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HomeMy WebLinkAbout02-1034PETITION FOR PROBATE and GRANT OF LETTERS Estate of ~ o~ `~~~~ ~ ~o (-, n also known as Deceased. Social Security No. ~ ~ ~~ "C7 c-(' L'~ lvo. ~?I-L/~ ~ I0.3 7 To: Register of Wills for the County of ~~-+-~b = in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut ~' 1- ~ named in the last will of the above decedent, dated ~~ c- ~ j ~ ~ ~t-~-':~'~ , 19~~ and codicil(s) dated (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Lw~b - County, Pennsylvania, with h c~ r last family or principal residence at ~ 05 ~ ~~ ~ N~~~, ~ ~ c k ~ v c° _ (list street, number anc~ muncipality) then X1`1 ~~Z years of age, died ..~ SRN ~-. ,-}~ ~ c`~ '.1., at hc:. .f.% N.,. ~ sc p Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: ~ /~' Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters "t c< ~~ ~ ~-ri~~~-~ y (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. ~~~~ ~o .~ ~v x[ .~ .s Na 4.. ~ o c m -'r ~G-,c - ~* w~ ,~ ~1 G ~ ~,~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF c,mr~rl anr3 The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed 1C ~%~a~-~- ~ ~~~ ~~, ~ before me this 20th day of ~~ a em :r ~ 2002 ,,~ ~ 0 Donna M.Otto,1st Deputy egister $ ~ `(~ ~ `-i~- NO. 21-2002-1034 _ Estate of CABBIE O. YOHN ,Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW NovemY~r ~~th ~~2002 , 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 10-20th,1989 described therein be admitted to probate and filed of record as the last will of CABBIE O YOHN and Letters 'T'ESTAMEN`T'ARY are hereby granted to JOYCE A. SMITH FEES Probate, Letters, Etc......... . Short Certificates(v ......... . ~dl~~>~RX • ~-Pages . (2.). . JCP TOTAL _ Filed . November. 20th, , 20,Q 525.00 5 3.00 5 6.00 510.00 544.00 2........... /~ Register of Wills ,/~~ Donna M. Ctto, lst Deputy ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE MAILED LETTERS TO EXECUTRIX ON November 20th, 2002 llo~so' RThis~is to certify that the information here given is correctl}~ copied from an original certificate of deadl duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. F(~e for this certificate, $2.00 P 831982 No. ~'.. p-a ~e.~.-~k~~,~.~e~.. Local Registrar JUN ' 4 2002 LT,tte M105.1sJ RSV. 2187 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH ST $TRE F4E NUMBER NAME OF DECEDENi1F.sr.Mbde. Lavl SE% SOCIAL SECVRITY NUMBER DALE I)F OEATN ~MerM, Day. barl h 0 Y i 205 - 09 -1405 June 2 2002 female n . o ,. Carr e .- , , ,. AGE (La9 evmwyl UNDER,YEAR VNDERtDAY DATE OF BIRTH BWTHPIACE'CManO PLACE OF DE14HICneU Orvy erro-,ee ~nwuclbna on r%nel voal ~MMm. Day. 'kerl $lalea FOregn CaF%ryl Md%ns Day /bus . M'SMp ~ HOSPIUL: OTHER: 1908 Carlisle, PA an.10 94 Yrs Uga,»rK ^ ERIOUps1»rx ^ DDA C „~ (~ Resdarre 0 sa hl ^ , . B, B- T. M. - COVNTY OF DEIRM CITY, BORO. TWP OF DEATH FACILfrY NAME (11 nol ms,Mlan, gne seM arw numoerl NMS DECEDENT OF NISMNK:ORIGIN7 -1 mMean Inslan. 84cR. NTAe, Nc. ~ E S oee +h ~ ~'••^Kya.apenlyCuMn . M.aitM. vr»rb Riun. «~. White Thornwald Herne ~ Carlisle Cumberland - ~ « ,B a DECEDENT'S USUAL OCCUPQgN KIND OF BUSINESSIINDUSTRY VNS DECEDENT EVERIN DECEDENT'S EDUCATION MMITAL STATUS-MamiM SURVIVING SPOUSE IGi.~e kaW drrork OOne OUS~g rrm U.S.ARMED FOir~1C~yEST ~ n eras NevM Martise, VROPnM, In Me, 9n+mapan nsmel d wMing Wa: Oo na use re§real Yes ^ No ld ENmenlarylSacenaary Cowge DirPrcao ($pealyT - „a Laborer „BShce Facto ,:. ,,. ~,~' 8 o•a5,1 ,.. 'lowed ,B. DENT'S MAILING AOORESS(Snea,. City/W+m. Slass. Z9 Coea1 DE C E a.c.e.nl w.a in ,7e ^ »s ~iu PA l ~ ~S F ~ T~ - 111ornWald Home . , D a A na. slal. i RESIDENCE aataaar+ ~ 442 Walnut Bottom Rd. ~ ~"~' Ey.ma oB.erMSeeel A bKawwT Carllsle ~ ~ ~ l i' [ ,w ne. rra,Im B aad ,c~. an ~Tm w,ePre. ,Te.c FATHE q(lla. a MOTHER'S NAME IFsg. MEtlle. Mertlen Sunamel ,.- Geor e Bricker ,.- Addis Titler INFORMANT'S NAME (Ty(>rPrn) I NFORMANT'S MMLIND ADDRESS ISeesl. CAy/,o•n. SWe, Zq Coeal ,B.To ce A. Smith :B». 233 Pine Grove Rd. Gardners PA 17324 N METHOD OF pSPOSITI O DATE OF DISPOSITION PLACE OF DISPOSTION-NamadCamwary, Crsmalory LOCQION.CiIy/b.rrl, Slav, Zq Cori ~~ T'' T BIIia1 LA Cmm~ien ^ Rerroval Iron Slau ^ - (M~• Day. MNI or Omar Plaea Dalalien^ oIMrISPedY, ^ June 6, 2002 Letort Cemetery Carlisle, PA „a „B. „c. re. ' $IGNa 1)F UNERALSERVICE NS QRPERS~N TINGAS H IICENSENUMBER NAME AND ADDRESS Of FACILITY Hoffman-Roth Funeral Herne • as z,e. 013144 L m. • iNmR 2,eC or.,,.rnM eer,Kyirg Bra I»al d my kno..leege, cream occurrs0 m IM Ism. eels erne pacer Ma,ae. • F E plrynean's rp avaweN M arcs d Osam b • d e nn - a t 1 ~ l (MargL OaY'tiaN . . ~ raua. . ~ . „s. n a 5 S (~ O - L n.. C i :,P, u~,-:c_ ,2 oa Ilarru 2a-26 mua MCOmpNW ay TIME I)F EATM D PRONOUNCED DEAD m. Day, Year WAS CASE REFER RED TO MEDICAL E%AMINEWCORONER7 • prad,«M prero.a,cw seam. 'M^ Nel.7 17. MITT I: Emn,M oiaeaees, inlurias a eornekealor.a wnicn uuaea IM W am. Do rb, enter IM of oyirq, sues as earoiat or respralory arreal, slgeM or MM IaJUn. i Approsimau PART 11: 01Mr sipnilkaM mnEMOrr mM,iOUNq b oNm. M L»I wey oM uuN on earl. Kne. I keava DNMMn rbl mslllling N II»,KrEeeNr9 CFM Shan w PMT I. 1 era erne am MIMEd11TE CADRE (Fwr /' ~ I Odasf. p CMbiePn ~~ / / I _ DUE W IOR AS A CONSEQUENCE OF): T Oai D r E S r}Mr, ons . a4rrueo y DUE 70 (ON AS A CONSEQUENCE OFI: i try. rewq b mrNa.le t u»e. Eraw UIgERLY8IG ~ ~ . sr nerse~ ~ OIIE 10 (OFI AS A CONSEQUENCE OF1: raslsrq n oaaml LAST e. - NMS AN AUTOPSY WERE AUTOPSY FINDMIGS MMNER OF DEATH DATE OF INJURY TIME OF INJURY INJVRY AT VADRKT DESCRIBE MOW INJURY OCCURRED. PERFORMEDT AWUBLE PRgR 70 (Manm.OaY. ,barl COMPLETKNa OF CAUSE l ^ OF DEIVMT ombioa Na1urY / mil( 1Ya ^ No 6j AeeaaN ^ Petering lnves,galion ^ ,~[/ `Aa ^ NoV=}~ Yes ^ No ^ SuciM ^ CwIO nd W oe,armmeo ^ PUCE OF INJURY. AI Ipnv. tarm,~Rreal. lxtpy. d8ta M ~ LOCATION IStreel. CAy/TOiwl Sma) pui1Q q, Ht. l$pac~hl ,E.. nn. ,f. ,M. ]M. CERTIFIER ICnxA oniy oral SIGNATURE TITLE ERTIFIER 'CFATIF/IHG PHYSICIAN IPnyican calAyVq raise d aeem vnM argtnn onvscan nas porquncM aemn arb compNeo Item 2,1 Te h Mal el my know»ege, seam eauma Auer b me CwaHal and manner ea su,M ..................................................... 710. • - d f ml - LK:EN E NU BER DATE $IQN IMmn, ,Marl /7 ~Q~ 2 Z ~ ' ' yvy to Cause o cea -1pNOVNCING AND CERTIFYING PHYSN:IAN IPnYSitan tsrn ponouncing oeam arW cM erne aw b m. t.axl•Urb manna. as a1„ea .......................... ae,m «cwrw a, IM mo. sera erne PLC. knoeaaege Te me Ma d m ^ a,e. ~7J ~// ,m 7 , , y , NAME AND ADDRESS Of PER50 COMPLETED CAUSE OF DEATH .~ 'MEDICAL E%AMINER/CORONER Ilem 2717 l(i, ~ i ( yPS Or Pnnl/_/ W! ~ on,ne Baia of esaminalon ane/a Investigation, in my oDmion, death occurreA a, me,lme, Oste, and place, and due tone eauae(a) and ^ i et_ ja 3 ~/. ~ / ,,.. REGISTMR'S SIGNATU UMBER DATE FILED (MOnm. Day riarl ~' ~~ Ia~~l N ~. . WILL OF a~.Qa-t o3 ~ CARRIE 0. YOHN I, Carrie 0. Yohn, of Carlisle, Cumberland County, Pennsyl- vania, declare this to be my last Will and hereby revoke all prior wills and codicils. 1. I direct that all my just debts, funeral expenses, grave- marker and administrative expenses shall be paid from my residuary estate as soon as practicable after my death. 2. I direct that all inheritance, estate, transfer, success- ion and death taxes of any kind whatsoever which may be payable by reason of my death shall be paid out of my residuary estate. 3. I direct that my entire estate be distributed as follows: A. I leave my entire estate of whatever nature and wherever situate to my daughter, Joyce A. Smith, should she survive me. B. Should my daughter predecease me, I then give all of my estate of whatever nature and wherever situate to my son, Richard L. Miller. 4. I appoint my daughter, Joyce A. Smith, as Executrix of this my last Will. If she should predecease me or cease to act in such capacity, I name my son, Richard L. Miller to so serve. 5. The Executrix of this Will shall have the power to dis- tribute my estate in kind or in cash, or partly in either. 6. I direct that no Executrix acting under this Will shall be required to enter bond in any jurisdiction. ti IN T S WHEREOF, I have hereunto set my hand this ~d T day of ~ 1989. ~l , Carrie 0. Yohn LAW OFFICES OF STEPHEN J. HOGG 401 E. LOUTHER STREET CARLISLE, PA 17013 ~~~ ACKNOWLEDGEMENT Commonwealth of Pennsylvania County of Cumberland ss I, Carrie 0. Yohn, the testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified accord- ing to law, do hereby acknowledge that I signed and executed the in- strument as my last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Carrie 0. Yohn Sworn to or affirmed and acknowledged be,f~o*~re~~y Carrie 0. Yohn, the testatrix, this ~ day of C.~'fi r~_, 1989. - ~` _ - C u ~ ~~ ,, . ~ '~"~ `~___ ~. •- `- ~"•--•_~•~ tary (~- blic/Att ney Y: AFFIDAVIT LAW OFFICES OF STEPHEN J. HOGG 401 E. LOUTHER STREET CARLISLE, PA 17013 Commonwealth of Pennsylvania ss County of Cumberland l• ~` and ~~ l~~=Z We, ~,Yle~ry ~ 1~., ~ w'~ the witnesseses w~ ho names a e signed to the attached or forego' g in- strument, being duly qualified according to law, do depose and say that we were present and saw the testatrix sign and execute the in- strument as her last Will; that the testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testatrix signed the Will as a witness; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ~ ~, ;1 Sworn too or affirmed an s this ~f day of _ ~, ~ iJ ~ t _ •- L"~-in ""~ .... C i l i r . ,~, t :4~.. ~~ bscribed to before me by witnesses, 1989. t, ,,_ _~_._.. ... - r '; ' V Notary lic/Att rney LAW OFFICES OF STEPHEN J. HOGG The preceding instrument consisting of this and one other page was on the day and date hereof signed, published and declared by Carrie 0. Yohn as and for her last Will in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. ,~ L~ ~ - ~ ~~ ~~ CERTIFICATION OF NOTICE UNDER RULE 5.6(al CERTIFICATION OF NOTICE UNDER RULE 5.6 a Name of Decedent: ~ ~ ~~ ~ ~ ~ ~ ~/o Date of Death: ~ \ a. \ o a-- Will No. a ~~ ~ ~ - o ~ ~ 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 -~~~r r ; ~ c, _ ~ © a 3 b / h _~.r'~3 Name Address i,: ~ ck - i 7 ~ a 4-- Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: ~~~vt~ 03 \ v 3 ~. C Signature Name ~ - Address a33 ~~~~ ~~~ . cy`c~ c~-'t'" ~ a l ~ `~ ~'~ ~. M Telephone (7' 7) y ~~ _ ~ ~ t ~ Capacity: Personal Representative Counsel for personal representative \, /7-~0~-~~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 MICHAEL A SCHERER OBRIEN ETAL 17 W SOUTH ST CARLISLE COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP (D1-OS) ~{~~' ~ ~ ~ DATE 04-21-2003 ~=- - ESTATE OF YOHN CARRIE DATE OF DEATH 06-02-2002 FILE NUM8ER 21 02-1034 ~~3 aP~ 2$ ~ 3=O1000NTY CUMBERLAND ESQ ACN 101 Anount Remitted ~~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: 0 REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF YOHN CARRIE 0 FILE N0. 21 02-1034 ACN 101 DATE 04-21-2003 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this fora with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 3,471.24 tax payment. 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 8. Total Assets (g) 3, 471.24 APPROVED DEDUCTIONS AND EXEMPTIONS: 1,665.06 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 121,918.92 11. Total Deductions (11) 123.583.98 12. Net Value of Tax Return (12) 120,112.74- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 120, 112. 74- NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) • 00 X 00 = . 00 16. Anount of Line 14 taxable at Lineal/Class A rate (16l •00 X 045 = .00 17. Amount of Line 14 at Sibling rate (17) • 00 X 12 = . 00 18. Anount of Line 14 taxable at Collateral/Class B rate (18) •00 X 15 - .00 19. Principal Tax Due (19)= .00 TAX CREDITS• DATE NUMBER + INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE d RFFl1Nn_ SFF REVERSE STOF OF THTS FORM FOR TNST RIIrTTONC 1 REV-l500EXllHlOl , , '* COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 w >- ::.:::$(f) u"'" w"U ",00 u"'-' .... .. " l'j-/{)/- /3 REV-1500 v OFFICIAL USE ONLY INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 02 1034 COUNTY CODE YEAR ----- NUMBER I- Z W C W U w C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITVlL) Yohn, Carrie O. SOCIAL SECURITY NUMBER 205-09-1405 DATE OF BIRTH (MM.OD.YEAR) 01/10/08 DATE OF DEATH (MM.DD.YEAR) 06/05/02 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) [K] 1. Original Retum D 4. Limited Estate ~ 6. Decedent Died Testate (AllaellcopyofWil) D 9. Litigation Proceeds Received D 2. Supplemental Retum D 4a. Future Interest Compromise (da18 of death after \2.12-82) D 7. Decedent Maintained a Living Trust (AlIaell copy of Trust) D 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95) 03. Remainder Retum (dale ofdealll prior 10 12-13-821 D 5. Federal Estate Tax Return Required .!... 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113{A) (Allac:hSdlO) NAME Michael A. Scherer, Esquire ---FIRM NAME (If AppUcable) O'Brien, Baric & Scherer TELEPHONE NUMBER (717) 249-6873 COMPLETE MAILING ADDRESS Michael A. Scherer, Esquire O'Brien, Baric & Scherer 17 West South Street Carlisle, PA 17013 z o 5 ;:) !:: a. <C U w II:: 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 (5) (Schedule E) 6. JoinUy Owned Property (Schedule F) (6) o Separate Billing Requested 7. Inler.Vivos Transfers & Miscellaneous Non.Probate Property (7) (Schedule G or L) 0.00 0.00 0.00 0.00 3,471.24 OFFICIAL USE ONLY'! i 0.00 0.00 , . ~.~~-~~~-"'-,-~~ 3,471,24 (B) 1 ,665.06 121,918.92 (11) (12) (13) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (Iotal Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 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) 123,583,98 -120,112.74 0.00 (14) 0,00 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ I-' ;:) a. :e o u ~ 15. Amount of Line 14 taxable at the spoosal tax rate, or transfers under See. 9116 (a){1.2) X.O (15) 0.00 . x .0 _~__ (16) 0.00 x.12 (17) 0.00 x .15 (18) 0.00 (19) 0,00 16. Amount of line 14 taxable al lineal rate 17. Amount of Une 14 taxable at sibling rate 18. Amount of line 14 taxable at collateral rate 19. Tax Due 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: STREET ADDRESS Thornwald Home 442 Walnut Bottom Road -CITYC I' I arise I STATEp";--- ---l-ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) Total Credits (A + B + C ) (2) 3. InteresUPenalty if applicable D. Interest E. Penalty TotallnteresUPenalty ( D + E ) (3) 4. If Une 2 is greater than Une 1 + Une 3. enter the difference. This is the OVERPAYMENT. Ch.ck box on Page 1 Lin. 20 to r.qu.st a r.fund (4) 5. If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Une 5 + SA. This is the BALANCE DUE. (5B) 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 transf.rred;.._.._................................................................................. 0 IK] b. retain the right to designate who shall use the property transf.rred or its income; ............................................ 0 IK] c. retain a reversionalY interest; or.......................................................................................................................... 0 [iJ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 IK] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ..............................".............................................................................. 0 ~ 3. Did decedent own an "in trust fo~ or payabl. upon death bank account or secunty at his or her death? .............. 0 IK] 4. Did decedent own an Individual RetirementAccount, annuity, or other non-probate property which contains a beneficiary designation? ..........,,,...,,...,..,...,..........................................,....................................,,,......... D [!] 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 belief, it is true, correct and complete. Declaratioo of preparer other than the personal representative is based on alllnronnalion of whicil preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN '"' n r; .~. _, ' ADDRESS '-)(-'i(() '-\...,:",....,..... '" \- Joyce A. Smiih, Executrix, 233 Pine Grove Road, Gardners, Pennsylvania 17324 SI~NATURE~~AN R~RESENTATIVE _____._ ADDRESS Michael A. Scherer, Esquire, 17 West South Street, Carlisle, Pennsylvania 17013 - ""'---~" ~,~ ""'~-- For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)]. DATE -.3-7-03. DATE ],Jc.E.3. 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. ~9116 (a) (1.1) (iill. 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 st.ppar.nt of the child is 0% [72 P.S. ~9116{a)(1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except 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 12% [72 P.S. ~9116(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. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY Estate of Carrie O. Yohn File Number 21-02-1034 Include the proceeds 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. Item Value at Date Number Description of Death 1. Members First F.C.U., savings account #163842-00 $39.00 2. Members First F.C.U., checking account #163842-11 $1,466.84 3. Thornwald Home, personal account $1,453.48 4. Refund from Prudential Life $511.92 TOTAL (also enter on line 5, Recapitulation) $3,471.24 SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Estate of File Number Carrie O. Yohn 21 - 02 - 1034 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hoffman-Roth Funeral Home $111.06 2. 3. 4. 5. B. 1. ADMINISTRATIVE COSTS: Personal Representative Commissions $1,000.00 Joyce A. Smith, Executrix 233 Pine Grove Road Gardners, P A 17324 Year(s) Commission Paid: 2003 2. Attorney Fees $500.00 3. Family Exemption - None 4. Probate Fees $54.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 8. 9. TOTAL (Also enter on line 9, Recapitulation) $1,665.06 SCHEDULE I ODEBTS OF DECEDENT. MORTGAGE LIABILITIES AND LIENS CarricO. Yohn File Number 21 - 02 - 1034 Estate of Item Number Description I. Commonwealth of Pennsylvania, Department of Public Welfare Amount $121,918.92 TOTAL (also enter on line 10, Recapitulation) $121,918.92 Estate of File Number Carrie O. Yohn 21 - 02 - 1034 Relationship to Decedent Amount or Share Number Name and Address of Person(s) Receiving Property Do Not List Trustee(s) of Estate I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Joyce A. Smith Daughter Entire Estate 233 Pine Grove Road Gardners, PA 17324 2. 3. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS $HQW'N ABOVE ON LINES 15 THROUGH 17, As ApPROPRIATE, ON REV 1500 COVER SHEET SCHEDULE J BENEFICIARIES II. NON-TAXABLE DISTRIBUTIONS A. Spousal distributions under Section 9113 for which an election to tax is not being made. 1. B. Charitable and Governmental Distributions 1. TOTAL OF PART II - Enter Total Non-Taxable Distributions on Line 13 of REV 1500 Cover Sheet MemberslST FEDERAL CREDIT UNION INSURANCE DEPARTMENT 5000 Louise Drive P. O. Box 40 Mechanicsburg, PA 17055 1-800-283-2328 or (717) 697-1161 REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner 163842 -00 12/05/1996 $39.00 $.00 $39.00 None CHECKING ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner 163842-11 12/05/1996 $1,466.84 $.00 '. $1,466.84 None 1J.BE,RS auEDIT UNION ?ft(}.l - nise A. Anders Insurance Products Supervisor February 27, 2003 Estate of: CARRIE O. YOHN Date of Death: 06/02/2002 Social Security Number: 205-09-1405 [~!a~1h3.j ;. '". " - 02/18/200) Check Check# 07/16/2002 estate 06/26/2002 5606 06/26/2002 5606 06/26/2002 10631245 06/24/2002 adj 06/24/2002 adj 06/18/2002 5599 06/18/2002 5599 06/06/2002 CIA 05/30/2002 5579 05/30/2002 5579 OS/29/2002 adj OS/29/2002 adj CS/2!f/2002 adj OS/29/2002 40399544 04/24/2002 04347277 04/15/2002 5558 04/10/2002 5552 03/27/2002 0~3046~3 03/12/2002 5530 03/11/2002 5527 03/11/2002 5527 02/28/2002 adj 02/27/2002 04263527 /2002 clean up OGI~6/2002 clean up 02/25/2002 cia 02/20/2002 5517 02/15/2002 5512 02/15/2002 5512 01/25/2002 CiA 01/24/2002 04217981 Q1/23/2002 1135607 01/18/2002 5499 01/11/2002 5492 01/11/2002 5492 12/31/2001 ADJ 12/27/2001 5482 12/27/2001 5482 12/26/2001 3%369031 12/18/2001 CIA CLNUP 12/18/2001 CIA CLNUP 12/18/2001 CIA CLNUP 12/18/2001 CIA CLNUP 12/18/2001 CIA CLNUP ~2/18/2001 CIA CLNUF ~2/18/2001 CiA CLNUP ~2/14/2001 5472 12/14/2001 5472 '2001 10267433 L~ ,200110267433 .2/05/2001 10267433 .2/05/2001 10267433 Resident Payment History 448 Carrie 0 Yohn Received From ESTATE OF RTF RTF MA ADJ ADJ RTF RTF CiA RTF RTF ADJ ADJ ADJ MA MA RTF CABLE RTF MA RTF RTF FOR MARCH RTF FOR MARCH ADJ MA MA CIA MA CIA CIA RTF CABLE RTF RTF CIA MA MEDICARE RTF RTf RTF ADJ RTF RTF MA CiA CiA CIA CIA CIA CIA CIA RTF RTF MA MA MA MA / t"{7/((/VW/tUJ IPmE Date Ar.lOunt Billed {PA6181 Due Fin Type Last From C1 Chg. Stmt -1,453.48 05131/02 pp ~ 12.50 04/30/02 pp ~1,465.98 05/31/02 pp 3,695.35 05/31/02 MA .88.95 05/31/02 MA 88.95 05/31/02 R1 -88.95 06/01/02 pp 799.01 06/01/02 R1 -177.90 04/30/02 MA -88.95 05/01/02 RI 799.01 05/01/02 R1 .88.95 03/31/02 MA 88.95 03/31/02 R1 88.95 04/01/02 RI 3,553.24 04/30/02 MA 3,670.86 03/31/02 MA 12.50 03/31/02 PP 710.06 04/01/02 RI 3,246.90 02/28/02 MA 12.50 02/28/02 pp 799.01 03/01/02 RI -88.95 03/31/02 R1 -)20.69 01/31/02 MA 3,610.86 01/31/02 MA 2.20 11/01/01 R1 2.20 12/01/01 RI 121.44 12/31/01 C1 12.50 01/31/02 PP 799.01 02/01/02 R1 -88.95 02/28/02 pp .15.84 12/31/01 MCB 3,325.6812/31/01 MA 501.6012/31/01 MCB 7.50 12/31/01 PP 868.01 01/01/02 RI -83.40 C:/25/:::2 PI' -2.20 11/30/01 MA 7.S0 1'0/31/01 pp 7.50 11/30/01 PP 3,210.7911/30/01 MA .60 12/05/01 MA -2.20 12/05/01 MA 87.80 12/05/01 MA 87.80 12/05/01 MA 6.60 n/OS/Ol ma 90.00 12/05/01 ma 1.2.80 10/31/01 MA 865.81 12/01/01 R1 -81.20 12/31/01 PP .87.80 12/05/01 MA 3,343.97 10/31/01 MA -87.80 12/05/01 MA -6.60 12/05/01 MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA A.INC 01(25/2002 A1NC 07/01/2002 A1NC 07/01/2002 A1NC AINC A1Ne 07/01/2002 A1NC 07/01/2002 R1 01/01/2002 A1NC ArNC 06/01/2002 RI 06/01/2002 AINC ArNC RI A.1NC ArNC AINC 05/01/2002 R1 05/01/2002 ArNe ArNC 04/01/2002 R1 04/01/2002 A1NC 04/01/2002 AINC A1Ne RI 06/01/2002 06/01/2002 RI 03/01/2002 03/01/2002 MA MA A1NC A1NC 03/01/2002 R1 03/01/2002 AINC 03/01/2002 ArNC AINC A1NC ArNe R1 MA MA MA MA MA MA MA 02/01/2002 02/01/2002 ~.~ Ari.~'::: (l2,'~1/2C02 MA MA MA AINe AINC 01/01/2002 ArNC 01/01/2002 A1NC MA MA MA MA PRE PRE PRE MA PRE PRE PRE ArNC R1 01/01/2002 A1NC 01/01/2002 PRE AINC PRE PRE ma ma MA MA MA MA MA MA MA f~K"tJ fruYYl -('Lu,,( Pagl! 1 f lvLv~l 02/1B/2003 Resident Funds History Res~ 44B Carrie 0 Yohn Pate Tran Period Year Refer Code 200 12/14/2001 200 12/27/2001 200 01/02/2002 200 01/09/2002 200 01/n/2002 200 01/18/2002 200 01/23/2002 200 01/31/2002 200 01/31/2002 200 02/01/2002 200 02/01/2002 200 02/15/2002 200 02/20/2002 200 02/28/2002 200 03/04/2002 200 03/04/2002 200 03/11/2002 200 03/12/2002 200 OH~1/2002 200 04/09/2002 200 04/09/2002 200 04/10/2002 200 04/21/2002 "')n" 04/21/2002 04/21/2002 200 04/30/2002 200 05/03/2002 200 05/07/2002 200 05/30/2002 200 05/31/2002 200 05/31/2002 200 06/03/2002 200 O€'/H/2002 200 06/18/2002 200 06/26/2002 210 01/05/2001 210 01/05/2001 210 01/31/2001 210 02/16/2001 210 10/11/2001 210 10/11/2001 210 11/30/2002 210 12/27/2002 12 2001 5472 12 2001 5482 01 2002 01 2002 01 2002 5!j'H 01 2002 5499 01 2002 5500 01 2002 01 2002 02 2002 02 2002 02 2002 5512 02 2002 5517 02 2002 032002 03 2002 03 2002 5527 03 2002 5530 03 2002 042002 04 2002 04 2002 5552 04 2002 5557 04 2002 5559 04 2002 5562 042002 05 2002 05 2002 05 2002 5578 05 2002 05 2002 5511 06 2002 06 2002 06 2002 5599 06 2002 5606 01 :<:001 01 2001 01 2001 02 2001 10 2001 10 2001 n 2002 12 2002 'otal Deposits, 26,232.70 WD wd DP dp wd wd wd INTER INTER dp dp wd wd INTER dp dp WD WD INTER dp dp wd wd wd wd INTER DP DP WD INTER WD dp dp wd WD dp dp nITER WD DP WD INTER INTER ~ 1 I ,- v "_Y (PAn3] Tran Type Fund Fund Name Oeser. UCCH MA CABLE MA VA PENSIQ AA SSS FOR D MA UCCH MA MA Pt Tru MA PC Tru MA Pc Tru MA Pt Tru MA Pt Tru cable ma MA Pt Tru BLUE eRaS ma MA Pt Tru Interest PPAY Private P Interest PPAY Private P SSS JA.:" MA MA Pt Tru VA PENSIO MA MA Pt Tru UCCH FOR ma MA Pt Tru cable ma MA Pt Tru Interest PPAY Private P VA PENSIO MA MA Pt Tru S$S FEa MA MA Pt Tru UCCH MA MA Pt Tru CABLE MA MA Pt Tru Interest PPAY Private P sss march ma MA Pt Tru va pensio ma MA Pt Tru MA. Pt Tru UCCH ma cable ma MA PC Tru Joyce Smi ma MA Pt Tru capital B ma MA Pt Tru Interest PPAY Private P SSS APRIL MA MA Pt Tru VA PENSIO MA MA Pt Tru UCCH MA MA Pt Tru Interest PPAY Private P DIANE ZElII M1\ MA Pt Tru sss may ma MA Pt Tru VA PEN FO ma MA Pt Tru UCCH ma MA Pt Tru UCCH MA MA Pt Tru VA PEN. DE lo(;\. MA ~t. 'l'ru sss DEe MA Interest MA MA Pt Tru MA Pt Tru TRANS TO PPAY Private P TRANS TO MA MA Pt Tru CORRECTIO MA MA Pt Tru Interest MA MA Pt Tru Interest mil Mil. Pt Tru Disbursements' 26,232.70 Balance: .00 1/-" ,- Amount 78<1. .61 15.00 90.00 823.00 784.61 7.50 266.85 ." .20 823.00 90.00 710.06 12.50 .22 90.00 823.00 710.06 12.50 ." 823.00 90.00 710.06 12.50 125.78 266.85 .21 823.00 90.00 710.06 ." 84.60 823.00 90.00 710.06 (";"",8) 9lJ.00 801.00 .45 891.45 178.88 178.88 .06 - .06 10 Page 3 A/~ , Hoffman-Roth Funeral Home, Inc. 219 North Hanover Street Carlisle, PA 17013 (717)243-4511 July I, 2002 Joyce A. Smith 233 Pine Grove Rd. Gardners, P A 17324 The Funeral Service for Carrie O. Y ohn 13757-89 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. Traditional Funeral Service Package. . . . . . FUNERAL HOME SERVICE CHARGES SELECTED MERCHANDISE: Woodbridge Pecan Casket . . . . . . . . . . . . . . . . . . . Monarch Interment Receptacle. . . . . . . . . . . . . . . . . . THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED . . . . . . . . . . . . . Cash Advances Opening Grave. . . . . . . . Clergy Offering . . . . . . . Certified Copies of Death Certificates. Flowers. . . . . . . . . . Hairdresser, . . . . . . . . TOTAL CASH ADVANCES AND SPECIAL CHARGES . Total Total Cost History 06/28/2002 Microdata Systems, Inc. 07/01/2002 Cumberland County VA TOTALAMOUNTDUE . This statement is net and payable In full within 30 days of receipt. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --- - - - - - - - - - - - - -- $3490.00 $3490.00 $2530.00 $880.00 $6900.00 $500.00 $75.00 $16.00 $140.98 $30.00 $761.98 $7661.98 $-7450.92 S ! 00.00 $111.06 ~\O-';\ ~~ .~ ,'It; C'f- \\,\) ,\ . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 1710$-6466 November OS, 2002 OBRIEN BARIC & SCHERER MICHAEL A SCHERER ESQUIRE 17 WEST SOUTH STREET CARLISLE PA 17013 Re: CARRIE YOHN CIS #: 650139848 SSN: 205-09-1405 Date of Death: 06/02/2002 Dear Attorney Scherer: Please be advised that the Department of public Welfare maintains a claim in the amount of $121,918.92 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $21,236.63, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $100,682.29, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisa~, if available. Sincerely, { ~K'.d.>~ Edna L. Guido Claims Investigation Agent 717-772-6614 717-705-8150 FAX Enclosure . 2 r! ....I~ -~ ':":\ -:; -, '1 ~ -;:-,. ~:~:~~c. -'-f,~._.Lj~:"-:~ -,l:' LtL=-J~~O_~----Y1- WILL OF CARRIE o. YOHN 21-2002-1014 I, Carrie O. Yohn, of Carlisle, Cumberland County, Pennsyl- vania, declare this to be my last Will and hereby revoke all prior wills and codicils. 1. I direct that all my just debts, funeral expenses, grave- marker and administrative expenses shall be paid from my residuary estate as soon as practicable after my death. 2. I direct that all inheritance, estate, transfer, success- ion and death taxes of any kind whatsoever which may be payable by reason of my death shall be paid out of my residuary estate. 3. I direct that my entire estate be distributed as follows: A. I leave my entire estate of whatever nature and wherever situate to my daughter, Joyce A. Smith, should she survive me. B. Should my daughter predecease me, I then give all of my estate of whatever nature and wherever situate to my son, Richard L. Miller. i I l . I 4. I appoint my daughter, Joyce A. Smith, as Executrix of this my last Will. If she should predecease me or cease to act in such capacity, I name my son, Richard L. Miller to so serve. 5. The Executrix of this Will shall have the power to dis- tribute my estate in kind or in cash, or partly in either. 6. I direct that no Executrix acting under this Will shall be required to enter bond in any jurisdiction. day of IN ~~EREOF, I ~~~~.hereunto set my hand this 7-0 -rt. , I I LAW OFFICES OF iOPHENJ. HOGG E. lOUTHER STREET ARLlSlE. PA 17013 ~ );fj t) The preceding instrument consisting of this and one other page was on the day and date hereof signed, published and declared by Carrie O. Yohn as and for her last Will in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. ..JJwu; '-f/; . -h:l u.:<2-/ 7d1J.l1S'o , 't LAW OFFICES OF STEPHEN J. HOGG 401 E. LOUTHER STREET CARLISLE. PA 17013 ACKNOWLEDGEMENT Commonwealth of Pennsylvania ss County of Cumberland I, Carrie O. Yohn, the testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified accord- ing to law, do hereby acknowledge that I signed and executed the in- strument as my last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. e~ t?j ~ Carrie O. Yohn ~ Sworn to or affirmed and ac~owledged befor~y Carrie O. Yohn, the testatrix, this 20 day of L/~ ,1989. \\:']l;~'('~; P-::-.~-:""~...,~,~ 1/-:::'::,-':; ':cri C: ;'-,:C;'~:;2~- ~-'-'---'--"----:l t\;(l::;ri~~! r~~<;J ~!(Y'~~n.1. i-:?'~. '.;..!,I,:::p:~: ~~;j::C Ca~'-;t,r:(. '). "71'.<.:r';r:-'t'" 'rl',' ~~~,!~'i;;~~:i;I'j~:L:~~:::00:'~~:"':~:~__.J . AFFIDAVIT Commonwealth of Pennsylvania ss County of Cumberland the wi~~~s~~;~~s1 ~me~'1~~~gned toa~~e attache~~r~o' g in- strument, being duly qualified according to law, do depose and say that we were present and saw the testatrix sign and execute the in- strument as her last Will; that the testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testatrix signed the Will as a witness; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. LAW OfFICES Of - WlIA'i 0 'fyN-''-- SwornJto or affirmed a~ ~bscribed this 2tf r day of O(~ NotBria' $Gal . 1 Stcph~l1 J. HoQ{!. N..);a,'( F:-~~:?. f . M;~=0;.:C_!2~~~~~'S~~~:-3.'~- j 7i1h! i SJ~ to before me by witnesses, , 1989. STEPHEN J. HOGG 401 E. LOUTHER STREET CARLISLE. PA 17013 .~'.. f,.: ,"': ...,- .~... . .'~'" -' q l::t a: ~ It '>" r- .,c..:e<'i_." 1~~ q 'fiW "i.... \ ~ J,~ ~ \'~~\ ~ \ ~', ,\'! ;l ~ a.'a. ~ l ~ 'lL'U1 Ii ~\ .~. ~i, Ul \ ~L S?~~ '& . \ i\ \~ ~~ 1: ~YiJ,~ co ~ 'r'<i c> . g 0- " 0. 1i. .... a.. (j) (j) o d o o o "b I- ~ . 4 'A ~ l'j '" OJ G ..... \\\~~ ~~.,... ~ "", 'i,.. ~~ 'i~ a ::.% S ~~ a ...;l .. ~3: t 0\Z is: Iz~ a<Q~ h aQ4 . u.- S ~\i \\ ih. 'i '5 iM \~ " ~~ ,~\ ~~ ", 'Zi ~ ~ 'i\ n . t ~ ..... ~ , v~. ~ Ul lI' o IT .... J ...... ...... cO rf'\ .... rf'\ ...... ~ ., o lI' lI' t'-" cO rf'\ .... rf'\ ...... ..: ... rr IT o t'-" o o o o J o u. o Ull); ~'re ~o ~ Name of Decedent: Date of Death: Will No.: 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 oft he administration of the above-captioned estate: State whether administration of the estate is complete: Yes [] No [] 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: ao Did the personal representative file a final account with the Court? Yes_ No [] b. The separate Orphan¢ Court No. (if any) for the personal representative's account is: ~ c. Did the Personal representative state an account informally to the parties in interest? Yes [~ No [-] Co Date: Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Signature Nallle Capacity: Address Telephone No. [--1 Personal Representative [] Counsel for personal representative 17 t3