HomeMy WebLinkAbout09-08-09 (3)1505607120
J REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO 60X.280601 21 0 9 ®~ ~ Z
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
207 22 1718 06 05 2009 04 26 1918
Decedent's Last Name Suffix Decedent's First Name MI
BURK THEDA K
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
~~ 9. Litigation Proceeds Received n 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
I__._I L_~ between 12-31-91 and 1-1-95) (Attach SCh. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
EDMUND G. MYERS (717) 761 4540
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~, 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
~~ 4. Limited Estate ~ 4a. Future Interest Compromise C~ 5. Federal Estate Tax Return Required
- (date of death after 12-12-82)
g Decedent Died Testate ~ Decedent Maintained a Living Trust 0 B. Total Number of Safe Deposit Boxes
X ~ (Attach Copy of Will) '~ (Attach Copy of Trust)
Firm Name (If Applicable)
JOHNSON DUFFIE
First line of address
301 MARKET STREET
Second line of address
PO BOX 109
City or Post Office
LEMOYNE
State ZIP Code
PA 17043
REGISTER LS USE~LY
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Correspondent's a-mail address: e g m CGJ d S W. C O m
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.
~D „A D,, Sandra B Weaver q ~~
ADDRESS
118 Standlake Way, Mechanicsburg, PA 17055
S ATURE OF PREPARER OTHER THAN REPRESENTATIVE ATE
~fj ~~ Edmund G. Myers G~ic~..' U ~
ennoccc
301 MARKET STREET, LEMOYNE, PA 17043
Side 1
1505607120
1505607120
REV-1500 EX
15056D7220
Decedent's Name: Tiled 8 K B V R K
RECAPITULATION
1. Real Estate (Schedule A) .......................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5.
6. Jointly Owned Property (Schedule F) ~I Separate Billing Requested ............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested ............. 7.
8. Total Gross Assets (total Lines 1-7) ....................................................................... 8.
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) ......................................................................11.
12~ Net Value of Estate (Line 8 minus Line 11) .............................................................12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................................................. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ... .......................................... .... 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .00 0 0 0 15.
16. Amount of Line 14 taxable
16
at lineal rate X .045 4 5, 9 4 3. 3 3 .
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 0 . 0 0 18.
19. Tax Due .................................................................... .......................................... .....19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Decedent's Social Security Number
207 22 1718
3,291.77
45,137.15
48,428.92
2,164.45
321.14
2,485.59
45,943.33
45,943.33
0.00
2,067.45
0.00
0.00
2,067.45
Side 2
15056D722D 1505607220
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-09-
DECEDENT'S NAME
Theda K BURK _ _
STREET ADDRESS
100 Mt. Allen Drive
__ _ _ _
CITY STATE - ',.ZIP
Mechanicsburg PA '~ 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
103.37
(1) 2,067.45
Total Credits (A + B + C) (2) 103.37
3. InteresUPenalty if applicable
p. Interest
E. Penalty __ _
Total Interest/Penalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1 ,964.08
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) ~ , 9 6 4. ~ 8
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.................................................................................~ ' z
b. retain the right to designate who shall use the property transferred or its income :.................................... ~~ ~ z
c. retain a reversionary interest, or ...............................................................................................................:~ r
~"
d. receive the promise for life of either payments, benefits or care? ............................................................. i [x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
-~
receiving adequate consideration? .....................................................................................
................................. ~ x
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... [_j ~ x
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................~ ~ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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 three (3) percent [72 P.S. §9116 (a) (1.1) (i)J.
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 zero
(0) percent [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 zero (0) percent [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 four and one-half (4.5) percent,
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 twelve (12) percent [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.
Rev-7508 EX+ (6-98j
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
BURK, Theda K 21-09-
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Bedroom Suite -Sold 350.00
2 Chase Bank Rewards 50.00
3 Erie Insurance -Refund on Car Insurance 69.00
4 Leffler Energy Oil Company Refund on Account 639.08
5 Messiah Village -Reimbursement 1,597.03
6 Penn Treaty -Refund on Account for Prescriptions 100.00
7 Penn Treaty -Refund on Account 7.00
8 Penn Treaty Nursing Home Insurance -Refund on Account 470.00
9 Verizon -Refund on Account 9.66
TOTAL (Also enter on Line 5, Recapitulation) I 3,291.77
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
Rev-1509 EX+I6-98)
. SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
BURK, Theda K 21-09-
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME
A. Sandra B Weaver
ADDRESS
118 Standlake Way
Mechanicsburg, PA 17055
RELATIONSHIP TO DECEDENT
B.
C.
JOINTLY OWNED PROPERTY:
Daughter
ITEM
NUMBER
LETTER
FOR JOINT
TENANT
DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT
NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR
JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSE % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTEREST
1 A 10/3/2002 Greystone Bank Certificate of Deposit 52,086.76 50.000% 26,043.38
Account
2 A 10/3/2002 Integrity Bank HPC High Yield Account 4,037.12 50.000% 2,018.56
No. 0201024756
3 A 10/3/2002 Integrity Bank Money Market Checking 34,107.06 50.000% 17,053.53
Account N o. 0201032587
4 A 1/1/2001 PNC Bank -Free Checking Account No. 43.36 50.000% 21.68
50-0351-3146
TOTAL (Also enter on Line 6, Recapitulation) 45,137.15
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98)
REV-1151 EX+112.99) SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c
IN RESIDENTED ~ DENTRN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
BURK, Theda K 21-09-
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
q, FUNERAL EXPENSES:
B.
1
See continuation schedule(s) attached
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State Zip
Year(s) Commission paid
884.45
2. Attorney's Fees JOHNSON DUFFIE 750.00
3. 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
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees 300.00
7. Other Administrative Costs 230.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 2,164.45
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
BURK, Theda K 21-09-
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Minister 100.00
2 Musselman's Funeral Home 560.22
3 Organist 75.00
4 Trinity Lutheran Church Luncheon 149.23
H-A Subtotal 884.45
Other Administrative Costs
5 Cumberland County Register of Wills Office -Filing Fees for Inheritance Tax Return 30.00
and Inventory
6 Reserves: Miscellaneous Estate Expenses 200.00
H-87 Subtotal 230.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 EX+(6-98)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
BURK, Theda K 21-09-
Include unreimbursed medical expenses.
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98)
REV-7573 EX+ (9-0O)
SCHEDULE J
ANIA
COM
R
NITA
~ BENEFICIARIES
NCETAXRETU
N
N
ER
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
BURK, Theda K 21-09-
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List Trustee s
I. TAXABLE DISTRIBUTIONS [include outright spousal
and transfers
distributions
,
under Sec. 9116(a)(1.2)]
Sandra B Weaver Daughter Entire Estate 45,943.33
118 Standlake Way
Mechanicsburg, PA 17055
Total 45,943.33
Enter dollar amounts for distributions shown above on lines 15 through 18, as approp riate, on Rev 1500 cov er sheet
II. 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 SHEE~ 0.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)
ESTATE OF THEDA K. BURK
SCHEDULE OF EXHIBITS
EXHIBIT A Copy of the Death Certificate for the Decedent since the Estate
was not probated
EXHIBIT B Copy off Decedent's Last Will and Testament signed and dated on
the 16` day of August, 2001.
EXHIBIT C Integrity Bank Account 02011024756. The ,statement provided is
for month ending, interest was not earned until end of following
month.
EXHIBIT D Integrity Bank Account 0201032587. The statement provided is for
month ending, interest was not earned until end of following
month.
EXHIBIT E PNC Bank Account SO-0351-3146. The statement provided is for
month ending, interest was not earned on this account.
376490
EXHIBIT A
~_
OCAL REGISTRAR'S CERTIFiCATi®N C)F ~EATFI
VVARlVING: It is illegal to duplicate thin copy lay photostat €>r photograph.
ee for this certificate, $6.00
This is to certify that the information here given i.
correctly copied from an original Certificate of Deatl
duly filed with me as Local Registrar. The origina
certificate will be forwarded to the State Vita
Records Office for permanent filing.
a~~~~~~3
certification Number
Loca:~ Registrar ~ Date Issued
Ev 112006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECGRDS
'RINi IN
`"E"T CERTIFICATE OF DEATH
<INK (See instructions and examples on reverse)
STATE FILE NUMBER
1, Name d Decedent (First midtlle, lass, wtlix) 2. Sax 3. Sodal Sewrlty Number 4 la W DeaM (Month da~ar) •
Theda K. Burk female 207_22 ._1718 `/~!'
5. Age (last BinhOay) Unda 1 ar Under 1 da 6. Data of Binh Monts, da , er 7. Birth kce CI aril state a fa ei count be, Place of Death CMck onl one`
91 MonNS Deys Hours Mrmtss
April 26,1918
New Cumberland
P Hospital' Other: (
Yrs , npatkM ^ER/OWpelienl ^DOA ^Nursing Home ^Residence ^ONrer-SDecity:
Bb. County of DeaM &. City, Bom, Twp. of Death Bd. Fadq'ty Name (N nd inslituNOn, give street antl number) 9. Was Decedent of Hispanic Ddgin? ~] No ^ Yes 10. Race: American Intlian, Black, While, etc
Dauphin Harrisburg (II yes, spadty Cuban, (Spedl)7
Harrisburg Hosp.
Mexkan,PUenoRican,etc.) bite
11. Decedents Usual lion ird of work done dud moss of wale' INe. Do rrot stale retire 12 Was Decedent ever m the 13. Decedent's EdursNon (Spedly only highest grade mmpleted) 14. Medial SWNS: Maried, Never Married, 16. Surviving Spouse pl wife, give maiden name)
Kad d Work Kind of usiness lNbusl
ry
P
l
~ U.S. Armed Forcesi Wdowe4 Divorced /Seedy)
Elementary I Secondary (P72) College (1-4 or 5t)
yC
O
1 n 1 C ^ Yea No 5 idowed
16. Decedent's Mailing Address (BUeel, dry! town, stale, zip code) Decedent's Did Decedent ~~~ r T
Actual Residence 17a
Stale p A Live in a
e n
100 Mt.Al ten Dr. .
ste~ueceo fd
? 17c. enl Twp.
Townahi
M
h
i
b
PA 17055 p
17b. Count' Cumber 1 a nd 17d. ^ No, Decedent Lived within
ec
an
cs
ur Actual Umilsol City/Born
76. Falhefs Name (Foal, midde, fast, suKx) 19. MoMeYa Name (FwL middle, maiden surname)
Oren H. Kauffman Ruth Goodyear
20a. Informant's Name (type / Prinll 20b. Inormant's Ma6ing Address (Street dty! town, slate, zp code)
Sandra B. Weaver 118 Standlake Way Mechanicsburg,PA
21a. Method of Disposition ' remalion ^ Donation 216. Date of DisposNbn (Month, day, year) 21c. Place of DISDpaIli00 (Name of cemetery, crematory ar other Waco) 21tl Location (City! sown, stele
ziD sole)
I
Bunel ^ RenavallranSlafe rw
'
Crema'norponatlanAulhorizetl
June 9,2009
Rolling Green Mem. Park ,
amp Hi 11
PA
^ Ogrer.
by ^
etlkal tamirerl Coroner? ^ Yes No ,
22e. Sre of Fu- asrel Service nsee ad e ) 226. License Number 22c. Name antl Address of Fadfiry
~ a,\)..~,,.+-++~ 011248E Musselman FH&CS Inc.324 Hummel Ave. Lemoyne, PA
Complete dams 23a-c only when cenihpng 23a. To the best of my knowledge, death acurted at N1e time, date aM place stated. (Signature and Nile) 23b. License NuMur 23c. Dale Signed (Month
day
year)
physidan is not available aI time of death to ,
,
cendy reuse of tleath.
Items 24-26 must be cartpleled by person
who
ronounces death 24. Tune ~ / /~/r ~ 26. a Pronamced Dead (Mo~lh, day, yeafj
'
/ 26. Was Case Referred to Medical Examiner t Cororei for a Reason ON1er than Cremation or Donation?
p
. ! b7 lA M. ,~
~~
~O ^ Yes []~+Fo
CAUSE OF DEATH (See Instructlo and eaampks) r Approximate inlervdl: Pad II: Enter other sioni6caN mnddiore conirrLul to tle th 26. Did Tobacco Use Contribute to Death?
Item 27. Pad I: Enter Nte chain of events -diseases, injuries, a compfratbns - NaI firectly caused b eats. DO NOT enter lertninal events such as cardiac arrest, i Onset to Death but not resuNing in the undertying cause gben in Pan I. ^ Ye
^ P
b
b
respiretory ertest a venlnwWr fits' n wlNioul sh 'ng the etblogy. List ty one eon each line. ~
r
IMMEDMTE C
USE
~
' ro
s
a
ty
~ ^ Unknown
A
(Final disease or
antldion resuNktg in death)
~~ ~~, /
(
~
\ 1 J i
29 II Fem
k:
_~ a `~'C• $
~
i
Due to r as a copse ence~ ~ lol pregnenl within past year
SequenNafiy list cm3Nons, it arty, b ~
lea ' b tlx CdDSe Nsled on hna a ^ Pregnant al lime of death
. Due Io
Enter 8re UNDERLYING CAUBE (or as a crops uence op: ~
^ Not pregnenl, but pregnenl wilMn 42 tlays
(disease a injury tlrel indialad the c
events resulting m death) LAST. of death
^
Due to (or es a coreequence oq: Not a pan
Dr 9 1, bW Dregnan143 days Io 1 year
d belore death
^ Unknown d pregnant within Me past year
30a Was an Autopsy 30b. Were Autopsy Fkadngs 31. Maurer of Death 32e. Dale W In'
Nry (MwdA, day, year)
32b. Descdbe How In)ury Occurted
32c. Place of IM ry: Home, farm, BIreW, Factory
Performed? pvaaaMe Prior m Com lelion
D
~laturel ^ Homidde ,
OHce Building, ale. (Spedyf
of Cause d Death?
^ Ves hdNO ^ Yes
^ No ^ Aaidenl ^ Panting Investpatbn 32tl. Tine W Injury 32e. Injury at Work? 32f. II Transporktion Injury (Seedy) 32g. Location of injury (Street, city 7 town, slate)
^ Suicitle ^ Could Not be Deknnhed ^ Yes ^ No ^ Drwer/Operates ^ Passe r ^ P slnan
M ^ Other- Speclly
33a. Certiller (clack only wei
• CenityNg physkian (Physican cenitying reuse of death when another physidan has pronounced deem and cempleled Item 23) 33b. S' nature antl Tsk of dlf , ^ ~~~~~~~
f
f ~
'
)
/~
~
To Me best of my knowledge, death occuned due to the cause(s)antl manneras ateted_________________________________ ^ ,
,
!
~
.r
, lI
r W
• Pronouncing aM certllying physician (Physician boN pronouncing death antl ceniying to cause of tle9lhj
Te the best of my knowledge, death occurred sl the time, date, and place, and due to the cause(s) end manner as atated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
• McMwl Examiner/Corona 33c. License Number ,'
~ y ~
4J 33tl. Da igned (Month, day, y'sar)
~ ~ fj (~
`r /
On the bask of examlretbn end / or Investigation, in my opinion, death occurred al ~
he
time, date, end place, antl due to the cauee(a) arts ma
nn
er es stete4 ^ WM Complel a of D
,%~',
(Item
27) e / Prin
t
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Disposition PermN No. ~ ~ ~ ~ "'
WILL
OF
THEDA BURK
I, THEDA BURK, of the Borough of Lemoyne, Cumberland County,
Pennsylvania, declare this to be my last will and revoke any will previously
made by me.
Item I. I devise and bequeath all of my estate of every nature and
wherever situate to my husband, JOHN J. BURK, providing he shall survive me by
sixty days.
Item II. Should my husband, Sohn J. Burk, predecease me or die on or
before the sixtieth day following my death, I devise and bequeath all of my
estate of every nature and wherever situate to my issue living on the sixty-fir:
day following my death, per stirpes.
Item III. I appoint my husband, JOHN J. BURK, executor of this my last
will. Should my husband, John J. Burk, fail to qualify or cease to act as
executor, I appoint my daughter, SANDRA WEAVER, executrix of this my last will.
Item IV. I direct that my personal representative shall not be required
to give bond for the faithful performance of his duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this ~,.~J:t~ day of
`,~~~ ~~ 1967.
~)
The preceding instrument, consisting of this typewritten page,
identified by the signature of the testatrix, was on the day and date thereof
signed, published, and declared by THEDA BURK, the testatrix therein named, as
and for her last will, in the presence of us, who, at her request, in her
presence, and in the presence of each other, have subscribed our names as
tnesses hereto.
~ ~ : .~
~''"~' ~E
~~ ~. _~ ,
% N/
. Page: 1
Enclosures: 12
Integrity
B A N K Statement Date: 05/20/2009
Account Number: 201024756
33451v1arket Street, Camp Hill, PA 1701 l CYCLE-013
(717) 9?0-4900
***************AUTO**3-DIGIT 170
1502 0.6950 AT 0.357 5 1 385
~Ilill~lll'11111'I~~~'II~~IIIIi~"I~III~II~I~~I~III~I~IIII'll'I~I
THEDA K BURK
SANDRA B WEAVER
118 STANDIAKE WAY
MECHANICSBURG PA 17055-9241
Checking
HPC HIGH YIELD
ACCOUNT NUMBER 0201024756
PREVIOUS STATEMENT RAT_n*TCE A5 OF 04/20/09 .....
PLUS 5 DEPOSITS AND OTHER CREDITS ...
LESS 17 CHECKS AND OTHER DEBITS ......
CURRENT STATEMENT BALANCE AS OF 05/20/09 ......
NUMBER OF DAYS IN THIS STATEMENT PERIOD 30 ...................
................
................
................... 3,202.78
2,379.96
1,545.62
4,037.12
• Account Transactions
DATE DESCRIPTION DEBITS CREDITS
04/21 AC-ERIE INSURANCE -1256038677 82.00
CK-00001373
04/29 AC-PPL EU -ELEC SVC 13.14
04/30 DEPOSIT 926.10
04/30 AC-PAWC -PAYMENT 13.22
05/01 AC-US TREASURY 303 -SOC SEC 1,117.00
05/07 AC-US TREASURY 303 -SSA ERP 250.00
05/08 AC-CHASE -CHECK PYMT 697.81
CK-00001376
05/11 DEPOSIT 83.00
05/11 AC-VERIZON -PaymentREC 23.70
05/20 INTEREST PAYMENT 3.86
• Check Transactions
SERIAL DATE AMOUNT SERIAL DATE AMOUNT
1364 04/23 10.00 1372* 04/21 400.00
1365 04/23 10.00 1374* 05/18 25.00
1366 05/06 10.00 1375 05/08 116.60
1367 05/06 10.00 1377* 05/11 7.15
1368 05/06 10.00 1378 05/13 83.00
1370* 04/21 9.00 1381* 04/27 25.00
• Balance By Date
04/20 3,202.78 04/21 2,711.78 04/23 2,691.78 09/27 2,666.78
04/29 2,653.64 04/30 3,566.52 05/01 4,683.52 05/06 4,653.52
05/07 4,903.52 05/08 4,089.11 05/11 4,191.26 05/13 4,058.26
05/18 4,033.26 05/20 4,037.12
PAYER FEDERAL ID NUMBER ... .............. 52-2389022
INTEREST PAID YEAR TO DATE .............. 34.72
*** INTEREST EARNED THIS STATEMENT PERIOD ***
DAYS IN PERIOD ......................... 30
INTEREST EARNED ........................ 3.86
ANNUAL PERCENTAGE YIELD EARNED (APY).... 1.25$
Integrity
B A N K
3345 A~lur-ket Street, Cm~rp Hrll, PA 17011
(717) 920-4900
***************AUTO**3-DIGIT 170
1159 0.6350 AT 0.357 5 1 109
I~I~~In~l~~l~lili~~~il~n~~ili~lll~il~l~lil~~ii~~l~~ln~~~~~~1~~
THEDA K BURK
SANDRA B WEAVER
118 STANDLAKE WAY
MECHANICSBURG PA 17055-9241
Checking
MONEY MARKET CHECK
ACCOUNT NUMBER 0201032587
PREVIOUS STATEMENT 1iA?~aNCE AS OF 04/30/09 ........................
PLUS 1 DEPOSITS AND OTHER CREDITS ...................
LESS 1 CHECKS AND OTHER DEBITS ......................
CURRENT STATEMENT BALANCE AS OF 05/31/09 .........................
NUMBER OF DAYS IN THI5 STATEMENT PERIOD 31
Page: 1
Enclosures: 1
Statement Date: 05/31/2009
Account Number: 201032587
CYCLE-031
37,657.40
107.66
3, 658.00
34,107.06
• Account Transactions
DATE DESCRIPTION DEBITS CREDITS
05/31 INTEREST PAYMENT 107.66
• Check Transactions
SERIAL DATE AMOUNT SERIAL DATE
1003 05/04 3,658.00
• Balance By Date
04/30 37,657.40 05/04 33,999.40 05/31 34,107.06
PAYER FEDERAL ID NUMBER ................. 52-2389022
INTEREST PAID YEAR TO DATE .............. 437.22
AMO;lNT
*** INTEREST EARNED THIS STATEMENT PERIOD ***
DAYS IN PERIOD ......................... 31
INTEREST EARNED ........................ 107.66
ANNUAL PERCENTAGE YIELD EARNED (APY).... 3.75
Free Checking Account Statement
For the period 04/18/2009 to 05!18!2009
For 24-hour information, sign on to PNC Bank Online Banking THEDA K BURK OR
on pnc.com• Primary account number: 50-0351-3146
Page 2 of 2
ew ersey: ra.nc es
Local Routing Numbers for Above Markets
0110, 0111, 0112, 0113, 0114, 0115, 0116, 0117, 0118, 0119, 0210, 0211, 0212, 0213, 0214, 0215, 02.16, 0219, 0260,
0280, 0310, 0311, 0312, 0313, 0319, 0360, 0510, 0514, 0520, 0521, 0522, 0540, 0550, 0560, 0570, 2110, 2111, 2112,
2113, 2114, 2115, 2116, 2117, 2118, 2119, 2210, 2211, 2212, 2213, 2214, 2215, 2216, 2219, 2260, 2280, 2310, 2311,
2312, 2313, 2319, 2360, 2510, 2514, 2520, 2521, 2522, 2540, 2550, 2560, 2570
If you have a.ny further questions about our Funds Availability Policies, please contact your local branch office or call
our toll-free customer service line for Consumer Customers at 1-88$-PNC'-Bank and for Business Customers at
1-877-BUS-BNKG between the hours of 6 am - 12 midnight Eastern Time, 7 days a week.
College is an adventr,rre, getting a loa-r to pay for it slronldn't be.
To leanr rrrore...vrsitpr:corrcanrprrs.conr or call 1-800-762-1001
Effective April 17, 2()09, authorized/approved restauinnt check card transactions will no loner be considemd ii detenni~in~ the balance
available in your account to pay checks and other withdrn~vals unfit the merchant has sirbmitiecl a final transaction amount
Free Checking Account Summary Theda K Burk Or '~'~
Account number: 50-0351-3146 Sandra B Weaver
Overdraft Protection Provided By: Contact PNC to establish Overdrak Protection
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions balance
Average monthly Charges
balance and fees
-t3.3F .pp
Traveling Chttside the Lhiited States?
Stop by yoiu• local PNC bi<Znch to order foreign ciurency before you go
- Com~enience -carry ciuzency with you for immediate expenses such as taxi fares, tips and meals.
- Avoid delays and save time vt~hen you travel.
- Haviig local ciurency for yo>u desti~atioii will give you added peace of mind.
- Competitive rates and no transaction fees.
- ~~rhen you iehun with excess c>,uiency, PNC can buy it back for t?. S. dollars.
Visit any PNC br~•u~ch for more i~fonnation
JERR}' R. DUFFLE
RICHARD 1V. STE14'ART
C. ROY 1~'EIDNER. IR.
EDtitLND G. 1\IYEKS
DAVID W. DELuCE
JOHN A. ST.ATLER
JEFFERSON J. SHIPMAN
JEFFREY B. RETTIG
KEVIN E. OSBORNE
RALPH H. WRIGHT, JR.
MARK C. DUFFLE
]oHN R. MNOSKY
1~91CHAEL J. CASSIDY
Register of Wills Office
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Jor=~isoiv
pUFFIE
September 4, 2009
RE: Estate of Theda Burk
Date of Death: June 5, 2009
Our File No. 3764-3
Dear Register:
Enclosed for filing, please find the following:
MELISSA PEEL GREEVY
WADE D. M.ANLEY
ELIZABETH D. SNOVER
ANDKEIV P. DOLLMAN
OF COUNSEL
HORACE A. JOHNSON
F. LEE SHIPMAN
(1965-2006)
1. 2 Original PA Inheritance Tax Returns. There is tax due in the amount of $1,964.08. The
Return is being filed to qualify for the three month prepayment discount.
2. Inventory
3. Two (2) copies of Pages 1 of the Return, which we ask that you time-stamp and
return to us in the enclosed envelope.
4. One (1) copy of the Inventory, which we ask that you time-stamp and return to us in the
enclosed envelope.
5. Check in the amount of $30.00 representing the filing fee of $15.00 for the Inheritance Tax
Retum and $15.00 for the Inventory.
There was no reason to probate this Estate, therefore, there is no file number assigned to this Estate. An Estate
Information Sheet has been enclosed. Should you have any questions, please do not hesitate to contact our office. Thank
you for your assistance in this matter.
Very truly yours,
SON, D FFIE~ STE~ EIDNER
a i I ,wf `'
Estate Administration Paralegal
Gr)
Enc.
:376480 ~:
301 MARKET STREET P.O. BOX 109 LEMOYNE, PENNSYLVANIA 17013-0109
WWWJDSWCOM 717.761.4540 FAX: 717.761.3015 MAILQJDSWCOM
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