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Home My WebLink About02-0189PETITION FOR PROBATE and GRANT OF LETTERS Estate of Annabel C. Davis No. also known as To: Deceased. Social Security No. 512-34-73~8 The petition of the undersigned respectfully represents that: Your petitioner(x), who is/ao~ 18 years of age or older an the execut 'in the last will of the above decedent, dated March 6, and codicil(s) dated N/A Register of Wills for the County of Cumberland Commonwealth of Pennsylvania or in the named ., 1~ 2001 (state relevant cirotmstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in h er last family or principal residence at · Township Cumberland 105 Cherry Lane. County, Pennsylvania, with Carlisle, Middlesex (list street, number and muncipality) Decendent, then 78 years of age, died February 2 , t9~ 2002 , at Holy Spirit Hospital, Camp Hill. Penn.~ylvmnqa 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' ia-Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: 2,500.00 WHEREFORE, presented herewith and the grant of letters theron. petitioner(s) respectfully request(s) the probate of the last will and codicil(s) testamentary (testamentary; administration c.t.a4 administration d.b.n.c.t.a.) ////James T. Davis ' //96 Cherry Lane ~/ Carl ~ ~1~ PA 17~lq OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~- ss COUNTY OF CUHBERLAND The petitioner(s) above-named swear(s) or affnnn(s) that the statements in the foregoing petition are true and correct to the b~', of the knowledge and belief of petitioner(s) and that as personal represen- tative,s) of the above dec~dent petitioner(s) will w~adj ~'~.trulY adminisJ~the/~/) estate according to law. · beforeme this 21st day of I// ~' MEalY C~f LF~S / Regtster ~(/ ~ Estate of ANNABEL C. DAVIS DECREE OF PROBATE AND GRANT OF LETTERS ,Deceased FEBRUARY 2 1 AND NOW the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated March 6, 2001 described therein be admitted to probate and filed of record as the last will of Annabel C. Davis Testamentary and Letters :1~ 200~ in consideration of the petition on are hereby granted to James T. Davis Will Book # 1 7 Page 4 4 FEES 'Probate, Letters, Etc .......... $ 2 5.0 0 Short Certificates( ~ .......... $ 6.0 0 Renunciation ................ $ JCP $ 5.00 TOTAL $ 36.00 Filed FEBRUARY 21, 2002 p £~ked' 'd~' '6H' ~fi~" ~'J~'~ ' ~A~ ...... ~/./- _ :. --J - _. , , MA~Y C/L EW 1R~ster of Wills / /' "~-~Z~TTORI~¥ (Sup. Ct. I.D. No.) Jered L. Hock, Esquire I.D. No. 19211 ADDRESS 3211 North Front Street; PO Box 5300 Harrisburg, PA 17110-0300 PHONE (717) 238-8187 LAST WILL AND TESTAMENT 21-02-189 I, ANNABEL C. DAVIS, a resident of Cumberland County, Pennsylvania, do hereby make, publish, and declare this to be my Last Will and Testament, hereby revoking any and all Wills and Codicils heretofore made by me. FIRST: I direct that all my just debts and funeral expenses be paid out of my estate as soon after my death as is practicable. SECOND: I give, devise, and bequeath all my estate, real, personal, and mixed, of whatever kind and wherever situated, of which I may die seized or possessed, or in which I may have any interest or over which I may have any power of appointment or testamentary disposition, to my spouse THOMAS S. DAVIS. If my said spouse does not survive me, I give, and bequeath the said property to my children: James T. Davis of Carlisle, PA; John R. Davis of Lafayette, CO; Michael S. Davis of Frostburg, MD; Terri A. Davis of Dallas, TX; and Todd P. Davis of Springfield, MA in equal shares or to their lineal descendants, per stirpes. THIRD: In the event that any beneficiary fails to survive me by thirty days, then this will shall take effect as if that person had predeceased me. FOURTH: I hereby nominate, constitute, and appoint JAMES T. DAVIS as Executor of this, my Last Will and Testament. In the event that such named person is unable or unwilling to serve at any time or for any reason, then I nominate, constitute, and appoint JOHN R. DAVIS as Executor in the place and stead of the person first named herein. It is my will, and I direct that my Executor shall not be required to furnish bond for the faithful performance of his duties in any jurisdiction, any provision of law to the contrary notwithstanding, and I give my Executor full power to administer my estate, including the power to settle claims, pay debts, and sell, lease or exchange real and personal property without court order. IN WITNESS WHEREOF I declare this to be my Last Will and Testament and execute it willingly as my free and voluntary act for the purposes expressed he[fin and I am ctf~[egal iage and sound mind and make this under no constraint or undue influence, this ~ day of ~./t~0d~C~ , 2001 at Carlisle, State of Pennsylvania. ~) '~/~,5 ~ t.~ ~, 0 L.S. The foregoing instrument was on said date subscribed at the end thereof by ANNABEL C. DAVIS, the above named Testator who signed, published and declared this instrument to be her Last Will and Testament in the presence of us and each of us, who thereupon at her request, in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses thereto. We are of sound mind and proper age to witness a will and understand this to be her will, and to the best of our knowledge testator is of legal age to make a will, of sound mind, and under no constraint or undue influence. residing residing at 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 fi!lng. WARNING: It is illegal to duplicate this copy by photoStat or photograph. Fee for this certificate, $2.00 P 8048491 No. [,,,,,,.~/ ~ Local Registrar F E B 0 6 ~ Date COMMONWEALTH OF PENNSYLVAN A * DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH 78 ~,. I J I,.8/X/X923 J, Hunt~ngdon, pA'l~ ACTA ,7.. gram PA · ,,~~ Middlesex 105 Cherry Lane .s~ Carisle, PA 17013 '~"" ,~.co~.V Cumberland A. John C~oss J,, Almeda Barnes ~- ~ ~ . II~FO~T'S~~ ~ ~ . /nomas b. USV~S ' ~' '~. ~m~ ~. ~05 Cherry Lane, ~ar~ie, PA ~70~3 -- ~ n ~ J,,,. February 5, 2002 [,.st. JOhn's Lutheran Cem J,. Belleville, PA 17004 = ~ ~pU~RV~E L N~ ~;; N LICENSE NUMAR ' NA~~ ' ' ~ J~, 9753L J=.Ba~us Fune=al HO~I Bellev~11% PA '17004 I 21-02-189 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent · Date of Death · Will No.: 21-02-189 Annabel C. Davis February 2, 2002 Admin. No.: To the Register: I hereby certify that notice, of beneficial interest 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 February 27, 2002 Nanle Thomas S. Davis Address 105 Cher~ Lane; Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Date: ~~ ,2002 Name Jered L. Hock, Esquire Address 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 TelePhone Capacity: X (717) 238-8187 __ Personal Representative Counsel for Personal Representative Document #: 228375.1 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent ' Date of Death · Will No.: 21-02-189 Annabel C. Davis February 2, 2002 Admin. No.: To the Register: I hereby certify that notice of beneficial interest 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 February 27, 2002 . Name Thomas S. Davis Address 105 Chertw Lane; Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Name Jered L. Hock, Esquire Address 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 __ Personal Representative Counsel for Personal Representative Telephone Capacity: X Document It: 2283 75.1 3.V-1500 EX + (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 OFFICIAL USE ONLY REV- 1500 [7 INHERITANCE TAX RETURN F,,ENUMBE. -- RESIDENT DECEDENT COU~N.~,~ COD E OyE A~R / ?? NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Davis Annabe 1 C 512 - 34 - 7398 DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 02/02/2002 I 08/01/1923 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Davis, Thomas S. CHECK APPRO- PRIATE BLOCKS COR- RE- SPON DENT RECA- PITULA- TION TAX COMPU- TATION 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach copy of Will) 9. Litigation Proceeds Received 2. Supplemental Return 48. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach a copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Remainder Return ( date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 0 8. Total Number of Safe Deposit Boxes 1 1. Election to tax under Sec. 9113(A) (Attach Sch O) NAME Jered L. Hock, Esquire FIRM NAME (If Applicable) Metzger Wickersham TELEPHONE NUMBER 717-238-8187 COMPLETE MAILINGADDRESS 3211 N. Front St.; PO Box 5300 Harrisburg, PA 17110-0300 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortga9es & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) [-~ Separate Billin9 Requested (6) 0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 2,914 0 (7) 0 8. Total Gross Assets (total Lines 1-7) (8) 9. Funeral Expenses & Administrative Costs (Schedule H)(9) 10, 6 96 10, Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 3,9 9 5 11. Total Deductions (total Lines 9 & 10) (11) 12. Net Value of Estate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax (13) has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) OFFICIAL USE ONLY 2,914 14,691 (11,777) 0 (11,777) SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (aX1.2) 0 x .0 0 0 (15) 0 16. Amount of Line 14taxableatlinealrate 0 x .0 0. 045 (16) 0 17. Amount of Line 14 taxable at sibling rate 0 x. 12 (17) 0 18. Amount of Line 14 taxable at collateral rate 0 X .15 (18) 0 19. Tax Due (19) 0 0 PA15001 NTF 29755 Copyright 2000 Greatland/Nelco LP - Forms Software Only Estat~ of Name Address Tax ID Executors (Page 1) James T. Davis 96 Cherry Lane Carlisle, PA 17013- 169-36-2314 512-34-7398 RA REV-1500 EX (6-00) Decedent's Complete Address: STREET ADDRESS Page 2 105 Cherry Lane Cumberland County CITY Carlisle Tax Payments and Credits: STATE PA ZIP 17013 Tax Due (Page 1 Line 19) Credits/Payments A. Spousal Poverty Credit 0 B. Prior Payments 0 C. Discount 0 Interest/Penalty if applicable D. Interest E. Penalty (1) Total Credits (A + B + C) (2) 0 0 Total Interest/Penalty (D + E) (3) If Line 2 is greater than Line I + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund (4) If Line I + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 0 0 0 0 0 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; I ~ b. retain the right to designate who shall use the property transferred or its income; ................. c. retain a reversionary interest; or ........................................................ d. receive the promise for fe of either payments benefts or care7 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receivin9 adequate cons derat on? ................................................... ~ ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary desi9nation? ........................................................ [-~ ~ 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 exam ned this return, includin9 accompanyin9 schedules and statements, and to the best of my knowledge and behef, it is true correct and complete. Declaration of preparer other tl'ian the personal representative is based on information of wh, ich preparer has any knowledge. S~GNATbrRE OF PF~..~.N..RE~.~:~SIBLE FOR FILING RETURN /,A~RESS .... . ADDRE~ ~- - DATF_/ . DATE 3211 N. Front St.; PO Box 5300; Harrisburg, PA 17110-0300 #~,: 'J~'i~;;'g¥ ~;~'i't:,' ~'~.'~ i~-' Li bi {;'"ii' :'/~',~' ~.~i 't~;:;;-~' j~'~,~;-'y' "ii' {96~i'i~'~' i~.;~ ~:a'ig 'i'r~6 ~ '~' :t'~,'g ~ i' L;~l~'6 {" i~-'a;.;,~ {,~;-'~' i6' ~.' ~6i-' ¥;~ '~'~ '~'ii~;~' ~'F ~,'i~,i ~ '~;;~ 'i'~' §~ ...................... [72 P.S. § 9116 (a)(1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate is 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)(ii)]. /he statute does not exerngt a transfer to a surv v ng spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(aXl.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 w ho has at least one parent in common w th the decedent, whether by blood or adoption, 0 PA15002 NTF 29756 Copyright 2000 Great~and/Nelco LP - Forms Software Only REV-1502 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE A REAL ESTATE FILE NUMBER Annabel C. Davis All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willin9 buyer and a willin9 seller, neither bein9 compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NO. DESCRIPTION TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9 PA15021 NTF 10871 Copyright 1999 Greatland/Nelco LP - Forms Software Only VALUE AT DATE OF DEATH REV- 1503 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Annabel C. Davis FILENUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NO. DESCRIPTION 1. TOTAL (Also enter on line 2, Recapitulation) (If more space is needed, insert additional sheets of the same size) g PA15031 NTF 10872 Copyright 1999 Greatland/Nelco LP - Forms Software Only VALUE AT DATE OF DEATH REV- 1504 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION PARTNERSHIP or SOLE-PROPRIETORSHIP ESTATE OF .z~nna]3e'l C. Da~"is FILE NUMBER Schedule C- 1 or C-2 (Includin9 all supportin9 information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-propiertorship. See instructions for the supportin9 information to be submitted for sole-proprietorships. ITEM NO. 1. 9 PA15041 NTF 10873 DESCRIPTION TOTAL (Also enter on Fine 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH Copyright 1999 Greatland/Nelco LP - Forms Software Only REV-1507 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE D MORTGAGES & NOTES RECEIVABLE FI LE NUMBER .z~_z~a]~e]. (]. DavJ.$ All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NO. 1. DESCRIPTION TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9 PA15071 NTF 10874 Copyri~lht 19~9 Greatland/Nelco LP - Forms Software Only VALUE AT DATE OF DEATH REV- 1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Annabel C. Davis Include proceeds of litigation & date proceeds were received by the estate. All prop. jointly-owned with right of survivorship must be disclosed on Sch. F. ITEM VALUE AT NO. DESCRIPTION DATE OFDEATH 11. PNC Bank Account No. 50-0390-4606 NOTE: All other assets were held as tenant by the entireties with surviving husband, and had been so held for years. TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9 PA15081 NTF 10875 Copyright 1999 Greatland/Nelco LP - Forms Software OnJy 2,914 2,914 RBV-1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER .A~z~a]:)e]. (2. Da-v'±s If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. JOINTLyIOWNED PROPERTY: DESCRIPTION OF PROPERTY LETTER DATE Include name of financial institution and bank % OF DATE OF DEATH ITEM FOR MADE JOINT account number or similar identifyin9 number. DATE OF DEATH DECD'S VALUE OF NO. TENANT JOINT Attach deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTERES' TOTAL (Also enter on line §, Recapitulation) $ 0 (If more space is needed, insert additional sheets of the same size) Copyright 1999 Greatland/Nelco LP - Forms Software Only RBV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Az~nabel C. Davis This schedule must be completed and filed if the answer to any of questions I through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF INCLUDE NAME OF THE TRANSFEREE, THEIR ITEM RELATIONSHIP TO DECD & DATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NO. ATTACH COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1. TOTAL (Also enter on line 7, Recapitulation) $ 0 NTF 10877 (If more space cs needed, insert additional sheets of the same size) Copyright 1999 Greatland/Netco LP - Forms Software Only REV-1511EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Anna;bel C. Davis Debts of decedent must be reported on Schedule I. ITEM NO. DESCRIPTION AMOUNT FUNERAL EXPENSES: Baggus Funeral Home, Belleville, PA - reimbursement to Thomas S. Davis ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN No. of Personal Representative(s) S~'eet Address City State Zip Year(s) Commission Paid: A~rneyFees Metzger, Wickersham, Knauss & Erb, P.C. (estimated) FamilyExemption:(Ifdecedent'saddressisnotthesameasclaimant, s,a~chexplanafion) Claimant Thomas S. Davis Street Address 105 Cherry Lane CityCarlisle State PA Zip l7013 Relationship of Claimant to Decedent HUSBAND Probate Fees Accountant's Fees Tax Return Preparer's Fees Metzger, Wickersham, Knauss & Erb, P.C. photocopies, postage, etc. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9 PA15111 NTF 10878 Copyright 1999 Greatland/Nelco LP - Forms Software Only 6,948 200 3,500 36 12 10,696 REV-1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Annabel C. Davis Include unreimbursed medical expenses. ITEM NO. 1. 1 9 PA15121 NTF 10874 DESCRIPTION Nipple's Convalescent Home pharmacy debt of decedent Nipple's Convalescent Home, Liverpool, PA - bill of decedent West Shore EMS - ambulance bill of decedent TOTAL (Also enter on line 10, Recapitulation) AMOUNT 565 2,904 526 3,995 (If more space is needed, insert additional sheets of the same size) Copyright 1999 Greatlar~d/Nelco LP - Forms Software Only REV- 1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER · ~t"zna]3e'l C. Da'v--is NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I 1. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and lransfers under Sec. 9116 (a) (1.2)] RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE 0 PA15131 NTF 33293 TOTAL OF PART II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS -- ENTER TOTAL NON-TAXABLE DISTRIBS. ON LINE 13 OF REV-1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) Copyright 2000 Greatland/Nelco LP - Forms Software Only $ 0 --NTER DOLLAR AMTS. FOR DISTRIBS. SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET REV-1514 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER .A.~z3a]3e'l C. Dav:J.s This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ~ Will ~-~ Intervivos Deed of Trust ~-~ Other NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE r-~ Life or [~ Term of Years [-~ Life or r-~ Term of Years ~] Life or 0 Term of Years ~ Life or ~ Term of Years 1. Value of fund from which life estate is payable $ 0 2. Actuarial factor per apprr~_~priate table Interest table rate -- [_~ 3 1/2% ["-] 6% 3. Value of life estate (Line I multiplied by Line 2) D10% 0 Variable Rate NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE D Life or 0 Term of Years ~ Life or ~--~ Term of Years ~ Life or J--~ Term of Years E] Life or E~ Term of Years 1. Value of fund from which annuity is payable $ 0 2. Check appropriate block below and enter corresponding (number) Frequency of payout -- ~ Weekly (52) ~ Bi-weekly (26) ~ Monthly (12) [~ Quarterly (4) ~ Semi-annually (2) II Annually (1) [J Other ( ) Amount of payout per period Aggregate annual payment, Line 2 multiplied by Line 3 Annuity Factor (see ins~'uctions) Interest table rate ~ 3 1/2°/, ~-~ 6% ~-~ 10% ~ Variable Rate % Adjuslment Factor (see instructions) Value of annuity -- if using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 $ If using variable rate and period payout is at beginnin9 of period, calculation is: (Line 4 x Une 5 x Line 6) + Line 3 $ $ 0 0 0 0 0 NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resultin9 life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16 and 17. (If more space is needed, insert additional sheets of the same size) 9 PA15141 NTF 10881 Copyright 1999 Greatland/Netco LP - Forms Software Only REV- 1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER .z~znat3el C. Dav±s This schedule is appropriate only for estates of decedents dying after December 12, 1982. I1. III. IV. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of ins~'ument which created the future interest and attach a copy to the tax return. Beneficiaries NAME OF BENEFICIARY Will J"] Trust J-] Other RELATIONSHIP 1. 2. AGE TO DATE OF BIRTH NEAREST BIRTHDAY For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ~ Unlimited right of withdrawal Explanation of Cor~promise Offer: Summary of Compromise Offer: 1. Amount of Future Interest 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......... $ 0 3. Value of Line I passing to spouse at appropriate tax rate Check One D 6%, D 3%o, D 0%° .................... $ 0 (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 Taxable at lineal rate Check One D 6%, D 4.5% ......................... $ 0 (also include as part of total shown on Line 16 of Cover Sheet) 5, Value of Line I taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......... $ 6, Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......... $ 7. 0 0 Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ........................... $ Limited right of withdrawal (If more space is needed, insert additional sheets of the same size) Copyright 2000 Greafland/Nelco LP - Forms Software Only 0 PA16471 NTF 33294 REV- 1649 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER A~nabel C. Davis Do not coi~plete this schedule unless estate is making election to tax assets under Section 9113(A) of Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust This election applies to the Trust(marital, residual A, El, Ely-pass, Unified Credit, etc.). If a trust or similar a~angement meets the requirements of Section 9113(A), and: a. The l~ust or similar arrangement is listed on Schedule O, and b. The value of the ~'ust or similar arrangement is entered in whole or in part as an asset on Schedule O, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such ~'ust or similar property treated as a taxable transfer in this estate. If less than the entire value of the ~'ust or similar property is included as a taxable a'ansfer on Schedule O, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the l~ust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. DESCRIPTION VALUE Part A Total $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is bein9 made. DESCRIPTION VALUE Part B Total $ 0 g PA16491 NTF 10882 (If more space is needed, insert additional sheets of the same size) Copyright 1999 Greatland/Nelco LP - Forms Software Only LAST WILL AND TESTAMENT I, ANNABEL C. DAVIS, a resident ,::f Cumberland County, ennsylv~nia, do hereby make, publish, and declare this to be my Last Will and Testament, ~ereby revoking any and all Wills ':tnd Codicils heretofore made by me. FIRST: I direct that all my just debts and funeral expenses be paid out of my estate as soon after my death as is practicable. SECOND: I give, devise, and beque~.h all my estate, real, personal, a id mixed, of whatever kind and wherever situated, of which I may die seized or }ossessed, or in which I may have any interest or over which I may have any power of appointment or testamentary {.isposition, to my spouse THOMAS S. DAVIS. If my said spouse does not survive me, I give, and bequeath the sait~. property to my children: James 1'. Davis of Carlisle, PA; John R. Davis of Lafayette, CO; Michael S. Davis of Frostburg, MD; Terri A. Davis of Dallas, TX; and Todd P. Davis of Springfield, MA in equal shares or to ffeir lineal descendants, per stirpes. THIRD: In the event that any beneflci try fails to survive me by thirty days, then this will shall take effect as if that person had predeceased me. FOURTH: I hereby nominate, constitr, te, and appoint JAMES T. DAVIS as Executor of this, my Last Will and Testament. In the event that such name5 person is unable or unwilling tc serve at any time or for any reason, then I nominate, constitute, and appoint JOHN R. DAVIS as Executor in the place and stead of the person first named , herein. It is my will, and I direct that ny Executor shall not be required t,'~ furnish bond for the faithful performance of his duties in any jurisdiction, any p~ >vision of law to the contrary not'~vithstanding, and I give my Executor full power to administer my estate, includit¢5 the power t° settle claims, pay. debts, and sell, lease or exchange real and personal property without court order~ -: . · IN WITNESS WHEREOF' I declare i:~:is to be my Last Will and Testammt and execute it willingly as my free and voluntary act for the purposes expressed h~e[fin and I am qf~[egal i~ge hnd sound mind and make this under no constraint or undue influence, this day of ~.~l~l~(obt~ , 2001 at Carlisle, State of Pennsylvania. ~ ~,~,i\~.5 ~ ~ t 0 L.S. The foregoing instrument was on said :late subscribed at the end there~'.,f by ANNABEL C. DAVIS, the above named Testator who signed, publishe., and declared this instrument te be her Last Will and Testament in the presence of us and each of us, who ther~)',upon at her request, in her presence, and in the presence of each other, have hereunto subscribed our names as witn.'.sses thereto. We are of sound mind and proper age to witness a will and understand this to be her will, and to thil/~best of our knoWledge testator is ~,~f legal age to make 'a Will', of sound mindl and under no constraint or undue influe ~:e. BUR,e.~U OF ZNDTVTDUAL TAXES ZNHERTTANCE TAX D'rVTSTON DEPT. 180601 HARR'rSBURG, PA 17118-0601 JERED L HOCK HETZGER WICKERSHAH P 0 BOX 5300 CUT ALONG THZS LINE REV-X547 EX AFP COMMONWEALTH OF PENNSYLVANIA DEPARTHENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAZSEMENT, ALLO#ANCE OR DZSALLOHANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUHBER COUNTY ACN PA !17110-0300 12-02-2002 DAVIS OZ-OZ-200Z 21 02-0189 CUHBERLAND 101 Amount Rsmitted RE¥-1547 EX *'FP ANNABEL C HAKE CHECK PAYABLE AND REMIT PAYNENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 ~'~ RETAIN LOWER PORTION FOR YOUR RECORDS *-~ NOTICE OF INHERITANCE TAX APPRAZSENENT, ALLOWANCE OR ESTATE OF DAVIS DZSALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ANNABEL CFZLE NO. 21 02-0189 ACN 101 DATE 12-02-Z00~ TAX RETURN HAS: ( ) ACCEPTED AS FZLED RESERVATION CONCERNING FUTURE 'rNTEREST - SEE REVERS". (X) CHANGED SEE ATTACHED NOTICE APPRAISED VALUE OF RETURN BASED ON: OR'rG'rNAL RETURN 1. Real Estate {Schedule A) (1) 2. Stocks end Bonds (Schedule B) (2) 3. CloseZy Held Stock/Partnership Znterest (Schedule C) (3) q. Hortgages/Notes Receivable (Schedule D) (q} 5. Cash/Bank Deposits,Misc. Personal Property (Schedule E) ($} 6. Jointly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Tote/ Assets APPROVED DEDUCTIONS AND EXEHPTZONS: 9. Funeral Expanses/Ad.. Costs/M/sc. Expanses (Schedule H) (9) 10. Debts/Hortgage L/ab/1/t/es/L/ens (Schsdul. Z) (10} 11. Total D.duct/ons 2191q.00 .00 .00 NOTE: To /nsur. proper .00 credit to your account, .00 subm/t th. upper port/on .00 of this form w/th your tax Payment. .0O (8) 10,110.00 12. 13. 1~. NOTE: 3~995.00 (11) Net Value of Tax Return (12) Charitable,Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) Net Value of Estate Sub.~ect to Tax (1fi) Tf an assessment was issued previously, llnes 14, 15 and/or 16, 17, reflect figures that lnclude the total of .ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 1~+ at Spousal rate (1.6) 16. Amount of Line lq taxable at Lineal,Class A rats (16) 17. A.ount of L/ns lq at Sibl/ng rate (17) 18. A.ount of Line lq taxabl~ at Collateral/Class B rats (18) D/$COUNT (+~ INTEREST/PEN PAZD (-) 2,91q.00 l~.lflS.00 11,191.00- 19. Pr,nc/pal Tax Due TAX CREDZTS: PAYMENT I RECEt-p1 DATE NUMBER .O0 11,191.00- ( ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS REgUZRED. ZF TOTAL DUE ZS REFLECTED AS A "CREDZT' (CR), YOU NAY BE DUE A REFUND. SEE REVERSE SZDE OF THIS FORM FOR ZNSTRUCTZONS.) IF PAID AFTER DATE /NDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE AMOUNT PATD .°°/ .00 .00 .00 · O0 x O0 = . O0 · 00 x 0~5= .00 · O0 x 12 = .00 · 00 x 15 = .00 (1~)~ . O0 18 and 19 ~ill RESERVATION: PURPOSE OF NOTICE: PAYNENT: REFUND (CR): OBJECTIONS: ADNIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class 8 (collateral) beneficiaries of the decadent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the laaful Class 8 (collatera1) rate on any such future interest. To fulfill the requirements of Section Z1¢0 af the Inheritance and Estate Tax Act, Act Z3 of ZOO0. (TZ P.S. Section Detach the top portion of this Notice and submit aith your payment to the Register of Hills printed on the reverse side. --Make check or money order payable to: REGISTER OF HILLS) AGENT A refund of a tax credit, which was not requested on the Tax Return, may ba requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office of the Register of Wills, any of the Z5 Revenue District Offices, or by calling the special Z¢-hour answering service for forms ordering: 1-800-56Z-Z050; services for taxpayers with special hearing and / or speaking needs: 1-800-¢¢7-50Z0 (TT only). Any party in interest not satisfied with the appraisement, alloaance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue) Board of Appeals, Dept. Z81021) Harrisburg) PA I?IZB-IOZ1, OR --election to have the matter determined at audit of the account of the personal representative) OR --appall to the Orphans" Court. Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue) Bureau of Individual Taxes) ATTN: Post Assessment Review Unit, Dept. Z80601, Harrisburg) PA 171Z8-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-IS01) for an explanation of administratively correctable errors. If any tax due is paid within three (3) calendar months after the decedent's death, a five percent ESI) discount of the tax paid is allowed. The ISZ tax amnesty non-participation penalty is computed on the total of the tax and interest assessed) and nat paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you mould appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning aith first day of dailnquency, or nine (9) months and one (1) day fram the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (61) percent per annum calculated at a daiIy rate of .00016¢. All taxes which became delinquent an and after January 1, 1982 ell1 bear interest at a rate which will vary from calendar year to calendar year aith that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOOZ are: Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor 1982 ZOZ .0005¢8 199Z 9Z .000Z¢7 198~ 16Z .000¢38 1993-199¢ 7Z .O0019Z 198¢ llX .000301 1995-1998 9Z .000Z¢7 1985 152 .000356 1999 7X .000192 1986 ZOZ .000Z7¢ ZOO0 8Z .000219 1987 9Z .000Z¢7 ZOO1 9Z .000Z¢7 1988-1991 11Z .000501 ZOOZ 6Z .00016¢ --Interest is calculated as falloas: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAIL~Z IHTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (IS) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. REV-!?0 EX (C-tS)' INHERITANCE TAX COMMONWEALTH OF PENNSYLVANIA EXPLANATION DEPARTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG~ PA 17128-0601 DECEDENT'S NAME FILE NUMBER ANNABEL C DAVIS 2102-0189 REVIEWED BY John Kealy ACN 101 ITEM SCHEDULE NO. EXPLANATION OF CHANGES H B-3 Reduced to $2,914. Family exemption can only be claimed against assets subject to will or intestacy. ROW Page 1 STATUS REPORT UNDER RULE 6.12 Name of Decedent · Date of Death · Will No. 21-02-189 Annabel C. Davis February 2, 2002 Admin No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 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: ao Did the personal representative file a final account with the Court? Yes No X account is: bo The separate Orphans' Court No. (if any) for the personal representative's Co in interest? Yes Did the personal representative state an account informally to the parties X No do accounts may be filed with the Clerk of the Copies of receipts, releases, joinders and approvals of formal or informal ,2002 O~and may be attached to this report. Si ' r~e Name Jered L. Hock, Esquire Address 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 Telephone (717) 238-8187 Capacity: X __ Personal Representative __ Counsel for Personal Representative Document #: 244508.1