HomeMy WebLinkAbout02-20-09 (3)J 15056051058
REV-15 0 0 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue ~=
Bureau of Individual Taxes ~ ., ~ County Code Year File Number
Po eox 2sosol a INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 -• RESIDENT DECEDENT 21 08 0932
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
182-46-4917 05/13/2008 03/20/1925
Decedent's Last Name Suffix Decedent's First Name MI
Smith Mrs Betty M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
N/A
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL INAPPROPRIATE OVALS BELOW
• 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required
death after 12-12-82)
• 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST B E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Jacqueline M. Verney (717) 243-9190
Firm Name (If Applicable) ra
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REGISTWILLS US~NLY __: ;
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First line of address r ~
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44 S. Hanover Street t
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Second line of address l7;~ ]ra• ~-.- ~'
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City or Post Office State ZIP Code ~i4TE FILED ~
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Carlisle, PA 17013
Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGN RE OF PERSON . ES NSI LE FOR FILING RETURN
~ DATEL}
941 Green Spring Road Newville, PA 17241
- -.
NATURE OF PREPARER OTHER THAN R PRESENTATIVE DATE
DRES ~ , ~~~ ~ ` ~ 7 ~ U /
44 S. anover Street Carlisle_ PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051058 15056051058
15056052059
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Betty M Smith 182-46-4917
RE _ __
CAPITULATION _.. .... _._ ___ _._._____ v.___,-______..~.
1. Reaf estate (Schedule A) . ........................................... . 1. 0.00
2. Stocks and Bonds (Schedule B) ...................................... . 2. 0.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 0.00
4. Mortgages & Notes Receivable (Schedule D) ............................ . 4. 0.00
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 17,826.65
6. Jointly Owned Property (Schedule F) Separate Billing Requested ....... 6. 0.00
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested........ 7. 0.00
8. Total Gross Assets (total Lines 1-7) .................................... 8. 17,826.65
9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. 12,214.55
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. 4,348.31
11. Total Deductions (total Lines 9 & 10) ................................... 11. 16,562.86
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 1,263.79
13. Charitable and Governmental BequestslSec 9113 Trusts for which
an election to tax has not been made (Schedule J) ........................ 13. 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 1,263.79
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_ 15. 0.00
16. Amount of Line 14 taxable
at lineal rate x .0 45 1,263.79 16. 56.87
17. Amount of Line 14 taxable
at sibling rate X .12 17. 0.00
18. Amount of Line 14 taxable
at collateral rate X .15 18, 0.00
19. TAX DUE ......................................................... 19. 56.87
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYM ENT
15056052059 Side 2
L 15056052059
REV-1500 EX Page 3
Decedent's Complete Address:
Flle Number
21 08 '0932
DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER
Betty M Smith 182-46-4917
STREET ADDRESS _ __ ___ ---- _
4570 Enola Road
__ -- ---
CITY STATE zip
Newville PA 17241
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1)
2. CreditslPayments
A. Spousal Poverty Credit 0.00
B. Prior Payments 0.00
C. Discount 0.00
Total Credits (A + B + C) (2)
3. Interest/Penalty if applicable 0.08
D. Interest
E. Penalty
Total InteresUPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
56.87
0.00
0.~8
56.95
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 consideration? .............................................................................................................. ^
3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? .............. ^ ^Q
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.
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 three (3) percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (O) percent
[72 P.S. §9116 (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 Jufy 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 zero (0) percent [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 four and one-half (4.5) percent, except as 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 twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
~~ttst `zil ~nD
OF
BETTY M.
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I, BETTY M. SMITH, of 4570 Enola Road, Ne ' ille, Cumberland County,
Pennsylvania, being of sound and disposing mind, memo and understanding, do hereby
make, publish and declare this as and for my Last Will an Testament, hereby revoking and
making void any and all former Wills, Codicils, or writing in the nature thereof, by me at an yr,,
ime heretofore made ~
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FIRST: I hereby direct my Personal Representative to pa y all my just debts, funerat~ T' ~ : --- ~T
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administrative expenses out of my estate
as soon as practi a
able after my death ~ ~
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,
SECOND: I direct that all taxes which may be assessed i consequence of my death, of
whatever nature and by whatever jurisdiction imposed, sh 11 be paid out of my estate as a part
of the administration of my estate.
THIRD: I hereby give, devise and bequeath to my belove husband, Raymond L. Smith, Sr.,
my entire estate, of whatever nature, provided he survive ~ e by sixty (60) days. In the event
my husband dies before the sixtieth (60`f') day following th day of my death this gift shall
lapse or be divested. Upon that occurrence, then I devise I such property to my children,
Raymond L. Smith, Jr. and Patricia Ann Belden, per st rpes.
,~
FOURTH: I nominate and appoint my husband, Raymo
my Last Will and Testament. In the event my husband is
serve in said capacity, then I nominate, constitute and apI
Smith, Jr. and Patricia Ann Belden as Co-executors. I
representative(s) shall not be required to give bond or sec
duties in any jurisdiction.
I L. Smith, Sr., as Executor of this
;ceased, unable or unwilling to
nt my children, Raymond L.
rect that my personal
ity for the performance of their
FIFTH: In addition to the powers conferred by case law, y statute and by other provisions of
this Last Will and Testament, my personal representative, d any successors in that capacity
shall have the following discretionary powers applicable t all real estate and personal property
held by them, which powers shall be effective without Or er of any Court and which shall exist
and continue until the time of actual distribution:
A. To retain any property of any nature received b them for whatever period it shall
be deemed advisable;
B. To invest and reinvest all or any part of the assts of my Estate without regard to
statutes limiting the property which a fiduciary may purchase;
C. 7'o sell, transfer, exchange or otherwise dispos of, any part of the assets of my
Estate, for cash or on terms, publicly or private y, or to lease, without liability on the
purchasers to see to the application of the proc eds, and to give options for these
purchases without the obligation to repudiate em in favor of a higher offer;
D. To execute and deliver any deeds, leases, assig ents or other instruments as may
be necessary to carry out the provisions of this ill;
E. To borrow money, if necessary to facilitate the dministration and closing of my
Estate, including the right to borrow money fro any bank, and to mortgage or
pledge any asset of the estate as security;
F. To loan to, and to purchase assets from, my Est te, even if also acting as Executor
thereof;
G. To assume continuance of the status of any beneficiary with regard to death,
marriage, divorce, illness, incapacity and simil incidents or matters in the absence
of information deemed reliable without liabilit for disbursements made on such
assumption;
H. T'o make any distribution hereunder either in k~d or in money, or partially in kind
or partially in money, considering of course th reasonable wishes of the
beneficiary. Distribution in kind shall be made at the appraised value of the
property distributed, as it is set forth in the Inheritance Tax Retum filed in my
Estate;
I. To exercise any subscription right in connection
to consent to or participate in any recapitalizati
merger of any corporation, company or associa i
held hereunder; and to delegate authority with e
investments under agreements, to pay assessm r.
rights of investors;
with any security held hereunder,
1, reorganization, consolidation or
on, the securities of which may be
spect thereto, to deposit
ts, and generally to exercise all
J. To continue in any partnership, joint venture, j int ownership or other business
enterprise of which I am a part at the time of m death;
K. To compromise claims;
L. To continue for whatever period of time my personal representative shall deem
necessary any ownership as a tenant in commo or as a partner, in real estate or
other property and to act as I would have done ad I been living;
M. To do all other acts in their judgment necessar or desirable for the proper
management, investment and distribution of th assets of my Estate;
N. I direct that my personal representative shall be~compensated for the services they
render as Trustee and Executor under this my ~ ast Will and Testament;
O. Should any changes occur in the Internal Reve ue Code or Pennsylvania statutes
after the date of the execution of this Will whic affect the tax liability of my estate,
then to the extent possible and as may be permi ed by law, my personal
representative shall have the power and discreti n to interpret this Will and to
administer my Estate in a manner which results in the lowest tax liability possible;
P. Should the principal of any Trust herein provid
TRUSTEE'S discretion, so as to make establisl
inadvisable, my TRUSTEE or my Executor ma
then remaining principal and any accumulated
the person or persons and in proportions they a~
termination, the rights of all persons who migh~
succeeding income beneficiary or in remainder
d for be or become too small, in the
ment or continuance of the Trust
make immediate distribution of the
r undistributed income outright to
:entitled to income. Upon such
otherwise have an interest as
shall cease.
SIXTH: To the greatest extent permitted bylaw, before ac~ual payment to a beneficiary or to
his of her account, no interest in income or principal shall >~e assignable by a beneficiary or
available to anyone having a claim against a beneficiary.
IN WITNESS WHEREOF, I hereunto set my hand ands al this ~9 ~ day of
~'t , 2002.
BET7
SIGNED, SEALED, PUBLISHED and
DECLARED in the presence of:
~ . l~,~
~ ~
SMITH
ACKNOWLEDGEMENT
I, BETTY M. SMITH, the Testatrix-whose na e is signed to the attached or
foregoing instrument, having been duly qualified acco ding to the law, do hereby
acknowledge that I signed and executed the instrumen as my Last Will and Testament;
that I signed it willingly, and that I signed it as my fre and voluntary act for the purposes
therein expressed.
~ ~.
BETT M. SMITH
Sworn orirmed and acknowledged before me by B TTY M. SMITH, the Testatrix,
this ay of , 2002.
N ary Public NOTARIAL. SEAS
~~~ K. SHAUt.IS, Notary Public
Carlisle ro. Cumberland Cou
MY Com isslon Expires Dec. ~, "~
AFFIDAVIT
We, Betty M. Smith, ~AGGU~~(il/E /t't•~/fK~~j' ~ ~'~'•~^t~rs ,
~~~~75r1G ` ,the Testatrix and the witne es, respectively, whose names are
signed to the attached or foregoing instrument, being fi st duly sworn, do hereby declare
to the undersigned authority that the Testatrix signed d executed the instrument as her
i
' Last Will and Testament and that she had signed Willi ly, and that she executed it as her
free and volunta act for the u oses therein ex ress d and that each of the witnesses
rY PIP P >
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in the presence and hearing of the Testatrix signed the ast Will and Testament as
1
witness and that to the best of their knowledge the Tes ~ trix was at that time eighteen (18)
years of age or older, of sound mind and under no constraint or undue influence.
TESTATRIX, _~'" ..Le 'L-~i ~ • ,residing at ~l o ~xs-~,~ A
WITNESS, ~• esiding at /~ ~ ~
WITNESS,
WITNESS,
residing at ~QT \ ~~ ~r'
residing at
~71J0
Subscribed, sworn to and acknowledged before me byI/Betty M. Smith, Testatrix,
and subscribed and sworn to before me by`/~A~4 u ~e ,f lit. (/~ ,
I ~v ~(• ~~'e ~ s ,and bier/+! ~~75~1 ~ ,the
witnesses, this ~~ day of
NOTARIAL SEAL
KATHLEEN K SHAUUS, Notary Public No y F
Carlisle Boro, Cumberlarxt Co
My Commission Expires llec. ~, 2003
2002.
REV-1508 EX+ (8-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Betty M. Smith 21-08-0932
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.
(It more space is needed, insert additional sheets of the same size)
. FILE No.994 12123 '08 15 18 ID~ACNB
December 23, 2008
Jacqueline M Verney
Attorney at Law
Re: Estate of l3etty M. Smith
-ICES FAX'717 334 1658 PAGE 2~ 2
~~Vl~~
rrnTro>v~AI, liArVi;
Dear Ms. Vemey:
The followin5 information is being provided as per your request:
Acct_ Type Account No. Account Accrued Ownership Date Opened
Principal on Interest to
D.O.D. p.O.D.
Checking 2153106 $9,345.94 $.02 Individual ] 1/20/03
Inquiries concerning ACNA Corporation stock information should he directed to the Registrar and Transftr
Company at 1-800-368-5948, if you need any additional information, please contact me at (717)339-5116.
Sincerely,
~~ a ~ ~ ~~
Lois A Kime
Deposit Services
YO liux 5110, Gi-111'ylsinc,, NA 17325 ~ r~~,~tirY17 i14.316f I uni racrKt5ti.1i~.2Z63 ~ www.acnb.cu~t1
Dec 22 2008 S:O1PM ,Egger Funeral .Home, - 7177?64589 p.3
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G~G~~v v
15 Big Spring Avenue
NEWVILI.E, PENNSYLVANIA 17241
F. CHARLES EDGER, Supervisor ~p¢e~~aC3~~,r.R008 FRANK C. EDGER, Funeral Director
Date of death May 13, 2008
Professional Services $3, 325.00
Cemetery Opening $500.00
Ratlin Oak Casket $3,050.00
Burial Vault $935.00
10 Death Certificates $6.00 a piece $60.00
Hair Dresser $30.00
Sentinel obituary $173.18
Patriot News Obituary $306.57
Sentinel Obituary $35.00
Total $8,414.75
Amount Paid $8,329.37
l~neral Bitl Paid In Full
REV-1511 EX+ (12-99)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Betty M. Smith 21-08-0932
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' E er Funeral Home, Inc 15 Bi S rin Ave Newville, PA 17241 re aid funeral services
99 9 P 9 p P
8,329.37
2 Egger Funeral Home, Inc 15 Big Spring Ave Newville, PA 17241 death certificates 35.00
3 St. Peter's Lutheran Church 210 Brick Church Rtl. Newville, PA 17241 church service 250.00
a St. Peter's Lutheran Church 210 Brick Church Rd. Newville, PA 17241 Pastor Carol Bowman 100.00
e St. Peter's Lutheran Church 210 Brick Church Rd. Newville, PA 17241 Vicar Jan Moody 100.00
s St. Peter's Lutheran Church 210 Brick Church Rd. Newville, PA 17241 Organist, Laurel Hankins 100.00
~ Lisa's Floral Shoppe 333 Greenspring Rd. Newville, PA 17241 273.48
e. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address
City ,State Zip
Year(s) Commission Paid:
2. Attorney Fees 2,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 175.00
5. Accountant's Fees
6. Tax Return Preparer's Fees 150.00
~. Advertise Letters: Sentinel-$126.70; Cumberland Law Journal-$75.00 201.70
TOTAL (Also enter on line 9, Recapitulation) I $ 12,214.55
(If more space is needed, insert additional sheets of the same size)
Dec' 22 2008. 5:O1PM Eger-'Funeral,Home ~, c7177764589~ p':3
~~ ~ ~ ~%~~~L.r/mf'/~ e./~1.G.
L7~
15 Big Spring Avenue
NEWVILLE, PENNSYLVANIA 17241
F. CHARLES EDGER, Supervisor ~Fp~~~008 FRANK C, EDGER, Funeral Director
Date of death May 13, 2008
Professional Services $3, 325.00
Cemetery Opening $500.00
Ratlin Oak Casket $3,050.00
Burial Vault $935.00
10 Death Certificates $6.00 a piece $60.00
Hair Dresser $30.00
Sentinel Obituary $173.18
Patriot News Obituary $306.57
Sentinel Obituary $35.00
Total $8,414.75
Amount Paid $8,329.37
Ftineral Bill Paid 1[n Full
V
Dec 22 2008 5:O1PM Egger Funeral Home 7177764589 p,2
15 Big Spring Avenue
NEVwII.LE, PENNSYLVANIA ~ 7241
F. CHARLES EDGER, Supervisor 717-776-3414 FRANK C. EDGER, Funerol Director
Death Certificates for Betty Smith
3 Heath Certificates $9.00 a piece $2'7,00
$8.00 processing fee $8.00
Total $35.00
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FILLING FLORIST:
TEVFTD # Contact:
Phone: Time:
City/State: Date:
Comments: To Be Paid Upon Receipt.
After 30 Days, There Will Be a Late Charge of $5.00 Per Month.
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~~ ' ' ~KELLE~~~'FIl`IAl`ICIAL>'CIROUP.
~ 17 E. HIGH STREET • SUITE 103
` CARLISLE, PA 17013
(717) 243-8553
FAX (717) 243-0577
Statement
Date
5/2/2008
To:
Betty M. Smith
4570 Enola Road
Newville, PA 17241
Amount Due Amount Enc.
$150.00
Date Transaction Amount Balance
03/31/2008 Balance forward 0.00
04/23/2008 INV #1431 I. Due 05/03/2008. 150.00 150.00
~~IO~
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Current 1-30 Days Past Due 31-60 Days Past 61-90 Days Past Over 90 Days Past Amount Due
Due Due Due
150.00 0.00 0.00 0.00 0.00 $150.00
SECURITIES, ADVISORY SERVICES, AND INSURANCE PRODUCTS ARE OFFERED THROUGH INVEST FINANCIAL CORPORATION,
(INVEST) MEMBER FINRA/SIPC, A FEDERALLY REGISTERED INVESTMENT ADVISER, AND AFFILIATED INSURANCE AGENCIES.
INVEST IS NOT AFFILITATED WITH KELLER FINANCIAL GROUP.
:. < - •, ~ ..- RETAIN THIS PORTION FOR YOUR RECORDS
REMITTANCE ADDRESS ~ ~ BILL O
THE SENTINEL- LEGAL JACQUELINE M. VERNEY
P.O.~ BOX 130 CARLISLE `PA 17013
AD NUMBER CLASS SALESPERSON BILLING DATE LINES
357069 10 PUBLIC NOTICES robik 10/10/08 30 * 2
AD DESCRIPTION START DATE STOP DATE
EXECUTOR NOTICE LETTERS TESTAMENTA 09/26/08 10/10/08
PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT
3 THE SENTINEL - LEGAL 3 LGL 119.70
TOTAL AD CHARGE 119.70
3 PROOF OF PUBLICATION 01PRF 7.00
DAYS RUN
DRDER PAY THIS AMOUNT 126.70
Betty Smith
152.04*
MESSAGE:
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PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Erica Peterson, Classified Manager, of The Sentinel, of the County and State aforesaid,
being duly sworn, deposes and says that THE SENTINEL, a newspaper of general
circulation in the Borough of Carlisle, County and State aforesaid, was established
December 13,1881, since which date THE SENTINEL has been regularly issued in
said County, and that the printed notice or publication attached hereto is exactly the
same as was printed and published in the regular editions and issues of
THE SENTINEL on the following day(s):
September 26, October 3,10 2008
COPY OF NOTICE OF PUBLICATION
~'' `°'~`~XECUTOR~NOTICE " 1; -
Letters Testamentary on the Estate of BETTY M. SMITH
:-.'late of the Town'sflipBf.UppAr Frankford,Cumberland:
'County, Pennsylvania,'deceased, have been granted
to the undersigned '~~;:: , € ~ : ~.
All persons knowing themselves to be indebted to said
. Estate will make payment immediately', and those ' ::"
,.having claims will present them for settlement. '. ,
Raymond•L: Smith,Ur. 8 Patricia Ann Belden „'
c%Jacqueline M. Verney, Esq. r ~ Lr°`, .,` ! ~ - "
44 S. Hanover St ,r. ? ,~A ' ;;`
Carlisle, PA 17013 'v iY:~ ^ ~ ,
Affiant further deposes that he/she is not
interested in the subject matter of the
aforesaid notice or advertisement, and that
all allegations in the foregoing statement
as to time, place and character of
publication are true. '
Sworn to and subscribed before me this
~- aoo
~ ~a ,
Notary Public
My commission expires:
NOIARIAI SEAL
BONITA A CANUP
Notary Public
CARI ISLE BOROUGH, CUMBERLAND COUNTY
My Commission Explces Jun 8, 2009
- - -
_. 1,
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717) 249-3166 Fax: (717) 249-2663
October 10, 2008
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Jacqueline M. Verney, Esquire
RE:
Betty M. Smith Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
September 26, October 3, and October 10, 2008
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 75.00
Total Amount Due $ 0.00
Becky H. Morgenthal, Executive Director
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss.
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
September 26, October 3 and October 10 2008
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
Smith, Betty M,, deed.
Late of Upper Frankford Town-
ship.
Executors: Raymond L. Smith, Jr.
and Patricia Ann Belden c/o Jac-
queline M. Verney, Esquire, 44
South Hanover Street, Carlisle, PA
17013.
Attorney: Jacqueline M. Verney,
Esquire, 44 South Hanover Street,
Carlisle, PA 17013.
NOTARIAL SEAL
DEBORAH A COLLINS
Nofary Public
CARLISLE BORO, CUMBERLAND COUNTY
My Commission Expires Apr 28, 2010
r
~~
Lis arie Coyne, Edito
SWORN TO AND SUBSCRIBED before me this
10 day of October, 2008
Notary
aEV-ISIZ Ex+ (tz os~
Pennsylvania SCHEDULE I
D[PARTMENT °r REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Betty M. Smith 21-08-00932
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1• Philhaven P.O. Box 550 Mt. Gretna, PA 17064 medical consultation 10.00
2. Green Ridge Village 210 Big Spring Road Newville, PA 17241 nursing home 3,994.97
3. Moffitt Heart & Vascular Group 1000 N. front St. Worleysburg, PA 17043 medical consultation 10.00
4. Cumberland Valley Endo Center 49 Brookwood Ave Carlisle, PA 17013 medical tests 116.00
5. Darryl K. Guistwite, D.O., Inc 56 Ashton St. Carlisle, PA 17013 medical services 217.34
TOTAL (Also.enter on Line 10, Recapitulation) I $ 4,348.31
If more space is needed, insert additional sheets of the same size.
,;; ;_.. ,.:a,t h ,: ,- ~Detail~lStatementofServicesForYour.Records z,,,,,,, ~~~,~,,,t,.~,,• '
_ ~ r ._2:, ~ 4 t °r"f`~.a~~ 4"+'y~ !4 ~ Jd F;r ~ f(r ~. ~ .':~~ tP ~~#^,A ,~k.5ae~'1M1 !}~a'i~~3E1 )" t > , - ~ '.
Account Smith, Betty M (241'35) s 'bue'Dafe:'~'Decembec 22, 2008
Program: Consult-Older Adult ,Statement Date: "December 7, 2008
Admit Date: 06/04/2007._,:..,. _ , _ , ., , Previous Statement Balance: $10.00
Discharge Date: ' ` Payments Received Since Last Statement: $0.00
Total New Charges: $0.00
Amount You Now Owe: $10.00
3511-126 (244135) ~ Page 1 of 1 Detail
'0' ~~ ~li
•J ~r'tmr~.r PO Box 550 Mt Gretna, PA 17064 ;Phone (888) 302-4710 Ext. 2413 or (717) 270-2413
~vh[Z Ve~ Business Office Hours: 8:30am - 4:OOpm M & F and 8:OOam - 8:OOpm T,W,Th
Promoting hoy~ hcolingmvl who~rnas
e
Total Pa ments: $0.00
New Charges or Services Since Your Last Statement:
Primary Insurance: Medicare (A & B) (03/01/1990)
Secondary Insurance: HOP Administration Unit (06/04/2007)
Payments Received Since Your Last Statement:
' Please detach and return this portion with your remittance to the address aoove.
Comments
f you have received new Insurance cards for 2009 please provide copies to the Business Office. Thank you!
Balance Forward
TOTAL BALANCE DUE:
$3,994.97
53,994.97
1 `~ " ~ ~~~~~~
c~ ~° I
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
SWAIM HEALTH CENTER BETTY M SMITH 61367GRV
-'~*'~ AN~ ~ ES~TIONS REGARDING 'YbUR BILL PLEASE ~ A ~. `~;• ~~~
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.175.,00,, ~ ~~ ~
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g
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ns pending 83.34! 91.66 0
00
03/11/08'
03/28/08 1 10 L 'OFFICE VISIT EST LEVEL 3 99213 414 8 :r
Medi
P 75.00,
• ,
{
~! .
03/28/08
04/15/08 care
ayment
Acceppt Assiggn Adj.
PS 45.86
-17
67
ERS/HOP AD .Payment 1
47 . '
. 10.00
~~s~~o~
~~ ~~~~
L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment.
DATE LAST PAID AMOUNT ~ ~ ~ ~ ~ , ~ ~ ~
00/00/00 0.00 10.00 0.00 0.00 0.00 0.00 .0.00
MOFFITT HEART & VASCULAR GROUP
MAKE
CHECK 1000 NORTH FRONT STREET
PAVAeLETO: WORMLEYSBURG, PA 17043
PAT~~ 1-BETTY M SMITH PRV~~ 10-LINE, DENNIS E, MD, FACC
~ 0.00 ~ 10.00
~' ~ &
10.00'
Ph: (717)-731-8315
Acct~~: 41070
Date: 04/25/08
Page 1 of 1
~ J ~ • 1 f d~ a . n
V ryt
~ . e _ ' 4,.4; ~
'VALL~Y~'ENDO~CENTER
CUM ER .
~4 9 "'<; ~~ OOKW s OD °~AVEIWE ~~ ~;;;_ . "~'- ~ .
CARLISLE, 'PA 17013 ~_
717-2~8-1462 " ,
To
BETTY M SMITH
4570 ENOLA RD
NEWVILLE, PA 17241
ADJ-MEDICARE A 06/27/07 AJB MED
108254005
PMT-MEDICARE P 08/13/07 AJB MED
ADJ-MEDICARE A 08/13/07 AJB MED
108356952
PMT-MEDICARE P 06/27/07 AJB MED
ADJ-MEDICARE A 06/27/07 AJB MED
108254005
PMT-MEDICARE P 08/13/07 AJB MED
ADJ-MEDICARE A 08/13/07 AJB MED
108356952
BILL BALANCE
TOTAL AMOIINT DIIE NOW:
INSURANCE LEGEND:
MED MEDICARE
-s Ia~a~
~~ ~~~~
Payments can be taken by
Credit / Debit-Card, Check or
Cash in the office or Check by
Mail
Please Detach and Return This Portion With Your Payment
-6.53
23.47
- 6.53
-12.60
-7.40
12.60
7.40
$58.00
$116.00
0.00 0.00 0.00 116.00 116.00
Finance Percentage: Finance Amount:
00'8 0.00
QUESTION? PLEASE CONTACT US BY E-MAIL AT
DRBEHNKECa1CVENDOCRINOLOGY.COM `
REMINDER - WE DID NOT RECEIVE YOUR PAYMENT LAST MONTH.
No Interest or Late-Fee has
been applied to your account
1^°) ~ °a ' y ~ vn".~;~~'r'L we ,~'T'`
~ ~ ~~ ~~
.r rte. 4t,~r
>~~ ,,~,.
.tea 4+~i
_.:
~~,_,, ~~~ ~ Darryi K,. Guistwite, D.O., Inc.
,~~. ~ ~ 56 Ashton Street
Carlisle, PA 17015-6914
(717) 609-2639
05/09/08
BETTY M. SMITH
C/O EDWARD BELDEN ~ '•
941 GREENSPRING ROAD 5766.0(1
NEWVILLE PA 17241
sate `° ~~..: gescription'•_._'-,. i,` '.`Char e
9 ~ ~ Credit
!14/02/G8 NURSING HOME EST. PATIENT
G~/25/0£2 Ins Pmt-MEDICARE 75.00
G4 /25/08 Adjustment 45.0
05j'8/08 Ins Pmt-PSER 18.7
TO AL FOR BET Y M. SMIT
~~~~~
o.oo
REV-1513 EX+ (I1-08)
j i~ pennsylvania SCHEDULE ,7
~ DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF
Betty M. Smith FILE NUMBER
21-08-00937.
NUMBER NAME AND ADDRESS OF PERSONS} RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Do Not List Trustee(s) OF ESTATE
Sec. 2116 (a) (1.2).)
1. Raymond L. Smith, Jr. 4570 Enola Road Nevwille, PA 17241 son
50%
2. Patricia Ann Belden 941 Greenspring Road Nevwille, PA 17241 daughter
50%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 16 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET
if more space is needed, insert additional sheets of the same size. $