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Home My WebLink About03-0871Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of John W. Clippinser also known as , Deceased Social Security No. 172 - 24- 8227 Thomas W. Clippinser and Sally J. Clippinser-Leeper Petitioner(s), who is/are 18 years of age or older, apply(les) for: (COMPLETE 'A' or 'B' BELOW:) A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut ors the Decedent, dated 03/17/2000 and codicil(s) dated None named in the last Will of State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: B. Grant of Letters of Administration (c.t.a.; d.b.n.c.t.a; pendente lite; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Relationship Residence (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania with his/her last family or principal residence at 32 Bare Road, Silver Spring Township, Mechanicsbur~, PA (list street, number, and municipality) Decedent, then 74 years of age, died 10/02/2003 at Select Specialty Hospital, PA (Location) Decedent 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 17055 situated as follows: ..x~.-;~ 6,~2~'~' ! ~- Wherefore, Petitioner(s) respec~ully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of le~ers in the appropriate form to the undersigned: I ~i~nat~ Typed or printed name and residence ~~~~~ ///~X I Thomas W. Clippinger ~~~/~ Z~,~~ ~ 200 Zei~ler Road, Dover, PA 17315 ~ ~ % ~ ~ ~D ' ~ / Sally J. Clippinger-Leeper ~~ ~. ~2~ ~t~f~f~681 Sand Spur Drive, gtters, PA 17319 I I "D - / ? ~. . "2 Prepared by the Pennsylvania Bar Association Copyrfght (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991) Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland 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~nd that, as personal representative(s) of the Decedent, Petitioner(s)will well and truly administer tl~'e estaMaccording to law. Sworn to or affirmed and subscribed / 'Th?~as'W. Clipping before me this~ day of ~-~L-'~ ,o~ /S-ally J~ C~ppingez/-]~eepe~J No. Estate of John W. Clippin6er Deceased Social Security No: 172- 24- 8227 Date of Death: 10/02/2003 AND NOW, ,,~d'~_~ , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters ~ Testamentary ['~ Of Administration (c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate) are hereby granted to Thomas W. Clippin6er and Sally J. Clippinger-Leeper in the above estate and that the instrument(s) dated 03/17/2000 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters ........... $ ShoR CeRificate(s) ..... $ Register of Wi/~),,~_..~~ Renunciation ........ $ Attorney: Paul G. Lutz, Esq. Affidavits ( ) .... $ Extra Pages ( ) .... $ I.D. No: 39901 Griffith Strickler Address: 110 South Northern Way Codicil ........... $ York, PA 17402 Telephone: 717/757-7602 JCP Fee ........ $ Inventory ........ $ Other ........... $ TOTAL ....... $ ~4P ~ Prepared by the Pennsylvania Bar Association -Col:~right (c) 1996 form software only CPSystems, Inc, Form RW-1 (1991) Estate of also known as Register of Wills of Cumberland OATH OF SUBSCRIBING John W. Clippinger County, Pennsylvania WITNESS No. ,,31- ~.¢- ~ ? I , Deceased Stanley J.A. Laskowski Douglas K. Marsico (each) a subscribing witness to the J'~ codicil(s) ~] will(s) presented herewith, (each) being duly qualified according to law depose(s) and say(s) that she/he/they was/were present and saw the above Testator(rix) sign the same and that she/he/they signed as a witness at the request of Testator(rix) in his/her/their presence and r'~ in the presence of each other r-~ in the presence of the other subscribing witness(es). (Signature) Stanley ~J.~A. Laskowski 3631 North Front Street Harrisburs, PA 17110-1533 (Address) (si~'~'e) -~s K. Marsico · ~/ 3631 North Front Street Harrisburs, PA 171!0-1533 (Address) Sworn to or affirmed and subscribed before me this ~,~(~)"f'J'l day of (~e.-r-~._r~ , ~oo~ Notary Public My Commission Expires: (signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTARIAL SEAL NANCY L. BRESKI, Notary Public Susquehanna Township, Dauphin County My Commission Expires March 16, 2004 NOTE: To be taken by officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization. Prepared by the Pennsy}vania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form #RW-2 (1991) LAST WILL AND TESTAMENT OF JOHN W. CLIPPINGER I, JOHN W. CLIPPINGER, of Mechanicsburg, Cumberland County, Pennsylvanial being of sound mind, memory and understanding, do make and publish this my Last Will and Testament, hereby revoking and making void all former Wills by me at any time heretofore made. ITEM I. I direct that all my just debts and funeral expenses be fully paid and satisfied as soon as conveniently may be after my decease. ITEM II. I give unto the following individuals the following specific items of tangible personal property: (a) To my son, Thomas W. Clippinger, I give my copper kettle. (b) To my son, Larry E. Clippinger, I give my antique engine and also my Remington .22 caliber rifle. (c) To my grandson, Adam Clippinger, I give my 243 Sako rifle. (d) To my grandson, Andy Clippinger, I give my Remington 30- 06 rifle. (e) To my grandson, Devin Leeper, I give my twelve-gauge Model 12 Winchester shotgun. ITEM III. I give all of the rest, residue and remainder of my estate unto my three (3), Thomas W. Clippinger, Larry E. Clippinger and Sally J. Clippinger-Leeper, in equal shares, share and share alike, or to their living issue per stirpes. ITEM IV. In addition to the powers conferred by law, I authorize my Executor, in absolute discretion: A. To retain in the form received, and to sell either at public or private sale any real or personal property. B. To manage real estate. C. To invest and reinvest only in forms of property defined as legal investments according to the laws of the Commonwealth of Pennsylvania. D. To exercise any optional rights arising from ownership of investments. E. To compromise claims without court approval, and without the consent of any beneficiary. ITEM V. It is hereby directed that my Executor, hereinafter named, shall pay all inheritance, state, succession and legacy taxes to which my estate or the transfer of any property 2 hereunder may be subject and to charge such tax as part of the administration, payable out of my residuary estate. ITEM VI. I nominate, constitute and appoint my two (2) children, Thomas W. Clippinger and Sally J. Clippinger-Leeper, to be and act as my co-Executors of this my Last Will and Testament. No personal representative or fiduciary appointed herein shall be required to post bond or give any security. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 17 day of ~' )~:1;~1/'~]' , 2000, W. CLI PPI~ER ~ The preceding instrument, consisting of this, and two other typewritten pages, was on the date thereof signed, published and declared by JOHN W. CLIPPINGER, the Testator therein named, as and for his Last Will, in the presence of us, who at his request, in his presence and in the presence of each other, have subscribed our names as witnesses here~-'~-~ . ~~/~ Residing at _ --- ~ Residing at 99-700/6447-1 JOHNW CLIPPINGER CALDWELL & KeARNS A PROFESSIONAL CORPORATION ATTORNEYS AT LAW 363! NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17110-1533 CERTIFICATION OF NOTICE UNDER RULE 5.7 Name of Decedent: John W. Clippinger Date of Death: October 2, 2003 Admin. No.: 21-03-0871 To the Register: I certify that notice of beneficial interest required by Rule ~fthe Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate: Name Address Larry Clippinger Thomas W. Clippinger Sally Clippinger-Leeper 234 Stoner Road, Mechanicsburg PA 17055 200 Zeigler Road, Dover PA 17315 681 Sandspur Road, Etters PA Notice has now been given to all persons entitled thereto under Rule 5.7. Date: ///'~//~', -,~ Signature: ~(J,y~'~ ~z.~ Name · Paul G. Lutz, Esquire Address · 110 S. Northern Way York, PA 17402 Telephone: (717) 757-7602 Capacity: 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 003362 LUTZ PAUL G 110 SOUTH NORTHERN WAY YORK, PA 17402 ........ fold ESTATE INFORMATION: SSN: 172-24-8227 FILE NUMBER: 2103-0871 DECEDENT NAME: CLIPPINGER JOHN W DATE OF PAYMENT: 12/22/2003 POSTMARK DATE: 12/19/2003 COUNTY: CUMBERLAND DATE OF DEATH: 1 0/02/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $7,500.00 REMARKS: TOTAL AMOUNT PAID: $7,500.00 SEAL CHECK# 513 INITIALS: AC RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS LAW OFFICES GRIFFITH STRICKLER LERMAN SOLYMOS & CALKINS 110 SOUTH NORTHERN WAY YORK PENNSYLVANIA 17402-3737 REV-1500 EX (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1 500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 COUNTY CODE -- _33__ YEAR NUMBER ~-- DECEDENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Z 21ippinger John W 172-24-8227 UJ DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) t't THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~[u 10/2/2003 I 4/12/1929 REGISTER OF WILLS t'll'U (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Z 0 a~ 0 Z 0 Z I X I 1. Original Return I I 2. Supplemental Return --]4. Limited Estate ~] 4a. Future Interest Compromise (date of death after 12-12-82) ~'~6. Decedent Died Testate (Attach copy of Will) ~] 7. Decedent Maintained a Living Trust (Atmch copy of Tru(~t) ----]9, Litigation Proceeds Received I 3. Remainder Return (date of death prior to 12-13-8 ~-] 5. Federal Estate Tax Return Required -- 8. Total Number of Safe Deposit Boxes [~] 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) [~ 11. Election to tax under Sec. 9113(A) (Attach S~I. THIS SEC~ON MUST BE :COMPLETED; ALL:CO:RRESPONDENCE AND: CONFIDENTIAL :TAX INFORMATION SHOULD BE DiREcTED:TO: NAME Paul G. Lutz, Esq. FIRM NAME (If Applicable) 3riffith Strickler TELEPHONE NUMBER 717-757-7602 COMPLETE MAILING ADDRESS 110 South Northern Way York, PA 17402 1, Real Estate (Schedule A) ( 1 ) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4, Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) §. Jointly Owned Property (Schedule F) (§) ---]Separate Billing Requested 7. Inter-VivosTransfors & Miscellaneous Non-Probate Property (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 t) (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 which an election to tax has not been made (Schedule J) 127,000 % '~[' ' 0 0 47,125 : 0 47,479 (8) 22,728 657 (11) (12) (13) USE ONLY 226,619 23,385 203,234 0 203,234 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 5. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)( 1.2) 1§. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20. 0 x.O 0. 00(15) 0 203,234 x.O45 (10) 9,146 0 x .12 (17) 0 0 x .15 (18) 0 (19) 9,146 >> BE SURE TO: ANSWER ALL QUEST!ONS: ON REVERSE StDE AND RECHECK MATH << : HASPXXNUMBER Decedent's Complete Address: STREET ADDRESS 32 Bare Road Cumberland Mechanicsburg STATE ZIP PA 17055- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty 0 7,500 395 0 0 (1) 9,146 Total Credits (A + B + C) (2) Total Interest/Penalty (D + E) (3) 7,895 0 0 1,251 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Erie 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) 0 B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) 1,251 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ....................... [~ ~'~ b. retain the right to designate who shall use the property transferred or its income; ......... [~ ~ c. retain a reversionary interest; or ................................ ~ ~ d. receive the promise for life of either payments, benefits or care? ................. ~ ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration7 ............................ ~ r~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death7 [~ [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................ ~ [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules an~'atatements, and to the beat of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is baaed on all information of which preper.~'r has any knowledge. SIGNATURE OF PERSO? RESPONSIBLE FOR FILING RE,~JRN ~ o ,/ DATE ~,~RESS ~3 ' '' j "" ' / ' 200 Zeigler Road Dover, PA 17315 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE 110 South Northern Way York, PA 17402 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.§ 9910 ia)(1.1)(i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [ 72 P.S. § 911 § (a) (1.1) (ii)] The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. § 9110(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 as noted in 72 P.S. § 911 §( 1.2) [72 P.S. § 911 §(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. § 9110(a)( 1.3)]. A sibling is defined, under Section 9102. as an individual who has at least one parent in common with the decedent, whether by blood or adoption. HASPXXNUMBER REV-1502EX + ( 1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER John W. Clippinger 21 2003 0871 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchange 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 wit right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 32 Bare Road Silver Spring Township Mechanicsburg, PA 17055 (see attached settlement sheet) TOTAL (Also enter on line 1, Recapitulation) $ 12 7, 0 0 0 HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) 127,000 REV*'1503 EX + (I-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS FILE NUMBER John W, Clippinger 21 2003 0871 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 237 Units Income Fund of America (see attached) 48 Units Investment Company of America (see attached) TOTAL (Aisc enter on line 2, Recapitulation) $ 5, 015 HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH 3,749 1,266 REV-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER John W. Clippinger 21 2003 0871 Include the =roceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be diselesed on Schedule ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 375 10 11 12 1 1/2 hp. Gas engine (see attached appraisal) 1985 Chevrolet Suburban Selling price 1999 Toyota Camry Selling price 30-06 Remington rifle (see attached appraisal) CD#47658-41 Members First CU (see attached) CD#47658-42 Members First CU (see attached) Checking#47658-11 Members First CU (see attached) Copper apple butter kettle (see attached appraisal) Enterprise Rent-a-car Pension payout Erie Erie Erie Insurance Group Insurance Group Insurance Group Total from continuation pages TOTAL (Also enter on line 5, Recapitulation) $ 47,125 1,200 9,400 210 2,512 2,042 342 150 637 26 47 2O 30,164 HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) Schedule E (Page 2) Item No. Estate of: John W. Clippinger Description Premium refunds 13 Funds to seller at Real Estate settlement (see attached settlement sheet) 14 Investment Savings#47658-05 Members First CU (see attached) 15 Miscellaneous household items Auction value of miscellaneous items 16 Philadelphia American Insurance Company Health insurance premium refund 17 Regular Savings#47658-00 Members First CU (see attached) 18 Remington .22 caliber rifle (see attached appraisal) 19 Sako 243 rifle (see attached appraisal) 20 Winchester 12 gauge shotgun (see attached appraisal) Value at Date of Death 503 16,573 12,404 176 58 55 235 160 Total (Carry forward to main schedule) 30,164 REV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER John W. Clippinger 21 2003 0871 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-I§O0 COVER SHEET is yes. DESCRIPTION OF PROPI:KIY % OF ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DATE OF DEATH DECD'S EXCLUSION DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE TAXABLE VALUE NUMBER DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1, Annuity#7701869 Bankers Life & Casualty Co. 17,124 100.000 0 17,124 (see attached) 2 1,428.131 Units IRA Income Fund of America 22,593 100.000 0 22,593 (see attached) 3 294.35 Units IRA Invest Co of America 7,762 100.000 0 7,762 (see attached) TOTAL(Also enter on line 7, Recapitulation) $ 47,479 (If more space is needed, insert additional sheets of same size.) HASPXXNUMBER REd-1511 EX + (1-97) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER John W. ~± zpplnger 21 03 871 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION FUNERALEXPENSES: Hoffman-Roth Funeral Home, Inc. Funeral expenses ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Prepareds Fees Thomas W. Clippinger Items for vehicle Cumberland County Landfill Cumberland County Law Journal Legal advertisement State__ Zip Total from continuation pages TOTAL (Also enter on line 9, Recapitulation) AMOUNT 6,615 8,957 269 83 36 75 6,693 $ 22,728 HASPXXNUMBER (If more space is needed, insert additional sheets of same size) Schedule H part 2 (Page 2) Estate of: John W. Clippinger Item No. Description Amount 10 11 12 13 14 15 Dillsburg Septic Septic system maintenance First Capital Credit Union Membership fee George L. Ebener & Associates Real estate appraisal Roy D. Gottshall,Auctioneer Appraisal fee Lowe's Sump pump Penn Waste Trash pickup Settlement costs to seller at Real Estate settltment Soft Touch Water Conditioning Repairs The Patriot News Legal advertisement Tractor Supply Co. Auto Battery Vital Records Death certificates Zimmerman Mechanical, Inc. Plumbing repairs 200 3OO 4O 71 37 5,364 165 217 32 260 Total (Carry forward to main schedule) 6,693 REV-1512 EX + (1-97) SCHEDULEI DEBTS OF DECEDENT, MORTGAGELIABILITIES,& LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER John W. ~± lpplnger 21 2003 0871 Include unreimbursed medical expenses. ITEM NUMBER Carlos R. Leffler, Utility expense Central PA HEMA ASSOC P.C. Medical expenses Inc. Dish Network Monthly payments Pinnacle Health Medical expense PPL Electric Utilities Utility expense Verizon Utility expense & MED ONC DESCRIPTION TOTAL (Also enter on line 10, Recapitulation) $ AMOUNT 376 17 53 21 163 27 657 HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER John W. Ctippinger 21 03 171 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLEDISTRIBUTIONS[includeoutrightspou~ldistributions, andtmnMem underSec. 911B(a)(1.2)] Adam Clippinger 200 Zeigler Road Dover, PA 17345 Andy Clippinger 254 Stoner Road Mechanicsburg, PA 170559603 Larry E. Clippinger 234 Stoner Road Mechanicsburg, PA 17055 Thomas W. Clippinger 200 Zeigler Road Dover, PA 17315 Total from 3randson ]randson ~on continuation pages ~on 235 210 67,780 67,499 67,510 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEFT I1. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) Schedule J part 1 (Page 2) Estate of: John W. Clippinger Item No. Description Relation Amount Sally Clippinger-Leeper 681 Sand Spur Road Etters, PA 17319 Daughter 67,350 Devin Leeper 681 Sand Spur Road Etters, PA Grandson 160 Total (Carry forward to main schedule) 0 LAST WILL AND TESTAMENT O__F JOHN W. CLIPPINGER I, JOHN W. CLIPPINGER, of Mechanicsburg, Cumberland County, Pennsylvania~ being of sound mind, memory and understanding, do make and publish this my Last Will and Testament, hereby revoking and making void all former Wills by me at any time heretofore made. ITEM I. I direct that all my just debts and funeral expenses be fully paid and satisfied as soon as conveniently may be after my decease. ITEM II. I give unto the following individuals the following specific items of tangible personal property: (a) To my son, Thomas W. Clippinger, I give my copper kettle. (b) To my son, Larry E. Clippinger, I give my antique engine and also my Remington .22 caliber rifle. (c) To my grandson, Adam Clippinger, rifle. (d) 06 rifle. (e) To my grandson, Devin Leeper, Model 12 Winchester shotgun. I give my 243 Sako To my grandson, Andy Clippinger, I give my Remington 30- I give my twelve-gauge ITEM III. I give all of the rest, residue and remainder of my estate unto my three (3), Thomas W. Clippinger, Larry E. Clippinger and Sally J. Clippinger-Leeper, in equal shares, share and share alike, or to their living issue per stirpes. ITEM IV. In addition to the powers conferred by law, I authorize my Executor, in absolute discretion: A. To retain in the form received, and to sell either at public or private sale any real or personal property. B. To manage real estate. C. To invest and reinvest only in forms of property defined as legal investments according to the laws of the Commonwealth of Pennsylvania. D. To exercise any optional rights arising from ownership of investments. E. To compromise claims without court approval, and without the consent of any beneficiary. ITEM V. It is hereby directed that my Executor, hereinafter named, shall pay all inheritance, state, succession and legacy taxes to which my estate or the transfer of any property hereunder may be subject and to charge such tax as part of the administration, payable out of my residuary estate. ITEM VI. I nominate, constitute and appoint my two (2) children, Thomas W. Clippinger and Sally J. Clippinger-Leeper, to be and act as my co-Executors of this my Last Will and Testament. No personal representative or fiduciary appointed herein shall be required to post bond or give any security. IN WITNESS WHEREOF, I have hereunto set my hand and seal this i~7 day of ~ ~l~· , 2000. / JOHN W. CLIPP/~ER ~ The preceding instrument, consisting of this, and two other typewritten pages, was on the date thereof signed, published and declared by JOHN W. CLIPPINGER, the Testator therein named, as and for his Last Will, in the presence of us, who at his request, in his presence and in the presence of each other, have subscribed our names as witnesses he r e~'7-~,~ · ~ ~~/~'~ R esidi ng at , ~~';~C;-~----~'- Residing at 99-700/6447-i U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT OMB NO. 2502-0265 I B. TYPE OF LOAN: 1.F-JFHA 2.J-'JFmHA 3. r-JcoNv. UNINS. 4.[--JVA 5. J-~'JCONV. INS. J 6. FILE NUMBER: 1 7. LOAN NUMBER: SETTLEMENT STATEMENT ~ NAILOR04 I 8. MORTGAGE INS CASE NUMBER: This form is furnished to give you a statement of actual settlement cos, ts. A, moun, ts pa,(d to and by the settlement agent are shown. Items marked "[POC]" were paid outside the closing; they are snown nere for informational purposes and are not included in the totals. 1.0 3/98 (NAILOR04.PFD/NAILOR04/T) C. NOTE: D. NAME AND ADDRESS OF BORROWER: JASON M. NAILOR 32 BARE ROAD MECHANICSBURG, PA 17055 G. PROPERTY LOCATION: 32 BARE ROAD MECHANICSBURG, PA 17055 CUMBERLAND County, Pennsylvania E. NAME AND ADDRESS OF SELLER: EST OF JOHN W. CLIPPINGER F. NAME AND ADDRESS OF LENDER: GATEWAY FUNDING DIVERSIFIED H. SETTLEMENT AGENT: 23-2386065 LEON P. HALLER ESC AGENT FIRST AMERICAN TITLE INS PLACE OF SE'I-I'LEMENT 1719 N. FRONT ST. HARRISBURG, PA 17102 I. SE3-1'LEMENT DATE: March 12, 2004 J. SUMMARY OF BORROWER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 101. Contract Sales Pdce 127,000.00 102. Personal Property 103. Settlement Charges to Borrower (Line 1400) 104. K. SUMMARY OF SELLER'S TRANSACTION 400. GROSS AMOUNT DUE TO SELLER: 105. Adiustments For Items Paid Bv Seller in advance 106. City/Town Taxes 03/13/04 to 01/01/05 107. SCHOOL TAXES 03/13/04 to 07/01/04 401. Contract Sales Price 112. 402. Personal Property 4,220.49 403. 404. 228.32 405. Adi~$tmepts For Items Paid Bv Seller in advance 406. City/TownTaxes 03/13/04 to 01/01/05 127,000.00 228.32! 274.22 407. SCHOOL TAXES 03/13/04 to 0751104 274.22' 108. WATER/SEWER to 408. WATEPJSEWER to 109. 409. 110. 410. 111. 411. 412. I 127,502.54 120. GROSS AMOUNT DUE FROM BORROWER 131,723.03 420. GROSS AMOUNT DUE TO SELLER 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 501. Excess Deposit (See Instructions) 502. Settlement Charges to Seller (Line 1400) Existing loan(s) taken subject to Payoff of first Mortgage Payoff of second Mortcjage (Deposit disb. as proceeds) 201. Deposit or earnest money 2,000.00 202. Principal Amount of New Loan(s) 120,650.00 203. Existing loan(s) taken subject to 503. 204. 504. 205. 505. 206. 506. 207. 507. 208. 508. 209. 509. Adjustments For Items Unpaid By Seller Adiustments For Items Unpaid By Seller 5,364.23 210. City/Town Taxes to 211. SCHOOL TAXES to 212. WATER/SEWER to 213. 214. 215. 216. 217. 218. 510. City/Town Taxes to 511. SCHOOL TAXES to 512. WATER/SEWER to 513. 514. 515. 516. 517. 518. 219. 519. 220. TOTAL PAID BY/FOR BORROWER 122,650.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 300. CASH AT SE'rrLEMENT FROM/TO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER: 131,723.03 122,650.00) 301. Gross Amount Due From Borrower (Line 120) 302. Less Amount Paid By/For Borrower (Line 220) 303. CASH ( X FROM) ( TO ) BORROWER 9,073.03 601. Gross Amount Due To Seller (Line 420) 602. Less Reductions Due Seller (Line 520) 603. CASH ( X TO) ( FROM) SELLER 5,364.23 127,502.54 5,364.231 122,138.31 The undersigned hereby a~rknowledg~receip~of? completed copy of pages 1&2 Borrower JASON M. NAILOR of this statement & any attachments referred to herein. ~t,~~ -..~'. ,,. ~)~ - 'EST~ W. CLIPPINGER HUD--1 (3-86) RESPA, HB4305.2 L. SETTLEMENT CHARGES .~. TOTAL COMMISSION Based on Price $ ~ 0.0000 % 3.810.00 PAID FROM PaID FROM Division of Commission (line 700) as Follows: E~ORROWER'S SELLER'S 701. $ 3,810.00 to GEORGE L. EBENER & ASSOCIATES FUNDSAT FUNDS AT 702. $ to SETTLEMENT SE'J-R-EMENT 703. Commission Paid at Settlement 3,810.00 704. TRANSACTION FEES to 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Origination Fee 0.0000 % to 802. Loan Discount % to 803. Appraisal Fee to 804. Credit Report to 805. TAX SERVICE FEE to GATEWAY FUNDING DRIVE 81.00 806. App. Fee to GATEWAY FUNDING DIVERSIFIED $300.00 POCb 50.00 807. DOC PREP to GATEWAY FUNDING DIVERSIFIED 185.00 808. UNDERWRITING PROCESS FEE to GATEWAY FUNDING DIVERSIFIED 75.00 809. EXPRESS/COURIER FEE to GATEWAY FUNDING DIVERSIFIED 35.00 :810. DU REVIEW FEE to GATEWAY FUNDING DIVERSIFIED 20.00 811. FLOOD CERTIFICATION to FIRST AMERICAN FLOOD 25.00 i900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From 03/12/04 to 04/01/04 @ $ 19.270500/day ( 20days 5.7500%) 385.41 902. Mortgage Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 years to 904. 905. 1000~ RESERVES DEPOSITED WITH LENDER 1001. Hazard Insurance 4.000 months (~ $ 34.00 per month 136.00 1002. Mortgage Insurance 2.000 months (~ $ 67.36 per month 134.72 1003. City/Town Taxes 3.000 months (~ $ 23.69 per month 71.07 1004. SCHOOL TAXES 11.000 months (~ $ 77.58 per month 853.38 1005. WATER/SEWER months @ $ per month 1006. months (~ $ per month 1007. months ~ $ per month 1008. AGGREGATE ESC ADJ months (~ $ per month -399.97 1100. TITLE CHARGES 1101. Settlement or Closing Fee to 1102. Abstract or Title Search to 1103. Title Examination to 1104. Title Insurance Binder to 1105. Document Preparation to 1106. Notary Fees to 1107. Attorney's Fees to (includes above item numbers: 1108. Title Insurance to LEON HALLER ESC AGENT FIRST AMERICAN TITLE INS 894.38 (includes above item numbers.1101-1104 ) 1109. Lender's Coverage $ 120,650.00 1110. Owner's Coverage $ 127,000.00 894.38 1111. CLOSING PROTECTION LETTER to LEON P. HALLER ESC AGENT FIRST AMERICAN TITLE INS 35.00 1112. ENDS 100/300/8.1 to LEON P. HALLER ESC AGENT FIRST AMERICAN TITLE INS 150.00 1113. 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recording Fees: Deed $ 38.50; Mortgage $ 64.50; Releases $ 103.00 1202. City/County Tax/Stamps: Deed 1,270.00; Mortgage 1,270.00 1203. State Tax/Stamps: Revenue Stamps 1,270.00; Mortgage 1,270.00 1204. 1205. 11300. ADDITIONAL SE'CrI~EMENT CHARGES 1301. Survey to ! 1302. Pest Inspection to ~ 1303. ~ 1304. 1305. See addit'l disb. exhibit to 116.50 284.23 1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section Kt 4,220.49 5,364.23 By signing page 1 of this statement, the signatories acknowledge receipt of a completed copy of page 2 of this two page statement. Certified to be a true copy. LEON P. HAL~'-~ESC AGENT FIRST AMERICAN TITLI Settlement AgEnt ( NAILOR04 1 NAILOR04 1 7 ) · PETER B. ARNOLD EdwardJones January 14, 2004 Historical Quote Symbol Description/Type Date Value AMECX INCOME FD AMER INC COM Adjusted NAY 10/02/2003 10/03/2003 $15.8200 $15.8600 /o/ Page 1 This information is for tax and estate purposes only and while believed accurate, is not guaranteed. There is no warranty that any trades were or would have been executed at these prices on the dates given. · PETER B. ARNOLD EdwardJones January l4,2004 Historical Quote Symbol Description/Type Date Value AIVSX INVESTMENT CO AMER COM Adjusted NAV 10/02/2003 10/03/2003 $26.3700 $26.5700 . oo Page1 This information is for tax and estate purposes only and while believed accurate, is not guaranteed. There is no warranty that any trades were or would have been executed at these prices on the dates given. st REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner INVESTMENT SAVINGS ACCOUNT: Account NumbedSuffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Maturity Date VISA CREDIT CARD ACCOUNT: Account Number Date Account Established Balance at Date of Death Name of Joint Cardholder MEMBERS 1" FEDERAL CREDIT UNION 47658 -00 03/09/1985 $57.82 $.00 $57.82 None 47658 -1 08/28/1987 $342.26 $.00 $342.26 None 47658 -05 07/07/1990 $16,573.22 $.48 $16,573.70 None 12/27/2002' $2,512.20 $.16 $2,512.36 None 06/06/2004 4121449998476589 04~0/1998 $52.98 Gladys L. Clippinger 47658-42 12~7/2002' $2,041.80 $.15 $2,041.95 None 12~6~004 *Transfer of funds from redeemed certificate #47658-40 purchased 12/27/00 M~rv~ERS 1sT F~DERAL CREDIT UNION · Supervisor~ December 3, 2003 Estate of: JOHN W. CLIPPINGER Date of Death: 10/02/2003 Social Security Number: 172-24-8227 5000 Louise Drive · EO. Box 40 · Mechanicsburg, Pennsylvania 17055 · (717) 697-1161 · www. memberslst.org OWNER Address FINAL SETTLEMENT Date ,, Date of Sale Auctioneer Other Sate Location Clerk Cashier PROCEEDS OF SALE: Cash .............................. _~ Checks ............................................ Miscellaneous (see attached list) ............................................. TOTAL PROCEEDS OF SALE ...................... $ , , ' LESS SELLER'S SALE EXPENSE: Auctioneer's Fee'__~_~_.~ .......................................................... Other Seller's Expenses Advanced by Auctioneer: Miscellaneous (see attached list) .............................................. DEDUCT TOTAL SELLER'S SALE EXPENSE ............................... TOTAL NET PROCEEDS TO SELLER ............................... I, (or we), the seller of goods, merchandise, and/or property sold at public auction on above date and location, acknowledge and accept this settlement of proceeds of sale. I (or we) agree to accept all responsibility for providing merchantable title to all goods, merchandise, and/or property sold, and for delivery of title to the purchaser. (Date) (Seller's Signature) Auctioneer or Cashier's Signature Form No. FS Reorder from: MISSOURI AUCTION SCHOOL Phone 1-800-835-1955 (Seller's Signature) BANKKltS LIFE AND CASUALTY COMPANY Annuity Services · 222 Merchandise Mart Plaza Chicago, IL 60654..2010 · Telephon~' 312-396-6000 Paul G Lutz Attorney-at-Law 110 S Northern Way York PA 17402 March 9, 2004 Policy 7,701,869 RE: John W Clippinger-Deceased Dear Mr. Lutz: This is in reply to your recent letter. John W Clippinger had one IRA annuity policy with us. The policy number is shown above. The policy was issued June 6, 2000. The opening payment for this policy was $17,389.43. The death benefit, which is figured as of the date of death, is $17,123.97. There were withdrawals from the policy totaling $3,525.00. The interest rate on this policy is 4.0%. The beneficiaries of this policy are Thomas Clippinger, Larry Clippinger and Sally Leeper. The beneficiaries must take a lump sum payout. Here is a claim form for each beneficiary. They must each complete and sign a form. They should be returned to us with a certified death cer- tificate (there was no death certificate with your recent letter). Also, the policy should be returned to us. Your friends at BANKERS, P. Pickering Life/Annuity Claim Department LCAM 426242 For local service, contact: Branch Sales Office 1051 2300 Vartan Way F1 2 Harrisburg PA 17110 Phone (717)545-7999 Register of Wills of Cumberland INVENTORY County, Pennsylvania Estateof John W. Clippin~er also known as , Deceased No. 2103-00871 Date of Death Social Security No. 10/02/2003 172-24-8227 Thomas W. Clippinger and Sally J. Clippinger-Leeper Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Attorney: Paul G. Lutz, Esq. I.D. No.: 39901 Address: 110 South Northern Way Personal Represent~ive / Signature: R~omas W. ~lip~.inger Signature: ~¢L~..~,~,. '.~ (~.~ 'Sally ~ C~ippin~r-L~per Address: 200 Zei~ler Road York, PA 17402 717/757-7602 Dover, PA 17315 Telephone: Telephone: 717/891- 3803 Dated: ~.~/~/ See attached Schedule A See attached Schedule B See attached Schedule E (Attach additional sheets if necessary) Description Value 127,000.00 5,015.00 i~U ~47,125.00 Total: 179,140.00 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form #Ri-7 (199;!) REV~- 1502EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER John W. Clippinger 21 2003 0871 All real property owned solely or es e tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchange 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 wit right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1. 32 Bare Road Silver Spring Township Mechanicsburg, PA 17055 (see attached settlement sheet) TOTAL (Also enter on line 1, Recapitulation) $ 127, 000 HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) 127,000 REV-1503 EX + (1-97} COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER John W. Clippinger 21 2003 0871 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 237 Units Income Fund of America (see attached) 48 Units Investment Company of America (see attached) TOTAL (Aisc enter on line 2, Recapitulation) $ 5, 015 HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) 3,749 1,266 R~V-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER John W. Clippinger 21 2003 0871 Include the ITEM NUMBEr 7 10 11 12 ,roceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule 1 1/2 bp. Gas engine (see attached appraisal) 1985 Chevrolet Suburban Selling price 1999 Toyota Camry Selling price 30-06 Remington rifle (see attached appraisal) CD#47658-41 Members First CU (see attached) CD#47658-42 Members First CU (see attached) Checking#47658-11 Members First CU (see attached) Copper apple butter kettle (see attached appraisal) Enterprise Rent-a-car Pension payout Erie Insurance Group Erie Insurance Group Erie Insurance Group Total from continuation pages TOTAL (Also enter on line 5, Recapitulation) DESCRIPTION VALUE AT DATE OF DEATH 375 1,200 9,400 210 2,512 2,042 342 150 637 26 47 2O 30,164 $ 47,125 HASPXXNUMBER (if more space is needed, insert additional sheets of the same size) Schedule E (Page 2) Item No. Estate of: John W. Clippinger Description Premium refunds 13 Funds to seller at Real Estate settlement (see attached settlement sheet) 14 Investment Savings#47658-05 Members First CU (see attached) 15 Miscellaneous household items Auction value of miscellaneous items 16 Philadelphia American Insurance Company Health insurance premium refund 17 Regular Savings#47658-00 Members First CU (see attached) 18 Remington .22 caliber rifle (see attached appraisal) 19 Sako 243 rifle (see attached appraisal) 20 Winchester 12 gauge shotgun (see attached appraisal) Value at Date of Death 503 16,573 12,404 176 58 55 235 160 Total (Carry forward to main schedule) 30,164 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 003907 LUTZ PAUL G 110 SOUTH NORTHERN WAY YORK, PA 17402 ........ fold ESTATE INFORMATION: SSN: 172-24-8227 FILE NUMBER: 2103-0871 DECEDENT NAME: CLIPPINGER JOHN W 05/05/2004 DATE OF PAYMENT: POSTMARK DATE: 05/05/2004 COUNTY: CUMBERLAND DATE OF DEATH: 1 0/02/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $1,251.00 REMARKS: CHECK# 536 SEAL TOTAL AMOUNT PAID: $1,251.00 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS '04 l'ill¥ -5 Pi2:1 2 BUREAU OF ZNDZVZDUAL TAXES TNHERTTANCE TAX DZVZSTDN DEPT. 280601 HARRISBURG, PA 17128-0601 COHHONNEALTH OF PENNSYLVANZA DEPARTHENT OF REVENUE NOTZCE OF ZNHERZTANCE TAX APPRAZSENENT, ALLONANCE OR DZSALLONANCE OF DEDUCTZONS AND ASSESSNENT OF TAX PAUL G LUTZ ESQ GRIFFITH STRICKLER 110 S NORTHERN HAY YORK PA 17.~OZ REV-1E47 EX AFP DATE 07-05-200R ESTATE OF CLIPP]NGER JOHN N DATE OF DEATH 10-02-2005 FZLE NUHBER 21 05-0871 COUNTY CUHSERLAND ACN 101 Amoun~ Rom/~ed I HAKE CHECK PAYABLE AND RENZT PAYHENT TO: REGISTER OF NZLLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THzS LZNE ~ RETATN LONER PORTTON FOR YOUR RECORDS ~ REV-15&7 EX AFP (01-03) NOTTCE OF ZNHERZTANCE TAX APPRAZSEHENT, ALLONANCE OR DZSALLONANCE OF DEDUCTZONS AND ASSESSHENT OF TAX ESTATE OF CLIPPTNGER JOHN NFZLE NO. 21 03-0871 ACN 101 DATE 07-05-200~ TAX RETURN NAS: (X) ACCEPTED AS F/LED ( ) CHANGED RESERVATZON CONCERNZNG FUTURE ZNTEREST - SEE REVERSR APPRAZSED VALUE OF RETURN BASED ON: OR]GZNAL RETURN 1. Roe1 Estate (Schedule A} 2. Stocks and Bonds (Schodulo 3. Closely HoZd Stock/PartnershAp Interest (Schedule C) (3) 4. Hortgagos/No~os RacoAvablo (Schedule D) (4) 5. Cash/Bank DeposAts/NAsc. Personal Property (Schedule E) (5) 6. JoAntly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Tote1 Assets APPROVED DEDUCTZONS AND EXEHPTZONS: 9. Funeral Exponsos/Adm. Costs/Nisc. Expanses (Schedule H) (9) 10. Debts/Nortgago LAabAIAtAes/Lions (Schedule Z) (10) 11. Total DoductAons 12. Net Value of Tax Return 127z000.00 5~015.00 .00 .0O ~7z125.00 .00 NOTE: To Ansuro proper credAt to your account, submit tho upper portAon of thAs form wAth your tax payment. 2Z,TZS.00 657.00 (11) 23.385.00 (12) ZO$,Z$~.O0 15. Amoun* of LAne 14 et Spousal rate 16. Amount of LAne 14 taxable at LAnoal/Class A rate 17. Amount of Line 14 et Sibling rate 18. Amount of LAne 14 taxable et Collateral/Class B rate 19. PrLncApal Tax Duo TAX CREDZTS: PAYMENT RECEZPT DZ$COUNT DATE NUNBER INTEREST/PEN PATD (- 12-19-200:3 CD005562 39~.7~ 05-05-200q CD00~907 .00 ZF PAZD AFTER DATE INDICATED, SEE REVERSE FOR CALCULATZON OF ADDZT/ONAL /NTEREST. 15. 14. NOTE: ASSESSHENT OF TAX: (15) .00 x O0 = .00 (16) 203,23q.00 x 0~5= 9,1~6.00 (17) . O0 x 12 = . O0 (18) .00 x 15 = .00 (19)= 9,1~6.00 ANOUNT PAZD 7,500.00 1,251.00 TOTAL TAX CREDZT BALANCE OF TAX DUE ZNTEREST AND PEN. TOTAL DUE 9,1~5.7~.26.00.26 I ( ZF TOTAL DUE ZS LESS THAN $1, NO PAYHENT ZS RE~UZRED. ZF TOTAL DUE ZS REFLECTED AS A 'CREDZT' (CR), YOU NAY BE DUE ~ A REFUND. SEE REVERSE SZDE OF THZS FORN FOR ZNSTRUCTZONS.} Char/table/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 Net Value of Estate Sub~ect to Tax (14) 20~,2~.00 Zf an assess;ant ~as issued previously, lines 14, 15 and/or 16, 17, 18 and 19 ~ill reflect figures that include the total of ALL returns assessed to date. ~7~79.00 (8) 226,619.00 RESERVATION: 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 the expiration of any estate for life or for years, the Comman~ealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class D (collateral) rate on any such future interest. PURPOSE OF NOTICE: PAYMENT: REFUND (CR): OBJECTIONS: ADMIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: To fulfill the requirements of Section ZlqO of the Inheritance end Estate Tax Act, Act 2S of ZOO0. (72 P.S. Section 91q0). Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side. --Make check or money order payable to: REGISTER OF NILLSj AGENT 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-1513). Applications are available at the Office of the Register of Hills) any of the 23 Revenue District Offices, or by calling the special Iq-hour anseering service far forms ordering: 1-800-362-20S0; services for taxpayers with special hearing and / or speaking needs: 1-800-q47-3020 (TT only). Any party in interest not satisfied eith the appraisement, allowance, or disallowance of deductions) or assessment of tax (including discount or interest) as shown on this Notice must object ~ithin sixty (60) days of receipt of this Notice by: --~rittan protest to the PA Department of Revenue) Board of Appeals) Dept. 281021, Harrisburg) PA 17128-1D21, OR --election to have the matter determined at audit of the account of the personal representative) OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue) Bureau of individual Taxes) ATTN: Post Assessment Reviae Unit, Dept. 280601, Harrisburg, PA 17lIS-0601 Phone (717) 787-6505. See page 5 of the booklet "instructions for inheritance Tax Return for a Resident Decedent" (REV-IS01) for an explanation of administratively correctable errors. If any tax due is paid within three (5) calendar months after the decedent's death) a five percent (51) discount of the tax paid is allo~ed. The 15X tax amnesty non-participation penalty is computed on the tote1 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 ties 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 af delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes Nhich became delinquent before January 1, 1982 bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January 1) 1982 ail1 baaF interest at a rate which mill vary from calendar year to calendar year ~ith that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOOq are: Interest Daily Interest Daily Interest Year Rate Factor Year Rate Factor Year ['~ 20X .0005q8 ~-8-1991 11X .000501 ~ 1963 162 .000q58 1992 92 .O00Zq7 2002 198¢ llZ .000301 1993-1994 72 .000192 2002 1985 132 .000556 1995-1998 9Z .000247 2004 1986 lOX .00027~ 1999 72 .000192 1987 lOX .OOOZ74 ZOOO 71 .OO019Z --Interest is calculated as follows: Daily Rate Factor 9Z .0002q7 62 .OOOl6q SZ .000137 42 .O001lO iNTEREST = BALANCE OF TAX UNPATD X NUNBER OF DAYS DELINQUENT X DAILY iNTEREST FACTOR --Any Notice issued after the tax becomes delinquent ~i11 reflect an interest calculation to fifteen (1S) days beyond the date of the assessment, l'f payment is made after the interest computation date sheen on the Notice) additional interest must be calculated. STATUS REPORT UNDER RULE 6.12 Name of Decedent John W. Clippinger Date of Death: October 2, 2003 Will No.: AdmilL No.: 2003-00871 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 eomplete: Yes 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 aoo:>unt with the Court? No. 1. The separate Orphans' Court No. (if any) for the personal representa,tive's aoo:>unt is: c. Did the personal representative state an areount informally to the parties in interest? Yes d Copies of receipts, releases, joinders and approvals of formal or informal aoo:>unts may be filed with the Clerk of the Orphans' Court and may be attached to this report. ~j cDate:~5+,,2~6 "1 I~'- - ^ - :...... ~:;;:~ ----~-~~~------------ SigneF 0: ~L-:,c5 -- c: 1I:;~~2 LU_"c. u:L 0._ 0:: o Address: 110 South Northern Way York PA 17402 Telephone No.: (717) 757-7602 l.D ('oJ Name: Paul G. Lutz, F.squire C'; ! I.,' J c., ~~.; c) U,J cc m"_ :::: , lor::;. C:~ = <'-.l Capacity: Counsel for Personal Hepresentative J