HomeMy WebLinkAbout04-0465 Register of Wills of CUMBERLAND County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of Frances ~. DuBois No. ~/-O Z~. ,~O %,,~"'"~
also known as ~:! ~-v ,
! ~, Deceased Social Security No. 202-24-1384
Petitioner(s), who is/are 18 years of age or older, apply(les) for:
(COMPLETE 'A' or 'B' BELOW:) '0Z~
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s} is/are the execut, or named in the last Will of
the Decedent, dated April 16, 2004 and codicil(s) dated .. _-
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
E3 B. Grant of Letters of Administration
(c.t.a.; d.b.n.c.t.a; pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and
heks:
[ Name Relationship Residence J
I
(COMPLbYI: IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in South Midd]cton Twp., Cumberland County, Pennsylvania with his/her last family
or principal residence at 197 Forge Road, Boilin~ Sprinl~s, PA 17007
(list street, number, and municipality)
Decedent, then 73 years of age, died April l 8, 2004 at Holy Spirit Hospital, East Permsboro Township, Cumberland Co., PA
(Location)
Decedent at death owned properb/with estimated values as follows:
(If domiciled in PA) All personal property $ ~,~ ~-"t ~O O
(If not domiciled in PA) Personal property in Pennsylvania $
(if not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $ / ,~"'~) , O O ~
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of
letters in the appropriate form to the undersi(=3ned:
Si~lnatu, re , Typed or printed name
IP.O. Box 123
I
IOak Run, CA 96069-0123
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991}
Oath of Personal Representative
Commonwealth of Pennsylvania
County of 0'. mberJar~c~
~e Pe~ione~s) above-na~d swea~s) or affirms) tha~ the ~te~n~ in the for~ Pe~on are true
and correct to the be~ of the knowl~ge and belief of Pet~ione~s) and ~ak as pemon~ representative(s) of
~e Decedent, Pet~ione~s) will well and tru~ administer the e~ata according to law.
before me thi~ day of
~ P.O. Box 123 L ~
~*~~;~~'~Z ,Oak Run, CA 96069-0123
No.
Estate of Frances S. DuBois Deceased
Social Security No: Date of Death: April 18, 2004
AND NOW, this day , 2004 in consideration
of the Petition on the reverse side hereon, having been presented before me,
IT IS DECREED that Letters ['~ -- Of Administration (c.t.a.; d.b.n.c.t.a~endente/ lite; durante absentia; durante minoritate)
are hereby granted to Sara Marie Somers /'
in the above estate and that the instrument(s) dated April 1~
described in the Petition be admitted to probate and filed of ~ Decedent.
FEES
Letters ........... $
Register of Wills
Short Certificate(s) ..... $
Renunciation ........ $ Attorney: E. Flower Escjuffe
Affidavits ( ) .... $ I.D. No: 83993
Extra Pages ( ) $ Address: 2109 Market~treet
Codicil ........... $ Camp Hill~ PA/~011
JCl=' Fee .......... $ Telephone: 4717) 737 3405 "
Inventory. ......... $
Other ........... $
TOTAL ......... $
Prep.red by the Pennsylvania Bar A~soclatlon Copyright (c) 1 gg6 form software only CPSystems, Inc. Form RW- ~ (lgg 1)
PETITION FOR v OBATE and GRANT OF LETTERS
also known as
i-. , To:
Register of Wills for the
, Deceased County in the
Social Security No. ,~ t*) 2 ~ 9,,<q - I '~ ~ ~-] ' of
Commonwealth of Pennsylvania
The petAion of,~h¢ unders, ig0e:d respectfully represents that'
Your petitioner(s), who is/a'{~ ]8 years of age or older~n th9 ~xecut e5 v~
in the last will of the above decedent, dated %t _ t (a E3 "4 named
and coiflicil(s) dated , 19
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in
County,,Pennsylvania, with
h_e_.--~.~ last family or principal residence at t
(list street, number and muncipality)
Decen, den_t~, then ~? ~ y~ears qf agg, died /-~- ( (~ r- 0 C~ 19
Except as fo[lows! decedent did not r~arry, was not divorced and did not have a child born or adoptec~
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 $ %%~'t c'} 00
(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) th~probate of the last will and codicil(s)
presented herewith and the grant of letters ~'a~t ~ ~ [(3~ ~
theron. (testamentary; admin~tration c.t.a.; administration d.b.n.c.t.a.)
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~
COUNTY OF f 88
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 a_dmini~ter the estate according to law.
bSe~o~rn to .or ~xff~r~.e~ and subscribed (- " ' ·
e ore me this (~ .d..ay of..~ ~'Jfl~ ~.
No.
Estate Of .., Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW 19~, 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
and Letters
are hereby granted to
Register of Wills
FEES
Probate, Letters, Etc .......... $
Short Certificates( ) .......... $- ATTORNEY (Sup. Ct. I.D. No.)
Renunciation ................ $.
$ ADDRESS
TOTAL $
Filed ................................... PHONE
Oath of Personal Representative
Commonwealth of Pennsylvania
County of
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing PetitiO/1 are true
and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representali~e-(s) of
the Decedent, Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed Thomas /~, Somers 'fkl J'ii~¥
be,ore me th,/,7% of
?. o,
: 4_0 Oak Run, CA 96069-01~'~-,.
f /' FOr !he/RegiSter
Estate of Fran,ces ~.DuBois Deceased
Social Security No: 202-24-1384 Oate of Death: April 18, 2004
AND NOW, this / ? day of ~-'J~:~c.~ , 2004 , in consideration
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters r~ Testamentary ~ of Administration
(c,t.a,; d.b.n.c,t,a.; pendente lite; durante absentia; durante m[noritate)
are hereby granted to Thomas ~ Somers ~c:/~, ~/~ ]'~'"lnRl~
in :the above estate and that the instrument(s) dated April 16, 2004
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
/ ~ Register 4~i,s
Renunciation ........ $ Attorney: Thomas E. Flower, Esquire
Affidavits ( ) .... $ I.D. No: 83993
Extra Pages ( ) .... $ /~,c/])O Address: 2109 Market Street
Codicil ........... $ Camp Hill~ PA 17011
JCP Fee .......... $ JO, (_~ Telephone: (717) 737-3405
Inventory ..........
Other ........... $
......... $ .
Prepared by the Penn~lvanla Bar A~soClaflon Copyright (c) 1996 form software only CPSystems, inc. Form RW-1 (1991}
his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent fining.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00 ~~[, ~-'~' -'t~ ~!~' ~?~ ~&~ g~'J~/Local Registrar
p !032672 APR 20
No. '~ Date
H105.143 RIv. 2J87 COMMONWEALTH OF PENNSYLVANIA ' DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
B~CK,NR ~. Frances S. DuBois F 3.202 -- 24 -- 1384
I
~E (Le~ ~y) DATE OF BIRTH StRTHF~ACE (City
(MO~A,
73 Ya' 930 .~ethlehem,PA ~D ~q ~ [] ,-~[] t~-~ []
-~D~ ~.Cumberland .~ast Pennsboro M~, ~.~R,,. ~ I ~0.Wh±te
.~ S~:retary ... Church of Wid~ ~. -
D~¢EOEN~S {Tm. Sma PA
107 Forge Road
(s#
,,. Boiling Springs, PA 17007
~ Raymond C. Austin ~[Evelyn - Meix~ll
NFORMAN~S MAILING ADU~ (S~e~, C~/to~m, S~ Z~ C~)
Sara I~.P.O. Box 123; Oak Run, CA 96069-0123
i PLACE OF DiSlaO~iTiON. Name ~ Cemitwy, Cmmat~y I LOCATION - CltyfTown, fitate, Zip Cobe
DATE OF mSPOS~T~O~ I or Omar mace /
~ o~{s~) [] ~. 4/20/2004 I~st Harrisburq C~etery O~,. Harrisburq~ PA
~ME ^ND ~R~ OF ~^C,',W
~ n~FD 0~2633 L
~ ~ LICENSE NUMBER DATE SIGNED
ptlylJC~lfl il +'lOt I~ll~l)l~ It §m~ d ~ to I (Slgnitum and T!tle)
Itlm124-2~ mtmt be c~mplited by ~ TIME OF ~)EATH _~ I DATE P~)NOJN~, EaD DEAD (M~h. Day, year) WAS CASE
IMMEDIATE CAUSE (FlnM
mauling in bel~) -'-') a. DUE TO (oR AS A-~ONS~OUE~C~
cabin,if Itly, Ila~l~g to imme<~lteE~ UNDERL%qNG { ~. DUE TO (OR AS A CONSEQUENCE OF}:
~ultlng on bell~ ) LAST
~1~. I~. ' ~ ~ ·
~ L~NBE NUMAR ~TE 81GNED {M~,
'04 r~PR20 P4:ld
ast ill anl estament
OF
F~C~ S. DUBOIS
I, F~~ S. DUBOIS, of South Middleton Township, Cumberl~d Co~,
Pe~sylvania, being of sound ~d disposing mind, memo~ ~d ~derstanding, do hereby m~e,
publish ~d decl~e this as ~d for my Last Will ~d Testment, hereby revoking ~d mahng void
any and all Wills or Codicils at ~y time heretofore made by me.
ARTICLE I
DEBTS
I direct the payment of all my legal debts, and the expenses of my last illness and funeral
from my Estate as soon after my death as conveniently may be done.
ARTICLE II
SPECIFIC BEQUESTS OF TANGIBLE PERSONAL PROPERTY
A. I direct that the silver cups and silver plaque which I have been storing for my
stepson, FLETCHER DUBOIS, currently residing in Heidelberg, Germany, and my
stepdaughter, AMY DUBOIS, currently residing in Barton-Upon-Humber, England, be delivered
to them as soon as practicable, to be divided between them as they may mutually agree.
B. I bequeath my large art prints by Gerald Putt to my stepdaughter, AMY DUBOIS,
and my stepson, FLETCHER DUBOIS.
C. I bequeath the fly rods and fishing tackle which belonged to my late husband,
Donald Dubois, to my son, EDMOND SOMERS, and my son, THOMAS P. SOMERS, to be
divided among them by my Executors in their sole and absolute discretion, in as nearly equal
shares as may be practical, giving due regard to their personal preferences.
D. I bequeath my glass pin, bearing the name of Evelyn, to my daughter, EVELYN
SOMERS, if she survives me.
ARTICLE III
BEQUEST OF REMAINDER OF TANGIBLE PERSONAL PROPERTY
I bequeath my household goods, furniture and other personal effects (excluding cash,
stocks, bond and automobiles) not herein otherwise specifically bequeathed, in equal shares, to
my son, EDMOND SOMERS, my daughter, SARA MARIE SOMERS, and my son,
THOMAS P. SOMERS, to be divided among them as follows: My son, EDMOND SOMERS,
shall first have the right to select one such item, and my daughter, SARA MARIE $OMERS,
shall then have the right to select one such item, and my son, THOMAS P. SOMERS, shall then
have the right to select one such item, and each such child shall then, in the order stated, again
have the opportunity to select one item of tangible personal property until all of my tangible
personal property has been so distributed. In the event that my son, EDMOND SOMERS, or my
son, THOMAS P. SOMERS, does not survive me, I direct that the mother of his then living
issue shall select items in place of such son, to be distributed among such son's then living issue.
If my daughter, SARA MARIE SOMERS, does not survive me, the father of her then living
issue shall select items in place of my daughter, SARA MARIE SOMERS, to be distributed
among her then living issue, and if my daughter, SARA MARIES SOMERS, is not survived by
issue, I give and bequeath her share to my sons, EDMOND SOMERS, and THOMAS P.
SOMERS, the items of tangible personal property to be selected in the manner above prescribed.
I request, but I do not require, that each of my children who is the parent of any of my
grandchildren shall, in the course of the herein prescribed selection of items of personal property,
include in the items they select two (2) items for each one of my grandchildren of which they are
2
a parent, to be delivered to such grandchildren or to a custodian as provided in Article VI of this
my Last Will and Testament.
ARTICLE IV
REST, RESIDUE AND REMAINDER
I give, devise and bequeath all the rest, residue, and remainder of my Estate, of whatsoever
nature and wheresoever situate, in equal shares, to my son, EDMOND SOMERS, my son,
THOMAS P. SOMERS, and my daughter, SARA MARIE SOMERS. If my son, EDMOND
SOMERS, or my son, THOMAS P. SOMERS, does not survive me, I give and bequeath his share
unto his then living issue, per stripes. If my daughter, SARA MARIE SOMERS, does not survive
me, I give and bequeath her share unto her then living issue, per stirpes, and if my daughter, SARA
MARIE SOMERS, is not survived by issue, I give and bequeath her share, in equal shares, unto
my son, EDMOND SOMERS and my son, THOMAS P. SOMERS, and if either son does not
survive me, to his then living issue.
ARTICLE V
REASON FOR NO FURTHER PROVISION
I have made no further provision in this Will for my daughter, EVELYN SOMERS, not
because of any lack of affection for her, but because I do not wish to jeopardize her receipt of any
existing government benefits. I ask, but not require, that my children, EDMOND SOMERS,
THOMAS P. SOMERS and SARA MARIE SOMERS, remember my daughter, EVELYN
SOMERS, with cards and gifts, as appropriate, on Christmas, Easter, and her birthday, and with
periodic cards and correspondence at other times.
ARTICLE VI
UNIFORM TRANSFERS TO MINORS ACT
In the event that any beneficiary of my Will shall not have reached the age of twenty-one
(21) years at the time for distribution of his or her share, distribution of said share may be made in
the discretion of my Personal Representative after considering the age and needs of the beneficiary,
either directly to the beneficiary or to a Custodian under the Pennsylvania Uniform Transfers to
Minors Act, 20 Pa. C.S.A. § 5301 et seq., or the applicable Uniform Gifts to Minors Act or
Uniform Transfers to Minors Act in the state of residence of such beneficiary as the case may be.
My Personal Representative may designate as such Custodian any institution or person, including
my Personal Representative, qualified to act as a Custodian for such beneficiary under such Act in
effect at the time such distribution is made. A receipt for any payment or distribution so made shall
be a full discharge therefor to my Personal Representative, who shall not be responsible to see to, or
be liable for, the application of such proceeds thereafter.
ARTICLE VII
TAXES
I direct that all taxes that may be assessed in consequence of my death, of whatever nature
or by whatever jurisdiction imposed, shall be paid out of my residuary estate as a part of the
expense of the administration of my estate.
ARTICLE VIII
APPOINTMENT OF PERSONAL REPRESENTATIVE
I name, constitute and appoint my son, THOMAS P. SOMERS, and my daughter, SARA
MARIE SOMERS, Co-Executors of this my Last Will and Testament, and should either fail to
qualify or cease to so act, I direct that the other shall complete the administration of my estate
without the appointment of an alternate Co-Executor. I direct that no fiduciary appointed herein
shall be required to post bond for the faithful administration of the dUties required in any
jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and
Testament, this f~ rt_~ day of t4?,~'t 6. ,2004.
F~~ S. DUBOIS
SIGNED, SEALED, ?UBkISHED AND DECLARED, by FRAN~~ S. DUBOIS, the
Testatrix above named, as and for her Last Will and Testament and in the presence of us, who,
at her request, in her presence and in the presence of ea~er, have subscribed our names
as witnesses.
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA :
: SS
COUNTY OF :
We, FRANC~ S. DUBOIS, ~/,,~. ,e,4. ~. ~/~)4.4. 4. ~'r", and
,~jP~..~,/.~ /./. h/',~ ~,~-.~ ~J,,~, , the 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
his/her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind
and under no constraint or undue influence.
Subscribed, sworn to and acknowledged before me by FR~N S. DUBOIS, Testatrix,
and subscribed and sworn to before me by ~~ ~. ~4~~ and
~. ~ ~t~r ~ witnesses, this /6 r~ day of ~r~t~ 2004.
, JR.
Pennsylvania Attorney I.D.#56113
ATTORNEY CERTIFICATION
COMMONWEALTH OF PENNSYLVANIA :
: SS.
COUNTY OF CUMBERLAND :
On this, the j~q~day of ~j0~i I , 2004, before me, the undersigned
officer, personally appeared Ralph H. Wright, Jr., Attorney I.D. #56113, known to me (or
satisfactorily proven) to be a member of the bar of the highest court of Pennsylvania and
certified that he was personally present when the foregoing acknowledgment and affidavit were
signed by the Testatrix and witnesses.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Notary Public
! ' A. Flicha~l, Nolary Public
L ~'°mmlsS~nEx~resNov. 12,2006
:.~27~.(~ 8 I'~i[~,r, Pel~syfvania Association Of Notaries
REGISTER OF WILLS OF LEBANON COUNTY, PENNSYLVANIA
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Frances Somers DuBois
Date of Death: April 18, 2004
Will No. 2004-00465 Admin. No. 21-04-0465
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 thc ] Q-/D day of May, 2004.
Name Address
Fletcher DuBois Karlstrasse, 20, 69117 Heidleberg
Germany 011-49-6221-28711
Amy DuBois 95 Newport Barton Upon Humber
North Lincolnshire DN185QF England
Edmond Somers P.O. Box 192, North Bridgton, ME 04057
Thomas P. Somers P.O. Box 132, Oak Run, CA 96069-0132
Sara Made Somers P.O. Box 123, Oak Run, CA 96069-0123
Evelyn Somers c/o Kim Shedd 486 West Onondaga Street, Syracuse, NY 13202
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
none
Date: ~--~- ]4 - 0 V ~' ~
Thomas E. Flower, Esquire
SAIDIS, SHUFF, FLOWER.&.LINDSAY
2109 Market Street
Camp Hill, PA 17011
(717) 737-3405
Capacity: Personal Representative
X Counsel for Personal
Representatives
COMMONWEALTH OF
,~ PENNSYLVANIA
,e~.,Z-'~,~)t:~'~ DEPARTMENT OF REVENUE
~'~-~-~-~-~-~-~-~-.~,~ DEPT. 280601 INHERITANCE TAX RETURN FILENUMBER
21 04 0465
~HARRISBURG, PA 17128-0601 RESIDENT DECEDENT COUNTY OODE YEAR NUMBER
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SEOURI]Y NUMBER
i-- DUBOIS, FRANCES S, 202-24-1384
Z
LU DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
~1 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
UJ 04/18/2004 09/16/1930 REGISTER OF WILLS
LU (IF APPLICABLE) SURVIVING SPOUBE'S NAME (LAST, FIRST, AND MIDDLE INITIAL/ SOCIAL SECURI~ NUMBER
[] 1 Original Retum ~ 2 Supplemental Return [] 3 Remainder Return/da~e of death p~erto 12 15 82)
O~.O~:~ [~4. Limited Estate ~,i4aFubJrelnterestCompromise(dateofdeathal~er121282} [~5FederalEMateTaxRetumRequired
c~.m [] 6 Decedent Died Testate A~ch~)pyofW'll/ [] 7 DecedentMaintainedaLivingTrus (Aah opyoTrust) 1 8 TotalNumberofSafeBepositBoxes
L J 9. Litigation Proceeds Received ~ 10. SpousaJ Poverty Credit (da,e of death ~ebee, 12-3191 and 1.1.95) ~ 11 Election to tax under Sec 9113(A)(Attach sch
z
~ NAME I COMPLETE MAILING ADDRESS
~ THOMAS E. FLOWER I SaMs, Shuff, Flower & Lindsay
~: SAIDIS, SHUFF, FLOWER & LINDSAY 210g Market Street
(~ TELEPHONE NUMBER
~ (717) 737-3405 Camp Hill, PA 17011
1 Real Estate (ScheduleA) (1) 137,000.00 i
2 Stocks and Bonds(Schedule B) (2) 309.28 '
3 Closely Meld Corporation, Partnership or So[e-Propbetorship (3)
4 Mortgages & Notes Receivable (Scneduie D) (d)
5 Cash, Bank Beposds & Miscellaneous Personal Property (5) 62,664.45
(Schedule E)
~ 6. Jointly Owned Property (Schedule F) (6)
[] Separate Billing Requested
"~ 7 Inter-Vivos Transfers & Miscellaneous Non Probate Properg/ (7)
I-- (Schedule G or L)
~ 8. Total Gross Assets (total Lines 1 7) (8) 199,973.73
LIJ 9 Funeral Expenses & Administrative Costs (Schedule H) (9) 22,348.84
10 Debts of Decedent, Modgage Liabilities, & Liens (Schedule I) (10) 2,459.00
11 Total Deductions (total Lines 9 & 10) (11) 24,807.84
12 Net Value of Estate (Line 8 minus Line 11) (12) 175,165.89
13 Charitable and Governmental Bequests/Sec 9113 Trusts for which an elecdon to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 175,165,89
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15 Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1 2) x 0 (15)
~' 16 Amount of Line14 taxable at lineal rate 175,165.89 x .04~ (16) 7,882.47
t'~ 17 Amount of Line 14 taxable at sibling rate x ,12 (17)
O
Q;I 18. Amount of Line 14 taxable at collateral rate x .15 (18}
19 Tax Due (19) 7,882.47
Decedent's Complete Address:
STREET ADDRESS
107 Forqe Road
CITY . ,
Boding Spnngs I STATEpA I ZIP17007
Tax Payments and Credits:
1 Tax Due (Page 1 Line 19) (1) 7,882.47
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if appliceble Total Credits (A + B + C ) (2) 0.00
D. Interest
E Penalty
Total Interest/Penalty ( B + E ) (3) 0.00
4, If Line 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 (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 7,882.47
A. Enter the interest on the tax due. (5A) 0.00
B, Enter the total of Line 5 + 5A. This is the BALANOE DUE. (58) 7,882.47
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; [] []
b. retain the right to designate who shall use the property transferred or its income; ...................................... [] []
c. retain a reversionaryinteres or ... [] []
d. receive the promise for/ire of e her paymen s, benefl s or ca e? .................................................................. [] []
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
w hou ecevngadequaeconsdea on? [] []
3.Bid decedent own an .....~n trus for or payable upon death bank account or secunty at h~s or her dea h? ............. [] []
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
con a ns a beneficiary designation? [] []
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I dec[are that I have examined this return, incruding accompanying schedules and statements and to the best of my knowledge and belief, it is true, correct and complete
Declaration of preparer other than the personaJ representative is based on all information of which prepaler has any knowledge
SIGXE O~-~PERS~'~ RESPONSIBLE FOR FILING RETURN DATE
Thomas P. Somers and Sara M. Somers, P.O. Box 132, Oak Run, CA 96069-0132
SI(~T~I~E OF PREPARER OT.J::LF.E T~"~N'~R~ENTATIVE DATE
ADDRESS
SAIDIS, SHUFF, FLOWER & LINDSAY, 2109 MARKET ST., CAMP HILL, PA 17011
For dates of death o~ or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January I, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 PS. §9116 (a) (1.1) (ii)]
The statute does not exemet 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 da[es of death on or after July 1, 2000:
The tax rate imposed an 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 PS. §9116(a)(1,2)]
The tax rate Jmposed on the cet value of transfers to or for the use of he decedent's neaJbenefic~a es s45° x
.... . '/o, e copt as noted in 72 P,S. §911fi{1 2) [72 p.S. §9116(a)(1)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. §9116(a)(1.3)]. A sibring is defined, under Section 9102. as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+
SCHEDULE A
COMMONWEALT~ OF PENNSYLVANIA REAL ESTATE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
FRANCES S. DUBOIS 21-04-0465
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the pdce at which property would be
exchanged between a willing buyer and a willing seller, nei her be ng compel ed to buy or sell, both having reasonable knowredge of the relevant facts,
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1~ dwelling house and lot at 107 Forge Rd., Boiling Springs (see attached settlement sheet) 137,000.00
TOTAL (Also enter on line 1, Recapitulation) $ 137,000.00
(If more space is needed, i~sed additional sheets of the same size)
REV 1503 EX+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
FRANCES S. DUBOIS 21-04-0465
All property jointly.owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~ 10 sh, GE common stock CUSIP 369604103 @30.9275 per share 309.28
TOTAL (Also enter on line 2, Recapitulatior $ 309.28
(If more space is needed, insed additional sheets of the same size)
GE stock value for date of death, Sunday April 18, 2004:
Date, Open, High, Low, Close
19-Apr-04, 31.18, 31.19, 30.40, 31.10
16-Apr 04, 30.88, 31.34, 30.78, 31.23
Friday average of high/low - 30.795
Monday average of high/low - 31.06
Average (taxable value) = 30.9275/share
GE: Historical Prices for GENERAL ELEC CO - Yahoo! Finance Page I of 2
Yahoo, MyYahoo, Mail S,~arch.,~,,,~b I ~arct~ j
FINANCE ~ ~?w"~J~ Siqn Up~'"~'""'"~"-'""~ F,nance Home- H~
Tuesday, October 5, 2004, ll:02AM ET - U.S. Markets close in 4 hours and 58 minutes.
Welcome, Guest [Siqn Tn] To track stocks & r
Quotes & Info Enter Symbol(s):[
General Electric Co (GE) At 10:42AM ET: 34.11 , O.Ol ¢
~0~99 Intetnet trad~ [] ~.ma
~- ,'"~, ~,,.,.,, ~-Scotfrade
lli[;~t $ 7 Trades ~
30 Free Trades Free Trades $8 Trades Just $~00 to Open!
ri e.
SET DATE RANGE ADVERTISEMENT
~ Daily
Start Date: ~ ~ I~004 ~. J~n ~, 2~03 C Weekly
O Dividends Only
First I Prev I Next I Last
PRICES
Date Open High Low Close Vo[ume Adj
Close*
19-Apr-04 31.18 31.19 30.40 31.10 18,000,200 30.73
16-Apr-04 30.88 31.34 30.78 31.23 25,801,000 30.86
* Close price adjusted for dividends and splits.
First I Prey I Next I Last
2'~ Download To Spreadsheet
Try
FREE
REV-~S08 E×+ 1~-981 ,~ ISCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
EBTATE OF FILE NUMBER
FRANCES S. DUBOIS 21-04-0465
Include the proceeds of litigation and the date the proceeds were received by the estate
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 M&T Bank checking account #1322729 5,535.39
2 M&T Bank savings account #15004200235932, principal 6,983.67 plus accrued interest 0.44 6,984.31
3 F&M Trust certificate of deposit #016-2954272, principal 2,981.55 plus accrued interest 41.21 3,022.76
4 F&M Trust certificate of deposit #016-2954302, principal 1,312.63 plus accrued interest 5.89 1,318.52
5 F&M Trust certificate of deposit #016-2954306, principal 7,401.$$ plus accrued interest 102.41 7,503.74
6 F&M Trust checking account #34-20787, principal 9,475.51 plus accrued interest 1.28 9,476.79
7 F&M Trust checking account #70-29918, principal 8,110.72 plus accrued interest 1.22 8,111.94
8 American Express traveler's checks, g @ $50 450.00
9 1992 Honda Accord, 96,500 miles 2,545.00
10 Household furnishings, per attached appraisal 17,715.00
TOTAL (Also enter on line 5, Recapitulation) $ 62,663.45
(If more space is needed, insert additional sheets of the same size)
REV- S. (rE SCHEDULE H
FUNERAL EXPENSES &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
FRANCES S. DUBOIS 21-04-0465
Debts of decedent must be reported on Schedule I,
ITEM
NUMBER DESCRIPTION AMOUNT
A FUNERAL EXPENSES:
1~ Ewing Brothers Funeral Home, professional services 1,867.38
B ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees 8,000.00
3 Family Exemption: (n decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 281.00
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7. Publish estate notices 224.99
8. Transfer tax and other settlement costs on sale of residence, see attached HUB-1 settlement sheet 2,482.43
9 Bekins Van Lines, transport household furnishings to heirs in California 5,359.46
lO Truck rental and associated costs to transport household furnishings to heir in Maine 1,989.58
11. Jim & Donna Gordon, pack, clean and prepare residence for sale 836.00
12 Total from attached continuation sheet for schedule H 1,308.00
TOTAL (Aisc enter on line 9, RecapitCation) $ 22,348.84
(If more space is needed, insert additional sheets of the same size)
ESTATE OF FRANCES S. DUBOIS 21-04-0465
SCHEDULE H
CONTINUATION SHEET
Photocopies 1.50
Erie Insurance, auto ins. 366.00
Shipley Energy 7.68
F&M Trust, fee for statement of d.o.d, balance 20.00
Craig Anderson-lawn care & mowing 448.00
Terry Lindsay, trash hauling 95.00
PNC check printing fee 27.60
MetEd, electric service 67.03
Sprint, phone service 68.65
Ship kitchen pots & carpet to heir in California 86.44
Misc., Inc., ship computer to heir in Maine 120.10
Continuation Sheet Subtotal: 1,308.00
REV-~2EX~2-03~ ~ SCHEDULE I
DEBTS OF DECEDENT,
GO'~I~NOHNE~IETAALNTcHEOTFA~PERNENT~uYF~ANIARESIDENTDEgEOENT MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
FRANCES S. DUBOIS 21-04-0465
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 South Middleton Twp., water & sewer 10890
2. Comcast, TV cable 27.32
3, Bank Card Services 20,59
4. Bank One 154,33
5. Gevalia 59.90
6. Larry Shoop, CPA, tax return prep 140.00
7~ Johnson, Duffle, lifetime legal services 235.00
8. Carlisle Pathology, unreimbursed medical 9.30
9. Alexander Spring Rehab, unreimbursed medical 20.30
10. AT&T Wireless 98.30
11. Shipley Energy, heating fuel 527.48
12. Waste Management, trash pick-up 46,26
13. Craig Anderson, snow removal & lawn care 468.00
14. Erie Insurance, homeowner's insurance premium 321.00
15. Met Ed, electric service 222.32
TOTAL (Also emer on line 10, Recapitulation) $ 2,459.00
(If more space is needed, insert additional sheets of the same size)
REV 1513 EX+ (9 00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUI~IBER
FRANCES S. DUBOIS 21-04-0465
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
t TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec, 9116 (a) (12)]
1 :LETCHER DUBOIS STEP-SON 387.50
2 \MY DUBOIS STEP-DAUGHTER 387.50
3 EVELYN SOMERS DAUGHTER 25.00
4 EDMOND SOMERS SON 0.33
5 SARA SOMERS DAUGHTER 0.33
6 THOMAS SOMERS SON 0.33
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
Il NON-TAXABLE DISTRIBUTIONS:
A SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
(If more space is needed, insert additional sheets of the same size)
M&T Bank
Re~ords Management/Mail Code DE-MB-12
4099 Mitohell Road
Millsbom, DE 19966
Re: Estate of Frances S. DuBois
Date of Death: April 18, 2004
Social Security No. 202-24-1384
Dear Sir/Madam:
The following is a complete record of the above decedent's accounts as of April 18, 2004,
decedem's date of death. If the decedent had a safe deposit box, indicate number ~]30eJ.
Balance on Date of Death
Account No. Type of Principal Accrued Names on Date
Account interest Account (All Opened
Owners)
Signature of Official 6/
Title: ~. ~i~i92 ~/vt~/
TRUST
June 30, 2004
Sa]dis, Shuff ?lorver & Lindsay
2]09 Market Street
Camp Hill, Pennsylvania 170i]
Re: Estate of Frances S. Dubois
Dear 3~r. Flower:
Enclosed pleaseJTnd a check in the amount of $] LS03.81. This check includes the
redemption cm~oum of the following Cert~cates of Deposit:
0 ? 6-29.54306 7.503.74
O16-2954302 ]318.52
O] 6-29542 72 2981.5.5
77~e statement asking for dnte of death balances was sent to our main office. You should
be receiving it in the next few days.
Ill can be of any assistance in the future, please don't hesitate to contact me.
Very Truly Yours,
Cindy Keck
Customer Service Re?resentutive
F & M Trust
Enclosures (3)
717-264-6116 888-264-6116 P.O. Box 6010 Chambersburg, PA 17201-6010
FINANCIAL SOLUTIONS... FROM PEOPLE YOU KNOW
Time Deposits Maintenance Withdrawxal Page 1 of 1
Account number I016-2954272
Withdrawal amount i ....... Close
Accrued i All accrued
Penalty amount 0 Effective date
Check number 2981 55 IK transaction code
Accept as is
Inquiry ! Process I x
WTH AMOUNT 2,981.55 ALPHA KEY DUBOIFS.fll
PENALTY 0-00 ACCRUED UNPAID 41-21
COMPOWND VALUE 2,9~0-34 FED TAX WITHHELD 0.00
AVAILABLE BALANCE 0-00 INTEREST ADJ AMTS 0-00
-ime Deposits Maintenance Withdrawal
Account number ~4302
Withdrawal amount
[ All accrued
Accrued
i 0 Effective date
Penalty amount
1318 52 IK transaction code
Check number
Accept as is
Inqui~ ~-~--- Process x
~ ~ ENTRY ACCEPTED
*ime Deposits Maintenance yVi~hdraxval
Withdrawal amount Close
All accrued
Accrued '~ 0 Effective date
Accept as is
..... Process
Inquiry
,J ,% J L~ g TIME CERTIFICATE OF DEPOSIT
[] 'ZERO c~g TF~UST
202--24-~8~ CHAMBERSBURG, PA 1720~
DEPOSITOR(S) F~a~ces ~ ~S ~;c~.o..,.~ (717)264-6116
ADDRESS Boiling Spui~gs Pa 17007 ,000.00
1
PAYABLE TO SAID DEPOSITOR)S), SUBJECT TO THE CONDITIONS PRINTED ON THE REVERSE SIDE OF CERTIFICATE VALtJE ~ 7~ 3'
q~ NIbRE ~ ~ ~MA~LOHEOK
: ~ ~ ~RCE~AG~ ~O MONTHLY ~ SEM,-ANNUALLY
{ CERTIFICA~ ' DA~ --~ ~ QUAR~ ERLY ~ ANNUALLY ~ COMPOUNDING-
Noa , 54302TJMECERTIFJCATEOFDEPOSJT [X~EGULARC/D
[] 'ZERO G/D TRUST
DEPOSiTOR(S) Frances So~e~s DuBo~s 202-24-~384
~ % %~TE tl ~ ~MAILGHECK
~' I ~ ~MONTHLY ~ SEMI ANNUALLY ~.~COMPOUND~NG%~3--~R&
--29 %
NO.O 16,. ~
DEPOSITOR(S) _ ~%aDces SOme~S D~OiS ..... 2D2~&=A~~4- CHAMBERSBURG, PA 17201
ADDRESS ~0~ Eo~ge Roar $
60-430 Bo~ng S~ngs~ ?~ ~7007 2~000.00
DATE ; CER~FICATE
~ QUARTERLY
6 0 ~O ~ ~ ~ S 5 . 9 5 ~ ~ MATURITY ~ ADD-ON ~ CREDIf AOOT NO
RE: FP~NCES SOMERS DUBOIS
DATE OF DEATH 4-18-2004
AC"O~ NT ! NF 0 Pd~.T I ON
X CHECKING SAVINGS __CERTIFICATE CE DEPOSIT
x ~_ ~ 0~I_ SHARES OF STOCK
_J_~I~ OPEN!:iD 12-28 2002 DATE CLOSED 5 24 2'004
ACCOUNT NUHBER 34 20787
AC(2OUNI ~ALAlqCE AT DATE OF DEATH $9,475.51
ACCRUED iNTEREST $1.28
~O_~_~'~r ~_./n~cp_ BALIuNCE $9,476.79
.~e. ~_,T FNIkNCES SOMERS DUBOIS
l~Ek~I~ zi-Je110!~ OF _.~eOUNT INDIVIDUAL ACCOUNT
z%CCOUNT !NFORPL~_T ! ON
X ~HL.~p._NG SAVINGS CERTiFiCATE OF DEPOSIT
S~mE D~PuSI~ SHARES OF STOCK
DATE OPENED 5 2 1997 DATE CLOSED 5-24-2004
ACCOUNT NU!,~B~R 70-29918
ACCOUNT BALiZ2qCE AT DATE OF DEATH $8,110.72
ACCRUED INTEREST $1.22
TO_A . ~.e.,_OURY BALANCE $8,111.94
N_~2,1E (S) ON ACCOUNI' FRANCES SOMERS DUBOIS
REGISTRATION OF ACCOUNT INDIVIDUAL ACCOUNT
RE: F~NCES SOMERS DUBOIS
DATE OF DEATH 4-18 2004
ACCOUNT !NNO~,~TiON
CIIECKING SAVINGS X CERTIFICATE ON DEPOSIT
SAFE DEPOSIT SHARES OF STOCK
DATE OPENED 3 12-1997 DATE CLOSED 6 30 2004
ACCOUNT NUMBER 016 2954272
ACCOUNT BAN~{CE AT' DATE OF DEATH $2~940.34
ACCRUED iNTEREST $14.61
TOTAL ACCOUNT BALANCE $2,954.95
N}iIE{S) ON ACCOUNT FRANCES SOMERS DUBOiS
REGISTPC, T!ON ON ACCOUNT INDIVIDUAL ACCOUNT
ACCOUNT iNPONi,~TION
CHECKING SAVINGS X CERTIP!CATE OF DEPOSIT
SAPE DBPOSiT SHARES OF STOCK
~ATE OPCiNED 3 21 1997 DATE CLOSED 6 30 2004
ACCOUNT NUNBER 016-2954306
ACCOUNT BAL~_NCE AT DATE OF DEATH $7,401.33
ACCRUED iNTEREST $30.42
TOTAL ACCOUNT BALANCE $7,431.75
N~}~E(S) ON ACCOUNT FRANCES SOMERS DUBOIS
REGISTNATION OF ACCOUNT INDIVIDUAL ACCOUNT
RE: FRANCES SOHERS DUBO!S
DATE OF DEATH 4--18 2004
ACCOUNT iNFORMATION
CN~CKING SAVINGS X CERTIFICATE OF DEPOSTT
SANE DEPOSIT __SHARES OF STOCK
DATE OPENED 3 12 1997 DATE CLOSED 6 30-2004
ACCOUNT NUMBER 016-2954302
ACCOUNT BAL!~CE AT DATE OF DEATH $1~312.63
ACCRUES IN%flREST $2.08
TOTA~ ACCOUNT BALr~NCS $1,314.71
NA~,iE(S} ON ACCOUNT FRANCES SOHERS DUBOiS
REGiS'!?k~T!ON OF ACCOUNT INDIVIDUAL ACCOUNT
ACCOUNT iNFOPi,~&TION
CHECKING SAVINGS CERTIFICATE OF DEPOSIT
SAFE DSPOSIT SHARES OF STOCK
DATE OPENED DATE C~OSED
ACCOUNT NUMBER
ACCOUNT BA~_~NCE AT DATE OF DEATH
ACCRUED INTEREST
TO?Ah ACCOUNT BALANCE
NAME(S) ON ACCOUNT
REGIST?A~ION OF ACCOUNT
No.:i~
; TIME CERTIFICATE OF DEPOSIT
DEPOSITORS! Frances Somers DuSois 202-24-~sSe
APDRESS 107 Forge Road
!3oi!ing Springs, PA 17007 $i2,000.00
3/']2/97 .60 Months 03./!2'02, 5.95% I~MA-URIrY ~ADE )N I ECREDI!ACCiN'}
No.lla- 2~ 5 ,~- ~ k o TIME CERTIFICATE OF DEPOSIT
[] 'ZERO C'D TRUST
DEPOSIIOR{S; Frances Seiners DuBois 902 2~-138~
107 Forge Rd ~ :_,,,~:: ,;1~}264-~!16
ADDRESS ~oiling Sprinqs Pa 17007 F
<.~ $~ 5,000.00
L
l
03/21/97 ' I
5yr 103/21/02 5. 95 :~ MAFUR]TY ~ADD,DN ~ CRED'~ACCf NO
No.o16 -~954302 TIME CERTIFICATE OF DEPOSIT 8~MEGULARO,'D
[] 'ZERO C/D
DEPOSITOR(S) Frances Seiners DuBois 202-24-1384
ADDRESS 107 Forge Road
~¢,,~3c Boi~ng Springs' ~A ~7~0~
I 8 QLJARTERLY ~NNUALLY
03/12/97 1 Year 03/12/98 5.30% MATUriTY ~ ADD O~
~. Kelley Blue Book
I~LLIE BOOK PRIVATE PART~ REPORT
Pennsylvania * May 20~ 2004
1992 Honda Accord LX Sedan 4D
Search Li$~ings for This Car
Consumer Rated Condition; Fair
Private Party Value Search Local Listinqs for This Car $2,545
Appraisal for f~m~ces dubois
107 forge rd
boiling springs pa 17007
no charge due to having furore sale
appraisal done by clyde e dehart jr 1ic#au003858-1
phone # 258-5858
DeHart's Auction Service Appraisal
D][NZNG ROOM
Oak table $250
4 Oak Chairs 125
Chestnut 1800s comer cupboard 900
Spongeware bowl 75
3 pc. Wedgeweod glass 40
Misc. Blueware dishes 35
German gold china set 10
5 pc. stainless set 25
Set of Dishes 35
Misc, Flatware 30
Misc. old dishes in comer cupboard 90
I900s painted wall table 60
6 cups and saucers 60
Holder 5
3 snack trays 15
Mini spoon collection 60
Pink Fenton Flower Vase 75
6 pc. whiskey set 35
Misc. Steins 25
Misc. Glassware in wall comer cupboard 60
Maple Checkerboard 35
1940s chimney lamp 40
7 pc. silver cup set 20
Teardrop Marble table top 175
5 cases of video tapes 50
3 Blue Wool Rugs 180
Brass Floor Lamp 15
11 Cases of cassettes 50
Toaster 5
Dutch water pitcher 40
TOTAL 2620
DeHart's Auction Service Appraisal
Uving Room
Wrought Iron Fireplace Candleholders $20
Brown ginger pot 20
Exercise Machine 10
Modem Cherry Rocker 80
Fred Bees Chumh pdnt 35
French marble mantle clock 150
Misc. mantle pieces 15
Blue star quilt modem 20
Hitchcock style rocker 80
2 wingback chairs 110
Pink wingback 20
Pine rocker 25
2 glass top end tables 65
3 stack library cases 250
Brass floor lamp 15
Misc. cd's 80
3 pc, stereo system 75
6 pc. german blue on ent. center 110
Misc. videos 25
vcr 15
2 crystal lamps 20
wrought iron star coffee table 125
Pink fenton bowl 45
3 legged plant stand 40
White floor lamp 20
Misc. Linens in 5 drawer chest 40
Forged metal leg glass hall lamp 175
1900s 5 drawer chest 250
Cane bottom chair 15
Water thermometer 20
TOTAL 1970
DeHart's Auction Service Appraisal
K~TCHEN
Toaster oven $t0
Microwave Stand 25
4 shelf mjSmon bookcase 20
Wood dough bowl 15
Oak hoosier cabinet 450
Microwave 10
Barrel back chair 25
Modem blue flower dish set 10
Grey silver anniversary dishes 25
Blue dutch canister set 20
2 dng spongeware blue bom 65
Wagner round gdll 15
Copper tee pot 6
9 pc spengeware enamelware 80
Misc. glasses 15
Tfal salt container 10
1800's coffee gdnder 125
2 stoneware pie plates 20
5 pc pyrex nesting bowls 60
Green enamel strainer 20
Misc. Kitchen goods 125
4 local crocks 45
Cherry grandfather clock 475
Cane strap rocker 45
TOTAL 1716
DeHart's Auction Service Appraisal
HALLWAY
1800s record cabinet $65
Walnut glass door bookcase 85
Tin wash tub 45
Misc. closet items 40
Uniden phone 12
Cherry mirror 15
Gerald Putt winged wisdom 0 ~y25' "'~
1981 nosey neighbors 0 35¥ ~ ~
Fishing print by Plusser 85
Oil Painting 30
Beveled mirror 40
Misc. pots and pans 40
4 hall area rugs 60
half moon table 25
TOTAL ~I~
Jill?. ,,,.2
DeHart's Auction Service Appraisal
BEDROOM 1
Tilt back cottage bed $575
Full size bed 125
2 cherry lingede chests 300
Jewelry (mostly costume) 325
Desk topper 25
1800 dresser chest case with print 85
Mini china cabinet 45
Wood turned lamp 10
TvVcr combo 125
Cherry dresser 150
TV stand 25
Cherry master dresser with mirror 250
2 dresser lamps 10
Nursing rocker 20
4 shelf maple bookcase 30
2 drawer rolled front end stand 150
Cherry bookcase 60
Master closet misc. 55
Wood tiffany box 15
Misc. Bedroom items 100
Wool Rug
TOTAL $2,480.00
DeHart's Auction Service Appraisal
BEDROOH 2
Small cherry dresser $150
Painted cottage chest 200
Hitchcock style st chair 20
Wool rug 60
Misc. books 20
Pine table lamp 15
Pine captains bed 100
5 shelf oak bookcase 150
Wood ironing board 15
Oak Mirror 45
Misc. sm. closet 30
Bethiam church pdnt 10
TOTAL 815
DeHart's Auction Sen/ice Appraisal
SECOND FLOOR
4 drawer oak chest $150
3 drawer oak chest 200
1800s blanket chest 175
Oak high chair with tray 200
Oak high chair with tray ~ 150
Cedar chest 125
Turned leg table 75
Misc. Attic stuff 350
2 white twin beds 40
Oak clothes trc=e 45
Chestnut rocker 65
Oak wash stand 275
Playpen 5
Table lamp 10
Wood clothes dryer 10
TOTAL 1875
DeHart's Auction Service Appraisal
BASEMENT
Farm cabinet $50
Dishes in cabinet misc. 125
Glass water bottle and cradle 75
Chest freezer 60
Dorm fddge 45
Doll cdb 40
Lead glass hanging lamp 10
Misc. box dishes 100
Double wood clothes rack 60
White table/yellow top 45
Small dorm fddge 25
Library table 125
Trunk 50
4 drawer filing cabinet 40
Misc. Basement items 425
3 sad iron 30
2 safes 150
TOTAL $1,455.00
DeHart's Auction Service Appraisal
FOYER
2 glass stars $50
2 clothes trees 65
Pine hall desk 45
Cherry drop leaf coffee table 75
Toy top 20
Pine Potatoe bin 20
Pine drop leaf table 150
Modem philco radio 25
Speed zone painting 20
Brass lamp 10
Green chair 15
Walnut drop Jeaf table 275
Loveseat sleeper sofa 50
Apple laptop computer 125
7 shelf oak bookshelf 150
Oak hall desk 325
Oak hall dress tree with mirror 475
Pine bookcase 25
2 seat school desk $125.00
Deco plant stand 30
3 shelf spool shelf 40
3 leg round plant stand 40
4 leg cast iron pot $40.00
GARAGE
2 Ladder back rockers 80
2 crocks 80
Runner sled 45
Misc. garage 250
Auto harp 125
Office misc. 2 old computer, stands printers E 125
stools desk and chair
Mahogany jewelry box 45
TOTAL $2,925.00
GRAND TOTAL all rooms 16398
OF
FRANC/~$ $. DUBOIS
I, FRANC/[S S. DUBOIS, of South Middleton Township, Cumberland County~
PemasyR, ania, being of sound and disposing mind. memoIT and understanding, do hereby make.
publish mad declare this as and for my Last Will and Testament, herebx revoking mad making void
may and ail Wills or Codicils at any time heretofore made by me.
ARTICLE 1
DEBTS
I direct the payment of ali my legal debts, and the expenses of my last ilhless and funeral
fi-om my Estate as soon after my death as conveniently may be done.
ARTICLE I1
SPECIFIC BEQUESTS OF TANGIBLE PERSONAL PROPERTY
A. I direct thal the silver cups and silver plaque which I have been storing for my
stepson, FLETCHER DUBOIS, currently residing m Heidelberg, Gerlnany, and my
stepdaughter, AMY DUBOIS, cnn'early residing in Bapon-Upon-Humber, England, be delivered
to them as soon as practicable, to be divided between them as they may mutually a~'ee.
B. ] bequeath nay large mx prints by Gerald Putt to in5' stepdaughter, AM5' DUBOIS,
and my stepson, FLETCHER DUBOIS.
C. I bequeath the fly rods and fishing tackle which belonged to my late husband,
Donald Dubois. to my son, EDMOND SO]VIERS, and my son, THOMAS P. SOMERS, to be
divided anong them by my Executors m their sole and absolute discretion, in as nearly equal
shares as may be practical, giving due regard to their personal preferences.
D. ! bequeath my glass pin, bearing the name of Eve13q~, to my daughter, EVELYN
SOMERS. if' she sm-vires me.
ARTICLE 1II
BEQUEST OF REMAINDER OF TANGIBLE PERSONAL PROPERTY
I bequeath my household goods, furniture and other personal effects (excluding cash,
stocks, bond and automobiles) not herein otherwise specifical]y bequeathed, in equal shin:es, to
my son, EDMOND SOMERS. my daughter. SARA MARIE SOMERS, attd my son.
THOMAS P. SOMERS, to be divided anaong them as follows: My son. EDMOND SOMERS,
shall first have the right to select one such item, and my daughter. SARA M.~IE SOMERS.
shall then have the right to select one such item. and my son, THOMAS P. SOMERS, shall then
have the fight to select one such item, and each such child shall then, in the order stated, again
have the opportunity to select one item of tangible personal property until all of my tangible
personal property has been so distributed, h~ the event that my son, EDMOND SOMERS, or my
son, THOMAS P. SOMERS~ does not survive me, I direct that the mother of his then living
issue shall select items in place of such son, to be distributed among such son's then living issue.
If my daughter, SARA MARIE SOMERS, does not survive me. the f}~ther of her then living
issoc shall select items in place of my daughter. SM-LA MARIE SOMERS, to be distributed
among her then living issue, and if my daughter, SARA MARIES SOMERS. is not survived by
issue, J sive and bequeath her share to my sons, EDMOND SOMERS, and THOMAS P.
SOMERS, the items o£tangibie personal property to be sclecled iu tlne manner abo~e prescribed.
i request, but I do not require, that each of my clnildrcn who is the parent of an:, of my
grandchildren shall, in tine course of tile herein prescribed selection o£ items o f personal property,
include in the items tiqey select two (2) items ~br each one cfm5 grandchildren of which lbey are
a parent, to be delivered to such ~andchildren or to a custodian as provided in .Article VJ of this
my Last Will and Testatnent.
ARTICLE IV
REST, RESIDUE AND REMAINDER
I give, devise and bequeath ail the rest, residue, and remainder of my Estate, of' wtnatsoever
nature and wheresoever situate, in equal shares, to any son, EDMOND SOMERS, my son,
THOMAS P. SOMERS, and my danghter, SARA NL~RIE SOMERS. I£my son, EDMOND
SOMERS, or my son. THOMAS P. SOMERS, does not survive me, I ~ve and bequcalh his share
unto Iris then living issue, per stripes, ffmy daughter, S.M~A M.M/IE SOMERS, does not sm-~'ive
me, I give mad bequeath her share unto her then living issue, pea' stirpes, and if my daughter. SARA
MARIE SOMERS, is not survived by issue, I give and bequeath bet share, in equal shares, unto
my son, EDMOND SOMERS and my son, THOMAS P. SOMERS, and if either son does not
suwive mc, to his then living issue.
ARTICLE V
REASON FOR NO FURTHER PROVISION
I have made no further provision in this Will for any daugbter, EVELYN SOMERS, not
because of' any lack of affection for her, but because I do not wish to jeopardize her receipt of may
existing government benefits. I ask, but not require, that my children, EDMOND SOMERS,
THOMAS P. SOMERS and SARA MARIE SOMERS, remember my daughter, E¥~ELS&N
SOMERS, wilh cards and gifts, as appropriate, o~a ChiSstmas. Easter, and her birthday, mad with
periodic cards and correspondence at other times.
ARTICLE V1
UNIFORM TI~dNSFERS TO MINORS ACT
hi the event that any beneficiary of nay Will shall not have reaclned tine age of twent~7~onc
(21 ) years at the time ~br distributim~ of his or lner share, distribution of said share may be made in
the discretion et'my Personal Representative after considering the age mad needs of thc beneficiary,
either directly to the bcneficiar5' or to a Custodima utader the Pe~msylvania Unifoma Trmasfers to
Minors Act, 20 Pa. C.S.A. ,~ 5301 et seq., 07- the applicable Unifom~ Gifts to Minors Act or
Unifoml Transfers to Minors Act in tine state el-residence of such beneficiary as the case may be.
M5 Personal Represeutative may designate as such Custodimn any institution or person, including
my Personal Representative, qualified te act as a Custodimq ['or such beneficim3, under suci~ Act i~
effect at the time such distribution is made. A receipt for any pa_vment or distribution so made s¼atl
be a full dischm'ge tlnere£or to my Personal Representative, who shall not bc responsible to see to, or
lne iiable for, the application of such proceeds thercafler.
ARTICLE
TAXES
I direct that all taxes that may be assessed in consequence of' my death, of whatever nature
or by whatever jurisdiction imposed, shaI1 be paid out of my residuary estate as a part of the
expense o£the administration of my estate.
ARTICLE VIII
APPOINTMENT OF PERSONAL REPRESENTATIVE
1 name, constitute and appoint my son, THOMAS P. SOMERS, and nay daughter, SARA
MARIE SOMERS. Co-Executors of this m5 Last Will and Testament, mud should either fail to
qualify or ccase to so act. J direct that the other slnall complete the administration of n?' estate
without the appointment of m~ alternate Co-Exect~tof I direct that no fiducim3, appointed bereth
shall be required to post bond for the faith:&fl administration of the duties required in any
jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will m~d
Tcstmnent. this./~ ~ day of ~/~ ,2004.
fi~c~ ~ ff Ov~> ~ ~r~ (SEAL)
s.
SIGNED. SEALED, PUBLISHED AND DECLARED, by FRANCIS S. DUBOIS, the
Testatrix above named, as and for her Last W~II and Testament and 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.
itness
/ '~ithess ' '
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
~ SS
COUNTY OF
We, FRANCIS S. DUBOIS, ~'4-,*~',+ ,~, /~4,.,~ ~e-Z" and
/~.~.~'~' /-Z {..v,/,~z,,.~r.., ~ , the 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
his/her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind
and under no constraint or undue influence.
NCIS S. DUBOlS
v itness//' f
Subscribed, sworn to and acknowledged before me by FRANCIS S. DUBOIS, Testatrix,
and subscribed and sworn to before me by /-,,,,w~, ~, /2,4.,~-~"7- and
/~4-~-~'.~ //. b,,,/¢/~.~,/-/ ,/..~ ,witnesses, this /&7','. dayof ,/-~'~/~ ,2004.
ALPH H. WRIGHT, JR.
Pennsylvania Attorney I.D.#56113
A'FI'ORN EY CERTIFICATION
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
On this, the /~"~ day of ,,~74.¢,~.- , 2004, before me, the undersigned
officer, personally appeared Ralph H. Wright, Jr., Attorney I.D. #561'~3, known to me {or
satisfactorily proven) to be a member of the bar of the hi§hest court of Pennsylvania and
certified that he was personalty present when the foregoin§ acknowledgment and affidavit were
signed by the Testatrix and witnesses.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Public
:227208
SAFE DEPOSIT BOX
DEPARTMENT OF REVENUE INVENTORY i
INHERITANCE TAX DIVISION
DEPT 280601 Please Print or Type
HARRLSBURG, PA 17128-0601
MUST BE CDMPLETED BY REPRESENTA-IVE OF FINANCtAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNEE) TD ABOVE A )L)RESS
.COUNTYCODE ... ,LAbTSNAM~E FILENUMBER SOCiAL SECURITY OR DEATH CERTIFICATE N MBER
~NAME REQUESTING THE OPENING OF THE SAFE DE IT~
/ (NAME~ ~
~ME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENTAT THE BOX OPENING
(STREET
b (NAME) (RELATIONSHIP)
STREET NAME) rCITY) (STATE) 'ZiP CODE)
c. NAME) (RELATIONSHIP)
STREET NAME] fC TY~ (STATE) (ZIP CODE]
~ NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
(CITY) (STA~)~
~ DATE OF CONTRACT TO RENT BOX ~ NUMBER OF BOX ~ TITLE UNDER WHICH BOX IS REQUESTED
~ NAME AND ADDRESS OF PErSON(S) HAVING ACCES~ TO BOX
b. (NAME)
(CITY) (STATE) (ZI~ODE) (C~TY)
~ NAM, AND TITLE OF E,PLOYE, TAKtNG THE INVENTO"Y
~ WAS A WILL IN THE BOX ~ YES ~ Ifyes, a. DateefwiH:
b, Hame and address of personal representative, if named in the will
(STREET NAME) (CII Y) (STATE) (ZIP CODE)
c, Name and address of attorney, if any
(NAME)
(STREET NAME) (OTY) (STATE) (ZiP CODE)
SAFE DEPOSIT BOX INVENTORY
iNSTR(JCTiON$
(1) Cash: Repot1 total only
(2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box Stocks are to be
designated by name of company, certificate number date of certificate, name ~n which stock is registered, and
number of shares and class of stock
(3) Obligations of U.S. Government: Number of items, date of issue, face value names in which registered and
type of ownership, i e, jointly held, payable on death, etc
(4) Bonds: Designate by name, amount, serial number, or other designation (Bearer Bonds)
(5) Bank and Savings and Loan Passbooks: Sta~e name of depositor, number of book, last date appearing in book,
name Df bank and branch, and balance
Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible.
(7) Deeds, Mcr[gages, Current Insurance Policies or ether evidences of indebtedness: Lis~ and describe as fully
as possible
(8) All other contents.
ITEM DESCRIPTION
i CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS ~ PERSON RECEIVING COPY OF
, CORRECT AND COMPLETE TO THE SEST OF MY KNOWLEDGE AND BELIEF.~ SAFE DEPOSIT BOX INVENTQRY:
SIGNATURE
PRINT TITLEDATE CHECK APPROPRIATE BOX:
m ~ C'~ ~ t ~ ~ ~ Executor(trix) ~ ACminislrator([rix)
~ Esla[e Represen[ative ~ Jo[n[ owner of safe deposit box
NOTE: Attach additional 81h'' x 11" sheet(s) if necessaw or use duplicates of this page of form.
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 004605
SOMERS THOMAS P
PO BOX 132
OAK RUN, CA 96069-0132
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 (;7,882.47
ESTATE INFORMATION: SSN: 202 241384
FILE NUMBER: 2104-0465
DECEDENT NAME: DUBOIS FRANCES SOMERS
DATE OF PAYMENT: 11/08/2004
POSTMARK DATE: 11/02/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 04/18/2004
TOTAL AMOUNT PAID: $7,882.47
REMARKS: TSOMERS
CHECK// 1039
INITIALS: VZ
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
g~.OZ~ Yd 'elS!lJeO
menbs asnoq~Jnoc) au0
3SFIOH/NFIO0 AINF)O0
Sll!M jo Ja~s!6a~l
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
();::';=\CE Of NOTICE OF INHERITANCE TAX
. APPRAISEI1ENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSI1ENT OF TAX
BUREAU OF INDIVIDUA~'C~~^,F[~';
INHERITANCE TAX DIIIISIOMIt..:.lAJ. ,~-".",
PO BOX 280601 D~'>"'-:'l":
HARRISBURG PA 17128-0601 i .I..>,.
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
01-10-2005
DUBOIS
04-18-2004
21 04-0465
CUMBERLAND
101
A.ldOUnt R&IIitted
1G[)~ JMII 0 M~ 9: liS
CLERK O~ , _
~H!\'\'(; ('QI..JR \
E ~ L...;",:I ",,;'I ~~r-J,_" r:'\ 0:\
THOMAS 1<", " ' . . , .
SAIDIS ET ,'1'" ,..
2109 MARKET ST
CAMP HILL PA 17011
*'
REY-l!j~7 Ell AFP Cl2-U~l
FRANCES
S
( XI CHANGED
III
(ZI
(31
(4)
(51
[61
(71
137. 000.00
309.28
.00
.00
62.664.45
.00
.00
[81
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HDUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
iiEii :iS47-ix--AFii-Coi":03y-ijiiYici-.OF-i:iiHiiiii'AN-CE-YAX-iiPPRiiisiMiijT~--ALiiiwAN-CE-ciR----.------ - -- - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF DUBDIS FRANCES S FILE NO. 21 04-0465 ACN 101 DATE 01-10-2005
TAX RETURN WAS' ( I ACCEPTED AS FILED
SEE ATTACHED NDTICE
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. Hortgages/No~as Receivable (Schedule DJ
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Hisc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Govern.ental Bequestsj Non-elected 9113 Trusts (Schedule J)
1~. Net Value of Estate Subject to Tax
14,999.80
2.459.00
[111
llZI
1131
1141
[91
1l0)
NOTE: To insure proper
credit to your accountl
submit the upper portion
of this form with your
tax payment.
199,973.73
17.41iR An
182,514.93
.00
182,514.93
NOTE: If an assessmen~ was issued previously, lines 14, lS and/or 16, 17, 18 and 19 will
reflect figures ~ha~ include ~he ~o~al of ~ re~urns assessed ~o da~e.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (IS)
16. Amount of Line 14 taxable .t Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
.00 X 00 = .00
182,514.93 X 045 = 8,213.17
.00 X 12 = .00
.00 X 15 = .00
1191= 8,213.17
TAX CR S:
rA' ,., AI10UNT PAID
DATE H\JI1llER INTEREST/PEN PAID [-I
11-02-2004 CD004605 .00 7,882.47
INTEREST IS CHARGED THROUGH 01-25-2005 TOTAL TAX CREDIT 7,882.47
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 330.70
REVERSE SIDE OF THIS FORM INTEREST AND PEN. .57
TOTAL DUE 331.27
~
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
[ IF TOTAL DUE IS LESS THAN $1, NO PAYI1ENT IS REQUIRED. '
IF TOTAL DUE IS REFLECTED AS A "CREDIT" [CRI, YOU HAY 8E DUE Oil
A REFUND. SEE REVERSE SIDE OF THIS FDRI1 FOR INSTRUCTIQNS.I :>0\
REV_147QEX(6_88}
'*
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG PA 17128~0601
DECEDENT'S NAME
Dubois, Frances S.
FILE NUMBER
REVIEWED BY
Daniel Heck
ACN
2104-0465
101
ITEM
SCHEDULE NO.
H 8-9,10
EXPLANATION OF CHANGES
The shipping expenses are not allowable as the decedent's Will did not have a stipulation
for the executor(s) to pay for the shipping of the furniture and household items to the
beneficiaries.
ROW
Page 1
; E. SUKE
,RT C. SAlDIS
'FREY S. SHUFF
is D. FLOWER,)R
)L). UNDSAY
N C. CAFFREY
"<GE F. DOUGLAS, 1Il
THEW]. ESHELMANt
MAS E. FLOWER
SN SMITH
LAW OFFICES
SAIDIS, SHUFF, FLOWER & LINDSAY
A PROFESSIONAL CORPORA nON
2109 MARKET STREET
CAMP HILL, PENNSYL VANIA 17011
TELEPHONE: (717) 737-3405 - FACSIMILE: (717) 737-3407
EMAIL: attorney@ssfl-law.com
www.ssfI-Iaw.com
January 31, 2005
Office ofthe Register of Wills
One Courthouse Square
Carlisle, PA 17013
RE: Estate of Frances DuBois
2004 - 00465
Dear Madam or Sir:
The enclosed check is for additional inheritance tax.
Very truly yours,
Thomas E. Flower
CARLISLE OFFICE
26 WEST HIGH STREET
CARLISLE, PA 17013
TELEPHONE' (717)243-6222
FACSIMILE, (717)243-6486
tBQard Certified Creditors
Rights Representation
REPLY TO CAMP HILL
-~.."
N
o
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT Of REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 28Q601
HARRISBURG, PA 17128-0601
REV-1162 EXI11-96)
:IVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
FLOWER THOMAS E
2109 MARKET STREET
CAMP HILL, PA 17011
h__ 10)<1
ESTATE INFORMATION: SSN, 202-24-1384
FILE NUMBER: 2104-0465
DECEDENT NAME: DUBOIS FRANCES SOMERS
DATE OF PAYMENT: 02/01/2005
POSTMARK DATE: 01/31/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 04/18/2004
NO. CD 004905
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $331.27
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$331.27
REMARKS: SAlOIS, SHUFF ET AL
CHECK#1047
SEAL
INITIALS: RSK
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
'homas E. Flower
.aldis, Shuff. Flower & Lindsay
1 09 Market Street
:amp Hill. PA 17011
Office of the Register of Wills
One Courthouse Square
Carlisle. PA 17013
_.., ~~~~ 7"~_":::=..J:
.a.= .:..-,,' :::') y' .;., . .z;.~~.... _.-.-__
-- ~'~~~~1..~~._-~-'...,*.
/:' r , ,', ~-, I'
I ~~ '/,\ v';:;..:;", Ji, .-
/7" \._ \~v ';:',~v,;::.f<:l;' ,-~ ''I -~ --: ::!:-
jU JA~31'0' J ~:/; :.~~~:.::.: .~ ,d , -l~
\ t";':"::{f.~':m~"~ t:
. ~"'.,."_._,.~' *
'J'~'''''''..,~;':.". --, ,...... ',,' ~ _
\, p ^ " ,<C:'" i!J" ",':>rAGE *
"--.........!. ..... ('~;:)9218 L-:..:'::':"_;'- ."
1""'<
~-
m
::0
::>.;;:
'~s~
-;:::
::1.:
r;;>
o
\.0
i
c/.
l. iiL"Hi,.""il"i!".I1,;,l1.I,j",'!,!l,j"\,l,,, 11,1
BUREAU OF INDIVIQUAlTAXES
INHERITANCE TAX DIVISION
PO BOX Z80601
HARRISBURG PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
'*
REY-16D7 EX AFP 112-041
THOMASrEFLOWER
SAIDIS ETAL
2109 MARKET ST
CAMP HILL
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
02-28-2005
DUBOIS
04-18-2004
21 04-0465
CUMBERLAND
101
Allount Rellitted
FRANCES
S
PA 17011
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax pay.ent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
~~:r&~~.!5r.A'~..r81~.~!'........;..:rA~!~e1r~A1r.~'~~A~.b~.A~l:6D~...ii......................
ESTATE OF DUBOIS FRANCES S FILE NO.21 04-0465 ACN 101 DATE 02-28-2005
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 PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 01-10-2005
PRINCIPAL TAX DUE:.
8,213.17
PAYMENTS (TAX CREDITS):
~
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
11-02-2004 CD004605 .00 7,882.47
01-31-2005 CD004905 .57- 331.27
TOTAL TAX CREDIT 8,213.17
BALANCE OF TAX DUE .00
INTEREST AND PEN. .02
IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .02
It
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1,
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Frances Somers Dubois
Date of Death: April 18, 2004
Will No. 21-04-0465 Admin. No. 2004-00465
Pursuant to Rille 6.12 of the Supreme Court Orphans' Court Rules, I report the
following with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete: Yes -X; No
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
3. . If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final account with the Court? Yes_;
No X.
b. The separate Orphans' 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 X; No
d. Copies of receipts, releases, joinders and approvals of formal or informal
accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report.
D"f-; ,!0r ~w~
.. J.D. No. 83993
SAIDIS, SHUFF, FLOWER & LINDSAY
2109 Market Street
Camp Hill, PA 17011
(717) 737-3405
'-'1
Capacity: _ Personal Representative
----X- Counsel for Personal Representative
vuf