Loading...
HomeMy WebLinkAbout04-0482PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of c~t,t.,,~-r"% ~a'.t~-~.~ No. also known as To: Deceased. Social Security Register of Wills for the County of ~ ~,~.e~.s~oo in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who ia/are 18 years of age or older, appl)/ (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in for letters of administration on the estate of County, Pennsylvania, with h c~ last family or principal residence at ~ t4,.~r~ ~,~4e g~j ~%,~-,a ~. (list street, number and municipality) Decendent, then '~ ~ years of age, died ~~ 7_~ , ~ ~r._n~ , Decendent at death owned property with estimated values as folllows: (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 situated as follows: 5e~ ~ ~-~,.~ ~'~v-~ /'-'~o-~,..~,, Petitioner~ after a proper search ha the following spouse (if any) and heirs: Name ascertained that decedent left no will and was survived by Residence THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. .-~ .- OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or af[ir~rne, d, and subscribed before me this/W-c~ day of ~F~(~' ~ Register~l No. 2 -o4-q?z Estate of o~4~a ~ ~-~ , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW ~'~ ~ c~ t9'2r~q , in consideration of the petition on the reverse side hereof, s~isfactory proof having been present.ed before me, IT IS DECREED that -i~/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted in the estate of FEES Letters of Administration ..... $~ Short Certificates( ) .......... $ Renunciation ................ $ TOTA]~ $. Filed ..~..-..~.!:. ~.cl-.- A.D. Register of Willsr"~¢ ATTORNEY (Sup. Ct. I.D. No.) ~ADD~SS 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. Local Registrar Fee for this certificate, $2.00 P 99:1_3881 No. ~ ' -Daie f H105.143 Rev, 2/87 TYPE/PRINT PERMANENT BLACK INK COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS '~ CERTIFICATE OF DEATH · . (First, Middle, Last) M. BYERS SOCIAL SECURITY NUMBER ~ DATE OF DEATH (Month, Day, Year) Female 184- 12 --2933 Mar. 28. 2004 DATE OF BIRTH BIRTHPLACE City arid (Morith. D~y, Year) Slate or Foreign Courtly CITY, BORO, TWP OF DEATH FACIHTY NAME 01 no~ i~stitutio~, 9ire streat and number) RACE - ^mmican Indian, Black, White, No [] Yes [] ff yes, specify Caban, (Specify) 300 North 'ette Street Me~n, pue~Rican, e{c. Wh'ite KIND OF BUSINESS I INDUSTRY DECEDENT'S EDUCATION MARITAL STATUS - Mamedl SURVIVING SPOUSE 1 7257 on othdr side) ~. Comt~ Cumberland. township?17d.[~] No, decedentlived within actual lirntls of Sh~t3'l-) [3 c~ ___ r. r. enE~_/~.r.~ city.ore AGE (Lasl Birthday) Yrs, 81 COUNTY OF DEATH Cumberland DECEDENT'S USUAL OCCUPATION 300 N. Fayette St. PA Arthur Hancock MOTHER'S NAME (First, Mid.e. Maiden Surname) Anna Varner INFORMANT'S NAME (Type/Print) J. Ni~ ;on METHOD OF DISPOSITION Susa, [] c~ [~at from s~ate [] DATE OF ~ISPOSITION 1, 200~ LICENSE NUMBER ~, date and place stated (Streat, City/Town, Slate, Zl~ Code) LOCATION - City/Town. State. Zip Code Shippensburg NAME AND ADDRESS OF FACILITY LICENSE NUMBER physician is nol available al time of death to (Signature ired Titla) resulting in death) .----b a. _.____ k ..-5~.~^*^c°"s~au~"~: ~ _ _l -/J ' J 1 TIME OF INJURY WAS AN ADTOPSY WERE AUTOPSY FINDINGS I MiNNER OF DEAT Yes [] Yes [] No [] ictde [] [Mol'Ch. Day. Year) ~ORONER? 17257 btdldlng, e~. (SpedJy) 'PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both pronoUnCing death ahd ceflitying to cause of death) TO the best of my knowledge, death occulted at the time, dale, and place, and due to the causes(i) · MEDICAL EXAMINER/COEONER On the basis of exarmnaflon and/or Investlgatton, In my opinion, death occurred It the time, date, and place, and due to the causes(s) and REGISTRAR'S SIGNATURE AND NUMBER -- ~; ' PART I1: Other sigmficent conditrons conthbutin9 to death, bul LOCATION (Street, City/Town, State) (llem 27) Type or Pn~ Dr. Margery A. Gordon Walnut Bottom Rd. ~ Shippensburg, pA 1725' DATE F;LED (M0~h. Day. Year) CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Date of Death: Estate N o.: Olive M Byers March 28, 2004 21-04-0482 To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on May 24, 2004. Name Address Kimberly Dewalt Richard A Byers Kathryn Nicholsen 300 N Fayette St Shippensburg PA 17257 300 N Fayette St Shippensburg PA 17257 2122 Orrstown Rd Shippensburg PA 17257 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except None. Date: Fore~ Esquire Attorney I.D. #18064 137 Park Place West Shippensburg PA 17257 Phone 717.532.9046 Fax 717.532.8879 e-mail fnmyers@earthlink.net Capacity: _X Counsel for Personal Representative IN RE: LOUIS W. MILLER, an incapacitated person ORPHAN'S COURT DIVISION No. 21-02-482 Description of Pleading: Report Submitted Pursuant to Section 5521(c) of the Probate, Estates and Fiduciaries Code Filed By: Blair Senior Services, Inc. 1320 12th Avenue Altoona, PA 16601 (814) 946-1235 IN RE: LOUIS W. MILLER, an incapacitated person. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION Case No.: 21-02-482 REPORT SUBMITTED PURSUANT TO SECTION 5521(c) OF THE PROBATE, ESTATES AND FIDUCIARIES CODE AND NOW, comes the Guardian, Blair Senior Services, Inc., and reports as follows to the Court on the Guardianship of Louis W. Miller pursuant to the requirements of 20 Pa.C.S. § 5521 (c): I. Guardian of the Estate A. Current principal and how it is invested: ^ checking account with Citizens Bank had a balance of $17,233.85 as of July 31, 2004. B. Current Income: Mr. Miller received Social Security benefits in the amount of $798.00 per month for October 2003 through December 2003 and $808.00 per month for 2004; Social Security Conserved Funds in the amount of $1,903.80; Veterans Pension in the amount of $1,200.00 per month for January 2004 through April 2004 and $1,375.00 per month for May 2004 through July 2004; Veterans Pension Retroactive Pay in the amount of $2,408.00; Funds transferred from resident account at Hollidaysburg Veterans Home in the amount of $11,785.42; and checking account interest in the amount of $81.15 for the period of October 2003 through July 2004. C. Expenditures of Principal and Income: The following expenditures were made on behalf of Mr. Miller during the period from October 1, 2003 through July 31, 2004: room & board - $13,781.20; consumer spending money - $640.00; Blair Senior Services' Fees ~ $1,070.00; legal fees - $37.00; medical - $32.00; and clothing - $359.32. II. Guardian of the Person A. Current Address: Hollidaysburg Veterans Home, Personal Care Unit, PO Box 319, Hollidaysburg, Blair County, Pennsylvania 16648. B. Major Medical and Mental Problems: Depression, s/p Carcinoma (head and neck) with radical surgery, Old Acute Cerebrovascular Disease, Vascular Dementia, Chronic Atrial Fibrillation, Chronic Ethanol Abuse, Neurogenic Bladder, Hypothyroidism. C. Living Arrangements and Support Services: Mr. Miller continues to receive care by registered nurses, LPN's and certified nurses aides. He is also seen monthly and as needed by Dr. Wiegering. Mr. Miller participates in activities at the Hollidaysburg Veterans Home as much as he is capable. D. It is the opinion of the guardian that the guardianship must continue due to Louis W. Miller's incapacity. E. Number and Lengths of time the guardian has visited Mr. Miller in the past year: 1. Direct Contacts - 22 visits lasting in duration from 15 minutes to 3 hours, for a total of 17 hours and 15 minutes during the reporting period between August 13, 2003 and July 31, 2004. 2. Collateral Contacts - a total of 26 hours and 15 minutes during the reporting period between August 13, 2003 and July 31, 2004. 3. Total hours of Contacts Direct and Collateral - 43 hours and 30 minutes during the reporting period between August 13, 2003 and July 31,2004. BLAIR SENIOR SERVICES, INC. Date D'~I~'M. Slat, Executive Director SS 4489000287008595 B' ERS,O- IV~ H~*300 N FAYETi'E ~' :' CRCD 840 07/30/04 08:4] ~[iR HAL 5,20~ 0~, STTS ~D iNT/EX X/Z ~.OHE PHONE 000-0023 CRDT LIMIT 5,000 C ~ ,Y~E CODE 2Y WORK PHONE Z~VLS '2RDT 204- OPPiN DATE 10-97 SOC SEC ~ 184-i2-29~3 LS ~AL ' ' 35 ~ ~,204. EXP D~.~z 10-04 CHECKING ~,: H BAi ~,204 PLST~ 0! TYPE ] i SAVINGS LST u~{T Al4 116 LST PMT DT 83-09-04 ANNUAL 'CHARG~ 00 O0 {'. AK ~',iE 'r27 LST MON }5-' 3-0~ y CREDIT LINE 05 99 H DSP At,{ [}LQ ¥ DAYS !3ELiN0'UENT ~ IiHES ] CYCLE !! rlHES 2 CYCLES ~ I±MRS i CYCLES RECOURSE FLAG (?ASH (}UT YTD iNT CROSS REFERENCE i 0 0 LST NH 06-10-04 216 F× PY AH 0.00 647 AUTH FLG PIN TR 0 RENEWAL CODE 4 CONTROL 8 174 OVERLiHIT NiST 18 US~R FLAGS V Z TERHS LEVEL ] SPECIAL Fi,AGS 0 H!SP 5432 iQ!Q ~QQQ HESC F ACNS 3 REAGE COUNTER 00 ~ONTHS GROSS ACTIVE 32 N STS CD CHG 05 03 06 DE~G SCENARIO 0002 4, ~5! AUTO PA{HNT FLA,q 0 SCORE: BIl ,~:b :FA 006 251.12 CRDT B[iREAC Fr'~' Ni O~Ef31T LiFE O ~ DUALiTy 0000000008{}0009(] 2 80 ;8'{)d~'912,03:30000 3 00000300,3,08000(h3 STATEMENT AND PROOF OF CLAIM FILE NO: 04-482 ~ pp~uATE OF PENNSYLVANIA ORATE COURT MBERLANO COUNTY Estate of O~LIVE M. BYERS I, NATIO~NAL CITY CORPORATION of ONE NATIONAL CITY PARKWAY, KALAMAZOO Mi 49009 submit the following claim against the estate for the sum set forth. * DESCRIPTION OF CLAIM AMOUNT Type of Account: CREDIT CARD Account Number: 4489 0002 8700 8595 $5,204.00 Date Opened: 10117/97 _ There is now due on the c~aim, above all iegal set-offs, the sum of: $5,204.00 i ] Notice to interested persons: This is a claim by a personal representative for an obligation that arose before the death of the decedent. A hearing will be held to determine whether to allow the claim. You may object to the claim before er at the hearing. I declare under penalties of perjury that this statement and proof of claim has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date ¢,3~,, 0Y ~ ~99 Claimant Signature, Ja~on Probate Ceordin 894 1236 PO BOX 509 Address Address _PORTAGE Mi 49081 City, State, Zip City, State, Zip * 1. Describe nature of claim or attach statement. Attach copy of receipt or other evidence of payment if submitted by assignee. 2. Claims must be presented either personally or by mail to the fiduciary on or before the last day for presentment of claims. This claim may also be flied with the probate court (see reverse side for proof of service), c~ ~- PLEASE SEE OTHER SIDE ~-~- Do not write below this line - For court use only PROOF OE SERVICE OE CLAIM I served upon Kimberly Dewalt, Richard Dyers,, fiduciary, a copy of this statement and proof of claim on __ 07130104 katherine Ni_cholson~ CIO ATTORNEY FORREST MYERS. ~ by ORDINARY US MAIL to I declare under the penalties of perjury that this proof of service has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Signature, JA~ ANDERSON, Probate Coordinator ACKNOWLEDGMENT OF SERVICE Service of the attached statemeet and proof of claim is acknowledged. Date Signature Page: i Bocui~,ent Name: unc!tl~d CUR BAL 5,204.05 STTS CD ENT/E'X X/Z IIOHE PHONE 000 0023 CRDT LIMIT 5,000 CYCLE CODE 2Y WORK PHONE RVLB CRD'n 204 OPEN DATE 10 9U SOO SEC 8 184-12-2933 LS EAL 5, 204.05 EXP DATE !0-(}~ CHECKING PRV E GAL 5,204 PhST~ 0i fYPE 11 SAVINGS !H'T PHT AM ]16 LST PMT DT 03-09-04 ANNUR~ CHARGE 00 00 0 AN Di~E 277 LST N~ON 05-03 04 Y CREDIT LINE 05 99 M i}SP At,( LL6 :: DA"S D'rLIN©UENP {! TIME:' 1 CYCLE ~ TIMES 2 {CYCLES ~ Tib[ES 3 ( YCI,ES RRCOURSE ELAS CACTI OUT YTi3 iN~ CROSS REFERENCE i 0 0 642 174 0 3 N 4,3bl 2ol.]2 0000000000000000 2 LST NM 06-10 06 216 AUTH FLG PCN T~ OVERLiNIT HIST TERHS hEVEi, 1 HiST ~432 !©iQ REAGE COUNTER 00 STS CE} CHG AUTO PAYMN~ FLA6 0 ~X P¥ AM 0.00 RENEWAL CODE 4 CONTROl, USER FLRGS V SPECIAL FLAGS HISO F ACBS MONTHS GROSS AC£IVR 32 OELQ SCENARIO 8002 SCORE: BH C05 CR CRDT BUREAL! FLAG X CPEUIT LIFE 0 / F3UAL!Ii 0 ~r~'r C)-P' ~ '00C300003000{3000 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 0O4639 BYERS RICHARD A 300 N FAYETTE ST SHIPPENSBURG, PA 17257 ESTATE INFORMATION: SSN: 184-12-2933 FILE NUMBER: 2104-0482 DECEDENT NAME: BYERS OLIVE M DATE OF PAYMENT: 11/17/2004 POSTMARK DATE: 11/16/2004 COUNTY: CUMBERLAND DATE OF DEATH: 03/28/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $24.29 REMARKS: BYERS TOTAL AMOUNT PAID: $24.29 SEAL CHECK# 1566 INITIALS: CCP RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COHHONHEALTH OF PENNSYLVANIA DEPARTNENT DF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. Z80601 HARRISBURG, PA 171ZS-OGD1 REV-15~S El( AFP C09-DO) ZNFORHATZON NOTICE AND TAXPAYER RESPONSE FILE NO. 21 04-0482 ACN 04136447 DATE 10-05-2004 KIHBERLY J DEWALT 500 N FAYETTE ST SHIPPENSBURG PA 17257-1106 TYPE OF ACCOUNT EST. OF OLIVE H BYERS [] SAVINGS S.S. NO. 184-12-Z955 [] CHECKING DATE OF DEATH 03-28-2004 [] TRUST COUNTY CUHBERLAND [] CERTIF. RENIT PAYNENT AND FORHS TO: REGISTER OF NILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17015 CITIZENS BANK OF PA has provided the Department with tho information listed below which has been used in calculating the potential tax due. Their records indicate ~hat at the death of the above decedent~ you were a joint omner/beneficiary of this account. If you foe1 this information is incorrect, please obtain written correction from the financial institution, attach a copy to this fora and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 787-8327. COHPLETE PART I BELON x x N SEE REVERSE SIDE FOR FILING AND PAYHENT INSTRUCTIONS Accoun* No. 6100586421 Da*e 05-05-1996 Es*ablishad Accoun* Balance 525.92 Parcan* Taxable X 50.000 Amoun* SubSac* *o Tax 161.96 Tax Ra*e X .15 Po*on*ia1 Tax Due 24.29 To insure proper credit to your account, two (Z) copies of this notice must accompany your payment to the Register of Hills. Hake check payable to: "Register of Hills, Agent". NOTE: If tax payments are made within three (3) months of the decedent's date of death, you may deduct a SZ discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. A.~ The above information and tax due is correct. i i 1. You may choose to remit payment to the Register of Hills with two copies of this notice to obtain a discount or avoid interest, or you may check box "A" and return this notice to the Register cf CHECK -~ Hills and an official assessment wiZ1 be issued by the PA Department of Revenue. ONE J BLOCK s. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the dacedant's representative. C. [] The above information is incorrect and/or debts and deductions ware paid by you. Yau must complete PART ~-Jand/or PART I-~-Ibelow. PART If you indica*a a differan* *ax re*e, please s*a*e your [] rala*ionship *o daceden*: TAX RETURN - CONPUTATION OF TAX ON JOINT/TRUST ACCOUNTS L/NE 1. Da*e Es*ablished I E. Accoun* Balance 2 3. Percen* Taxable 3 ~ ~. Aaoun* Subjac* *o Tax q 5. Deb*s and Daduc*ions 5 - 6. Amoun* Taxable 6 7. Tax Ra*e 7 ~ 8. Tax Due 8 PART DATE PAID DEBTS AND DEDUCTIONS CLAIHED PAYEE DESCRIPTION ANOUNT PAID TOTAL (En*er on Line 5 of Tax Compu*a*ion) $ Under penal*/es of perjury, I declare *ha* *he fac*s I have roper*ed above are *rue, correc~ and :omple*e *o *he bes* of ay kno.ladga and belief. HOHE ( ~/~ ) ~3~ - 7 > ~ TAXFAYER SZGBATURE TELEPHONE NUHBER DATE 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 004712 MYERS FOREST N ESQ 137 PARK PLACE WEST SHIPPENSBURG, PA 17257 ESTATE INFORMATION: SSN: 184-12-2933 FILE NUMBER: 2104-0482 DECEDENT NAME: BYERS OLIVE M DATE OF PAYMENT: 1 2/09/2004 POSTMARK DATE: 1 2/09~2004 COUNTY: CUM BERLAN D DATE OF DEATH: 03/28/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $1,194.99 REMARKS: FOREST N MYERS TOTAL AMOUNT PAID: $1,194.99 SEAL CHECK#10793 INITIALS: SK RECEIVED BY' GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-1500 EX + (6-00) I-- Z LU LU UJ Z 0 0 Z Z O X COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL Byers~ Olive~ M DATE OF DEATH (MM-DO-Year) 03/28/2004 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DATE OF BIRTH (MM-DD-Year) 09/09/1922 FILE NUMBER 2 1 -0 4 OFFICIAL USE ONLY 0 4 8 2 COUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 1 8 4- 1 2-2 9 3 3 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 [] 1. Odginal Return r--I 4. Limited Estate ~6. Decedent Died Testate (Attach copy of Will) E~9. Litigation Pro(~eds Received El2. Supplemental Return [~] 4a. Futura Interest Compromise (date of death after 12-12-82) [~7. Decedent Maintained a Living Trust (Attach copy of Trust) ] 10. Spousal Poverty Credit (dateofdeath between 12-31-91 and 1-I-95) El3. Remainder Return (dateofdeath pdorto 12-13-82) [~5. Federal Estate Tax Return Required __ 8. Total Number of Safe Deposit Boxes [] 11. Election to tax under Sec. 9113(A) (AUach Sch OI THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME I COMPLETE MAILING ADDRESS Forest N Myers I 137 Park PI W FIRM NAME (If Applicable) Law Office Forest N Myers TELEPHONE NUMBER 717.532.9046 Shippensburg PA 17257 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership 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) ] 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, Modgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (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) 522~,:~0:oo i 323.92 OFFICIAL USE ONLY (8) (11) 12~272.90 13,495.77 52~323.92 25~768.67 26~555.25 26~555.25 (12) (13) (14) 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) 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. 0.00 X __ (15) 26,555.25 X .045 (16) 0.00 X .12 (17) 0.00 X .15 (18) (19) 0.00 1~194.99 0.00 0.00 1,194.99 > > BE SURE TO ANSWER ALL QUESTIONS ON ;REVERSE SIDE AND RECHECK ;MATH < < Decedent's Complete Address: STREET ADDRESS 300 N Fayette St CiTY Shippensburg Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty ISTATE PA (1) ZIP 17257- Total Credits ( A + B + C ) (2) 1,194.99 Total Interest/Penalty ( D + E ) 0.00 0.00 0.00 1,194.99 If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) (5A) (5B) 1~194.99 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 properly 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 promise 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 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. SIGNATURE O/~ PieRSON RESPONSIBLE FOR FILING RE.T,I,I,I)RN SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS 137 Park P'P'P~W Shippensbur,q DATE PA 17257 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 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(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-1502 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Byers, Olive, M 21 04 0482 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with ri~iht of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION Residence Residential Real Estate located at 300 N Fayette Street, Shippensburg Borough, Cumberland County, Pennsylvania VALUE AT DATE OF DEATH 52000.00 TOTAL (Also enter on line 1, Recapitulation) $ 52,000.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Byers, Olive M 21 04 0482 Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT FUNERAL EXPENSES: Fogelsonger-Bricker Funeral Home ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees Forest N Myers, Esq. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Kimberly Dawalt Zip Street Address 300 N Fayette St city Shippensburg State PA Relationship of Claimant to Decedent daughter Probate Fees Letters of Administration, Short Certificates, JCP fee Inheritance Tax Return filing fee Accountant's Fees Zip 17257 Tax Return Preparer's Fees Cumberland County Recorder of Deeds; recording fee, deed 7,084.40 1,500.00 3,500.00 149.00 39.50 TOTAL (Also enter on line 9, Recapitulation) $ 12,272.90 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Byers, Olive, M 21 04 0482 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 20.89 10 11 12 13 14 15 Chambersburg Imaging Assoc PC ...8573 Medical; acct no. H16858573 Chambersburg Imaging Assoc PC ...9080 Medical; acct no. H13909080 ProMed Services Inc ...4761 RE: Cumberland Valley EMS. Medical; acct no. 244761 Chambersburg Hospital ...0261 Medical; account no. H00018040261 Chambersburg Hospital ...5360 Medical bill; acct no. H000017615360 Chambersburg Hospital ...1311 Medical; acct no. H000016871311 Aspire Consumer Credit acct no. 4791060016267808 CardioVascular Assoc Medical; acct no. 30530 Chambersburg ALS - West Shore Medical; acct no. 15586 Chambersburg Hospital ...8448 Medical; account no. H00018038448 Chambersburg Hospital ...5655 Medical bill; acct no. H00018315655 Chambersburg Imaging Assoc PC ...5655 Medical; acct no. H18315655 Chambersburg Imaging Assoc PC ...8448 Medical; acct no. H 18038448 Cumberland County Personal Tax Cumberland County/Shippensburg Boro R/E Tax 47.00 55.78 80.00 128.10 86.88 3,598.42 213.01 1,551.11 133.12 906.94 30.83 52.00 10.00 252.99 TOTAL (Also enter on line 10, Recapitulation) $ 13,495.77 (If more space is needed, insed additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent Byers, Olive, M 21 04 0482 Decedent's Name Page 1 File Number Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER DESCRIPTION AMOUNT 16 59.96 17 18 19 20 21 22 23 24 Cumberland Valley EMS / ProMed Svcs medical; acct no. 185 Cumberland Valley Neurosurgical medical; acct no. 26509 Donahoe Michael T MD Medical; acct no. BYEOL000 Moffitt Heart & Vascular Group Medical; acct no. 113074 ProMed Services Inc ...2095 RE: Cumberland Valley EMS. Medical; acct no. 252095 ProMed Services Inc ...3592 RE: Cumberland Valley EMS. Medical; acct no. 252095 Pulmonary Assoc Medical; acct no. 11313 Citizens Bank (formerly Mellon) Loan account National City Corporation Consumer Credit acct no. 4489 0002 8700 8595 36.46 66.27 407.51 50.78 56.28 73.26 374.18 5,2O4.0O SUBTOTAL SCHEDULE I 6,328.70 GRAND TOTAL SCHEDULE I $ 13,495.77 REV-1513 EX + (9-nm COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Byers, OI ye, M NUMBER I. 1. 2. 3. II. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outdght spousal distributions, and transfers under Sec. 9116 (a)(1.2)] Kimberly Dawalt 300 N Fayette St Shippensburg PA 12757 Richard Byers 300 N Fayette St Shippensburg PA 17257 Kathryn Nicholsen 2122 Orrstown Rd Shippensburg PA 17257 FILE NUMBER 21 04 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Lineal Lineal Lineal O482 AMOUNT OR SHARE OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET 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 l! - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If more space is needed, insed additional sheets of the same size) 33.33 33.33 33.33 . ..~o_-------~ C::. <;--, -', , .... ~ ~ 1':;-, " t'~ (~ ~~^. ~, "'- ~ ~ r ... r:', ~ ^ ~ ~ -.4 '-- ...... '\., ~ \1-\ -G.;, '" -, ~" \,.'" " ~ ;.. " .,.'~ ,,-, ~ r- -J ' ..... z .; <:::. ---.. ~ <;) ~ ~. ~ ~. ~'::,;~, ., ~ '0 '-'\ <::: ~ i< ....... ~. ~---, ~I~,~ ~ ':'", ~ -- ~ -.() ~ ~ ~ ~ -., -...... "'" ~ .~ ...; ......, .'<.) C" '-...., "'G., - ':t. ~ --- '\1.:\ 00 Gc, ~\ \.:;, \::::.I ~\ '-,. ~ ~ ::: 0,"- ..., "", 7-~ ~ .::::J ~"- ~ ~ '- .... ~ (J z:::.J c. . . '- ~. -~ \J' \1.' \ "'-.. ')-..... ~, ~ "....., .\ >,,,).,,, .~ <: " I';",., ~ "-r#l; .. '~ ".._, ."F, ' -\7;,"\-;' li \\~ I '.?~,:.4 ;. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE '* BUREAU OF INDIVID~t(TA~E$' INHERITANCE TAX DIVISro!t'; PD BOX 280601 -- ,-- HARRISBURG PA 17128-06111- NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REY-lS47 EX AF' 112-04) {"if U' t..~. DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 02-21-2005 BYERS 03-28-2004 21 04-0482 CUMBERLAND 101 OLIVE M r':;=~:- _ FOREST rN' 'MYERS F N MYERS LAW OFFICE 137 PARK PL W SHIPPENSBURG PA 17257 Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV :r!4""Ex..A~p..r~r:6!".No"YcE.lr'.lNHE;tiflNcE.TAx.A.ptlRA.fsEiriN'~.ALrcrQIN"cE.oR.............. ... DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BYERS OLIVE M FILE NO. 21 04-0482 ACN 101 DATE 02-21-2005 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule GJ 8. Total Assets (1) (2) (3) (4) (5) (6) (7) 52.000.00 .00 .00 .00 .00 323.92 .00 (8) NOTE: To insure proper credit to your account. subllit the upper portion of this form with your tax paYllant. 52.323.92 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expanses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts 14. Net Value of Estate Subject to Tax (9) UO) 12.272.90 13.495.77 Ul) (2) (3) 114J 25.768 67 26.555.25 .00 26.555.25 (Schedule J) I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ Abb returns assessed to date. ASSESSMENT OF TAX: IS. Allount of Line 14 at Spousal rate (IS) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due NOTE: .00 X 26.555.25 X .00 X .00 X 00 = 045 = 12 = 15 = (9)= .00 1.194.99 .00 .00 1.194.99 ~ TAX CREDITS: (+J AMOUNT PAID DATE NUI1BER INTEREST/PEN PAID (-) 11-16-2004 CD004639 .00 24.29 12-09-2004 CD004712 .00 1.194.99 TOTAL TAX CREDIT 1.219.28 BALANCE OF TAX DUE 24.29CR INTEREST AND PEN. .00 TOTAL DUE 24.29CR I . IF PAID AFTER DATE INDICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1. NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ. YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 2/17/2006 MYERS FOREST N ESQ 137 PARK PLACE WEST SHIPPENSBURG, PA 17257 RE: Estate of BYERS OLIVE M File Number: 2004-00482 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 3/28/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, ~~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Personal Representative(s) v~ Register of Wills ofCurnberhmd County STATUS REPORT UNDER RULE 6.12 Name ofDecedent 0 \ \ ~ e. M J3 ~E' ( .s DateofDeath_~rc.h Ol~, d..~ Estate No.: .~ \ ~<tH - &i8~ Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes JX1 No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No ~ b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes 1Zl No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: "3 -\I.\-~ \=-~ Signature 3o-YP5~ iJ ~\,e'(\ Name n( .. . "'\. \ '3 + Par 1<- t' a-CQ (.,v SN OPP/1 S 6u.(ld f4. l::r J S + Address 7(1-. 53~. C1<t4<o Telephone No. Capacity: Qg Personal Representative o Counsel for personal representative ~;./ ~ , e;. ., /' In Re: Estate of BYERS OLIVE M ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO. 2004-00482 NOTICE OF FAILURE TO FILE STATUS REPORT Personal Representative: DEWALT KIMBERLY J Counsel for Personal Representative: MYERS FOREST N ESQ Date of Decedent's Death: 3/28/2004 The Orphans' Court record indicates that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orphans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report. If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of such delinquency and the undersigned will requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. Date: 4/3/2006 ~~.~ .. Glenda Farner Strasbaugh Clerk of the Orphans' Court Distribution: Personal Representative Counsel for Personal Representative Estate File Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name ofDecedent: 0 \ \\1 e, tv\. ~G~e(.s DateofDeath:krch ~~I c},t!xp-{ Estate No.: .~ \ -<P-~ - <Pi 8" Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes 00 No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. lfthe answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No a b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes 1Zl No 0 . c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. o ~...J.. oC ~$ Signature Date: 3 -\,"\...~ 3o-reS1 iJ ^<-ter\ Name n(. .., \ '3 ~ PeLr t< t' a-c..e (,,0 SN ppen S bu.fl:3 f4 I + () S::f- Address 7(1-. 53~. 0<t4<c Telephone No. -. (~. . . Capacity: ~ Personal Representative o Counsel for personal representative .~