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Home My WebLink About02-0190Estate of ~Ieather M. also known as Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Kiraly No. ~/- O~fL- 190 200-64-2710 , Deceased Social Security No. Melinda A. Kiraly Petitioner(s), who is/are 18 years of age or older, apply(les) for: (COMPLETE 'A' or 'B' BELOW:) A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut__ the Decedent, dated and codicil(s) dated None named in the last Will of 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: 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 heirs: Name Relationship Residence (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland Mechanicsburg County, Pennsylvania with his/her last family or principal residence at 826 Rid~ewood Drive, Mechanicsbur~ (list street, number, and municipality) Decedent, then 16 years of age, died 12/13/2001 at Altoona, PA Decedent at death owned property with estimated values as follows: (If domiciled in PA) · All personal property (If not domiciled in PA) Personal property in Pennsylvania (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania (Location) $ Wronsful Death/S $ situated as follows: x~ ;~ , ~l I Melinda A. Kiraly _~ ~/~ _~ 826 Rid~ewood Drive, Mechanicsburs, 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 undersigned: I m Sic, lnature Typed or printed name and residence PA 17055 p~l~- ~J,,~..~_ 5. ,aBar Assoc,ation repared by tl'ie ~'ennsylvan' ' Copyright (c) 1996 form software only CPSystems, Inc. Form RW-1 0991) (L66L) I.-M~ mJo:~ · 3Ul 'suJeisASdO AlUO eJeM:~]os ~JJo~[ 966[ (3) iqS!JAdoo uoN~!oossy J~3 e!U~^l,(suued eql Xq peJedeJd 0 0 ' B E $ ......... ~¥.LO.L $ ........... Jeqlo $ .......... /dolue^uI OT.g/_ - OgL/LT.Z :euoqdelel 0 0 ' ~ $ .......... ee-t ~OLI ¥& 'II~H dumg $ ........... I)3)POO ~eea~S q~SI q~nos E0[ :sseJpp¥ [9~I9 :ON 'a'l $ .... ( ) selSed $ .... ( ) s~,!^ep!~¥ s~ue~ 'q ieeqoTN :XeuJo~¥ 0 0 ' g $ ........ uo!le!ounue~ O0'8L $ ..... (s)e~,e3!j!~eo ~oqs $ ........... sJe31e-I S33d luepe3ec] jo II!M 1SCl eq~, se pJo3eJ .to pal!.[ pue eleqoJd o; pea!~upe eq uoN!~,ed eLll u! peq!J3sep pemp (s)tue~umlsu! eq; leql pue em~se e^oqe eql u! ~I~l~.)~ '¥ ePUTIe~ ol pelueJ6 XqeJeq eJe (eie~.JOU!LU elueJnp '.e!luesqe elueJnp ~e~.l eluepued :'e'ro'u'q-p '.'e'r3) Uo!leJ1s!u!Lup¥ JO ~ X~elueu~eisel ~ sJeae~ leq1 Q33UO3Q SI 11 'eu~ eJojeq pelueseJd ueeq 5u!^eq jooJd X~oioejsNes 'uoeJeq ep!s esJe^eJ eq1 uo uo!~!ied eql jo A Jo X~ 8 L s!4~, euJ eJojeq ~ T~'~~ ~ peqposqns pue Pe~'uJ!~e ~° °1 UJ°MS '~el oq.v~,,,~ m, e3se eq~, ~e~s!u!uape ,(im~, pue Ile~ II!J (s)Jeuo!lNed '~,uepeoeo eq~, .~0 (s)e^ge3ueseJde~ leuosJed se '~eq~ pue (s)Jeuo!~,P, ed .~0 Je!leq pue e6pel~ou)t eq~, .~0 ~,seq eq~, ol ~3eJJ03 pul~ enn eJe uo!~g,ed 5u!oFieJol eq~, u! s~,ueuJm, e~,s eqi ~,eq~, (s~uJ!~e Jo (s)Jee~s peu~eu-e^oqe (s)Jeuo!~g, ed eq/ PUeI;[eqmnD lo Xiunoo e!ueAIJ(SUUed Jo q~,l.eJ~uomtuoo eA!lelueseJdeM leuosJed jo q ,eo 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 filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 7886108 No. Date DEC 1 7 2001 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH (Coroner) AGE (Last BiHIxlay) UNDER 1 YEAR Momh, Days 16 Y~' Student 826 Ridg~a:xxl Dr'ive Mechanicsburg, Pa 17055 Anthony Kiraly INFORMANT'S NA_ME (T2fbe/PrinQ Melinda Kiraly METHOD OF DISPOSITION Buelal [] Cremation [] RemovalfrmliState{~ [= Female ['.%~;CUR%~IUM~ER 2710 3ATEOFDEAT,{Mo~h. Oa¥.Yea,) [.,peo 30,1984l,' Altoona,Pa ~[] E,~ o~D "~ ,~.O ~erland ~ ~. ~ ~ 1~.~. ,,. ~l~a ~li~ ~icsb~. Pa 1705~ ~t ~~g ~to~,,,./ ~isb~, Pa ~E ~*~ OF ~c,t~ 011654-h TIME OF INJURY WAS AN AU~SY DATE O~ INJURY PERFORMED? , Year) COMPLETION OF CAUSE ~ ~m~ ~. ~ ~ 0 ~. ~ ~ 0 RACE - Amedom~ Indian. Black[, White, etc. ~oec~y) INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. · 21-02-190 Register of Wills of Cumberland County, Pennsylvania Estate of Heather M. Kiraly also known as RENUNCIATION , Deceased No. ~/-O.2- lC/C) The undersigned, Anthony Kiraly, Father (Relationship) (Capacity) the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters be issued to Melinda A. Kiraly WITNESS of (Address) (Signature) (Address) (Signature) (Address) Sworn to or affirmed and subscribed before me this /~ -~ day My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) Robin H Jenkins My Commission DD084550 Expires January 15, 2006 NOTE: Renunciations executed outside the Office of Register of Wills in some counties are required to be notarized. Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form #RW-4 (1991) CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: HEATHER M. KIRALY Date of Death: Will No.: DECEMBER 13, 2001 Admin. No: 21-02-0190 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 March 1, 2002: NAME ADDRESS Melinda A. Kiraly Anthony Kiraly 826 Ridgewood Drive, Mechanicsburg, PA 17055 5722 South Newton Avenue, St. Petersburg, FL 33707 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: none. Date: I Capacity: Michael L. Bangs, Att~mqy-at-Law 302 South 18th Street, 13~,gvhp Hill, PA 17011 (717) 730-7310 Counsel for Personal Representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 05-01-2003 Michael L Bangs, Esquire 302 South 18th Street Camp Hill, PA 17011 717-793-0972 Re: Estate of Heather M Kiraly File Number 2102-0190 Court Number: Cumberland-Orphans-2102-0190 Dear Mr. Bangs: The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 16 year old decedent died as a result of a motor vehicle accident. The sole heirs to decedent's estate are her parents. Therefore, any proceeds paid to settle the survival action would pass to decedent's parents and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(1.2). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $12,600.00 to the wrongful death claim and $1,400.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death / survival action. cc: ~berlandC~ountYC[k..~k of Orphans Courts[/~ Sincerel~y, Bureau of Individual Taxes 6/27/2002 Michael L Bangs, Esquire 302 South 18th Street Camp Hill, PA 17011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 717-793-0972 Re: Estate of Heather M Kiraly File Number 2102-0190 Court Number: Cumberland-Orphans-2102-0190 Dear Mr. Bangs: The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 16 year old decedent died as a result of a motor vehicle accident. The sole heirs to decedent's estate are her parents. Therefore, any proceeds paid to settle the survival action would pass to decedent's parents and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(1.2). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 90,000.00 to the wrongful death claim and $10,000.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merrgman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death / survival action. cc: Cumberland County Clerk of Orphans Courts ~~~Sincerely' ~ ~ Bureau of Individual Taxes BUREAU OF ZNDZVZDUAL TAXES INHERZTAHCE TAX DZVTSTON DEPT. 280601 HARR][SBURG, PA 171Z8-0601 MICHAEL L BANGS $02 S 18TH ST CAMP HILL COMMONWEALTH OF PENNSYLVANZA DEPARTMENT OF REVENUE NOTZCE OF ZNHERZTANCE TAX APPRAZSEMENT, ALLO#ANCE OR DZSALLOHANCE OF DEDUCTZONS AND ASSESSMENT OF TAX REV-l;47 EX AFP C01-05) PA ~ 17011 DATE ESTATE OF DATE OF DEATH FZLE NUMBER COUNTY ACN 12-01-Z005 KIRALY 12-15-2001 21 02-0190 CUMBERLAND 101 Amount RaeJ. tted HEATHER M MAKE CHECK PAYABLE AND REM/T PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THZS LXNE ~ RETAZN LOWER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03} NOTZCE OF ]:NHERZTANCE TAX APPRAZSEHENT, ALLOWANCE OR DZSALLOWANCE OF DEDUCTZONS AND ASSESSMENT OF TAX ESTATE OF KIRALY HEATHER MFZLE NO. 21 02-0190 ACN 101 DATE 12-01-Z005 TAX RETURN NAS: (X) ACCEPTED AS FZLED { ) CHANGED RESERVATZON CONCERNZNG FUTURE ZNTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate {Schedule A} 2. Stocks and Bonds (Schedule $. Closely Held Stock/PartnarshLp /ntarast (Schedule C) ($) q. Mortgages/Notes Reca/vabla (Schedule D) (q) 5. Cash/Bank DaposLts/Misc. Personal Property (Schedule E) (5) 6. Jo/ntly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTZONS: 9. Funeral Expensas/Adm. Costs/M/sc. Expanses (Schedule H} (9) 10. Debts/Mortgage L/ab/1/~ias/Lians (Schedule Z) (10) 11. Total Deductions 12. Nat Value of Tax Return 13~550.00 .00 .00 NOTE: To /nsure proper .00 credit to your account, .00 subm/t the upper portion .00 of th/s fora with your tax payment. .0O 1:5,550. O0 8,5q3.07 .00 (11) 6,5~3.07 (la) 5,006.95 13. lq. NOTE: CharLtable/Govarnmantal Bequests; Non-elected 9115 Trusts (Schedule J) (15) . O0 Nat Value of Estate Sub.~act to Tax (lq) 5,006.9~ 1~: an assessment ~as issued previously, lines 14, 15 and/or 16, 17, 18 and 19 ~111 reflect figures that include the total of ALL returns assessed to date. (1.~) 5,006.9:5 x O0 = .00 (z6) .00 X Oq5= .00 (17) . O0 x 12 = . O0 (z8). .00 x 15 = .00 (19)= . O0 AMOUNT PAZD ASSESSMENT OF TAX: 15. Amount of L/ne lq at Spousal rata 16. Amount of L/ne lq taxable at Lineal~Class A rata 17. Amount of L/ne lq at Sibl/ng rata 18. Aaount of Ltna lq taxable at Collateral/Class B rata 19. Pr/ncipal Tax Due TAX CREDITS: PAYMENT RECE/PT DZSGOUNT (+) DATE NUMBER INTEREST/PEN PAID (-) IF PAID AFTER DATE /NDICATED, SEE REVERSE FOR CALCULAT/ON OF ADDITZONAL ZNTEREST. TOTAL TAX CREDZT I .00 BALANCE OF TAX DUEl . O0 ZNTEREST AND PEN. .00 TOTAL DUE . O0 ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT 'rS REQU'rRED. 'rF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE S'rDE OF TH'rS FORM FOR /NSTRUCTIONS.) RESERVATION: PURPOSE OF NOTICE= PAYNENT: REFUND (CR): OBJECTIONS: ADHIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December IZ, 198Z -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonmealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. To fulfill the requirements of Section gl¢O of the Inheritance and Estate Tax Act, Act Z$ of ZOO0. (72 P.S. Section 91¢03. Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side. --Make check or money order payable to: REGIETER OF NZLLS, AGENT A refund of a tax credit, ahich was not requested on the Tax Return, amy be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1315). Applications are available at the Office of the Register of Hills, any of the Z$ Revenue District Offices, or by calling the special Z¢-hour snseering service for fores ordering: 1-BOO-$BZ-ZOSO; services for taxpayers aith special hearing and / or speaking needs: 1-BOO-¢¢7-3OZO (TT only}. Any party in interest net satisfied with the appraisement, alloeance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (603 days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of AppeaIs, Dept. 2810Zl, Harrisburg, PA 171ZB-ZDZ1, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal 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. lB0601, Harrisburg, PA 171Z8-0601 Phone (717) 767-6S05. 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 (SZ) discount of the tax paid is allowed. The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not 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 es you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the data of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .00016¢. All taxes which became delinquent on and after January 1, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2003 are: Interest Daily Interest Daily Znterest Daily Year Rate Factor Yea.~r Rate Factor Year Rate Factor 1982 ZOZ .OOOSCB 1987 9Z .000Z¢7 1999 7Z .00019Z 19&3 16Z .000¢38 1988-1991 XXZ .000301 ZOO0 8Z .000Z19 198¢ 112 .OOO301 199Z 9Z .000Z¢7 ZOOZ 92 .O00Zq? 1985 15Z .OO0~S6 1993-199¢ 7Z .00019Z 200Z 6g .00016¢ 2986 lOX .000Z7¢ 1995-1998 9Z .000Z¢7 ZOO3 SZ .000137 --Interest is calculated as follows: ZNTEREST= BALANCE OF TAX UNPAID X NUNBER OF DAYS DELZNQUENT X DAZLY ZNTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (1S) days beyond the date of the assessment. Zf payment is made after the interest computation date shown on the Notice, additional interest must be calcuIated. KIRALY PETITION / DISK 57 IN RE: ESTATE OF HEATHER M. KIRALY, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-02-0190 AND NOW this ~ of the Petition for Compromise or Settlement of Survival Action, it is hereby ordered and directed that the Petition is GRANTED. BY THE COURT, ORDEj~s a.__..,~ __ day of ,2003, upon review KIRALY PETITION / DISK 57 KIRALY PETITION / DISK 57 IN 1~,: ESTATE OF HEATHER M. KIRALY, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION AND NOW comes the Administratrix of the Estate of Heather M. Kiraly, Melinda A. Kiraly, by and through her attorney Michael L. Bangs, Esquire, and petitions the Court based upon the following: 1. The Decedent is Heather M. Kiraly who died in a motor vehicle accident on December 13,2001, at the age of sixteen and whose residence upon death was 826 Ridgewood Drive, Mechanicsburg, Cumberland County, Pennsylvania. The Decedent died intestate. 2. The Administratrix of the Estate is Decedent's mother, Melinda A. Kiraly, who was appointed as Administratrix on February 21, 2002, by Letters of Administration, said Letters of Administration having been duly advertised. Attached hereto and marked as Exhibit A are true and correct copies of the Certificate of Grant of Letters of Administrations and proofs of publication. PETITION FOR COMPROMISE OR SETTLEMENT OF SURVIVAL ACTION NO. 21-02-0190 K1RALY PETITION / DISK 57 while operating it in Cambria County, Pennsylvania, in Munster Township while traveling east on State Route 22. As a result of the accident, another individual along with Decedent was killed and two others were seriously injured. 7. Erie Insurance Group provided underinsurance motorist coverage for the Administratrix, Melinda A. Kiraly, which covered the Decedent in the amount of $100,000. Previously, this Court approved an Order for Compromise of those policy limits, the said Order dated July 24, 2002, which provided for distribution of those particular proceeds. 8. The defendant driver had a policy of insurance through Ohio Casualty Group in the amount of $50,000. The $50,000 is subject to four (4) different claims, one by the Administratrix of Decedent herein; a claim by the Estate of Bradley Landis, the other individual who died in the accident; a claim by Charles Montgomery who was injured in the accident; and a claim by Michael Hann who was injured in the accident. All parties are represented by counsel and the parties have reached a resolution of the distribution of the policy limits in the following amounts: A. Estate of Heather M. Kiraly B. Estate of Bradley Landis C. Charles Montgomery D. Michael Hann $14,000 $14,000 $12,000 $10,000 $50,000 9. Attached hereto and marked as Exhibit B is a proposed breakdown of the $14,000 proceeds, less counsel fees and expenses, plus a proposed apportionment between the survival action and the wrongful death action. KIRALY PETITION / DISK 57 10. Attached hereto and marked as Exhibit C is a true and correct copy of a letter of approval from the Department of Revenue authorizing the apportionment between the survival action and the wrongful death action. WHEREFORE, Petitioner requests this Honorable Court to approve this Compromise or Settlement of Survival Action in the amounts listed herein. Respectfully submitted, MICH/[EL L. BANGS Attorney for Petitioner 302 South 18th Street Camp Hill, PA 17011 (717) 730-7310 Supreme Court ID #41263 KIRALy PETITION / DISK 57 VERIFICATION I hereby verify that the statements made in the foregoing Petition are tree and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unswom falsification to authorities. Date: ME][,IIqDA A. KIP~L5/, ~,d~inistt.~a~rix of the Estate of Heather M. Kiraly KIRALY PETITION / DISK 57 EXHIBIT A Certificate of Grant of Letters of Administration Proofs of Publication of Letters of Administration '~~' ' "' I I i I I~ llll II IIIIII STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND SHORT CERTIFICATE I, MARY C. LEWIS Register for the Probate of Wills and Granting Letters of Administration &c. in and for said County of CUMBERLAND do hereby certify that on the 21st day of February A.D., Two Thousand and Two, Letters of ADMINISTRATION in common form were granted by the Register of said County, on the estate of KIRALY HEATHER M , late of HAMPDEN TOWNSHIP in said county, deceased, to KIRALY A MELINDA IN TESTIMONY WHEREOF, of said office at CARLISLE, ~.D., Two Thousand and Two. and that same has not since been revoked. I have hereunto set my hand and affixed the seal PENNSYLVANIA, this 21st day of February 2002-00190 21-02-0190 12/12/2001 200-64-2710 File No. PA File No. Date of Death s.s. # Register NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL State of Pennsylvania, County of Cumberland. PROOF OF PUBLICATION Lori Saylor, Classified Advertising Manager of THE SENTINEL, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following dates, viz Copy of Notice of Publication ~ADMiNISTRATION ~)'n?. '.the'Estate ~f HEATHEB~; M, KIRALY, late of ' j Hampden ~ownship, ', '~c00n~ of Cbmberland/~' Pennsylvania d~eased, were granted to ;, , MELINDA A;, KIRAL~;. odFebrua~21 2002:~ ?: themselves t0 be indebt; ed to ~id.Estate are ':~: requested to make ':~ immed ate payment,," ~ah'd thbSe' having claim's will p~esent them, without delay, to the ~ ;' a26RidgeWsod Drive ' Mechanicsburg, PA 17055 '~. ~ . ~ Michael L. Bangs, .~ ~ ~' A~orney-at~Law 302 South 18th Street Camp Hill, PA 17011 March 7, 14 & 21,2002 Affiant further deposes that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. March 27, 2002 Sworn to and subscribed before me this 27th day of March ,2002. Notary Public My commission expires: [SHIRLEY ~)?~AL ~AL S/:,~I Carlisle Boro., Oumberiand Ccur tv My Commission Expires Auq 9 20~'~~ PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 STATE OF PENNSYLVANIA : : COUNTY OF CUMBERLAND : SS. Roger M. Morgenthal, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: MARCH 15, 22, 29, 2002 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Kiraly, Heather M., dec'd. Late of Hampden Township. Admirdstratrix: Melinda A. Kiraly, 826 Ridgewood Drive, Mechan- icsburg, PA 17055. Attorney: Michael L. Bangs, At- torney-at-Law, 302 South 18th Street, Camp Hill, PA 17011. '~Ed t' Roger M Morgentha, i or SWORN TO AND SUBSCRIBED before me this 29 day of MARCH, 2002 LOIS E. SNY~EP-, K1RALY PETITION / DISK 57 EXItlBIT B Proposed Breakdown and Apportionment of Proceeds Proceeds from Ohio Casualty Group Counsel fees: Michael L. Bangs, Esquire (contingent fee of 25%) Costs: Register of Wills (filing fee for Petition) Apportionment: 90% Wrongful Death Action 10% Survival Action $14,000.00 ($3,5oo.oo) ($39.00) $10,461.00 $9,414.90 $1,046.10 KIRALY PETITION / DISK 57 EXHIBIT C Letter of Authorization from Department of Revenue COMMONWEALTH OF PENNSYLVANIA DEPARTMENT bF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 05-01-2003 Michael L Bangs, Esquire 302 South 18th Street Camp Hill, PA 17011 717-793-0972 Re: Estate of Heather M Kiraly File Number 2102-0190 Court Number: Cumberland-Orphans-2102-0190 Dear Mr. Bangs: The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 16 year old decedent died as a result of a motor vehicle accident. The sole heirs to decedent's estate are her parents. Therefore, any proceeds paid to settle the survival action would pass to decedent's parents and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(1.2). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $12,600.00 to the wrongful death claim and $ 1,400.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death / survival action. cc: Cumberland County Clerk of Orphans Courts Inheritance Tax Division Bureau of Individual Taxes IN RE: ESTATE OF HEATHER M. KIRALY, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-02-0190 ORDER AND NOW, thisbe_ d~av of A~n Petition for Compromise or Settlement of Survival ., 2002, upon review of the it is hereby ordered and directed that the Petition is GRANTED. BY THE COURT, KIRALY COMPROMISE OF SE'VFLEMENT PETITION / DISK 46 / JUNE 20. 2002 ESTATE OF HEATHER M. KIRALY, Deceased JUL 1 7 2002 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-02-0190 PETITION FOR COMPROMISE or SETTLEMENT OF SURVIVAL ACTION AND NOW comes the Administratrix of the Estate of Heather M. Kiraly, Melinda A. Kiraly, by and through her attorney, Michael L. Bangs, Esquire, and petitions the Court based upon the following: 1. The Decedent is Heather M. Kiraly who died in a motor vehicle accident on December 13, 2001, at the age of sixteen (16) and whose residence upon death was at 826 Ridgewood Drive, Mechanicsburg, Cumberland County, Pennsylvania. The Decedent died intestate. 2. The Administratrix of Decedent's estate is her mother, Melinda A. Kiraly who was appointed as the Administratrix on February 21, 2002 by Letters of Administration, said Letters of Administration having been duly advertised. Attached hereto and marked as Exhibit A is a true and correct copy of the Certificate of Grant of Letters of Administration and Proofs of Publication. 3. The Decedent was a sixteen-year-old minor and student at the time of her death. 4. The sole potential heirs of the estate are her mother, Melinda A. Kiraly, and potentially her father, Anthony Kiraly. 5. There are no creditors who have or made claims against the estate. 6. The facts and circumstances constituting the cause of action are that the Decedent was a passenger in a vehicle driven by Mark J. Shannon. Mr. Shannon lost control of his vehicle KIRALY COMPROMISE OF SETTLEMENT PETITION / DISK 46 / JUNE 20. 2002 while operating it in Cambria County, Pennsylvania, in Munster Township while traveling East on State Route 22. As a result of the accident, another in'dividual along with Decedent was killed and two others were seriously injured. 7. Erie Insurance Group provided an underinsured motorist coverage for the Administratrix, Melinda A. Kiraly, which covered the Decedent in the total amount of $100,00.00. Erie has tendered the policy limits. Attached hereto and marked as Exhibit B is a true and correct copy of that letter. 8. The only other source of potential insurance coverage is a $50,000.00 policy which covered the driver's vehicle. Currently, all parties are negotiating a resolution of those policy limits and they will be the subject of another Petition before this Court when that is resolved. 9. Attached hereto and marked as Exhibit C is a proposed breakdown of the total proceeds less counsel fees and expenses, plus a proposed apportionment between the survival action and the wrongful death action. 10. Attached hereto and marked as Exhibit D is a true and correct copy of a letter of approval from the Department of Revenue authorizing the apportionment between the survival action and wrongful death action. WHEREFORE, Petitioner requests this Honorable Court to approve this Compromise or Settlement in the amounts listed herein. ~'/i/'~{/~~ Respectfully sub;itted,~ .,/ MICHAEL L. BANG',$,494ct26'3') Attorney for Petitio/n~? 302 South 18th Str~eei, Camp Hill, PA 17011 (717) 730-7310 KIRALY COMPROMISE OF SETTLEMENT PETITION / DISK 46 / JUNE 2{). 20{)2 VERIFICATION I hereby verify that the statements made in the foregoing document are true and correct. understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. Date: STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND estate of KIRALY HEATHER M in said county, deceased, to SHORT CERTIFICATE MARY C. LEWIS Register for the Probate of Wills and Granting Letters of Administration &c. in and for said County of CUMBERLAND do hereby certify that on the 21st day of February A.D., Two Thousand and Two, Letters of ADMINISTP~ATION in common form were granted by the Register of said County, on the , late of HAMPDEN TOWNSHIP KIRALY A MELINDA (J.-,.A.~'I', ~'1~'1', and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 21st day of February A.D., Two Thousand and Two. 2002-00190 21-02-0190 12/12/2001 200-64-2710 File No. PA File No. Date of Death s.s. # Register NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 STATE OF PENNSYLVANIA : COUNTY OF CUMBERLAND : SS. Roger M. Morgenthal, Esquire, Editor of the Cumberland La;v Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, , MARCH 15,22,29,2002 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Kiraly, }leather M., dec'd. Late of Hampden Township. Administratrix: Mellnda A. Kiraly, 826 Ridgewood Drive, Mechan- icsburg, PA 17055. Attorney: Michael L. B~mgs, At- torney-at-Law. 302 Sotlth lSth Street, Camp Hill, PA 17011. oger M Morgenthal, Editor SWORN TO AND SUBSCRIBED before me this 29 day of MARCH, 2002_ State of Pennsylvania, County of Cumberland. PROOF OF PUBLICATION Lori Saylor, Classified Advertising Manager .of THE SENTINEL, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following dates, viz Copy of Notice of Publication ' ESTATE NOTICE L~ETTERS OF , , , ADMINISTRATION On · ' the Estate of HEATHEB M, KIRALY, late of ' '/ Hampden Township, ': CoUnty of Cumberland~ Pennsylvania, deceased, were granted to · MELINDA A; KIRALY on February 21,2002. · ~ All persor~s knowing themselves to be indebt- ed to s, aid Estate are requested to make immediate payment, and those having claims will p~esent them, without delay,, to the, undersignea. Melinda A. Kiraly . · 826 Ridgew0od Drive ' Mechanicsburg, PA 17055 Michael L. Bangs, .~ ~ · Attorney.at. Law · 302 South 18th Stre¢ ' Camp Hill, PA 170 March 7, 14 & 21,2002 Affiant further deposes that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. March 27, 2002 Sworn to and subscribed before me this 27th day of March ,2002. Notary Public My commission expires: _ NOTARIAL SHIRLEY O. DURNIN, i~u[~,rj Pub;lc Carlisle Boro., Cumberiand STEVEN L. METZLER, AIC, AIM Assistant Vice President and Branch C~aims Mana6er ERIE INSURANCE GROUP Branch Office · 4901 Louise Dr. · Rossmoyne Business Center · P.O. Box 2013 · Mechanicsburg, PA 1705.5-0710 (717) 795.8200 · Toll Free 1-800-382-1304 · Fax (717) 795-2315 - http://www.erie-insurance.com Date: April 23, 2002 Michael Bangs, Esquire Law Offices 302 S. 18th Street Camp Hill, PA 17011 Erie Claim #: Erie Insured: Date of Loss: Your Client: 010170593069 Melinda'Kiraly 12/31/2001 Estate of Heather Kiraly Dear Mr. Bangs: I am sending this in regard to your above referenced client. Please be advised that at this time Erie is in a position to offer the $100,000.00 underinsured motorist policy limits from Melinda Kiraly's policy numbered Q051008837 as settlement of your client's claim under that policy. As I am sure you are aware, we will require the settlement to be court approved. I have enclosed a copy of our proposed release as well. ' Please have your client properly execute the release and return it to my attention along with a copy of the court approval for issuance of the settlement check. Per your request, we have also set up a claim under policy Q042203600, issued to William Agnew, Jr., and that claim number is 010170609990. I will also be handling that file, and at this point we are investigating policy coverage. I have enclosed copies of the policy and UIM endorsement for Mr. Agnew. I would request that you please send me confirmation from the primary care physician as to the health of Heather Kiraly prior to the accident. Claim Representative (717) 795-2251 The ERIE Is Above All In SERvIcE~ Since 1925 KIRALY COMPROMISE OF SETTLEMENT PETITION / DISK 46 / JUNE 20, 2002 EXHIBIT C Proceeds from Erie Insurance Group Apportionment: 90% to Wrongful Death Action 10% to Survival Action Counsel fees 25% to Michael L. Bangs, Esquire Costs Register of Wills (probate fees) Cumberland Law Journal (advertising of Grant of Letters) The Sentinel (advertising of Grant of Letters) $100,000.00 ($25,000.00) ($36.00) ($75.00) ($97.07) 6 6/27/2002 Michael L Bangs, Esquire 302 South 18th Street Camp Hill, PA 17011 COMMONWEALTH Of PENNSYLVANIA DEPAI~TMEN¥ OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 717-793-0972 Dear Mr. Bangs: Re: Estate of Heather M Kiraly File Number 2102-0190 Court Number: Cumberland-Orphans-2102-0190 The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 16 year old decedent died as a result of a motor vehicle accident. The sole heirs to decedent's estate are her parents. Therefore, any proceeds paid to settle the survival action would pass to decedent's parents and would be subject to a zero percent inheritance tax rate. 72 P.S. {}9116(a)(1.2). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 90,000.00 to the wrongful death claim and $ 10,000.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. {}8302; 72 P.S. {}{}9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death / survival action. cc: Cumberland County Clerk of Orphans Courts Bureau of Individual Taxes Register of Wills of County, Pennsylvania INVENTORY Estate of Heather M. Kiraly also known as , Deceased No. 21-02-0190 Date of Death 12/13/2001 Social Security No. 200 - 64- 2710 Melinda A. Asnew, Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/VVe understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Attorney: Michael L. Bangs I.D. No.: 41263 302 South 18th Street Personal Representative Signature: Melznda A. Agnew Signature: Address: Telephone: Camp Hill, PA 17011 717/730-7310 Address: Telephone: 826 Ridsewood Drive Mechanicsbur8, PA 17055 717/729-1619 Dated: Description (See continuation page(s) attached) (Attach additional sheets if necessary) Value Total: 13,550.00 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form #RW-7 (199Z) Estate of: Date of Death: County: INVENTORY Heather M. Kiraly 12/13/2001 Cumberland CASH: Erie Insurance First Party Benefits Erie Insurance - Proceeds from Survival Action Ohio Casualty - Proceeds from Survival Action 5,000.00 7,500.00 1,050.00 TOTAL RECEIPTS OF PRINCIPAL ............... 13,550.00 13,550.00 REV- 1500 EX + (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE CA HP EP CR KO C O R R E S R E C A P I T U L A T I O N C O M T I 0 DEPTiZ80601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER 21-02-0190 COUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 200-64-2710 HARRISBURG, PA 171Z8-0601 T DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Kiraly Heather M. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 12/13/2001 01/01/1985 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) I~1' Original Return ~ 247! Supplemental Return 13 B 4. Limited Estate Future lnterest Compromise (date of deathafter 1Z-lZ-8Z) RL ' I O 6. Decedent Died Testate Decedent Maintained a Living Trust TKA C (Attach copy of Will) (Attach copy of Trust) E S J XI 9. Litigation Proceeds Received I 110. Spousal Poverty Credit (date of death between 1;'-31-91 and 1-1-95) THIS RE'rURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER (date of death 3. Remainder Return priorto 1Z-13-8Z) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes Election to tax under Sec. 9113(A) (Attach ScL O) NAME Michael L. Bangs FI R M NAM E (I f Applicable) TELEPHONE NUMBER 717/730-7310 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or (3) Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) [] Separate Billing Requested 7. Inter-Vivos Transfers 8, Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. 14. COMPLETE MAILING ADDRESS 302 South 18th Street Camp Hill, PA 17011 None N:m~e None None 13,550.00 None None ,:.-: 8,543.07 None Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) Net Value Subject to Tax (Line 12 minus Line 13) (8) (11) (12) (13) OFFICIAL USE ONLY 13,550.00 8,543.07 5,006.93 (14) 5,006.93 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) 5,006.93 X .0 0 (15) 16. Amount of Line 14 taxable at lineal rate 0.00 X .0 45 (16) 17. Amount of Line 14 taxable at sibling rate 0.00 X .12 (17) 18. Amount of Line 14 taxable at collateral rate O. 00 X .15 (18). 0.00 0.00 0.00 0.00 19. Tax Due (19) O. 00 Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 826 Rid~ewood Drive CITY STATE ZIP Mechanicsbur8 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount PA 17055 (1) 0.00 Total Credits(A+B+C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + 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) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 0. O0 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 b. retain the right to designate who shall use the property transferred or its income; ........... ' c. retain a reversionary interest; or .................................... d. receive the promise for life of either payments, benefits or care? .................. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................ [] ~-~ Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................ ~ J--~ 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 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATUF}EOFPERSONE{ESPONSIBLEFORFILIN~RE-'~URN Melinda A. Agnew DATE ~~~~) ~'~/) _ _ _8_2_ _~_ ~ ~_ _d$_e_¥ _o_o~ _ _D~_, ve ~/ /~ Mechanicsburs, P~--k-f6~- .................... '~ J S;~GNATUREOFPREPARERO~HERTHANREPRESENTATIVE~ Michael L. Bangs DATE .........................-- F~0; C~ate's C~f'd;'~ '~r'affer' ~July 11 ;1994 and before January 1, 1995, the tax rate' imposed On the net value'of ~r~ansie;S t0' or ~0r the uSe'of th; .... surviving spouse is 3% [72 P.S. 9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after 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 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2) [72 P.S. 9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(aX1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (c) ZOO0 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) REV-1508 EX + (1-97) COMMONWEALTHOFPENNSYLVANIA INHERITANCETAXRETURN RESlDENTDECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Heather M. Kiraly SSf/ 200-64-2710 12/13/2001 21-02-0190 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owne4 with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 3 DESCRIPTION Erie Insurance First Party Benefits Erie Insurance - Proceeds from Survival Action Total recovery of $100,000.00 allocated 90% to Wrongful Death Action and 10% to Survival Action or $10,000.00. Less proportionate share of counsel fees (25% or $2,500.00). Total net to Survival Action equals $7,500.00. (See Petition attached with Order of Court dated 7/24/02) Ohio Casualty - Proceeds from Survival Action Total recovery of $1,400.00 less proportionate counsel fees (25% or $350.00) equals net to Survival Action of $1,050.00. TOTAL(AlsoenteronlineS, Recapitulation) $ (Ifmorespaceisneeded, inse~additionalshee~ofthesamesize) VALUE AT DATE Of DEATH 5,000.00 7,500.00 1,050.00 13,550. O0 Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev, IN iKE: ESTATE OF HEATHER M. KIRALY, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-02-0190 ORDER AND NOW, this _'2..l-4-T~day of_ .I-I.kJ.,L/. 2002, upon review of the , Petition for Compromise or Settlement of Survival Action, it is hereby ordered and directed that the Petition is GRANTED. BY THE COURT, K IRAL Y COMPROMISE OF SE'i-FLEMENT PETITION / DISK 46 / JUNE IN R.E,: ESTATE OF HEATHER M. KIRALY, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-02-0190 PETITION FOR COMPROMISE or SETTLEMENT OF SURVIVAL ACTION AND NOW comes the Administratrix of the Estate of Heather M. Kiraly, Melinda A. Kiraly, by and through her attorney, Michael L. Bangs, Esquire, and petitions the Court based upon the following: 1. The Decedent is Heather M. Kiraly who died in a motor vehicle accident on December 13, 2001, at the age of sixteen (16) and whose residence upon death was at 826 Ridgewood Drive, Mechanicsburg, Cumberland County, Pennsylvania. The Decedent died intestate. 2. The Administratrix of Decedent's estate is her mother, Melinda A. Kiraly who was appointed as the Administratrix on February 21, 2002 by Letters of Administration, said Letters of Administration having been duly advertised. Attached hereto and marked as Exhibit A is a true and correct copy of the Certificate of Grant of Letters of Administration and Proofs of Publication. 3. The Decedent was a sixteen-year-old minor and student at the time of her death. 4. The sole potential heirs of the estate are her mother, Melinda A. Kiraly, and potentially her father, Anthony Kiraly. 5. There are no creditors who have or made claims against the estate. 6. The facts and circumstances constituting the cause of action are that the Decedent was a passenger in a vehicle driven by Mark J. Shannon. Mr. Shannon lost control of his vehicle KIRALY COMPROMISE OF SETTLEMENT PETITION / DISK 46 / JUNE while operating it in Cambria County, Pennsylvania, in Munster Township while traveling East on State Route 22. As a result of the accident, another individual along with Decedent was killed and two others were seriously injured. 7. Erie Insurance Group provided an underinsured motorist coverage for the Administratrix, Melinda A. Kiraly, which covered the Decedent in the total amount of $100,00.00. Erie has tendered the policy limits. Attached hereto and marked as Exhibit B is a true and correct copy of that letter. 8. The only other source of potential insurance coverage is a $50,000.00 policy which covered the driver's vehicle. Currently, all parties are negotiating a resolution of those policy limits and they will be the subject of another Petition before this Court when that is resolved. 9. Attached hereto and marked as Exhibit C is a proposed breakdown of the total proceeds less counsel fees and expenses, plus a proposed'apportionment between the survival action and the wrongful death action. 10. Attached hereto and marked as Exhibit D is a true and correct copy of a letter of approval from the Department of Revenue authorizing the apportionment between the survival action and wrongful death action. WHEREFORE, Petitioner requests this Honorable Court to approve this Compromise or Settlement in the amounts listed herein. Respectfully submitted, , ?-') MICHAEL L. BANG'~(~M~D26~) Attorney for Petitio~r.-' ' 302 South 18th St~, Camp Hill, PA (717) 730-7310 17011 VERIFICATION I hereby verify that the statements made in the foregoing document are true and correct. understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. 09. 3 KIRALY COMPROMISE OF SETTLEMENT PETITION / DISK .161 JUNE EXHIBIT A STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND SHORT CERTIFICATE I, MARY C. LEWIS Register for the Probate of Wills and Granting Letters of Administration &c. in and for said County of CUMBERLAND do hereby certify that on the 21st day of February A.D., Two Thousand and Two, Letters of ADMINISTRATION in common form were granted by the Register of said County, on the estate of KIRALY HEATHER M late of HAMPDEN TOWNSHIP in said county, deceased, to ~IRALY A MELINDA [Lu~'l', ~'i~Sl~, MIUU~) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 21st day of February A.D., Two Thousand and Two. 2002-00190 21-02-0190 12/12/2001 200-64-2710 File No. PA File No. Date of Death s.s. # Register NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L. 1784 STATE OF PENNSYLVANIA : COUNTY OF CUMFIERLAND : SS. Roger 5I. M'orgenthal, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberlanc~ Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and ciesignated by the local courts as the official le al periodical for the publication of all legal notices, and has, since January 2, 1952, been regularl ~, issued weekly in the said County, and that the printed notice or publication attached hereto is ' exactly' the same as was printed in the regular editions and issues of the said Cumberland Law Jourrml on the folloxving dates, viz: MARCH 15, 22,.__~29, 2002 Affiant further deposes ti'mt he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not irtterested in the subject matter of the aforesaid nodce or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true.. IGraly, Heather M., dec'd. l~m: of FlaJnpdcn Township. Admimslratrix: Mellnda A. Ktraly. 82(3 RMgewood Drive. Mechan. icsl)~rg PA 17055. AIIorHey: Michael l.. lhlngs. At- torney-at-Law. 302 South 18th SIreet, Camp Hill. PA 17011. ger M Morgenthal, Editor SWORN TO AND SUBSCRIBED before me this _ 29 day of_ MARCH, 2002 State of Pennsylvania, County of Cumberland. PROOF OF PUBI'ICATION Lori Saylor, Classified Advertising Manager _of THE SENTINEL, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following dates, viz Copy of Notice of Publication ADMINISTRATION on · Ihe Estate of HEATHEB M. KIRALY, late of Hampden Township, ." County of Cumberland, Pennsylvania, deceased, were granled to MELINDA A, KIRALY on February 21,2002, ·. Allpersons knowing · themselves to be Indebt- ~ '~ed to s,aid Eslate are i requested Io make i immediate payment, and those having claims i will present them, wilhout delay, to the undersigned, i Melinda A. KIraly ' 826 Ridgewood Drive · i Mechanicsburg, PA 17055 Michael L. Bangs, · Attorney-at,Law/ 302 South 18th Strew' Camp Htll, PA 170 : . March 7, 14 & 21,2002 Affiant furthe'~ deposes that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true, March 27, 2002 Sworn to and subscribed before me this 27th day of March ,2002. / Notary Public My commission expires: J Carlisle Bore., Cumberiond Co~?~ J STEVENL METZLER A$slslanl Vice President and 8ranch Claims ERIE INSURANCE GROUP Branch Office · 4901 Louise Dr. , Rossmoyne Business Center , P.O. Box 2013 · Mechanicsburg, PA 17055-07 t0 (717) 795-8200 · Toll Free 1-800-382-1304 · Fax (717) 795-2315 · http://VcWW, erie-insurance.com Date: April 23, 2002 Michael Bangs, Esquire Law Offices 302 S. 18Ih Street Camp Hill, PA 17011 Erie Claim #: Erie Insured: Date of Loss: Your Client: 0101705930.,59 Melinda'Kiraly 12/31/2001 Estate of Heather Kiraly Dear Mr. Bangs: Iarn sending this in regard to your above referenced client. Please be advised that at this time Erie is ira a position to offer the $100,000.00 underinsured motorist policy limits from Melinda Kiraly's policy numbered Q051008837 as settlement of your client's claim under that policy. As I am sure you are aware, we will require the settlement to be court approved. I have enclosed a copy of our proposed release as well. Please havc your client propcrly execute the release and return it to my attention along with a copy of thc court approval for issuance of the settlement check. Per your request, we have also set up a claim under policy Q042203600, issued to William Agnew, Jr., and that claim number is 010170609990. I will also be handling that file, and at this point we are investigating policy coverage. I have enclosed copies of the policy and UIM endorsement for Mr. AD':ew. I would request that you please send me confirmation from the primary care physician as to the health of Heather Kiraly prior to the accident. Sincxqrely, ,,, Claim Representative (717) 795-2251 The ERIE Is Above All In sERvIcE® Since 1925 KIR ~,L'1' COMPROMISE OF SE'T'/-LEMENT PETITION / DISK 46 ! .lONE 211 2002 EXHIBIT C Proceeds from Erie Insurance Group Apportionment: 90% to Wrongful Death Action 10% to Survival Action Counsel fees 25% to Michael L. Bangs, Esquire Costs Register of Wills (probate fees) Cumberland Law Journal (advertising of Grant of Letters) The Sentinel (advertising of Grant of Letters) $I00,000.00 ($25,000.00) ($36.00) ($75.00) ($97.07) 6 6/27/2002 Michael L Bangs, Esquire 3(12 South 18th Street Camp Hill, PA 17011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 717-793-0972 Dear Mr. Bangs: Re: Estate of Heather M Kiraly File Number 2102-0190 Court Number: Cumberland~Orphans.2102-0190 The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 16 year old decedent died as a result ora motor vehicle accident. The sole heirs to decedent's estate are her parents. Therefore, any proceeds paid to settle the survival action would pass to decedent's parents and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(1.2). Accordingly, regardless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 90,000.00 to the wrongful death claim and $ 10,000.00 to the survival claim. Proceeds ora survival action are an asset included in the decedent's estate and, although sub3ect to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. §8302; 72 P.S. {}{}9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). " I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be at'tending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death / survival action. cc: Cumberland County Clerk of Orphans Courts Bureau of Individual Taxes REV-1511 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Heather M. Kiral¥ SS~/ SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS 200-64-2710 12/13/2001 FILE NUMBER 21-02-0190 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1 Myers -Harner Funeral 1 2 3 4 Home - Funeral Expense Zip17055 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Melinda A. A~new Social Security Number(s) / EIN Number of Personal Representative(s) Street Address 826 Rid~;ewood Drive City Mechanicsbur6 State PA Year(s) Commission Paid: Attorney's Fees Michael L. Bangs Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent Probate Fees Register of Wills Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs Cumberland Law Journal Estate Advertising Register of Wills Filing of Petition for Compromise/Settlement Register of Wills Filing for Additional Compromise Petition The Sentinel - Estate Advertising TOTAL (Also enter on line 9, Recapitulation) AMOUNT 2,298.00 3,000.00 3,000.00 43.00 (If more space is needed, insert additional sheets of the same size) 75.00 18.00 12.00 97.07 8,543.07 Copyright (c) 1996 form software only CPSystems, Inc. Form REV- 1511 EX (Rev. 1-97) REV-1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Heather M. NUMBER II. SCHEDULE J BENEFICIARIES Kiraly SS~// 200-64-2710 12/13/2001 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 911~)(1.Z)] Melinda A. Agnew 826 Ridgewood Drive Mechanicsburg, PA 17050 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) FILE NUMBER 21-02-0190 AMOUNT OR SHARE OF ESTATE Anthony Kiraly 5722 South Newton Avenue St. Petersburg, FL 33707 Mother Father One-Half One-half ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE $ 0.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1513 EX (Rev. 9-00) REGISTER OF WILLS OF CUMBERLAND COUNTY REPORT OF STATUS OF ADMINISTRATION (For Resident Decedents Dying after July 1, 1984) ESTATE NO. 21 - 02- 0190 Name of Decedent: Social Security No.: HEATHER M. KIRALY 200-64-2710 Date of Death: December 12, 2001 Name of Personal Representative: Melinda A. Kiraly Capacity Executor (check one) Administrator X Administrator c.t.a. Administrator d.b.n. Is the administration of the estate complete? Yes No X If "Yes", how was the administration ended? (check one) By court accounting By account stated to parties in interest Did the parties release the personal representative? Other (explain) Total amount paid to date to creditors and for funeral and $8,572.07 administrative expenses Total value of distributions to date to beneficiaries $0.00 If administration is not complete, estimated value of assets $12,474.03 still in administration NOTE: This status report is due no later than the due date for filing of the Pennsylvania inheritance tax return or, if no inheritance tax return is required, nine (9) months after the date of death; if the administration of the estate has not been concluded, a summary report shall be filed annually thereafter until the administration is complete. I certify under penalty of perjury that the foregoing information is correct to the best of my knowledge, information and belief. Attorney for Estate Date: REGISTER OF WILLS OF CUMBERLAND COUNTY REPORT OF STATUS OF ADMINISTRATION (For Resident Decedents Dying after July 1, 1984) ESTATE NO. 21 - 02- 0190 Name of Decedent: Social Security No.: HEATHER M. KIRALY 200-64-2710 Date of Death: December 12, 2001 Name of Personal Representative: Melinda A. Kiraly Capacity Executor (check one) Administrator X Administrator c.t.a. Administrator d.b.n. Is the administration of the estate complete? Yes X No If "Yes", how was the administration ended? (check one) By court accounting By account stated to parties in interest Did the parties release the personal representative? Yes Other (explain) X Total amount paid to date to creditors and for funeral and $8,572.07 administrative expenses Total value of distributions to date to beneficiaries $12,474.03 If administration is not complete, estimated value of assets $0.00 still in administration NOTE: This status report is due no later than the due date for filing of the Pennsylvania inheritance tax return or, if no inheritance tax return is required, nine (9) months after the date of death; if the administration of the estate has not been concluded, a summary report shall be filed annually thereafter until the administration is complete. I certify under penalty of perjury that the foregoing information is correct to the best of my knowledge, information and belief. Date: ~ ~.~ ~{(~-0~ ~/~4 Attorney for Estate IN RE: ESTATE OF HEATHER M. KIRALY Deceased ) 1N THE COURT OF COMMON PLEAS OF ) CUMBERLAND COUNTY, ) PENNSYLVANIA ) ) ORPHANS' COURT DIVISION ) ) NO. 21-02-0190 RECEIPT AND RELEASE I, ANTHONY KIRALY, the undersigned, being an intestate heir under the Estate of HEATHER M. KIRALY, deceased, do hereby: 1. State and acknowledge that I am an adult individual; 2. Waive the filing of an Account or Schedule of Distribution by the personal representative of the Estate; 3. Acknowledge that I have received all sums of money to which I am entitled as an intestate heir of the Estate of HEATHER M. KIRALY; 4. To the extent of said distribution, release MELINDA A. KIRALY, Administratrix, of the Estate of HEATHER M. KIRALY, and her heirs and personal representatives, from all liabilities, whether due to her negligence or otherwise, which she may have by reason of her administration of the Estate; 5. Agree to refund to the Estate and to the said MELINDA A. KIRALY, Administratrix, any portion of the distribution to which I am not properly entitled, and, to the extent of said distribution, to indemnify her and the Estate for claims made against her and to reimburse her and the Estate all expenses and costs incurred in connection with any such claim; and 6. Declare that this instrument shall be legally binding upon me, my personal representatives, and assigns. IN WITNESS WHEREOF, I have hereunto set my hand and seal this . . ,2003. day of (SEAL) STATE OF ) ( SS: COUNTY OF ) On this, the ! q.~,~ day of ~--r~.~ ,2003, before me, the undersigned officer, personally appeared AIqTHONY KIRALY, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that (s)he executed same for the purposes therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. Notary Public ....~ Vktian C~rk ~:-_.:/~:4 MYCOMMISSK::)N# D0021131 EXPL~S -~_'k~'..~.~g ~.~ust 28, 2005 ,~o',,-. t~[~a~ ~&:~,b~b, h~U 1'~OY FAIN INSURANCE INC IN RE: ESTATE OF HEATHER M. KIRALY Deceased ) IN THE COURT OF COMMON PLEAS OF ) CUMBERLAND COUNTY, ) PENNSYLVANIA ) ) ORPHANS' COURT DIVISION ) ) NO. 21-02-0190 RECEIPT AND RELEASE I, MELINDA A. KIRALY, the undersigned, being an intestate heir under the Estate of HEATHER M. KIRALY, deceased, do hereby: 1. State and acknowledge that I am an adult individual; 2. Waive the filing of an Account or Schedule of Distribution by the personal representative of the Estate; 3. Acknowledge that I have received all sums of money to which I am entitled as an intestate heir of the Estate of HEATHER M. KIRALY; 4. To the extent of said distribution, release MELINDA A. KIRALY, Administratrix, of the Estate of HEATHER M. KIRALY, and her heirs and personal representatives, from all liabilities, whether due to her negligence or otherwise, which she may have by reason of her administration of the Estate; 5. Agree to refund to the Estate and to the said MELINDA A. KIRALY, Administratrix, any portion of the distribution to which I am not properly entitled, and, to the extent of said distribution, to indemnify her and the Estate for claims made against her and to reimburse her and the Estate all expenses and costs incurred in connection with any such claim; and 6. Declare that this instrument shall be legally binding upon me, my personal represematives, and assigns. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ece ke , 003. day of MEI{INDA -A. I~-RALY (SEAL) COMMONW~{7~TH OF PE ~NN_S/~LVA~IA ) (SS: COUNTY OF ~' ~-' ff-)~d'~. [~/t~,t~ff ) On this, the da ,2003, before me, the ~dersigned officer, personally appe~ed MEL~DA A. ~Y, ~o~ to me (or satisfactorily proven) to be the person whose nme is subscribed to the within inst~ent ~d ac~oMedged that (s)he executed sine for the p~oses therein contained. IN WITNESS WHEREOF, I have herefllnto set my hand and official seal. · ! NOTA~UAL SEAL I ~ $. CH~SS~.~,~ff P~ I