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Home My WebLink About02-0215 PETITION Estate of VALERIA A. VERGOT ~ FOR GRANT OF also known as VALERIA ANN VERGOT ~/ , Deceased STEPHENJ. VERGOT LETTERS No.21 02 Social Security No.203108752 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 and aver that Petitioner(s) is/are the execut or [] Decedent, dated 10/8/91 and codicil(s) dated named in the Last Will of the 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 incapacitated: B. Grant of Letters of Administration (c.t.a., d.b.n.c.ta.: pendente lite, durante absentia; durante minodtate) Petitioner(s) after a proper search has/have ascertained the 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 County, Pennsylvania, with his/her last family or principal residence at 4905 EAST TRINDLE ROAD~ MECHANICSBURGr PA 17050 HAMPDEN TOWNSHIP (list street, number and municipality) Decedent, then 87 years of age, died FEBRUARY 17 ,2002 , at COUNTRY MEADOWS NURSING CENTER (Location) 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 ........................................................................................ $ Total $ Real Estate situated as follows: NONE 450,000.00 0.00 450~000.00 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 Typed or printed name and residence Signature STEPHENJ. VERGOT 1418 COUNTRY DRIVE~ MECHANICSBURG~ PA 17055 RW-1 /2" ~--~ Oath of Personal Representative Commonwealth of Pennsylvania County of CUMBERLAND The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s)will well and truly administer the e~sta'tela~cc°r 'n~/l~/~ ]Z/~/~ law. Sworn to and affirmed and subscribed STEP~HE¢I-~. ~ER~OT before me this 2?th day of February 2002 DECREE Of REGISTER CUMBERLAND COUNTY Estate of VALERIA A. VERGOT also known as VALERIA ANN VER(~OT Deceased No. 21 O~ 215 Social Security No: 20310~7~2 Date of Death: 2/17/02 AND NOW, February 27, 2002 m reverse side hereon, satisfactory proof having been presented before me, , in consideration of the Petition on the IT IS DECREED that Letters I~ Testamentary I~ of Administration ((c.t.a., d.b.n.c.t; pendente lite; durante absentia; durante minoriate) are hereby granted toSTEPHEN J. VERGOT Continued on a Separate Pa,qe in the above estate and that the instrument(s), if any, dated described in the Petition be admitted to probate and filed of record as the Last Will of Decedent. FEES Letters .................................... $ 340o00 Short Certificates(s) ..... _~ ....... $ 15.00 Renunciation .......................... $ Extra Pages( 2 ) ............... $ 6.00 I.T.R ....................................... $ JCP Fee ................................. $ 5.00 Inventory ................................$ Other ...................................... $ TOTAL ............................. $ Put Letters File 366.00 Register o~ Signature Attorney: MURREL R. WALTERS III I.D. No: 24849 Address: 54 EAST MAIN STREET MECHANICSBURG Telephone: 7171697-4650 M'ary C. Lewis~ FJ~bruary 27, 2002 in Attorney P]urrel R. Walters, liDiATE FILED: PA 17055 his is to certify that the information here given is correctly copied from an original certificate of death drily 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 80gg4gg No. Local Registrar ~5/Date BLACK INK Valeria A. Vergot 87 .~ ~ t 3/4/1914 .Steelton, PA C%~nberland ..Hampden .ODuntry Meadows Nursing Center ,,. Widowed ,,. ~CE~.,'S Pennsylvania ,,c.~ . · . Hampden 4905 E. Trindle Road ~.~E~'u~ ...m.. ~ Mechanicsburg, PA 17055 ,~.e~.~ C%~mberland ~? ,,..~ .. COMMONWEALTN OF PENNSYLVANIA - DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH ,~ Wllite ,,. Michael Ceperlch ,. Ellen Dercinovic ~.ooSJ~e~e~nz~J' Verg°t .mu~o~0,~o~T~. l~_8~,~.t~.~rive Mecbanjcsburgt PA 17055 ,,.m~..[3 ~.~~ [] ~eb 20 2002 [ Gate of ...... · - I,,~. · , I,,=. Heaven cemete,~ I,,.Mecnan~csburg, PA 17055 ...... ~,~..~-'~ I'~°~'" (I I°"-"°"°""C~°°~'°, .......... ) ~.~..~o.o~.~..,.~.~6;~; .... 'J , - menne( II Itat~ . . ....... '...: ........ : ...................... ~J LAST WILL AND TESTAMENT 21-2002-215 I, VALERIA ANN VERGOT, a resident of Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my LAST WILL and TESTAMENT, hereby revoking any and all Wills and Codicils previously made by me. I I declare that I am not married, my beloved husband, STEVE J. VERGOT, having predeceased me, and that I have two (2) children, STEPHEN J. VERGOT and MICHAEL L. VERGOT, and two (2) grandchildren, STEPHEN A. VERGOT and PATRICIAANN VERGOT. II I direct that my debts and funeral expenses be paid as soon after my death as is practicable by my Executor out of my residuary estate, but not from any assets, funds, death benefits or insurance proceeds which are otherwise excludable or exempt from my gross estate for federal estate valuation or tax purposes. III I direct that all estate, succession, legacy, inheritance or other transfer taxes, however designated that shall become payable by reason of my death in respect of all property comprising my gross estate for death tax purposes, whether or not such property passes under this LAST WILL, shall be paid by my Executor. out of my residuary estate, but not from any assets, funds, death benefits or insurance proceeds which are otherwise excludable or exempt from my gross estate for federal estate valuation or tax purposes. IV V Ail the rest, residue and remainder of my property, whether real or personal, wherever situate, including any property over which I may have a power of appointment, I give, devise, and bequeath as follows: 40% to my son, STEPHEN, per stirpes; 40% to my son, MICHAEL, per stirpes; 10% to my grandson, STEPHEN, per stirpes; 10% to my granddaughter, PATRICIA, per stirpes. VI I nominate, constitute and appoint my son, STEPHEN, as Executor of this LAST WILL, to serve without bond. If my son, STEPHEN, is unable or unwilling to act in that capacity, then I nominate, constitute and appoint my son, MICHAEL, as Executor of this LAST WILL, to serve without bond. IN WITNESS WHEREOF, I, VALERIA ANN VERGOT, have set my hand to this LAST WILL this ~ day of ~ , 1991. VALERIA ANN VERGOT ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA : COUNTY OF CUMBERLAND : ss. I, VALERIA ANN VERGOT, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my LAST WILL; that I signed it as my free and voluntary act for the purposes therein expressed. VALERIAANN VERGOT Sworn or affirmed to and acknowledged before me by VALERIA ANN VERGOT, Testatrix, this ~ day of ~7~/- , 1991. AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA : ss. COUNTY OF CUMBERL~ND : We,/~r~ ~ ~f~ ~ a nd ~ ~/-~ ~o/77 ~ ~ , the witnesses whose names are signed to the attached or foregoing instrument being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her LAST WILL; that VALERIA ANN VERGOT signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that/ to the best of our knowledge, the Testatrix was at the time~ years of age or more, of sound mind and/under nQ ~o~str~n~/or undue influence. ~~ -- Sworn or affirmed to and acknowledged before me this CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: VALERIA ANN VERGOT Date of Death: February 17, 2002 Will No. Admin. No. 21-02-0215 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 6, 2002. Name Address Stephen J. Vergot Michael L. Vergot 1418 Country Drive Mechanicsburg, PA 17055 8818 Peter Point Road Edisto Island, SC 29438 Stephen A. Vergot 1418 Country Drive Mechanicsburg, PA 17055 Patricia A. Vergot 618 Whimey Avenue Pittsburgh, PA 15221-3345 // Notice has now been given to all persons entitled thereto under !Rule 5.~///~/except: none Date: 3/6/02 .,,. Murrel R. Walters, III, Esquire ..~? 54 East Main Street , Mechanicsburg, PA 17055 (717) 697-4650 Capacity: X Personal Representative Counsel for personal representative lC ~)~ COMMONWEalth Of PENNSYLVANIA DEPARTMEnt Of REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER 2 1 -0 2 0 2 CO~JNTY CODE YEAR UJ I-. Z Ll.I Z o 13,. o Z z DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) VERGOTI VALERIA ANN DATE OF DEATH (MM-DD-Year) 02/17/2002 DATE OF BIRTH (MM-DD-Year) 02/04/1914 SOCIAL SECURITY NUMBER 2 0 3-1 0-8 7 1 5 NUMBER 5 2 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER r-] 3. Remainder Return (date of death pdorto 12-13-82) O5. Federal Estate Tax Retum Required __ 8. Total Number of Safe Deposit Boxes [~]11. Election to tax under Sec. 9113(A) (Attach Sch O) r~-'l 1. Odginal Return r'-] 4. Limited Estate r~16. Decedent Died Testate {Attach copy of Will) '--19. Litigation Proceeds Received NAME MURREL R. WALTERS III ESQ. --]2. Supplemental Return E~4a. Future Interest Compromise (date of death after 12-12-82) D7. Decedent Maintained a Living Trust (Attach copy of Trust) '--110. Spousal Poverty Credit (date ofdealh between 12-31-91 and 1-1-95) THIS SECTION MUST BE COMPL~ I ~D. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: COMPLETE MAILING ADDRESS 54 EAST MAIN STREET MECHANICSBURG PA 17055 FIRM NAME (If Applicable) TELEPHONE NUMBER 717/697-4650 385~612.89 OFFICIAL USE ONLY CC (8) (11) 7~ 100.00 285.00 439~599.29 7~385.00 (12) (13) 432~214.29 (14) 432~214.29 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnemhip or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) r-"] Separate Billing Requested 7. Inter-Vivos Transfers & 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 Beductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11 ) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) x .o (15) 432,214.29 x .o45 (16) x .12 (17) x .15 (18) (19) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 19~449.64 19~449.64 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20. > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decetlent"s Complete Address: TREET ADDRESS 9_05 EAST TRINDLE ROAD IY MECHANICSBURG ISTATE PA I Z~P 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 972.48 Interest/Penalty if applicable D. Interest E. Penalty (1) Total Credits ( A + B + C ) (2) Total Interest/Penalty ( D + E ) (3) 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) If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + EA. This is the BALANCE DUE. (EB) Make Check Payable to: REGISTER OF WILLS, AGENT 19~449.64 972.48 18~477.16 18~477.16 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ........................................................................... [] [] b. retain the right to designate who shall use the property transferred or its income; ........................................[] [] c. retain a reversionary interest; or ...................................................................................................... [] [] d. receive the premise for life of either payments, benefits or care? ............................................................. [] [] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................................................... [] [] 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 designation? ....................................................................................................... [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties o1' pedury, I declare that I have examined this return, including accoF~anying schedules and statements and to the best of my knowledge and belief, it is tie, correct and complete. Declaration of preparer other than the personal representative is based on all inf~pnflation of wh ch preparer has any knowledge. SIGNATURE OF P~.~R~I~ ADDRESS SYEPHL~, 1418 l~,~lLJh SIGNATURE OF PREPA~.~ ADDRESS MURREL R · VEI~'GO,T // '1'1~ 1~,71~'ECHANICSBURG ~' T H ~i~'¢NTATIME WALTERS III ESQ. 54 EAST MAIN STREET, MECHANICSBURG DATE 5/9/O2 PA 17055 DATE 5/9/02 PA 17055 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. {}9116 (a) (1.1) (i)]. For dates of death on or after Jan uary 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 benefic'ar'es is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. l SCHEDULE B I STOCKS & BONDS I ESTATE OF ~ ~ VERGOT, VAL, ERIA ANN 21 02 All property jointly.owned with right of survivorship must be disclosed on Schedule F. REV-1503 EX~+(1.97) _~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ITEM NUMBER DESCRIPTION 1. SERIES H U.S. SAVINGS BONDS 4 @1000; 1 @5000; 1@ 500 SERIES E/EE U.S. SAVINGS BONDS 15 @ 5OO ASHLAND OIL INC. 300 SHARES COMMON @ 44.07 TOTAL (Also enter on line 2, Recapitulation) $ 0215 VALUE AT DATE OF DEATH 9,500.00 31,265.40 13,221.00 53~986.40 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (1.97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E I CASH, BANK DEPOSITS, & MISC. J PERSONAL PROPERTY FILE NUMBER VERGOT, VALERIA ANN 21 02 021~ Include the proceeds of litigation and the date the proceeds were received by the estate, All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE 1. AMERICAN EXPRESS OF DEATH 3 4 7 MUTUAL FUND # 011207608545002 24908.711 SHARES @ 4.810 MUTUAL FUND # 012407608541002 2296.668 SHARES @ 4.850 ANNUITY # 930025805712004 ANNUITY # 930039895873004 ANNUITY # 930067273548004 ~NC BANK CHECKING # 5140065837 COUNTRY MEADOWS RESIDENTIAL CARE REFUND RING AND NECKLACE PER APPRAISAL BY MUMMA'S JEWELRY STORE VERIZON TELEPHONE REFUND COMCAST CABLE TELEVISION REFUND 10 120,097.34 11,161.01 145,432.92 32,970.71 64,729.26 7,742.98 2,364.40 1,100.00 3.01 11.26 TOTAL (Also enter on line 5, Recapitulation) $ (if more space is needed, insert additional sheets of the same size) 385~612.8!) REV-1§11EX[ 1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF VERGOT, VALERIA ANN SCHEDULE H I FUNERAL EXPENSES & I ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: 1. 21 02 o210 DESCRIPTION AMOUNT ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) STEPHEN J. VERGOT Social Secudty Number(s) / EIN Number of Personal Representative(s) Street Address RENOUNCED City State Year(s) Commission Paid: AttomeyFees MURREL R. WALTERS III ESQ Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Zip Street Address City Relationship of Claimant to Decedent Probate Fees REGISTER OF WILLS CUMBERLAND COUNTY Accountant's Fees State Zip TaxRetum PreparefsFees ALAN CEPERICH C.P.A. 6,600.00 400.00 100.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 7~ 100.00 REV-S512 EX"* (1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF R T A I N Include unreimbursed medical expenses. ITEM NUMBER I SCHEDULE I I I DEBTS OF DECEDENT, I ~BILITIES, & LIENS I FILE NUMBER CRUMAY PARNES ASSOCIATES MEDICAL DESCRIPTION PENNSYLVANIA DEPARTMENT OF REVENUE 2001 PERSONAL INCOME TAX AMOUNT 100.00 185.00 TOTAL (Also enter on line 10, Recapitulation) $ 285.00 (If more space is needed, insert additional sheets of the same size) REV-1513 EX.+ (1-97) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBER [. 3 SCHEDULE J I ENEFIClARIES I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) STEPHEN J. VERGOT 1418 COUNTRY DRIVE MECHANICSBURG, PA 17055 MICHAEL L. VERGOT 8818 PETER POINT ROAD EDISTO ISLAND, SC 29438 STEPHEN A. VERGOT 1418 COUNTRY DRIVE MECHANICSBURG, PA 17055 PATRICIA A. VERGOT 618 WHITNEY AVENUE PITTSBURGH, PA 15221 21 02 021~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE SON SON GRANDSON GRANDDAUGHTER ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINEI NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) 40 % OF RESIDUE 40 % OF RESIDUE 10 % OF RESIDUE PERSONAL PROPERTY PLUS 10% OF RESIDUE 15 THROUGH 17, AS APPROPRIATE ON REV 1500 COVER SHEET COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX{11-96) CD 001167 MURREL R WALTERS III 54 EAST MAIN STREET MECHANICSBURG, PA 17055 ........ fold ESTATE INFORMATION: SSN: 203~10-8752 FILE NUMBER: 2102-0215 DECEDENT NAME: VERGOT VALERIA ANN DATE OF PAYMENT: 05/10/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 02/17/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $18,477.16 REMARKS: TOTAL AMOUNT PAID: STEPHEN d VERGOT C/O MURREL R WALTERS III $18,477.16 SEAL CHECK#4 INITIALS: SK RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS REGISTER OF WILLS BUREAU OF TNDZVZDUAL TAXES ZNHERTTANCE TAX DTV/SION DEPT. Z80601 HARRISBURG, PA 17128-0601 COHNONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLO#ANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-ISdI? EX AFP MURREL R WALTERS III Ell 5q E MAIN ST MECHANICSBURG PA ~7055 ,jUL DATE ESTATE OF DATE OF DEATH FILE NUHBER COUNTY ACN 06-2q-2002 VERGOT 02-17-2002 21 02-0215 CUMBERLAND 101 Amount RaaLttad VALERIA A HAKE CHECK PAYABLE AND RENZT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV'1547 EX AFP (01-02) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF VERGOT VALERIA A FZLE NO. 21 02-0215 ACN 101 DATE 06-Z~-2002 TAX RETURN NAS: { X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAZSED VALUE OF RETURN BASED ONe ORIGINAL RETURN 1. Real Es~a~e (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Stock~Partnership Interest (Schedule C) (3) fi. Mortgages/Notes Receivable (Schedule D) (q) 5. Cash/Bank Depos/ts/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 EXEHPTZONS: 9. Funeral Expenses/Adm. Costs/N/sc. Expanses (Schedule H) (9) 10. Debts/Mortgage Liab/1/t/as/L/ens (Schedule Z) (10) 11, Total Deduct/ons 12. Ne~ Value of Tax Return 55~986.q0 .00 :585~61Z.89 .00 .00 NOTE: To /nsure proper cred/t to your account, subm/t the upper port/on .00 of th/s form w/th your tax payment. .O0 (8) 7,100.00 285. O0 1S. NOTE: ASSESSMENT OF TAX: 15. Amount of L/ne lq at Spousal rata 16. Amount of L/ne lq taxable at L/neal/Class A rata 17. Amount of L/ne lq at Sibl/ng rata 18. Amount of L/ne lq taxable at Collateral~Class B rata 19. Pr/nc/pal Tax Due TAX CREDZTS: PAYMENT RECEZPT DZ$COUNT (+) BATE NUMBER INTEREST/PEN PAID (-) 05-10-2002 CD001167 972.q8 q39,599.29 (11) 7. 385. no (12) q32,Z1q.29 Charitable/Governmental Bequests; Non-elected 911:3 Trusts (Schedule J) (15) Nat Value of Estate Subject to Tax Zf an assessment was issued previously, lines 1~, 15 and/or 16, 17, reflect figures that include the total of ALL returns assessed to date. .00 q32,21q.29 ZF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDZTZONAL INTEREST. 18 and 19 will 19,qqg.6q .00 .00 .00 ( ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS REQUIRED. IF TOTAL DUE [S REFLECTED AS A "CREDIT" (CR), YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF TH/S FORM FOR INSTRUCTIONS.) TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 18,q77.16 AMOUNT PAID (15) .00 x O0 = .00 (16) q32,Z1q.29 x Oq5 = 19,qq9.6q (17) . O0 x 12 = .00 (18) .00 x 15 = .00 (19)= 19,qq9.6q RESERVATION: Estates of decadents dying on or before December 11, 1981 -- 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 Coeeonaaalth hereby expressly reserves tho right to appraise and assess transfer Inheritance Taxes at tho tawful Class B (collateral) rate on any such future interest. PURPOSE OF NOTICE: PAYNENT: REFUND (CA): OBJECTIONS: ADNIN- ISTRATIVE CORRECTIONS: D/SCOUNT: PENALTY: INTEREST: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act ZS of ZOO0. (72 P.S. Section 9140). Detach the top portion of this Notice and submit eith your payment to the Register of Hills printed on the reverse side. --Make check or money order payable to: REGXSTER OF NXLLS~ AGENT A refund of a tax credit, ahich was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1513). Applications are available at the Office of the Register of Hills, any of the 15 Revenue District Offices, or by calling the special lq-hour ansaaring service for forms ordering: 1-800-361-Z050~ services for taxpayers with special hearing and / or speaking needs: 1-800-447-$010 (TT only). Any party in interest not satisfied with the appraisement, allowance, 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. 281011, Harrisburg, PA 17128-1011, 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. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. Sea 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 (5) calendar months after the dacedent's death, a five percent (51) discount of the tax paid is allowed. The 1SI 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 end in the the same time period as you ~ould 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 end one (1) day from 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 daily rate of .000164. All taxes which became delinquent on and after January 1, 1982 will bear interest at e 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 1981 through 2001 are: Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor 1982 201 .000S48 1992 91 .000247 1983 161 .000458 1995-1994 7Z .000192 1984 111 .000301 1995-1998 91 1985 1SI .000356 1999 71 .000192 1986 lOX .000274 ZOO0 81 .000219 1987 9Z .000247 2001 91 .000147 1988-1991 111 .O00SO1 ZOOZ 6Z .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELIN~iUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen C1S) 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. PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION ~ Name of Decedent: Date of Death: STATUS REPORT UNDER RULE 6.12 Valeria Ann Vergot February 17, 2002 Estate No.: 21-02-0215 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court rules, respect to completion of the administration of the above-captioned estate: State whet~ administration of the estate is complete: Yes ,./ No I report the following with If the answer is No, state when the personal representative reasonably believes that the administration will be complete (date) If the answer to No. 1 is yes, state the following: A. Did the personal representative £fle a ~inal account with the court? Yes .. No. O/' ' Bo Co Do Date: February 12, 2004 "OD The separate Orphans' Court No. (if any) for the personal representative's account is: (Not Applicable in Dauphin County) Did the personal repre,~entative state an account informally to the parties in interest: Yes t;" No. Copies of receipts, releases, j oinders and approvals _o,f formal ~informal accounts may be filed with the Clerk of the Orp~hans Cou and may be attached to this report. ~,//~~~~ and m~ MURREL R. WALTERS, III, ESQUIRE ou~eq~tl~10 54 East Main Street Mechanicsburg, PA 17055 717-697-4650 0 [: 6 ~t ~ l El]J C~acity: Personal Representative ~X__ Counsel for Personal Representative