to the best of //k~wledge and belief. ~x~
Sworn to or affirmed~ subscribed before '
me this day of (Name)
/ 19 (Address)
Register
(Name)
(Address)
ARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH VITAL RECOROS
LOCAL REGISTRAR'S CERTIFICATION OF DEI~,TH
CERT. NO. T 5436701
May 19, 2003
Date of Issue of This Certification
David E.
Clouser
Name of Decedent F~r ~ Middle Last
Male 184-07-8164
Sex Social Security No. Date of Death
Feb. 9, 1917 Perry Co., PA
Date of Birth Birthplace
Forrest Park Health Center Cumberland Carlisle
Place of Death ecu,dy C~,y Bo,o,gh o~To~,~h~p
Fa cilit'¢ Name
White Laborer
Race Occupation Armed Forces? (Yes or No)
Widower Decedent's 2711 Spring Road Carlisle
Marital Status Mailing Address
Number Street
Sally A. Myers
Mary Campbell .Funeral Director
Informant
Name and Address of David Myers Funeral Home, Newport, PA 17074
Funeral Establishment
Interval Between
Onset and Death
5-13-2003
Pennsylvania
Part h Immediate Cause
Failure to thrive
(a)
Multi infarction dementia
(b)
(c)
(d)
Part I1: Other Significant Conditions
Yes
PA 17013
State
Manner of Death
Natural ~ Homicide []
Accident ~ Pending Investigation []
Suicide [] Could not be Determined []
Name and Title of Certfier
Describe how injury occurred:
Carol Robinson
m. Oo
(M.D., D.C., Coroner, M.E.)
Address
100 S. High Street, Newville, PA 17241
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 f iling~:C,r,)./ /~_~ ~o~,~ /~ 50-455
~ - ~ Distr~ct No,
May 16, 2003 /1/~)l-]~aa~-~;'~tv'~t.~, New Bloomfield, PA 17068
City Borough, Township
Date Received b/ Local R~f4istrar Street Address
21-2003-472
OF
DAVID E. CLOUSER
I, DAVID E. CLOUSER, of R. D. #2, carlisle, North Middleton
Township, Cumberland County, Pennsylvania, being of sound and dis-
)osing mind, memory, and understanding, do hereby make, publish and
~eclare this my Last Will and Testament, hereby expressly revoking
all other writings in nature testamentary by me at any time hereto-
fore made.
FIRST: I direct that all my debts and funeral expenses be paid
as soon after my decease as may be practicable.
SECOND: I direct that inheritance tax on property disposed of
in, shall be paid from my residuary estate.
THIRD: I hereby give, bequeath and devise all the rest and
residue of my estate and property, real, personal and mixed, of
soever nature and wheresoever situated, of which I may die seised or
possessed or to which I may be entitled or of which I may have the
right to dispose at the time of my death, absolutely and in fee
simple to my wife, Mary C. Clouser, if she is living at the time of
my death.
FOURTH:
In the event that my wife is not living at the time of
~-AVID E . 'C-~.~USE R
PAGE ONE OF TWO
my death, or in the event that she and I shall die simultaneously,
then I give, bequeath and devise all my property to my sister, Mary F.
Stum and my niece, Mary M. Campbell, in equal shares.
FIFTH: I hereby appoint my wife, Mary C. Clouser, as Executrix
of this, my Last Will and Testament, but in the event that she is unable
or unwilling to serve, I then appoint my sister, Mary F. Stum and my
niece, Mary M. Campbell, as Executrices of this, my Last Will and
Testament, and I direct that they shall not be required to give bond or
other security in any jurisdiction wherein proceedings may be held in
connection with my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 1st
day of March, 1985.
?
(SEAL)
PAGE TWO OF TWO
LAST WILL AND TESTAMENT
OF
DAVID E. CLOUSER
LAW OFFICES
GERALD K. MORRISON
P.O. Box 232
NEW BLOOMFIELD, PA. 17068
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: David E. Clouser
Date of Death:
Will No.
To the Register:
Ma_M_a_y__[~2003
Admin No. 2003-00472
I certify that notice of beneficial interest required by
Rule 5.6(a) of the Orphan's Court Rules was served on or mailed to
the following beneficiaries of the above-captioned estate on
June 25, 2003
Name
Carol Allen
William O. Stum
Vickie Gibe
Michael Stum
James A. Stum
Cindy Chamberlin
Beverly Schoolcrafi
Mary M. Campbell
Address
114 CME, Newville, PA 17241
515 Adams Rd, Carlisle, PA 17013
103 N Pitt St, Apt A, Carlisle, PA 17013
411 Pine Rd, Mt. Holly Springs, PA 17065
154 Bridge Rd, Newville, PA 17241
45 Chamberlin Rd, Shippensburg, PA 17257
7414 Spencer Hwy, Pasadena, TX 77505
2711 Spring Rd, Carlisle, PA 17013
Notice has now been given to all persons entitled thereto under
Rule5.6(a)except
Date: June 25, 2003
Signliature
Name Scott W. Morrison, Esquire
Address Center Square
New Bloomfield, PA 17068
Telephone (~717)582-2300
Capacity Personal Representative
X Counsel for personal
Representative
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD 003268
MORRISON SCOTT W ESQ
P O BOX 232
NEW BLOOMFIELD, PA 17068
........ fold
ESTATE INFORMATION: SSN: 184-07-8164
FILE NUMBER: 2103-0472
DECEDENT NAME: CLOUSER DAVID E
DATE OF PAYMENT: 11/21/2003
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 05/1 3/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I 914,820.69
REMARKS:
TOTAL AMOUNT PAID:
RECEIVED MARY M CAMPBELL IN CO
SCOTT W MORRISON, ESQ
914,820.69
SEAL
CHECK# 128
INITIALS: VZ
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
~ COMMONWEALTH OF J ~ ~ ~f.. 4
,.,-- .500
DEPARTME,TOFREVE,UE RESIDENT
· DEPT. 280 01 INHERITANCE TAX RE URN
I b IDENT
I-- CEDEN¥S NAME (LAST, FIRST, AND MIDDLE INIT~~
"' O,~
z ,.,. ~
Z
I-
Z
IAI
Z
O
IAI
O
Clouser, David E.
DATE OF DEATH (MM-DD-Yea') ~H (MM-DD-Year}
05/13/2003 ..J 02/09/'r917
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
N/A
[] 1. Original Retum
F'-] 4. Limited Estate
[~-'J 6. Decedent Died Testate (^t~ch copy orWi,)
r-'-~ 2. Supplemental Retur~
"'-'] 4a. Future Interest Compromise (da. of death at~ 12-12-S2)
[] 7. Decedent Mainlained a Living Trust (Ntach copyo~Tmst}
[] g. LitigalJon Proceeds Received [] 10. Spousal Poverty Credit(daeo~deah ~ee, t2-31-91 a~d 1-1-95)
NAME
FiRM NAME (If Applicable)
TELEPHONE NUMBER
717~J.~.)..~-2300
OFFICIAL USE ONLY
FILE NUMBER
2 1 -~) 3 0 4 7 2
...... _ _ ----
BER
1 8.._.__~4-0 7-8 1 6 4
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
["~ 3. Remainder Return (~ of~ea~ prkxto 12-13-82)
"-]5. Federal Estate Tax Return Required
1_._ 8. Total Number of Safe Deposit Boxes
~--~11. Election to tax under Sec. 9113(A)I~ach Sch O)
COMPLETE MAILING ADDRESS
P. O. Box 232
New Bloomfield
PA 17068
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) -(2)
3. Closely Held Corporation, Partnemhip or Sole-Proprietorship (3) '
4. Mortgages & Notes Receivable (Schedule D) ~ (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E) (5)
6. Jointly Owned Properly (Schedule F) (6)
~ Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Prope~ (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for wh!ch 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
82,500.00
31,613.65
OFFICIAL U~~
(8) 114,113.65
10,237.50
5,071.53
(11)
(12)
(13)
15,309.03
98,804.62
(14)
98,804.62
15. Amount of Line 14 taXable at lhe ~pousal tax
rate, or transfers under Sec. 91 !6 (a)(1.2)
x ~ (15)-
16. Amount of Line 14 taxable at lineal rate
X
17. Amount of Line 14 taxable at sibling rate .. X .12 (17):.,
18. Amount of Line 14 taxable at cellateral rate 98,804 62 x .15 (18) ... '
19. Tax Due
20. ["-] ' e ,.. ' e · ' m e , e ~., (19)
14,820.69
14,820.69
~lete Address:
STREET ADDRESS
. 2711 Spring Road
Carlisle
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1) 14,820.69
3. Interest/Penalty if applicable Total Credits (A + B + C ) (2)
D. Interest
E. Penalty
Total Interest/Penalty ( D · E ) (3)
4. If Line 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (4)
A. Enter the interest on the tax due. (5) 14,820.6-q
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A)
(58) 14,820.69
Make Check Payable to' REGISTER OF WILLS AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"
IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred; Yes No
b. retain the dght to designate who shall use the property transferred or its income; ....................... ; ................ [] []
c. retain a reversionary interest; or .................................................................................................. [] []
d. receive the promise for life of either payments, benefits or care?
2. , .............................................................. [] []
If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?' ·
3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death? ................. [] []
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary des anation?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YE8 Y '
-- ~ ............. , OU MUST COMPLETE
Under penalties of u d ~ * ~ ~ SCHEDULE G AND
Becaration of re pe~q: ry ecaretha,~lhavee_x__am_ medl;hls re~m, mclud ' SC -"------'----' ~~_~_~UUL.E_¢ AND FILE IT AS PART OF THE RETURN.
p pare other U~en the pemonal re res . . ~ ,~. y ng hedules and statements and to Ihe -- . . .
~-n"o'i~h'~p~ has an ' best o1' my Knovde~. -e and belief ,t is true, correct and corn .
c""'~.~.U. KI:: ~_~ PERSON RESPONSIB~/~ FOR FILING ,ETURN y kao~edge. , -- plete
ADDRESS 2711 pring Ro;d ..... "'""-
DATE
Carlisle
SIGNATURE OF~I'~N REPRESENTATIVE PA 17013
~ ~~ ~.. DATE
ADDRESS ~"~2 ! ! I/.~..(_?~O 07>
New Bloomfield
.~ii~~..__ , ~ _ PA 17068
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, l~e fax rate Imposed on the net value of transfers to or for the use of the Survivin~ ~l~3use is 0% [72 P.S. §9116 (a) (1.1) (ii)].
The statute ~ a transfer to a su~,ivin9 spouse from tax, and the statutory requiremerlts for disclosure of assets and illin9 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 orfor the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except es noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)~'~'3i]. A siblin9 is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption. '
SCHEDULE A
COM O.W _T. OF.E..SYLW.,^ / REAL ESTATE
ESTATE OF
~ FILE NUMBER
All real property owned solely or aa a tenant in common must be reported at fair market value. Fair madcet value eo as the price at which property would be exchanged
sur is d~
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
ITEM -
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1. One and one-half story brick dwelling situate in North Middleton Township, Cumberland 82,500.00
County, Pennsylvania, described in deed recorded in Cumberland County Deed Book "T",
Volume 30, Page 611 - sold to Carma J. ^mold on 8/25/03 - see attached settlement sheet
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
82,500.00
' '~" / SCHEDULE E I
COM~"W~T. OFPE..S~.V^.,^ / CASH, BANK DEPOSITS, & MISC.
Include ~e P~s of I~a~ and ~e date ~e ~s were ~ by ~ ~. All ~ ~i~ ~ ~e ~ of su~bomhip must ~ d~c~s~ on
ITEM ~h~ule F.
NUMBER
1.
DESCRIPTION
Bank Ch. ecking Account #2672~
M&T Bank Passbook Savings Account ¢Y21000000809395
The Bank of Landisburg Certificate of Deposit #066509601
Real Estate tax refund
Personal property sold to James Stum
Sale of furniture
utility refunds
Erie Insurance - refund
TOTAL (Also enter on line 5, Recapitulation)
VALUE AT DATE
OF DEATH
8
567.59
20,034.19
765.13
1,589.16
329.55
71.61
78.00
(If more space is needed, insert additional sheets of the same size) 31,613.65
EV-1511E~ + (1-97~ ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Clouser. David E. 21 03
0472
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
5.
6.
7.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Reprosentative (s) Mary M. Campbell
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address 2711 Spring Road
c~ Carlisle
Year(s) Commission Paid: 2003
Attorney Fees Scott W. Morrison
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
195281181
State PA . Zip 17013
Street Address
City
Relationship of Claimant to Decedent
Probate Fees Donna M. Otto
Accountant's Fees
Tax Return Preparer's Fees
State . Zip
5,560.00
4,450.00
227.50
TOTAL (Also enter on line 9, Recapitulation) $ 10,237.50
(If more space is needed, insert additional sheets of the same size)
'
COMMONWEALTH OF PENNSYLV^N ^ I DEBTS OFDECEDENT.' -
INHERITANCE TAX RETURN m
FILE NUMBER '
Include unreimbumed medical expenses.
ITEM
NUMBER
Dauphin Oil Co., Inc. - account
Sprint - telephone bills
3. PP&L - electric bills
10.
11.
12.
13.
14.
DESCRIPTION
15.
Blue Mountain Anethesia Assoc. - medical account
Lanc. HMA Phys Mgmt - medical account
Forest Park Health Center - medical account
Erie Insurance Group - insurance
Philhaven - medical account
York Water Disposal, Inc.
Robin K. Sollenberger - taxes
Pecks Septic Service - account
Graham Medical Clinic PC - medical account
Chester G. Raudabaugh - account
Robert McKee. account
The Sentinel - estate advertising
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
AMOUNT
170.14
221.81
137.99
23.21
240.62
420.00
133.00
26.67
29.91
806.60
324.35
25.52
129.90
200.00
98.69
5,071.53
Continuation of REV.I$00 Inheritance Tax Return Resident Decedent
Clouser, David E.
Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens
21 03 0472
ITEM
NUMBER
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
DESCRIPTION
and Law Journal - estate advertising
Perry Village -'account
Cumberland Goodwill Fire Rescue EMS - account
Central Penn Medical Group Emergency - account
Settlement costs
Nurse Anethetists of Carlisle - account
Carlisle Digestive Associates - account
Family Practice Center - account
Vascular Associates - account
Sulligan - water test
Register of Wills--recording cost
SUBTOTAL SCHEDULE I
AMOUNT
75.00
840.00
36.35
33.71
832.00
26.50
33.01
9.77
162.05
14.73
20.00
2,083.12
5,071.53
GRANDTOTALSCHEDULEI $
REV-1513 EX ~-
ESTATE OF
NUMBER
[.
NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS ~Sr~:~9~ ~6 (Ut~a I~tl.~)~j~! distributions, ~nd ~-~,-,~'~ under
1. Mary M. Campbell
2711 Spring Road
Carlisle, PA 17013
2. Carol Allen
114 CME
Newville, PA 17241
3. William O. Stum
515 Adams Road
Carlisle, PA 17013
4. Vickie Gibe
103 N. Pitt Street, Apt. A
Carlisle, PA 17013
5. Michael Stum
411 Pine Road
Mt. Holly Springs, PA 17065
6. James A. Stum
154 Bridge Road
Newville, PA 17241
7. Cindy Chamberlin
45 Chamberlin Road
Shippensburg, PA 17257
FILE NUMBER
21 O3 O472
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Tn_~_,f_~{s) OF ESTATE
Niece
Niece
Nephew
Niece
Nephew
Nephew
Niece
one-half
one-fourteenth
one-fourteenth
one-fourteenth
one-fourteenth
one-fourteenth
one-fourteenth
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS: ~
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART ]Z - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If n~o~e space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Clouser, Da~/id E.
21 03
Paqe 2
Schedule J - Beneficiaries. 1
0472
NUMBER
8.
NAME AND ADDRESS OF PERSON{S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Beverly Schoolcraft
7414 Spencer Highway
Pasadena, TX 77505
RELATIONSHIP TO DECEDENT
Do Not List Tr
Niece
AMOUNT OR SHARE
OF ESTATE
one-~u~eenth
Manufacturers and Traders Trust Company, 1100 Wehrle Drive, P.O. Box 767, Buffalo, NY 14240-0767
July 8, 2003
Scott W. Morrison, Esq.
Center Square, P.O. Box 232
New Bloomfield, PA 17068
Phone (302) 934-2916
Fax (302) 934-2955
Dear Mr. Morrison
Re: Estate of David E. Clouser
_Social Security No.: 184-07-8164
Date of Death: Mc02 13, 2003
In response to your request, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following accounts.
Type of Account
Account Number
Ownership (Names oj~
Opening Date
Balance As of Date of Death
Interest
Total
Checking
2672061740
David E. Clouser
07/18/84 (closed 06/13/03)
$8,178.42
$ 0.00
............................
Type of Account
Account Number
Ownership (Names oJ)
Opening Date
Balance As of Date of Death
Interest
· Total
Passbook Savings
21000000809395
David E Clouser
05/02/94 (closed 06/13/03)
$567.35
$ 0.24
..................... ...........
These accounts were converted fror~ the acquisition of another financial institution. Unfortunately, we are unable
to access any information pertaini,~.d to the date the account was made joint
This letter does not include any accoun~ in which the deceased may have been listed as Power of ,4ttorney, Custodian of Uniform
Transfers, Representative Payee, or T, eistee under a Written Agreement.
(302) 934-2916
LANDISBURG, PA 17040
ESTABLISHED 1903
July 1, 2003
Scott W. Morrison
Attorney At Law
Re: Estate of David E. Clouser
Sir:
Regarding the information you requested on David E.
Clouser, Deceased, information is as follows:
Certificate of Deposit AccOunt No. 066509601, opened
1/19/88, sole owner-David E. Clouser, accrued interest-
$34.19, balance as of date of death-S20,000.00, 2.60%.
Thank you/
LANDISBURG - 717-789-3213
BLAIN - 536-3118
· SHERMANS DALE ~ 582-8511
GERALD K MORRISON ESQUIRE
CENTER SQ '
PO BOX 232
NEW BLOOMFIELD PA 17068
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
June 23, 2003
Re: DAVID CLOUSER
SSN: 184-07-8164
Dear Attorney Morrison:
Pursuant to your letter dated June 18, 2003, the Department of Public
Welfare (DPW), Estate Recovery Program, has reviewed the information you
provided regarding the above-referenced individual.
It has been determined that this individual did not receive any type of
assistance during the questioned period.
Therefore, according to the information you provided, the Department's
Estate Recovery Program will not seek any recovery from this estate.
If you have any questions, please feel free to contact me.
Sincerely,
Ronald D. Hill, Manager
TPL - Casualty Unit
(717) 772-6604
(717) 772-6553 FAX
Safe Deposit Box Inventory
Dated: June 13, 2003
Inventory of Safe Deposit Box # 173 rented by David E Clouser at M and T Bank, North
Middleton Office.
Contents Include:
Death Certificate of Mary C. Clouser
Marriage Certificate for David E. Clouser & Mary C. Duncan
Blue Cross Membership Card for Clouser, Contract # 199388850, Dated 9/01/1965
Capital Blue Cross/PA Blue Shield Membership Cards (2)for David Clouser
Group # 600281000, Dated 03/01/1971
Memorial Contract between Rice Memorial Works and David E. Clouser dated 7-13-
1982; including letter from Rice Memorial works and picture of memorial stone
purchased.
Copies of Direct Deposit Authorization forms for social security for David E. clouser and
Mary C. Clouser
Certificate of Membership and Indenture Agreement for Cemetary plots for David E. and
Mary C. Clouser
Certificate of Deposit #066-509-6-01 held at Bank of Landisburg, original deposit
amount of $20,000, titled David E Clouser, Mary Stum, POD
Original and 1 Photocopy of each of the following: Deed to property on Spring Road in
North Middleton township; Certificate of title for said property; Agreement of Sale for
said property; and disclosure of settlement charges
Last Will and Testament of Mary C. Clouser
Inventory Conducted by:
Debra Flyte
Branch Sales Associate
North Middleton Office
M ~l~d T Bank
In the Presence of:
Mary M. Campbell
Executrix of the Estate of
David E. Clouser
OF
DAVID E. CLOUSER
I, DAVID E. CLOUSER, of R. D. #2, Carlisle, North Middleton
P, Cumberland County, Pennsylvania, being of sound and dis-
posing mind, memory, and understandinq, do hereby make, publish and
declare this my Last Will and Testament, hereby expressly revoking
all other writings in nature testamentary by me at any time hereto~
fore made.
FIRST: I direct that all my debts and funeral expenses be paid
as soon after my decease as may be practicable.
SECOND: I direct that inheritance tax on property disposed of
herein, shall be paid from my residuary estate.
THIRD: I hereby give, bequeath and devise all the rest and
residue of my estate and property, real, personal and mixed, of-what-
soever nature and wheresoever situated, of which I may die seised or
possessed or to which I may be entitled or of which I may have the
right to dispose at the time of my death, absolutely and in fee
simple to my wife, Mary C. Clouser, if she is living at the time of
my death.
FOURTH:
In the event that my wife is not living at the time of
( SEAL
PAGE ONE OF TWO
my death, or in the event that she and I shall die simultaneously,
then I give, bequeath and devise all my property to my sister, ~4ary F.
Stum and my niece, Mary M. Campbell, in equal shares.
FI~TH: I hereby appoint my wife, Mary C. Clouser, as Executrix
of this, my Last Will and Testament, but in the event that she is unable
or unwilling to serve, I then appoint my sister, Mary F. Stum and my
niece, Mary M. Campbell, as Executrices of this, my Last Will and .
Testament, and I direct that they shall not be required to give bond or
other Security in any jurisdiction wherein proceedings may be held in
connection with my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and Seal this 1st
day of March, 1985.
~ SER ~ . -. (SEAL)
kGE TWO OF TWO
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT, 280601
HARRISBURG, PA Z71Z8-0601
SCOTT W HORRISON ESQ
PO ~OX 252
HEW BLOONFIELD
COHHONWEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOHANCE OR DISALLOHANCE
OF DEDUCTIONS AND ASSESSNENT OF TAX
R~,: c!: Wii!s
'04 FEB25 A8:30
Bt~l'nb~a.:'~O 0o., PA,
DATE 01-12-2004
ESTATE OF CLOUSER
DATE OF DEATH 05-13-2005
FILE NUHBER 21 03-0472
COUNTY CUHBERLAND
ACN 101
REV-i~4? EX AFP C01-03)
DAVID E
Amoun'l: Remitted I
HAKE CHECK PAYABLE AND REHIT PAYHENT TO:
REGISTER OF WTLLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LXNE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~.~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX
ESTATE OF CLOUSER DAVID E FILE NO. 21 05-0472 ACN 101 DATE 01-12-2004
TAX RETURN HAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks end Bonds (Schedule B) (2)
$. Closely Held Stock/Partnership Interest (Schedule C) (3)
~. Nortgeges/Notas Receivable (Schedule D) (q)
S. Cash/Bank Deposits/Nisc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
B. Total Assets
APPROVED DEDUCTIONS AND EXEHPTIONS:
9. Funeral Expenses/Adm. Costs/Nisc. Expenses (Schedule H) (9)
10. Debts/Nortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Return
82~500.00
.00
.00
.00
$1z615.65
.00
.00
(8)
10,237.50
NOTE: To insure proper
credit to your account,
submi~ the upper portion
of this fore with your
tax payment.
15.
1~.
NOTE:
114,113.65
5~071.55
(11) 15.30q. 03
(12) 98,804.62
Charitable/governeental Bequests; Non-elected 9113 Trusts (Schedule J) (13)
Net Value of Estate Subject '[;o Tax (1~)
If an assessment ~as issued previously, lines lI, 15 and/or 16, 17,
reflect figures that include the total of ALL returns assessed to date.
.00
98,804.62
ASSESSHENT OF TAX:
15. Amount of Liae lfi et Spousal rate
16. Amount of Line 1~ taxable et Lineal/Class A rate
17. Amount of Line 1~ a~ Sibling rate
18. Amount of Line 1~ taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
PAYHENT RECEIPT DISCOUNT (+)
DATE NUNBER INTEREST/PEN PAID (-)
11-21-Z00~ CD005268 .00
IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULAT/ON OF ADDITIONAL INTEREST.
18 and 19 ~ill
(15) .00 x O0 = .00
(16) .00 x 045= .00
(17). .00 X 12 = .00
(18). 98,804.62 x 15 = 14,820.69
(19)= 14,820.69
ANOUNT PAID
14,820.69
TOTAL TAX CREDIT I 14,820.69
BALANCE OF TAX DUEl .00
INTEREST AND PEN. .00
TOTAL DUE .00
( IF TOTAL DUE IS LESS THAN $1, NO PAYNENT IS REgUIRED.
ZF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU NAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) '~:~"'~
RESERVATION:
PURPOSE OF
NOTICE:
PAYNENT:
REFUND (CR):
OBJECTIONS:
ADHIN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 1Z, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after tho expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collatmra1) rate on any such future interest.
To fulfill the requirements of Section 11~0 of the Inheritance and Estate Tax Act, Act 13 of ZOO0. (71 P.S.
Section 91q0).
Detach the top portion of this Notice and submit with your payment to the Rag/star of Hills printed on tho reverse s/da.
--Hake check or money order payable to: REGISTER OF HILLS, AGENT
A refund of a tax credit, which ams not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance end Estate Tax" (REV-ISIS). Applications are available at the Office
of the Register of Hills, any of the Z$ Revenue District Offices, or by calling the special Z~-hour
ansmering service for forms ordering: 1-800-562-Z050; services for taxpayers aith special hearing and / or
speaking needs: 1-800-4q7-5010 (TT only).
Any party in interest not satisfied with the appraisement, allomance, or disallowance of deductions, er assessment
of tax (including discount or interest) es sheen on this Notice must object mithin sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. ZSIOZ1, Harrisburg, PA 17118-1021, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appea! to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in ariting to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Reviea Unit, Dept. 180601, Harrisburg, PA 17128-0601
Phone (717] 787-6505. See page 5 of tho booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanatlon of administratively correctable errors.
If any tax due is paid within three (5) calendar months after the dacedant's death, a five percent (SI) discount of
the tax paid is aZlowed.
The 151 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 is charged beginning with first day of delinquency, or nine (9) months and one (1) day frae the date of
death, to the date of payment. Taxes ehich became delinquent before January 1, 1981 bear interest at the rate of
six (61) percent per annum calculated et a daily rate of .00016~. Ail taxes mhich became delinquent an and after
January I, 1982 will bear interest at a rate ahich will vary from calendar year to calendar year mith that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOOS are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1982 ZOZ .000548 1987 91 .0001~7 1999 71 .000192
1983 161 .000438 1988-1991 111 .000501 ZOO0 81 .000219
198~ 111 .000301 1991 91 .0002~7 2001 91 .0002~7
1985 151 .000356 1993-199~ 71 .000191 ZOOZ 61 .000161
1986 101 .O0027q 1995-1998 9Z .O00Zq7 2003 51 .000137
--Interest is calculated as folloas:
INTEREST = BALANCE OF TAX UNPAZD
X NUNBER OF DAYS DELINQUENT
DALLY 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 t~
Notice, additional interest must be calculated.
STATUS REPORT UNDER RULE 6.12
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND , PENNSYLVANIA
Name of Decedent: David E. Clouser
Date of Death: 05/13/2003
File No. 2003-00472
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect
to the 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:
If the answer to No. I is "Yes", state the following:
a. Did the personal representative file a final account with the Court? YES __
b. The separate Orphan's Court No. (if any) for the personal representative's account is:
NO X
Date:
05/04/2004
Did the personal representative state an account informally to the parties in interest?
YES X NO __
Copies of receipts, releases, joinders and approvals of formal or informal accounts may
be filed with the Clerk of the Orphans' Court and may be attached to this report.
orrison, Es~luire
- =~' e~!U~;-] Name (Please type or print)
4 West Main Street
Address
9O:~W _q- ~VN ~70.
New Bloomfield PA 17068
· ~'; (717)582-2300
! ~ :- ',;;'!~ Tel. No.
Capacity: __ Personal Representative
X Counsel for personal representative