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Home My WebLink About02-0823 Will PETITION FOR PROBATE and GRANT OF LETTERS Estate of.~:Eq~m...~.:....~.~.I.?;~. .... ............ .................... ............... No. .... "" ....c:lJ,,:..O.~.~..~~.~..... ............. also known as................................................................ ................ ....... ........ ............ .... ..,. ........ "" .... ............................ .... ..........., Deceased Social Security No. U.k}~.7'.~.n.L............................................. The petition of the undersigned respectfully represents that: Your petitioner(s), is/are 18 years of age or older and the execut..r.;i,f!:................................................ named in the last will of the above decedent, dated....4.P.~.P.JL..................19...??. and codicil(s) dated .....~.9.~~................................................... To: Register 01 Will:; lor the Cumber.Land County ol~n the Commonwealth of Pennsylvania ..................................................................................................................................................................................................... (state relevant circumstancell, e.g. renunciation. death of executor, etc.) Decedent was domiciled at death in Cumberland County, Pennsylvania, with h ~.~................. last family or principal residence at .. Th!?.. ~.r..~Ag~...~ 1:.. .:B.~~.!:. ..g~.~~.~.. A~.~ ~.~.~.~~.. .!:-.~ Y~!!-.~.. .~!7.~ ~.~E...................................... .........nQ9...!}.~D.J:;...G);'.~~.~...~.+.Y."~....,...~~~.t~.n.i:-.~.~.t?).!:~g,....~4....1.?9.?.~.....,~...~ff .0~!....... (list street, number and municipality) prw;rr-r', Decedent, then ..}.L years 01 age, died ....$.~.P..1;.~~t?~.~...~..............................................................~ ..f9.!t?..., at ...'n)..~.. .~;t;'J4g~.~... .~t..~.~.~.t... .9.~.~~~.. A~ .~J.f? !:.~.4...IA ~.~~.!L~.E7?: !:.~~./... ~~ ~.~~.~.~.~.~.~':1E~.!... .~~........................ Except as lollows, decedent did nof marry, was not divorced and did nof have a child born or adopted after execution of the will offered lor probate; was not the victim 01 a killing and was never adjudicated incompetent: .......N.9.~.I);..................... ..................................................................................................................................................................................................... Decedent at death owned property with estimated values as follows: (if domiciled in PAl All personal property $ .).9.9.,.9.9.9.:.9.0............ (if not domiciled in PAl Personal property in Pennsylvania $ .................9.,.9.0............ (if not domiciled in PAl Personal property in County $ .................9....9.9............ Value of real estate in Pennsylvania $ ..................9.....9.9........... situated as follows: ........ ........ .................................... "" .... ........................ .... "" .... .... .... .... ........................................ ........ .......... ..................................................................................................................................................................................................... ................................................................................................................................................................................................"... WHEREFORE, petitioner(s) respectlully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters ...r.~~.t.iH!!~~J:;.~~y........ ........................ ................................ ........................................ .................. thereon. (testamentary: administration e.t.a.; administration d.b.n.c.t.a.) ................................................................................. :::::~.:..::.::......::;.g:.:~........~::::::~j~/t1 I1:1;::z;l):;Jmm CAROLYN R. SMITH ! ..4.Q .~Ji. ..G,;IJ.l?~ 9.~.l?.. G.?~~.1;................................. 5; ,,- .~~ Enola PA 17025-1476 D:8...............l................................................................. ,,~ ~"ii -0. (II ................................................................................. !'o a . ~ ................................................................................. i]j . . . . .. . . . . . . .. . . .. . . .. . . .. . . .... . . . . . . . . . . . . . . . . " . . ,. , . .. . , . . . , . . . , . . . . .. , . . . . , . . . . . .......,..........,...,............................,.....,........................." . . . . .. . . .. . . " . . .. . . .. . . .. . . ., . . .. . . . . . , . . . . . , , . . . . , . . . , . . . , . . . . . , . . . , , , . . , , . . , . . ......................,......,..,.,.............."..................."...."....,.. / l-Y7-/d{ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA } CUMBERLAND COUNTYOF~ The petitioner(s) above-named swear(s) or affirms(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. SS Sworn to or affirmed and subscribed before me this ........+.?th..... day of Y=~8~:~"'" Donna M. Otto. . 1St Deputy For the Register .....,...... .... ........ ,... .... .... .... ...................................."....................................... .~~A~9.E~...~.~....~.~~.~~........................................................................i .. ... ...A..f3.~;(./...t!..Jk/,4........................... 1! ................12..~....................................................f}) ..................................................................................................................... No. .21,,2002"'823........ Estate of ......)1A~IqN..p.,....~~.,JI~................................................................ , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW, ............J?~P:\=~~:r...P!;!':l........................~..?Q'O'?, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s), dated ............................ ..................................................................................................................................................................................................... described therein be admitted to probate and filed of record as the last will of .....W\.~~9.~...~.:....~.t:1.~.P!:................................ ...................................................................."............................................................................................................................... and Letters .. r.lP.!'i.t~~~:9::t;!!\;t:y....................... .C'AtOL'YN..'S.;.I'lARl!Ul'HER..n/k/a:..................................................................... are hereby granted to ..!;:.~~q~!:N..~~....~l1:~I~.. ................ .... ................................ .... .... .... .... ................................ .................. ............................ .... ............................................ .... .................... .... ........................ .... .... .... ....- '.~"~"""""""""""""""" ................. 'ff) C ~~~~ Donna M. otto 1st Deputy FEES Probate, Letters, Etc...............$ P9...RR........." i"'"'' Short Certificates() ....~.........$ ..')':'\...RR........... 9.r;9.R.~r;. ..R.:... .~.~VIM~I~K ,.....!.~ ,..,... ~.S.QlJ.I~~... ATTORNEY (Sup. Ct. I.D. No.) 46998 116-118 Warren Street Tunkhannock .....................................................,.................,...........,.' ADDRESS PA 18657 .C:i.7.R.l....e).9.::JUR................................. .... ........ ..... PHONE Renunciation .........................$ ........................ ~~I.....................................$........................ x-Pages (2) 6.00 JCP TOTAL ..........$ ....~.~QQ............ 296.00 Filed Mail short certificates to executrix.. send the certified letter to attorney on 9/12/02 Ilitl~,)\I)'J jnV'll)\l, -"ius IS fO cerriCy fil:lr rhe informarion here given is correctly copted from an original certificate of death duly filed with me as Local R~'gistrar The original ccrtificate win he forwarded to the Statr: Vital Records omcr: for penmll1cnt fllillg. WARNING: It is illegal to duplicate this copy by photostat or photograph. No, ~"h /(~\1\LQl. N;,.--.--o (l~f: . ~'- lj."'~.. (.?7\ ~~I" ::.' I~~ llU -"T \_~ l * ~~ _,' ~., '\,' * ! \.a...-' ~". -' ,/~i ....~ /~,\ ~:.fp~_----<\\..'rl ....:;'/MEN1 ~~ ~ ,.." ,"1"""'''''111111/11111 t~~~ K~I~ I ~oClI Registrar Fet for thi~ cel"titlcHC, $2.0n P 8606355 ., )It#-;'"''' I, . JV .J>; .;{ C: Ci d- l):1te rno~ 14JA.. 2fa7 COMMONWEAL.TH Of PENNS'tlVAMIA. DEPAR1MfNT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH iYPE,PflINl " >>UIIU,I'<UH IllAOO;INIl w-.MEOf{)ECi~N'Tll-....M_,l""l 1. M::.trion S. Smith ~.~.'~'----=-~~~~5flc I. Female SW~"cf"U"""UI SOCI"'lSfCUAIT'lNlIloI8fll 1.191 t)"l'eOf'lVlTl1}>lCfl\/'.Oa,,_1 - 34 Se tember 2 02 AGE ('''''llonnc.vl 1.INllER1V(AR ...... '. \JHDEA I 0#11' ........1.......... 1I1R1tlPLAcEl0v.od :;"".",fO''''9''C<Il'',,"VI PI...foalOFOEAJIlICf>tlclo~",...""_,...."","",",on__1 """ ,,-_0 EI'l/OUliIo&I_O ,,-,"_0 ::1\'10 94 Vro J:.OUl4t'fCf()Llll"jol Norristown, PA , FACIlfl'YiII"'lllE (1In<l'''''''''''''''. g,""..,H1""".......-, lUoCj;._..._n._o,\WIq,&oc ,-, ClJ1lber land ..., Silver Spring IQNDOFeuS(Nj;S&nNDUSTRV White tlECEDEWl'SlJSUAl.OOCUPIITlON ~':..~::""'=':::1.~ lIa. Hanemaker 1 Own Hare DECl:DEiIIl.S.........INGADOReSSlSll...C"..--.._.wCo<lol DECf:OENT'S 2100 Bent creek Boulevard ~~NCf Mechanicsburg, PA 17055 ..,o:...~""" I',''''~.I I4AAIv.lSWUS."""" ~-.-. oo.or-'~otvI I'. Widowed ,~.~"'"'.--~ SORvlvlN35POUSE 1......_....dOo_ 11..St.oIO "' -- h.. -""'1 17"'O:r...~=ol MOTHEfl'SNAME.y.._._s...--. ,t. Phi INFORMANrSMAlUNQADOIlESS\SlI....C~_.1JfJc.x.1 .4056 caissons CQurt Enola PA 17025 Pl...ACEOFDl$POSlTlClN'_oIC-.y,Cr....-o<y lOClO"lON.~.Sl_.r'l'~ ._- .. ver Spr ng - j ,. f.llTliE:A'SIOIdolElh"."_,l."J <It. Charles Steiner IfOFORMANT'SHAloIE(l~,O'\lI Carol R. Smith METHOO Of OISI'O'SIlD+ a...n.l1Xl c.-_O __51....0 Ol....-(S_....' \1tI.C<lu ,.... " - " , ", 1 , 2'~. c -- .Mal 21.. n'c 7 SSO#FAC/lITV zzl 8 M9Iket Plaza llCl'NSE: tlUWEll m 1'7055 OATEPAONO\.INCEDDEAD(""".....O~_l ...11: 55 PM . Se tember 4 2002 "._TI, EnlOl'....._.....Il."'IU'_""~__.......,Il...""'.'h OQnDl.n1..,,,,,,,,,,,,,".r"V,"Il, JuCh.IC..a...ot,._.lO<y.".... """"*"'''''... r..... l,"O<lIy"""~_""'iNCII_ DAJESlGNtD l"'O<'JIh,o..Y,*"'1 ~. 2k v.sC~~AAiOl0:0Al.EKA"'INEflICOflOOlER7. ..,1Kl Cstto.Q~~ OIJElOlOIIl''''CONSEOU~NC€OFl: DUElO\OR...s"COHSE~>>CiOf), f=;..<i.. u... . ~ ,Appnl>l...... '-- i--- , , PoUITN:OU"rllOllnollo....~COOIU_rw;I.._,1l<.A ....._"'i"'....~_~..1'IU'lT1 I: DUEllJ(OOjIlS"'C;QNSlOlJ,ENCEOFl WERE ...UTOf'SY FI"IOINOS ~EPAlOftllJ C()I.lPU.TlOfolCWCAu:5E ~~m t,lANNEAOlOEIlTH OATEQFlNJUlIY 1"""''''.O'~._1 TItolEOfRi.lt.lIlY INJURVJa.....OfU(1 OESCIllflE HCJN'''I..I!JAVOCCU_O ~~ ..0 ~I"f" -. - Ii!' o o -- o o o .,.. 0 >>00 .......- -- eo.....""'boI_ Ao 2tO. 21. atnlfli;"'Ct-od<""'~"""" .CDllJII'Y_PlfySJCl...iII(pI'I.'.'"."c..~~"'<lo."'_.""'"..ph"""'._ha.lIl'''"''''nc'''''''''''''"''''c''''''''"'".;"omlJ\ l/O_boI..~I....,~.._~_...,..u""(.I.nd"'._....,.,.... ATlJAE...iIIONUloI8EA""U/J r'\) ~~--- l<kl ,", \ hll o",n,: SlOPlEOIIlklo-lr>. Dav,_' o 1 ~ JlL__ -------- _E D.o.oonESS EA~~tlnl;p'_...ust:OI'PEATIl 1".....21I'i'fPllo<PMI /;. J. f>UvPC/f..,fll':/ ~fO f<i/VVl d\. iI'''P 012. rwr'/P /-JiLl....,. fA.... f 7t;I11 O...lEF'lEO(.....".O.Y_I )4. 3Q.p./~nlhe.e. .S: -J ()t)J.._____ .~NQANDCl!A'.,VIIOOPIlVSICIAH("""""OMl"""''''''''''''._.c'''g''''.iI'.''''C..'............IOC.,,''''oI'''''.'". TD...._IDI"',......~.,d.."'''''c......,.I...._.d....~....pl.u..''''_I._'"''Ml.\_'''"''''"' ..~"".-1 "1iIIOlCAl UAMINENCOROtlEl\ On 1M b..l. oI.......""l1on .ndI~I..".."II.llo.., In..., .V'..;..... d"'''"",,.,,''.d .1'''. limo. d.lo, ."d pl.~.. ."d dV.'O I,.. <."..,(.1_ .............................. ..... .'. ..............".,.....,................ ........ .....-...... ........ ~'. 21-2002-823 LAST WILL AND TESTAMENT OF MARION S. SMITH I, Marion S. smith, of R. D. #1 Box 308, Millerstown, pennsylvania, 17062, Perry County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking all wills and Codicils heretofore made by me. ITEM I. I direct that all my debts and funeral expenses, including my cemetery lot and gravemarker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my death as part of the expense of the administration of my estate. ITEM II. I devise and bequeath all of my estate of every nature and wherever situate to my three (3) children, Harland C. Smith, Gail smith Kriebel, Carolyn S. Bareuther and their issue per stirpes. ',\.) ~-~ ITEM III. I direct that any and all Inheritance, Estate and Transfer taxes imposed upon my estate passing under my will or otherwise, shall be paid out of the principal of my residual estate. . .<;: ->\\-. , ,~ \.~., ITEM IV. I appoint Carolyn S. Bareuther, Executrix, of this my Last Will and Testament. I relieve my Executrix from the necessity of posting security in connection with her duties as such in any jurisdiction in which she may be called upon to act. '---{;: ,'(1 ,,\-'~~ '" 1 IN WITNESS WHEREOF, I have hereunto set my hand to this my Last will and Testament. which consists of ~ pages, to each of which I have affixed my signature this :J..Gil day of lipV' i (_. one thousand nine hundred and ninety-nine (1999). I q , /I-Y) ~/Jl~11 ~IA/ ,1/ ~7N";Y'1/ Mar~on S; Sm~th 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF D~ ss . . . . " We, MARION S. SMITH, and Co.foh/n 5. &reufher, the v Ga.ll5, k rl~be I , and testatrix and the witnesses respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last will and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the will as witness and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. , ,L Wess d .ai~ji.. "~fc~(.J Witne " ;.-', b/TIiX fk) Subscribed and sworn to and acknowledged before me by MARION S. SMITH, Testatrix and subscribed and worn to and acknowledged before me by 5. e e , and tlro' S. , witnesses this ~~1h ay of , 1999. I (l'k4 fJ2[fi/~ Notci0PIlbh I NOTARIAl seAl JODI A. McN!ELY. Notary Public MaryM1le Ioro, Perry County Ntl eom..-aon ExpI_ April 7, 2003 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDl\llDUAl TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SKUMANICK GEORGE P JR ESQUIRE 11 6-118 WARREN STREET TUNKHANNOCK, PA 18657 ---~---- fold ESTATE INFORMATION: SSN: 191-34-6371 FILE NUMBER: 2102-0823 DECEDENT NAME: SMITH MARION S DATE OF PAYMENT: 11/20/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 09/04/2002 NO. CD 001867 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $13,500.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: C/O GEORGE P SKUMANICK JR ESQ CAROLYN R SMITH CHECK#100 SEAL INITIALS: CW RECEIVED BY: REGISTER OF WILLS $13,500.00 MARY C. lEWIS REGISTER OF WILLS JRD/June 30, 1992/] 7858 In Re: Estate of MARION S SMITH Late of SILVER SPRING TOWNSHIP Estate No.: 21-02-823 ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO. 21-02-823 NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT ORPHANS' COURT RULE Personal Representative: CAROLYN S BAREUTHER N.K.A. CAROLYN R SMITH Counsel for Personal Representative: GEORGE P SHUMANICK JR ESQ Date of Grant of Original Letters: 09-12-2002 Date of Delinquency Notice: 12-22-2002 The undersigned, Mary C. Lewis, Register of Wills, in accordance with Rule 5.6, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of Common Pleas of Cumberland County, that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk ofthe Orphans' Court his, her or its certification required by Rule 5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e), Supreme Court Orphans' Court Rules, was given by the Register of Wills on DECEMBER 22,2002, and that the ten (10) day notice to file the certification has expired. Accordingly, in accordance with Rule 5.6(e) the Court is hereby notified of such delinquency and the undersigned requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. Date: 01-02-2003 b~~h~~f}i~rft^~ t'-~J <;: hi ii-, Register f 11 Distribution: Personal Representative Counsel for Personal Representative Estate File A hearing is scheduled for c2 ~/'i-03 at 9: <:,./7.-/111 In Courtroom NO.3. If the Certification of Notice is filed prior to the hearing date, the hearing will automatically be ",ocono! ~ George 1. er, .J. February 14, 2003 George P. Shumanick, Jr. 116-118 Warren Street Tunkhannock, PA 18657 IN RE: ESTATE OF MARION S. SMITH Failure to File Certification Dear Mr.Shumanick: A hearing was set for February 14, 2003, at 9:30 a.m., in the Courthouse in Carlisle, at which you failed to appear. The certification must be filed in the office of Register of Wills. We must hear from you within twenty-four hours; please phone Jackie in the Register of Wills office at 240-6409, if you have any questions. Sincerely, Sandra S. Gobrecht, Secretary Judge Hoffer's Chambers REV.1500EX(6-o0) COMMONWEALTH Of PENNSYLVANIA DEPARTMENT Of REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 1\-<r;l~ !,~ o:O.r REV-1500 v w .... ';:t.$0 U"'''' wQ.u ",00 u"'.. Q.JD Q. '" INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z W C W o W C DECEDENT'S N~ME (LAST, FIRST, AND MIDDLE INITIAL) SMITH MARION S. DATE OF DEATH (MM-DD-YEAR) OFFICIAL USE ()NL'{ FILE NUMBER L~-~~ COUNTY CODE YEAR JL~LL_ NUMBER DATE OF BIRTH (MM-DD-YEAR) 09-04-2002 07-27-1908 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) [!] 1. Original Return o 4. limited Estate o 6. Decedent Died Testate (AtIacl\CO\lyofWdl) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (date of death after 12-12-82) o 7. Decedent Maintair.M a living Trust (A.t\achcopyoiTrusl) o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) SOCIAL SECURITY NUMBER 191 - 34 -6371 THIS RETURN MUST BE FILED IN DUPLICATE WITH TI REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Return (date of death pOOr to 12-13-82) o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (A.ttactISct\C .... z W Q Z o Q. W W '" '" o u COMPLETE MAILING ADDRESS NAME Geor e P. Skumanick Jr. FIRM NAME (If Applicable) Es TELEPHONE NUMBER (570) 836-3170 116-118 Warren Street Tunkhannoc:lsr:PA 1.8657 :::0 ~(" 0 :Dro IAL USE ONLY , x.O_ (15) x .0 45 (16) 13,467.57 x .12 (17) x .15 (18) (19) 13 ,461L57 1. Real Estale (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) (1) (2) (3) (4) (5) 0.00 0.00 0.00 0.00 308 186.66 (8) 308,186.66 (11) 8,907.37 (12) 299,279.29 (13) 0.00 (14) 299,279.29 z o ~ ::l I- 0: <( o w a:: 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent. Mortgage Liahilities, & liens (Schedu~e I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) (9) (10) 7 , 779.41 1,127.96 (6) 0.00 (7) 0.00 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o !ci I-' ::l ll.. == o o ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 299,279.29 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20 [Xi CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: STREET ADDRESS Brid es at Bentcreek 2100 Bentcreek Blvd. Mechanicsbur CITY Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 13,500.00 C. Discount (1) 13.467.57 Total Credits(A+ B + C) (2) 13,500.00 3. InteresUPenalty if applicable D. Interest E. Penalty TotallnteresUPenalty ( D + E ) 4. If Une 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Une 1 + Une 3 is greater than Une 2, enter the difference. This Is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Une 5 + 5A. This is the BALANCE DUE. 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;.......................................................................................... 0 [XJ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 [XJ c. retain a reversionary interest; or..................................,.................,..................................................................... 0 [X! d. receive the promise for life of either payments, benefits or care? ........................................................"............ 0 [Xl 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . ..... ....... ...... ..... ............................... ........ ........................... ..... ............... 0 [XJ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [XJ 4. Did decedent own an IndiVidual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........ ....... ..... ... .................. ....... ...... ... .......... ............ ... ........... ........................... 0 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and befief, it is true, correct and complete Declaration of pre other than the personal representative is based all information of which preparer has any knowledge. FILING :3 Tunkhannock ,... JliIllIlIinlfn-. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate impoSed on e net ~alue of transfers to or for the use of the surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)). . 'v For dates 01 death on or after January 1, 1995, the tax rate imposed on the net value of transfe~o or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116(a)(I.2)]. The tax rate imposed on the net value oftranslers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(I)]. 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. 99116(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. Enola PA 1702 RESENTATIVE REV.15D2EX + (1.971 '* SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARION S. SMITH 21-2002-0823 All real property owned solety or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointJy-owned with right of survivorshin must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE TOTAL (Also enter on line 1, Recapitulation) $ O. 00 (If more space IS needed, Insert additional sheets of the same size) REV-1S03 EX. (1_971 *' SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MARmON S. ':SMITH FILE NUMBER 21-2002-0823 All property jointly~wned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. NONE TOTAL (Also enteron line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV.1504EX~11-97) . SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE.PROPRIETORSHIP COMMONWEALTH OF PENNSYLVANIA \NHER\1ANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21-2002-0823 ESTATE OF MARION S. SMITH Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole--proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ''''~''''I'."''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF MARION S. SMITH FILE NUMBER 21-2002-0823 All property jointty.owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. NONE TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~eV.1508 ex. (2-B7] ,. SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY Please Print or Type FILE NUMBER 21-2002-0823 COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MARION S. SMITH (All property jointly-owned with the Right of Survivorship must be disclosed on Schedule F) ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Commerce Bank 742 Wertville Eno1a, PA 17025 Saving No. 616069218 Checking No. 0513147157 1,566.62 11,566.14 2. Vangaurd Life Strategy Account P . 0 . Box ill 0 Valley Forge, PA 19482-1110 No. 012289025 80,418.61 3. Members 1st Federal Credit Union P.O. Box 40 Savings No. 199282 Mechanicsburg, PA 17055-0040 10,697.04 4. Orrstown Bank 77 King Street Orrstown, PA 17257 Account No.26206249 203,938.25 TOTAL (Also enter on line 5, Recapitulation) S 308 186. 66 (Attach additional 8~" X 11H sheets if more space is needed.) REV-1509 EX + (1.g7) '* SCHEDULE F JOINTL Y.OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21-2002-823 ESTATE OF MARION S. SMITH If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT{S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. NONE B. c. JOINTLY -OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY . I %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bCllk account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed forjoinUy-held real estate. VAlUE OF ASSET INTEREST DECEDENT'S mEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV~~10EX.(1..g7) '* SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN R SlOEN1 OECEDEN1 FILE NUMBER 2192002-0823 ESTATE OF MARION S. SMITH ThiS schedule must be compieted and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE TIiE NAME OF THE TAANSFEREE,TIiEIRRELATlONSIiIPTOOECEDENTANOTIi E OATE OF TRANSFER. DATE OF OEA TH DECO'S EXCLUSION TAXABLE VALUE lUMBER ATTACIiACOPVOFTHE DEED FOR REAL ESTATE , VALUE nF ASSET INTEREST 'IFAPPLICII&LE\ 1. NONE TOTAL (Also enter on line 7, ReCllpitulation) $ II.<____u ~~~__ ,_ ~___'__' ,__~... __'_"~'___I _L..__~~ _".L.._ ____ _,__I REV_1511EX+(1-971 '*' SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21-2002-0823 ESTATE OF MARION S. SMITH Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Malpezzi Funeral Home 6,332.91 8 Market Plaza Way Mechanicsburg, PA 17055 Gingrich Memorials 95.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Carolyn R. Smith 0.00 Sodal Security Numberts) I EIN Number of Personal Representative{s) Street Address 40 5 6 Caissons Court City Enola State PA Zip 17025 Yea~s) Commission Paid: 2. Attomey Fees 3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Cumberland County Register of Wills 296.00 5. Accountanfs Fees 6. Tax Retum Preparer's Fees 7. Harland C. Smith (For Airlines Tickets to Attend 817.00 8. Funeral) Rothermel,s Flowers 238.50 TOTAL (Also enter on line 9, Recapitulation) $7,Q9.4l (If more space is needed, insert additional sheets of the same size) REV_1S12 €x. p.9l) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECE.DENT FILE NUMBER 21-2002-0823 ESTATE OF MARION S. Smith Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. 2. 3. 4. 5. 6; 7. 8. Diamond Pharmacy ROBC Limited Partnership (Nursing Home) Silver Spring Ambulance Holy Spirt Hospital Classis Cleaners (Funeral Suit) Pizza Hut (Food for Nursing Staff) Walmart (Dress) 2003 Tax Return Prep 388.88 492.87 46.72 27.89 10.03 36.67 24.90 100.00 TOTAL (Also enter on line 10, Recapitulation) $ 1, 127 .96 (If more space IS needed, Insert additIOnal sheets of the same size) REV_1513 EX + (1-97) '*' SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MARION S. SMITH NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY 1. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Gail S. Kriebel 321 High Street Mechanicsburg, PA 17055 2. Carolyn R. Smith 4056 Caissons Court Eno1a, PA 17025 3. Harland C. Smith 1499 U.S. Highway 45 Ontonagon, MI 49953 FILE NUMBER 21-2002-0823 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Daughter Daughter Son AMOUNT OR SHARE OF ESTATE 1/3 1/3 1/3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. NONE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. NONE 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) MemberslST .fEDERAL CREDIT UNION P.O. 60)(40. Mechanlcsburg, PA 17055.0040 (717) 697-1161 TOLL FREE (BOO) 2B3-232B www.members1storg W.E CHECK/CASH RECEIPT E:c:2297--1210 EST('~TE CHECKS RELEAfiE 1566.62 0~/14/02 ISH RECEIVED: " ~ Your...i.,.'......d'illAlll>d,.,5180.0I0 NCUA ......"('.....l'_'~__.l'........._"-1' OF MARION S 0',!114/02 \2I'l:40AM 1\2191212 6 313 TI~A BR:06 '" 1110 S~lITH/ CHECI<G 11~;EIj::,.14 EFF DATE:09/14/02 RELEASE 09/14/1212 . .00"' .121121 TOTAL HECVD: 13,132.7& CASH RETURNED: y.\ h~\ L . vanguaru - MY num" .... Uz=,'- ~ ''-'->. ~ .. VANGAURG LIFE STRATEGY ACCOUNT My IIome My Portfolios Re....rell ft.n:I.. " stock.. SenIicelI PI8nning " AdvIce Welcome, Carolyn I want to ... At Vanguard Total .<-,';. ,...', $0.00 flIP '1, 0 J, $80,418.61 C7/Htr' ; ."rtf#lI#I For more detailed account Information, go to Vanguard News for September 20 Consider this ... My Services . Select a service or browse our We can help you diversify your holdings. . . . C 1995-2002 The Vanguard Group, Inc. All rights reserved. Vanguard Marketing Corp., Disbib. E~d, https://flagship3.vanguard.comNGApplhnw/MyHome 9/20/2002 >/~eml1~rslST . I' P.O. Box 40 .. Mechanicsburg, PA 1705S-004wffi (717) 697-1161 . TOLL FREE (600) 263-2326 . . www.memberslst.org 'I'....-......r_,_..sl...- NCUA ...............~_.t.ii.~_ SHDP Journal Voucher 09/14/02 09,37AM 10769 6 313 TMA BR,06 222297-11 25.00 ESTATE OF MARION S TO CHECKING BAL: 10,697.04 SMITH/ EFF DT.09/14/02 61109 AMT, /tIEMB FEES. DESCRIPTION.. .00 DON'T GET A LOAN ELSEWHERE WITHOUT TALKING TO US FIRST! ESTATE OF MARION S SMITH C/O CAROLYN R SM ITH 4056 CAISSONS CT ENOLA PA 17025 SIGNATURE --~-----~-- ----- .--- -_._-~__ ----___0_- _______~ -~--------- ----~~--- z:-- ~ ~_.~ - = == - - - !!!!!!!!!!! ....... """""" #m~ ORRSTOWN BANK Securities offered throuqh T.H.E. Financia! Group. Inc. 77 East King Street Ormown, PA 17257 (717) 530-2608 Investment products offered through Onstown Bank are not FDIC insured are not a deposit or other obligaUon of or guaranteed by Orrstown Bank and are sub)ecl: to investment risks, including possibe kiss of the principal amount invested. oaM B001 0447655 001195 000584 DGAZ MARION S SMITH C/O CAROLYN SMITH 4056 CAISSONS COURT ENOLA PA 17025-1476 Acct # 26206249 Office # DGM Period 08130102 - 09130102 Rep # Rep Phone # DG48 (717) 530-3523 Page 1013 Rep Name DENNIS CRAWFORD Fixed AcooLlntVal.!.IeS!.Il1ll1lary' Description This Statement Cash and Equivalents $12,105.47 Stocks 8,965.00 Fixed Income 182,264.25 Government Bonds 76,631.00 Corporate Bonds 105,633.25 % 6 4 90 Last Statement $11,216.75 10,814.00 181,907.50 76,344.25 105.563.25 % 6 5 89 Investment Allocation September 30, 2002 I Equiv. Total Assets $203,334.72 100 $203,334.72 $203,938.25 100 $203,938.25 Account Value Net Change .().3% Decrease Description Debits Dividend and Interest Charged Sweep Activity - Purchases DREYFUS GENERAL MONEY MKT FUND Total Account Activity Summary This Period Description Credits Dividendllnterest/Principal Payment Sweep Activity - Redemptions DREYFUS GENERAL MONEY MKT FUND Total This Period $0.00 $888.72 000 888.72 $888.72 $888.72 f~L-f Account carried with Fiserv Securities, Inc., a member of the NYSE, NASD and other principal exchanges, Sf PC Malpezzi Funeral Home 8 Market Plaza Way Mechanicsburg, PA 17055 (717)697-4696 October 15, 2002 Carolyn R. Smith 4056 Caissons Court Enola, PA 17025 The Funeral Service for Marion S. Smith We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff. . . . . . . FUNERAL HOME SERVICE CHARGES SELECTED MERCHANDISE: Poplar Casket (Oxford). . . Guardian Vault . . . . . . Register, Memorial Cards. Adm. . THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED . . . . . . . . . . . . . $5850.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. 4. CASH ADVANCES $3260.00 $3260.00 $1765.00 $780.00 $45.00 Opening Grave, . . . . Cemetery Equipment. . . Newspaper Notices - Local . f. Certified Copies of the Death Certificate . TOTAL CASH ADVANCES AND SPECIAL CHARGES . CONTRACT PRICE . . . . . . . . . . , . HISTORY 09/18/2002 Payment. . . . 10/15/2002 Service Discount . $750.00 Ii L s~ ~-,( -t. Cli;<:/.~" ,r $95.00 $8640/1 Co i, 'to (2-;}'.00 ",.1 $40.00 . /1'~f.M/Uj $971.40 '10 . <X) $6821.40 ..-------.. '1.. y." '1& TOTAL AMOUNT DUE . $-6106.51 $-488.49 $226.40 f roJ '/lp./Jt'lllj (IIi! I C iJ rtf C ~(,1 1/.)(,15. r ttJlJ J /?j(;(f' ;4 fJ'f) flIJV~' -R 'r1 r-, \ 0 \ill \ t . 0 ...-I ~ c:l3 ~ (O~ rl ~ \ If\ l?:i ::g * ~ b\ ~ ~a~l '" < Q ~U\1~\ '"'. ~. o o ... o .. - ... J "-' "-' to rf' ... o rf' % "-' ~ -.: r-' -~ . n.1866P/GS LGBRR U034496 GS 05SEP 1.2SMITHjHARLANDjVERLA MS L UA5189Q 06SEP IWDMSP HK2 1025A 1124A FR 1 OPERATED BY GREAT LAKES AIRLINES NDj1152CTjARVS 1014A OT #DPTS 1025A OT ISPj1152CTjARVS 1124A OT IRDj jj 249 805j815A F:3500 H:2573.1 DEBOER/BURBANK *OT* ~ UA1476Q 06SEP MSPMDT HK2 1200N 458P FR 1 ISPjl017CTjDPTS 1200N OT IDTjl017CTjARVS 458P OT l UA1785Q 08SEP MDTORD HK2 1250P 152P SU 2 IDT/0333CTjDPTS 1250P OT IRDj0333CTjARVS 152P OT #DPTS 245P OT > l UA 731Q 08SEP ORDMSP HK2 245P 409P SU 2 IRDj0333CTjARVS 148P OT #DPTS 245P OT ISPj0333CTjARVS 409P OT i UA5190Y 08SEP MSPIWD HK2 440P 536P SU 2 OPERATED BY GREAT LAKES AIRLINES ** ELECTRONIC TICKET *** ONE-IWDRj906 884-4898 2 UALNjETKT ADV PHOTO ID AND CC USED TO PURCH REQ AT CKIN DRS-MS VERLA SMITH@1499 US HWY 45@ONTONAGON MI Zj49953@USA KTG-TjLGB 05SEP1657Z GS GS*** ELECTRONIC TICKET *** >*TEO ** LINEAR FARE DATA EXISTS *** >*LFO TFQ-TKj$Bj@QRCAREjF526801001845040~ ~ (! Kit /3 J':L- ~Q-USD 688.38jUSD 51.62USjUSD 77.00XT/~~_~~.:~.:~O)SEP @QRCARE ~-'l \othermel1s Florist 18 West Cooyer Street 717-766-9351 09/05/02 12:27p.m. EMP II: l)Gl) VIRBlt!IA POS II: 000013 PO; Tenltin:51: 11 .3007:; VERSIONII: 5.3.3 R..;..cei_p't Custokier I1l...lmt1er: OO~I078 CAROLYN SMITH (In P~~~:~;'~~ <:CHECK II 138Q~ CHECK AMT 238.50 Th-3nl<:s ~ ~ ~ Chec>: for weekly speci,ls, ~ JnAbJ./ f.5'O. LIO --T J f..! )) 0 0 ------ 15-9.00 /flack- ~o.()O 1-Y "3/"U to:5. /CO (IJ~Jd +t ISoo ,90 -- /i.90 1-\ ~ -- // DIAMOND PHAR.MACY SERV.u.,:ESb':i:.:> .KUL'l'.t:.:k iJKl.V~ ~~~~~,R ~~ ~~iU~ PATE> _~NUMBE}< QTY. DESCRIPTION DPT "I ~~ AMOllNT ....... CD~ ..... SALES TAX rTEM."1'Cl'l"AL , *.- PREV1US BALANCE 325.26 1/29/02 CK #632-THANK YOU 325.26- .00 325.26 * ACTIV TY FOR 8 ITH, MARION -8 ~. T - " ACTIV TY FOR 8 ITH, MARION -8 T "Z - 1/14/02 7049673 30 CHEW ASPIRIN 81MG 01 .95 .00 .95 1/14/02 7049674 14 ZOLOFT 50MG TAB 01 33.60 .00 33.60 1/14/02 7049678 30 ARICEPT 5MG TABLE 01 124.19 .00 D4.19 1/14/02 7073791 60 CALCARB 600 W/VIT 01 3.19 .00 3.19 1/14/02 7049686 60 TRAZODONE 50MG TA 01 26.85 .00 26.85 1/20/02 7166331 3 XALATAN 0.005% OP 01 52.20 .00 52.20 1/20/02 7049682 5 COSOPT EYE DROPS 01 45.88 .00 45.88 1/20/02 7049662 4 MIACALCIN NASAL' 2 01 70.32 . .00 70;32 3/28/02 7181751 30 NITROGLYCERIN .2M 01 29.40 .00 29.40 3/28/02 7181860 480 MILK OF MAG SUSP 01 2.30 .00 2.30 ~~ l\ ? jJ } / \: 0K{{{~< '* y'" ~~ .00 I I I I I I I I I TOTAL TAX ~EVIOU$ >BALANCE 325.26 + CHARGES THIS-MONTH 388.88 FINANG'E CHARGE + .00 TOTALCMRGES 714 . 14 TOTAL PAYMENTS & CREDITs 325.26 388.8.8 1111 DIIIIIQ 01111111 II ~lIIlE"TV CHECK HERE IF TAX DEDUCTIBLE ITEM - [] 096 I I Membersl"" FEDERAL CREDIT UNION PO, 80. ~ MechanicSburo. PA 17055 BAL FWD THIS CHECK TOTAL Mise BAL FWD. -1 I I 60-822412313 I . F..-.,,,,, f/N/N 4 {"30JO.;l .: 23 UB 2 21, .':00"1 : :1 ~~~,:~~ \~''f~ "f1.~~~\~TrT~' .~ : ,:"";?''''iX;''", f.C>',.:i.;^.;.;r,./,"0 9< '~'~~<J~ , "~~ i'.:' /";>.." J\-.;'lI-$1:2 ~..'('o.l/;~.. ;r\ . NON NEGOTIABLE NUMBER DATE TRANSACTION DESCRIPTION CHECKSlWITHDRAWAlSI DEPOSlTlINTERESTi FfESJDEBIT - CREDlTjt) AVAILABLE BA(ANCE ~;( 55 Ii! S"L .-" ."'-._'~._A_. _______ -............ DETACH AND REtURN fQ'PPb'RT'rONWffHvoUl=f'Pj,YMENf'-- , .__..-,_..j._-"-~._- QUANTfTt I A0429 A0425 UNIT PRICE 300.00 7.50 AMOUNT 300.00 75.00 10.0 MILEAGE Late Pay Charge \~) >. \1\. \ ~\ \) q~J?~ 0.00 TOTAL CHARGES THIS CALL $ 375.00 PLEASE PROVIDE THE PATIENT'S SECONDARY INSURANCE INFORMATION. PA BLUE SHIELD 65 SPECIAL HAS NOT PAID THE CLAIM TO DATE. A bill was submitted directly to your insurance company. Their policy is to send payment to the policy holder. You are responsible for pay- ment in full regardless of the amount paid by the insurance company. DESCRIPTION OF PAYMENT REFERENCE PAYMENT DATE AMOUNT Medicare Contractual Allowance 880649246 09/09/02 141. 41 Medicare Part B Payment 880649246 09/09/02 186.87 ---------- TOTAL PAYMENTS THI CALL $ 328.28 200677 -130 (P1) PAY THIS AMOUNT 1111" 46.72 -. 3:3 AMBULANCE BilLING OFFICE: po. BOX 726, NEW CUMBERLAND, PA 17070-0726 !!JHOLY ~ The Spiri' of Caring .,9~~-' ((^ -~d Holy Spirit Hospital 503 N 21ST STREET CAMP HILL PA 17011 # 1-877-254-9239 ....-.............................._--.......-.------. ........................... ...,...............,.......................,.......-.-._........-.._-,-.-..,...,....-.-....,....-.-..............'..,.......,'.-.....-...-..'.....'-.-.-......-.. .~Mi~~~~ll~~~( ........~:~~~~:...~~~r-].................................... .......~.~.~~.~2G.~......... ;'#1~1i't'~~~1P~*~1*ij*~!r*~ ~~~~lmt~ml~~jj~z.i.... . r Account Information, Pleue Call 1-877-254-9239 Statement of Account 11/28/02 Transaction Date Description \"LA']1!D:1 '\ Amount PREVIOUS BALANCE Qut.. .00 08/03/02 ICE PACK SML 6.00 08/03/02 DERMABOND Ct \ (1~ 87.75 08/03/02 ORBITS 236.00 08/03/02 LEVEL II I FC 312.00 08/03/02 ED LEVEL III FC 170.00 08/03/02 NON-EVA EARIPUL OX FOR 02SATUR 32.00 08/03/02 REP LAC FACE,EAR,EVE,NDSE<2.5C 205.00 09/17 /02 MEDI PART B PVMNT MI0 MEDICARE D/P 111.58- 09/17/02 MEDI PART B CIA MI0 MEDICARE D/P 235.53- 09/18/02 MEDI PVMT-HDSP DP MI0 MEDICARE DIP 158.46- 09/18/02 MEDI CIA HOSP-OP MI0 MEDICARE D/P 420.64- 11/27/02 BC 65 SPEC PVMT B99 BLUE CROSS 36 94.65- Estimated Insurance Due: .00 Total Patient Credits: roUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT 3ALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU. \/110 MEDICARE OIP .00 B99 BLUE CROSS 36 .00 'LEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. Account Balance: 27.89 I-~ _ _ _________._____~l._I!!_lt_.!!C!~_~~!_~.!~_~l.!~)'~.~q!t'!l!~.,.___--.__,______________________________________________-,..__~,.. ~.__ I . :nlHli t1HNil I ::t:~ .l!. lj" I tHail! 1_ --, Classic Drycleaners _ _ and Laundromats "The Suede and leother Experts" 315 Nopth Enala Rd. Enola PA 17tll25 _________________...:Gi2--3.:..'?fi5 "___,_.._.~__~_____."._"__. I i Ii fli Ei'HTHj CAIWLYN D '1','\llir.l.~:AI'\n N, I." ,,".", ~'~ (;I'~ .i"', ,/'.', ff~"" T.. ,,_ '\ .. \.., ~~.:. i \'iL.a ~~;;:~ ~::~ "".J s~rfH;rAlfj[YN----"- ........ '-"-'I2il-::il,\\lr---if,'2Tii. 0!i/;:'I702....tir "~b CASi~;S COURI ENDLA. PA. 17025 ____.___.b,AliH __._._....._.___ "___~...__.l______..~..~__L_._.____.L__._.L_".._,,~_~____.. i Suit - 2 Pc. Gr'~el'l61kPly lL t5 Pr-epay J.0'~ vmu' 5111PLY THE REST IN 2:ll0C. 8V HAfIIUSllUilG V, Iii MAGAZINE [\AM.. ~ ~ tu~. 5UBTflTAL i1.15 I)!c' 'NT -i. 1.2 PflE.pmfi'lU:\ ___2 PIECES ___,_._______--1NV(1L-Q)]lJ.L.,j",~~ WE m~ rllllll~I\llllllllj~Mfll\mli~illl~II;~illl~illill\ Rb ~1(~13~4 ,,~"".'''I' ..~, """'I"""'~:::' I"'I"""'''H ["'A "I[]' \{"~ -" (' I' i ,.~ -" ! 1 II I I"" I a~...., ' !I..~ L...ll-.~'\...J \,,, I,l I ~ I I l,,~ HlHltl f\1\ ~\l\ <) /" \" /s{~/ T-5 Cd ,,- / Not Responsible for Garments After 30 Days. AVAILABLE 8ALANCE en> 193 i/ /0 7'::;' 01 ;<5 ,j.-./ ~3 T-~ -/?j~ i/ ;v,L '10 [~.n- -/,'7{. J &3;<, t..J ~.B (P/'i ;.,1 5D ~ 3'16> I:] WAL*MART. ~WAYS LDN PRICES. f>JJNAYS WAIAMRT. ~~~?) I}!!:!!F: T WE SELL FOR LESS HANAGER ROBERT FRANk ( 717 ) 691 - 3150 ST# 1886 OPI 00000341 TEl iR TRI 00143 SPEC ORDER 0078142208'8~n\~~D __ '6 TYLEIIOL 030045044902ti.\,>, 9 ~ LACE KNT FLO 065288690732 it "l' 9 . D KNIT GOWN 065288695729 9.88 D SUBTOTAL 26.86 flC<;- n I TOTAL 26.86-~ CHECK TEND 26 . 86 X. if,? CHANGE DUE 0 . 00 _ I '1(- . - # ITEMS SOLD 1 ~~.q~ TC' 4369 7228 6721 6155 7815 1IIImll~~~I~~IIIIIIIIIIIIIIIIIIIIIIII~~III~II~111111111I WAL-HART CREDIT CARD - APPLY TODAY! 09/04/02 15:03:04 \~-l Chubb and Associates Certified Public Accountants P. O. Box 6597. Harrisburg, PA 171J2-0597 (717) 541-1860 (717) 944-1426 INVOICE NO.: 0003509-IN DATE: 04/11/03 CLIENT CODE: 0005093 Smith, Marion S. c/o Carolyn R. Smith 4056 Caissons Court Enola, PA 17025 PAGE NO. : 1 FOR PROFESSIONAL SERVICES Individual Income Tax Returns PREPARATION OF FEDERAL AND STATE INDIVIDUAL INCOME TAX RETURNS FOR 2002. $100.00 TOTAL INVOICE AMOUNT $100.00 ---------- ---------- /7~ b) UI1I/d- // r r.1,' . i\t6 V - - ~-~ A finance charge of one and one-half percent (1 & 1/2 %) per month (annual rate of 18%) will be added to any account balance which remains outstanding for more than thirty (30) days from the date such balance is invoiced. PLEASE REMIT COpy WITH PAYMENT '. \\~ " \ , >c o' $} . '" JRDIJune 30, 1992117858 ' In Re: Estate of MARION S SMITH Late of SILVER SPRING TOWNSHIP ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA Estate No.: 21-02-823 NO. 21-02-823 NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT ORPHANS' COURT RULE Personal Representative: CAROLYN S BAREUTHER N,KA. CAROLYN R SMITH Counsel for Personal Representative: GEORGE P SHUMANICK JR ESQ Date of Grant of Original Letters: 09-12-2002 Date of Delinquency Notice: 12-22-2002 The undersigned, Mary C. Lewis, Register of Wills, in accordance with Rule 5.6, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of . Common Pleas of Cumberland County, that neither the above named personal representative'nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its certification required by Rule 5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule Y6(e), Supreme Court Orphans' Court Rules, was given by the Register of Wills on DECEMBER 22,2002, and that the ten (10) day notice to file the certification has expired. Accordingly, in accordance with Rule 5. 6( e) the Court is hereby notified of such delinquency and the undersigned requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. . Date: 01-02-2003 b~~\~~f'ffl 'f'^~ 1L, S2 11 ii, Register f II Distribution: Personal Representative Counsel for Personal Representative Estate File A hearing is scheduled for c2 -)'1-<>3 at q; ?oh. Po In Courtroom No.3. If the Certification of Notice is filed prior to the hearing date, the hearing will automatically be "mOOn", ~ George i er,.1. .!1I- P"l- /.:v \. BI\REAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION iJEPT. 260601 HARRIS8URG~ PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX H DATE ESTATE OF DATE OF DEATH FILE NUMBER " 2cfAA4TY ACN 07-21-2003 SMITH 09-04-2002 21 02-0823 CUMBERLAND 101 Allount Remitted '03 JUL 21 GEORGE P SKUMANICK JR ESQ 116-118 WARREN ST TUNKHANNOCK PA 18657 c,:~'; CtHlli '* REV.1547EllAFPcDl-D!l MARION S MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ... REY=i54"-Ex-';:iip--foFii3Y-iitii:"icE-oF-YNHERifANcE-T'Ax-iipjiRAYSEifENT~--';:Li.-OWAtiCE-ijR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX MARION S FILE NO. 21 02-0823 ACN 101 ESTATE OF SMITH TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total ~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. A.aunt of Line 14 at Spousal rate (15) 16. AMOunt of Line 14 taxable at Lin.al/Class A rate (16) 17. ABount of Line 14 at Sibling rat. (17) 18. A.aunt of Line 14 taxable at Collateral/Class 8 rate lI8) 19. Principal Tax Due D RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule Bl 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) S. Cash/B.nk Deposits/Misc. Personal Property (Schedule El 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 308.186.66 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule Hl 10. Debts/Mortgage Liabilities/Liens (Schedule Il 11. Total Deductions 12. Net Value of Tex Return 13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts (Schedule ~l 14. Net Value of Estate Subject to Tax (9) (10) 6,962.41 1.127.96 (1l> (12) (13) (14) NOTE: .00 300,096.39 .00 .00 X 00 = X 045 = X 12 = X 15 = + AMOUNT PAID 13,500.00 DATE 11-20-2002 INTEREST/PEN PAID 1-) 675.22 NUM8ER CD001867 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE DATE 07-21-2003 ATTACHED NOTICE NOTE: To insure proper credit to your account I submit the upper portion of this form with your tax paYllent. 308,186.66 8.090 ~7 300,096.29 .00 300,096.29 (19)= .00 13,504.33 .00 .00 13,504.33 14,175.22 670.89CR .00 670.89CR . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) REV-1.o170E:.f(6-88) '* INHERITANCE TAX EXPLANATION OF CHANGES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 260601 HARRISBURG PA 17128.0601 DECEDENT'S NAME Marion S. Smith FILE NUMBER REVIEWED BY Sheila Megonnell ACN 2102-0823 101 ITEM SCHEDULE NO. H B-7 EXPLANATION OF CHANGES The deduction for travel expenses has been disallowed. The executor or administrator of the estate is the only person entitled to claim these expenses in conjunction with the administration of the estate. ROW Page 1 /7,;/'/ - / .::J/ ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRIS8URG~ PA 11128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT GEORGE P SKUMANICK JR ~ 116-118 WARREN ST TUNKHANNOCK PA 1~657 C~l 19 :L9 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN *' REV-IU7 EX AFP (Ol~U) 08-11-2003 SMITH 09-04-2002 21 02-0823 CUMBERLAND 101 Allount Re..itted MARION S MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, sub.it the upper portion of this for.. with your tax paYMent. CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ... REv:ic.oj-EiCAFP--foFo3r-----...--iNHERITANC'E--TAxsTAfEHENT-oTAccoUiff--.ii.--------------------- ESTATE OF SMITH MARION S FILE NO.21 02-0823 ACN 101 DATE 08-11-2003 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PRO~ECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 07-21-2003 PRINCIPAL TAX DUE, ... ... PAYMENTS (TAX CREDITS): 13,504.33 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) lJ-~-20-2002 CDOO1867 675.22 13,500.00 1--- 07-23-2003 REFUND .00 670.89- TOTAL TAX CREDIT 13,504.33 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 * IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SlOE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTEO AS A "CREDIT" ICR), YOU MAY BE OUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. } Name of Decedent: Date of Death: CERTIFICATION OF NOTICE UNDER RULE 5.6(a~ Will No. ~),~// -- ~ ~ ~ OC2,~ 3 Admin. No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on : Na!Tle Address. Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: __Counsel for personal representative Name of Decedent: STATUS REPORT UNDER RULE 6.12 Admin. No.: 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. Statewhe.,t~her administration of the estate is complete: Yes 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: o If the angwer tO No. 1 is Yes, state the following: a. Did the personal r[_~sentative file a final account with the Court? Yes No b. The separate Orphan~' Court No. (if any) for the personal representative's account is: Date: Did the personal representative state an account informally to the parties in interest? Yes [-~ No [~ c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the. Orphan.q' Court and may be attached to this repop'r.'T/ SignaJam / Capacity: Nalne Address Telephone No. [~ersers0nal Representative ['--1 Counsel for personal representative ) / 70 ~ 8~