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Home My WebLink About04-0528 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of CHESLEY D. HAM No. ;(1- OLt- 5:1."l also known as To: Register of Wills for the Deceased. County of Cumberland in the Social Security No. 004-40-4365 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl ies for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in Cumberland County, Pennsylvania, with his last family or principal residence at 125 West Main Street, Borough of Mechani~s- burg. (list street, number and municipality) Decendent, then 65 years of age, died April 23 ,J}~ 2004 , at 125 West Main Street, Mechanicsburg, PA 17055 Decendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property $ 15,000.00 (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ None situated as follows: ~-:;C'. d Petitioner_ after a proper search h~ ascertained that decedent left n~ will ancrwas survived by the following spouse (if any) and heirs: L. Name Relationship = Resideuce I Commonwealth of Pennsvlvania Statutory Heir Harrisburg, ~ (20 Pa.C.S.2103(6) -0 --' , The Commonwealth has renounc ~d in favor of the ndersigned Petdtioner. THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. ~ ~4~ ., ~ ... <) c ... ""~ .- '" .,~ ...... !X:~ 219 East Main Street -g.g Mechanicsburg, PA 17055 ~''::: .-.<l) ..e.ll. <l),- :;0 Cd c OIl CIi " .,., .- ~ t OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA } 55 COUNTY OF CUMBERLAND 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. tZzd2~~ Swom to or af~ed and subscribed J - . Marlin R. McCaleb '" before me this ~ day of '-" <l) June ~ 2004 ... =s ~~~%-;~;~ L ~ as = 01) ti5 No. :2/- 04 - 5;).. fI Estate of CHESLEY D. HAM , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW June tt l~x 200~in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that MARLIN R. McCALEB is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to MARLIN R. McCALEB in the estate of CHESLEYD. HAM ~ .,,,A. Y."",-" '';~~ R,gi~~ of Wilb .-:: ~--'-" JJ.j FEES Letters of Administration ..... $ t::}D. O() Marlin R. McCaleb (No.06353) Short Certificates() . . . . . . . . .. $ C, .Oc> ATTORNEY (Sup. Ct. I.D. No.) Renunciation ................ $ c:; ('of) 219 East Main Street, P.O. Box 230 --J(P $iO.oD Mechanicsburq, PA 17055 TOTAL _ $ 14.60 ADDRESS Filed JR.,,; .4-.-: .l?4 . . . . . . . .. A.D. 19_ (717) 691-7770 PHONE . . Hl0<;.~(l:; RFV ()1,Q,{, This is to certify that the information here given is correctly copied from an original certificate of death dU~t filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent fi ing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 ~'.h~' ~1b 77 Local Registrar p 10040532 fjJUL ;J ~ JlO-t:I f' No. c2/- OLI-5~ "g Date ..-. ,.... .~ J t. . d --' ~ L ~: ""- I .~ -0 --' 1" r: 0;": Hl05144Rtlv 1/91 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS TYP[/PRINT CERTIFICATE OF DEATH IN (Coroner) PERMANENT 1/29-247 SWE FILE NUMBER BLACK INK SEX SOCiAl. SECURITY NUMBER DATE OF DEATH (Menlh, Deay 'roar) D HAM a, Male ., 004-40-4365 c, April 23, 2004 BIRTHPlACE (ClIy and PLACE OF DERH IChocl<. onIV one see instruclions on other side) Stale or Foreign COunlry) HOSPITAl: Unknown ,,,,,,,.IonlO ~='IYIO 7. Io, .C FACILITY NAME (I' nol.nstitution, give street and number) RACE. American Inclian, &ack, While, Me. Street (Speedy) ... 10, Hhite MARiTAl SWUS. Married SURVfVtNG SPOUSE Never M.rriltd. Widowed, (It Wile. gIVe fTldiden namel """'"*'IS-'Yl Widowed two 17b. Coun Cumberland t7d.~ ~:::::~~Ol ~1echani csburg _. FATHER'S NAME (First, Middle, last) MOTHER'S NAMIi (First Midde. Maiden Surname) 11, Unknown 10, Unk nown INFOAMANT'~ NAME (Type[Pfint) Norri s INF~15" "'tiUa s~~rs'e"" 'R:'Sa'd'"'.st{i't e 1 ~1BG , Pa. 17055 0., M 1 C h a elL. METHOD OF OtSPOSITION PLACE OF DISPOSITION. Name ot Cemetery. Crem.wry LOCATION. CilylTown, Stale, Zip Code o BuriallK]. Cremalion 0 Removal from State 0 or Other Place ~ Donahon .~ISD6CifvL .,.. Longsdorf Cemetery .,llew Kingstown. Pa. " 218. if> SIG LICENSE NUMBER NAME AND ADDRESS OF FACILITY ~ ...FD-014318-L ...M ers f. H. 37 East Main St MBG, Pa. 1705 ~ 1edQe, death occurred at the time, dale and place slated LICENSE NUMBER DATE SIGNED (Signatu,eandTJIIe) (Monlh. Day, Year) 23.. n., 23c. TIME OF DEATH ORE PRONOUNCED DEAD (Month, Day, '1M,) ~ CASE REFERRED TO MEDICAL EXAMINER/CORONER? 1 :00 April 25, 2004 ""~ NoD .C, as, 28, 27. PART I: Enler lhe diMases, injur. or complicalions which caused the dealh. Do not entet lhe mode of dying, such as cardiac or respiratory luntst. shock 01 heart taiklre. IApproximate PART II; Other signilicanl conditions conlribullng to death, but List only one cause on each line : Interval between not resuhing mlhe UnderlyIng cause gi"en in PART I. : onset and death Chronic Obstructive Pulmonary Disease , . i DUE TO (OR AS A CONSEQUENCE OF); , . ! I DUE TOtOR ASA CONSEQUENCE Of): . -------- -- -'--'-.--..'-.'-- ---.--- DUE 10(00 ASA CONSEQUENCE Clt'): o. WERE AUTOPSY FIHOINGS MANNER OF DE~H DATE OF INJURY N.Nt..ABlE PRIOR 10 (Month, Day, Year) COMPLETION OF CAUSE ~ OF DEATH? NiUurae HomlciOe N.~ ",.0 NoD Accident D Pending InvestigatiOn - D Coufd not be determined 2", 2", 28, CERTIFIER (Check onty one) "CERTIFYINQ PHYSICIAN (PtlySiclan certifying cause 01 death when another physician has pronounced death and completed l1am 23) Coroner Tothebutotmrkno~.dnlhoccurred""Io"'caUM(.)Mdm.n""".~ed.,...,...... ...,.",..,..,... .....,.. ......... r OATE SIGNED lMooIh, Da9" Year) z 310, April 2 , 2004 w .PRONOUNCINQ AND CERTIFYING PtfYSICIAN (Physician both pronOUl1C1flQ death and cer1ilying 10 cause 01 death) D 31, fil To the beet of my knowtedge, death occut'Nd at the....., da....net pa.c., and due to the c.UM(.J.nd IMnfMIr a. .ts;tect.. . .. ,..".,...........,. ~ NAME AND ADDRESS OF PERSON WHOCOMPLETEDCAUSE OF DEATH 0 (Ilem 27) Type or Print Michael L. Norris, Coroner 0 "MEDICAL EXAMINER/CORONER 6375 Basehor,e Road, Suite #1 On the baI, ot examlnelktn and/or Inwltlgatlon, in my optnlon, death occurred at the tlm.. dat., end pla~, end dUI to the clu..(a) end ~... w m.nner.. "Ited.. . . . . . . . . . . ., . . . . . . . .. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . .. Mechanicsburg, Pa. 17050 :; 31.. ~ Z AEGIST ORE FILED (Month, Day, Year) l;l, ( ~,I II)! .C. ..--- ------.,--.-. -_.....---- ..-.. ..-------.-.---.---- RENUNCIATION c:;2/ - 0 J.j. - 5.;L. ({ In Re Estate of CHESLEY D. HAM deceased. To the Register of Wills of Cumberland County, Pennsylvania. Warren Klunk, Representative for the Commonwealth of The undersigned Pennsylvania, Department of Revenue, statutory heir of per 20 Pa.C.S. 2103(6), the above decedent/hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters be issued to Marlin R. McCaleb WITNESS my hand this ,,< 7~1, day of /IIA; , f9C~4 ~ ;/f~ ~ (S~ature) . Warren Klunk, epresentat~ve for the Commonwealth of Pennsylvania, Department of Revenue, Bureau of Individual Taxes Dept. 280603 Harrisburg, P lAdd.e:?~ 28- 060 3 (Signature) ,"-- ~~; . ~- LL ~ (Address) I ":5 J -- (Signature) ~ p , .'" -~ -". -~ (Address) CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Chesley D. Ham Date of Death: April 23, 2004 Will No. 21-04-0528 To the Register: I certify that notice of beneficial interest and estate administration required by Rule 5.6(a) of the Orphans' Court Rules was personally served on the following beneficiaries of the above-captioned estate on June 8, 2004. Name Address Warren Klunk Commonwealth of Pennsylvania Department of Revenue Bureau of Individual Taxes Dept. 280603 Harrisburg, PA 17128-0603 Notice has now been given to all persons entitled thereto under Rule 5.6(a). Mar~~~ Date: June 8, 2004 Attorney I.D. No. 06353 219 East Main Street P.O Box 230 Mechanicsburg, PA 17055 - , (717) 691-7770 FAX: (717) 691-7772 .,.~ Counsel for Estate of Chesley D. ~.._.- Ham G. I ':5 '"J "-::j"" P .1. .., LAW OFFICES MARLIN R. McCALEB 0, tJAYD OFFICIAL USE ONLY AEV~ 1500 EX + (6-00) REV-1500 INHERITANCE TAX RETURN FILE NUMBER COMMONWEALTH OF PENNSYLVANIA 21-04-0528 DEPARTMENT OF REVENUE RESIDENT DECEDENT DEPT. 280601 COUNTY CODE YEAR HARRISBURG, PA 17128~O601 NUMBER 0 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER E Ham Chesle D. 004-40-4365 C DATE OF OEATH (MM-OD-YEAR) THIS RETURN MUST BE ALEO IN OUPUCATEWlTH THE E 0 04 23 2004 REGISTER OF WILLS E IF AP UCABL SURVIVING spous IN tAL SOCIAL S CUR\TY UMBER N T X 1. OrigInal Return 2. Supplemental Return 3 date of death . RemaInder Return rlorlo 12-13-82) CAPB 4. Limited Estate 4a. Future Interest Compromise (date of death after 12.12-82) 5. Federal Estate Tax Return Requlred HpRL 6. Decedent Died Testate 7. Decedent MaIntained a LIvIng Trust 1 8. Total Number of Safe Oeposlt Boxes EplO CRAC (Attach copy of WlJI) (Attach copy of Trust) KOTK o 9. Lltfgatlon Proceeds Received 0 10. Spousal Poverty Credit 0 ES 11. Election to tax under Sec. 9113(A) (date 01 death between 12-31-91 and '1~'1-95) (Attach Sch 0) P N.AME COMPLETE MAILING ADDRESS C 0 0 Marlin R. McCaleb Es 219 East Main Street R N FlAM NAME Of Appllcable) P. Box 230 R 0 O. E E Law Offices-Marlin R. McCaleb Mechanicsburg, PA 17055 S N T TELEPHONE NUMBER 0 1. Real Estate (Schedule A) (1) None O~FICIAr..~SE ONLY 2. Stocks and Bonds (Schedule B) (2) None c::::> :0 (.;::::) (3) None C) ';j1 iTl 3. Closely Held Corporation, Partnership or c. ,:") _:.D c) Sole-Proprietorship '''\!(} :;:,j;" ;--:;-1 ~.'":... .; \:--) 4. Mortgages & Notes Receivable (Schedule O) (4) None ("11 'j'.) \ ,"', R 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 11 ,529.45 :~'l -- ,i\:> ;;.:.. " ('-') E (Schedule E) C. -,..., C -" -1'1 -:;..:: -"" A 6. Jointly Owned Property (Schedule F) (6) None C) P 0 - \,1'. I Separate Billing Requested .. C) T 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) None f.n ""l'1 U L (Schedule G or L) A T 8. Total Gross Assets (total Lines 1-7) (8) 11,529.45 I 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 8,156.70 0 N 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule l) (10) 1,469.15 11. Total Deductions (total Lines 9 & 10) (11) 9.625.85 12. Net Value of Estate (Une 8 minus Line 11) (12) 1,903.60 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13) 1. 903 .60 made (Schedule J) 14. Net Value Sub'ect to Tax (Line 12 minus Line 13) (14) 0.00 C 0 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES M T P 15. Amount of Line 14 taxable at the spousal tax U A T rate, or transfers under Sec. 9116(aX1.2) X ,0 0 (15) 0.00 X A 16. Amount of Line 14 taxable at lineal rate 0.00 ,045 (16) T X 0.00 I 17. Amount of Line 14 taxable at sibling rate X ,12 (17) 0.00 0 N 18. Amount of Line 14 taxable at collateral rate X ,15 (18) 0.00 19. Tax Due (19) 0.00 20. CopyrIght (e) 2000 icrm software only The Lackner Qroup, 1 nc. Form REV-1500 EX (Re" 6.00) v~ Decedent's Complete Address: STREET ADDRESS 125 West Main Street CrN I STATE I ZIP Mechanicsburg PA 17055 Tax Payments and Credits: ,. Tax Due (Page 1 Line 19) (l) 85.66 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits ( A + B + C) (z) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 0.00 4. It line 2. is greater than Line 1 + Line 3, enter the ditterence. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 0.00 S. \f Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE. (5) 85.66 A. Enter the interest on the tax due. (SA) 0.00 B. Enter the total of Line 5 + SA, This is the BALANCE DUE. (58) 85.66 Make Check Payable to: REGISTER OF WillS, "GENT "::~;;;:);;1 !)li!ll!!llliiliilllllliJ!!IIIII!!IIIIIII!!!!!IIIJ!!!!!llil!lillllll!!!III!!!!!!!!ii!!!!!!I!!I!IIIIIII!I!!I!!IIII!1111111111!1!!)!I!!!!!llmlllll!!I!!!!I!I!!lliillliJlJJlmllllmllliililiilllliliJll!JI)!Jl!IWII!I)I!!!)!)JJII!II]]!illl:::111::'. .. : ..' .:,:::!,il;!::~i~!!~;!;i!;;!; .f:~1!!:!lliii ,:;\;;ii(~:::~;:; . !!!!~(i!:!:!::l:!ii!i)iI1!!!!!i!!;i;! . 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 promise for life of either payments, benefits. ot" ca.t'e'? . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate cOf\sidetat\on? . . " , 0 []] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ... . 0 []] 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. Under penalties of perjury, I declare that 1 have examll1ed thIs return, !nclud{N!~\~'St.n&iu.\eS and statements, and to the best 01 my knowledge and belief, It is true, correct and complete. Declaratlol1 of preparer other than the personal repr~sentatlve Is based 011 all Information of which prElparer has any Icnowledge. SIGNA.TUR OF PERSON SIBL FOR FILING RE.\URN Marlin R. McCaleb DATE 219 East Main Stret I-AJ/~c:J.:r - - -Me~hanl~sbur - - - FA - - fioss- - - - - - -- - u -- - - - - - - -- , SIG Law Offices-Marlin R. McCaleb DATE 219 East Main - -- - -~------------------ For dates of death on or after July 1, ,qqol\ and before January ~, ~995, '[he 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) (iJ]. For dates of death on at 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) (iO). 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 e'len 11 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.$. 9116 (a) (1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2) [72 P,S. 9116(a)(1)], The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(aX1.3)]. A sibling is defined, under Section 9102, as an individual who has at \east one parent in common w.lth the decedent, whether by blood or adoption. Copyright (cl 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) AEV- 1508 EX + (1~97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Chesley D. Ham SSff 004-40-4365 04/23/2004 21-04-0528 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 Cash in Decedent's possession. 537.00 2 Cash in Decedent's possession. 660.00 3 M&T Bank, - Checking Acct. #403904ll-principal balance as of 10,184.77 D.O.D. 4 1982 Plymouth Reliant automobile, - carried at no value (car was 0.00 inoperable and could not be driven without substantial repair; Estate had to pay $75.00 to have car towed to junkyard for disposal) . 5 Protective Life Insurance Co. , - refund of premium. 47.68 6 Two .357 Smith & Wesson handguns. 100.00 TOTAL (Also enter on line 5, Recapitulation) S 11,529.45 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1S08 EX {Rev. 1-97) m M&fBank 499 Mitchell Street, Millsboro. DE 19966 June 9, 2004 Law Offices Marlin R. McCaleb Frankeberger Place 219 East Main Street P.O. Box 230 Mechanicsburg. PA 17055 RE: Estate of Chelsey D. Ham Date of Death: April 23, 2004 Social Security Number: 004-40-9365 Dear Mr. McCaleb: In response to your request. please be advised that at the time of death, the above- named decedent had on deposit with this bank the following accounts. 1. Account Type........,....."..,........ Checking Account AccountNumber....................... 40390411 Ownership (Names ofJ.............. Chelsey D. Ham Opening Date..... ,..... ................08/28/64 Balance on Date of Death .........$10.184.77 Accrued Interest $ 0,00 Total................................... ....$10, 184.77 For additional information on the above account. please contact our Mechanicsburg branch at (717) 255-2031. Sincerely, (JudtN.J iJ11/Lf~1v Charlene Warrington, Records Management 1-888-502-4349 REV~'5'1 EX +(1-97) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Chesley D. Ham SS1t 004-40-4365 04/23/2004 21-04-0528 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES, 1 Myers Funeral Home, - funeral expense. 4,200.00 B. ADMINISTRATIVE COSTS, 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number{s) I ElN Number o~ Personal Representative{s) Street Address City State _ Zip Year{s) Commission Paid: Z. Attorney's Fees Law Offices-Marlin R. McCaleb 1,950.00 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 Register of Wills 74.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 Colony House Restaurant, - rent for May, June and July, 2004. 720.00 2 Colony House Restaurant, - repairs to apartment. 920.00 3 Cumbereland Law Journal, - advertising Letters. 75.00 4 Register of Wills, - Short Certificate. 3.00 5 Register of Wills, - filing Inventory and Appraisement. 30.00 6 Reserve, - for final expenses (filing Account, Releases" etc.) . 100.00 Total of Continuation Schedule(s) 84.70 TOTAL (Also enter on line 9, Recapitulation) $ 8,156.70 (If more space is needed, insert additional sheets of the same sjze) Copyright (e) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97) Estate of: Chesley D. Ham Soc Sec If: 004-40-4365 Date of Death: 04/23/2004 Continuation of Schedule H-B7 (Other Administrative Costs) Item Description Amount If 7 The Patriot-News, - advertising Letters. 84.70 _..______..w____ 84.70 REV~1512 EX + (1-97) SCHEDULE I COMMONWEA.L TH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Chesley D. Ham SSII 004-40-4365 04/23/2004 21-04-0528 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Protective Life Insurance Co., - loan against life insurance 1,271.15 policy. 2 Quantum Imaging, - account payable, medical. 198.00 TOTAL (Also enter on line 10, Recapitulation) $ 1,469.15 (If more space is needed, Insert additional sheets of the same size) Copyrlght{c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. '~97) REV-1513 EX +(9-00) SCHEDULE J COMMONWEAl.. TH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Cheslev D. Ham SStl 004-40-4365 04/23/2004 21-04-0528 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [Include outrIght spousal distributions, and transfers under s~. 9116(aX1.Z)1 ENTER DOLLAR AMTS, FOR DISTRIBUTIONS SHOWN ABOVE ON LN, 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS, A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 Commonwealth of Pennsylvania, - statutory heir pursuant to 20 1,903.60 Pa.C.S. 2103(6) (Decedent was not survived by a spouse, or issue, or parents or their issue, or grandparents or their issue). TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 1,903.60 (It more space is needed, insert additional sheets of the same size) Copyright (c) 2000 form software only The Lackner Group, Inc. Fo,m REV-1513 EX (Re', 9-00) Register of Wills of CUMBERLAND County, Pennsylvania INVENTORY Estate of Chesley D. Ham No, 21-04-0528 also known as Date of Death 04/23/2004 , Deceased Social Security No. 004-40-4365 Marlin R. McCaleb, Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I !We verify that the statements made in this Inventory are true and correct, l!We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Marlin R. McCaleb Esq. personalRepresendt4~ Attorney: Signature: _ . Marlin R. McCaleb 1.0, No,' 06353 Signature: Address: 219 East Main Street Address: 219 East Main Stret Mechanicsburg, PA 17055 Mechanicsburg, PA 17055 Telephone: 717/691- 7700 Telephone' 717 /691- 7770 Dated: /-2/- 07.../ Description Value ...., c:;;::) ::'0 (.-, c.:-) ~.~~ o;;Jl :-,', ,'''..., '-- ' > ~ c:) _-::-rJ 1-,'0 '~.--::; (See continuation page(s) attached) -'~-\~f:~8 '" !',--1 - -' \~") ,- n-- ,., ~ ./" '", ;"") "'lJ -: --'i-, :% _" --1"\ - ,: (~'S - -~: rTl .. (::J en --n N (Attach additional sheets if necessary) Total: 21,846.71 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. \ Prepared by the Pennsylvania Bar Association FormN'RW-7 (1992) ./~ Copyrlght(c) 1996 form software only CPSystems, Inc. INVENTORY Estate of: Chesley D. Ham Date of Death: 04/23/2004 County: Cumberland CASH: - - - -- Cash in Decedent's possession. 537.00 Cash in Decedent's possession. 660.00 M&T Bank, - Checking Acct. 10,184.77 #403904ll-principal balance as of D.O.D. -------------- 11,381. 77 PERSONAL PROPERTY: ------------------ 1982 Plymouth Reliant automobile, - carried at no value (car was inoperable and could not be driven without substantial repair; Estate had to pay $75.00 to have car towed to junkyard for disposal). Liberty Mutual Insurance Co., 5,052.26 - proceeds of life insurance paid to Decedent's Estate. Liberty Mutual Insurance Co., 5,265.00 - proceeds of life insurance paid to Decedent's Estate. Protective Life Insurance Co., 47.68 - refund of premium. Two .357 Smith & Wesson 100.00 handguns. -------------- 10,464.94 -.-------------- TOTAL RECEIPTS OF PRINCIPAL............... 21,846.71 - COMMONWEALTH OF PENNSYLVANIA '*' DEPARTMENT OF REVENUE ;".:,....{._....,..c..:,.. ......_._ ~ ,,_ NOTICE OF INHERITANCE TAX BUREAU OF INDIVIDUAU-TAXES jAPPRAISEHENT. ALLOWANCE OR DISALLOWANCE INHERITANCE TAX DIVISION OF DEDUCTI~S AND ASSESSMENT OF TAX PO BOX Z80601 HARRISBURG PA 111Z8-0601 REV-15~1 EX AFP (03-05) 12 DATE 04-04-2005 ESTATE OF HAM CHESLEY D DATE OF DEATH 04-23-2004 FILE NUMBER 21 04-0528 MARLIN R MCCALEB LAW OFCS COUNTY CUMBERLAND ACN 101 219 E MAIN ST I Allount Relli tted I PO BOX 230 MECHANICS BURG PA 17055 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 ..... 1!r-Y!r4"Yf.m.m~'1m,.wtm.b'r.IJIIMAW4M!r.m.lWllTft""~.~tW~AtY.aW".............. ... DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HAM CHESLEY D FILE NO. 21 04-0528 ACN 101 DATE 04-04-2005 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) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account. 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 subllit the upper portion of this forll with your 4. Hortgages/Notes Receivable (Schedule D) (4) .00 tax paYllent. 5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) (5) 11.529.45 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 8. Total Assets (8) 11 ,529.45 APPROVED DEDUCTIONS AND EXEMPTIONS: 8.156.70 9. Funeral Expenses/Ada. Costs/Hisc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 1.469.15 11. Total Deductions (11) 9.625 85 12. Net Value of Tax Return (12) 1,903.60 13. Charitable/Governll8ntal Bequests; Non-elected 9113 Trusts (Schedule J) (13) 1.903.60 14. Net Value of Estate Subject to Tax (14) .00 NOTE: 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~ ALL returns assessed to date. ASSESSMENT OF TAX: .00 X 00 15. Allount of Line 14 at Spousal rate (15) = .00 16. AlIOunt of Line 14 taxable at Lineal/Class A rate (16) .00 X 045 = .00 17. Allount of Line 14 at Sibling rat. (17) .00 X 12 = .00 18. Allount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 = .00 19. Principal Tax Due (19)= .00 . . + AMOUNT PAID DATE NUI1BER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 II IF PAID AFTER DATE INDICATED. SEE REVERSE ( IF TOTAL DUE IS LESS THAN $1. NO PAYHENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "'CREDIT"' (CR). YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) ~~ COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-04-0528 t-:- c:::;) c:::::; c..:f"1 ESTATE OF CHESLEY D. HAM, DECEASED ================================== -";i,. - --l ACCOUNT OF Marlin R. McCaleb, Administrator -n .....;,:;.. r;-;) C) ======================================================~======--============~=== Date of Death: April 23, 2004 Date of Executor's Appointment: June 4, 2004 Date of First Advertisement of Letters: June 18, 2004 Accounting for the Period: April 23, 2004 to May 16, 2005 =========================================================================---==== Purpose of Account: Marlin R. McCaleb, Administrator, offers this account to acquaint interested parties with the transactions that have occurred during this administration. It is important that the account be carefully examined. Requests for additional information or questions or objections can be discussed with: Marlin R. McCaleb Esq. Attorney Identification No. 06353 Law Offices-Marlin R. McCaleb 219 East Main Street Mechanicsburg, PA 17055 717/691-7700 GROSS ESTATE 23,822.69 (Principal Receipts + Income Receipts) --------- --------- "{- ~S SUMMARY OF ACCOUNT Estate of Chesley D. Ham, Deceased For Period of 04/23/2004 through 05/16/2005 Fiduciary Current Acquisition Page Value . Value ------ ------- ----------- Proposed Distributions 0.00 0.00 to Beneficiaries =============== =============== PRINCIPAL Receipts: Per Inventory Filed 1-2 21,846.71 Subseq Prn Receipts 1,956.00 Net Gain (or Loss) on Sales 3 0.00 or Other Disposition --------------- 23,802.71 Less Disbursements: Debts of Decedent 4 4,346.65 Funeral Expenses 4 4,200.00 'Administration Expenses 4 3,137.70 Federal and State Taxes 0.00 Fees and Commissions 5 1,950.00 Family Exemption 0.00 13,634.35 --------------- --------------- Balance before Distributions 10,168.36 Distributions to Beneficiaries 0.00 --------------- Principal Balance on Hand 6 10,168.36 For Information: Investments Made Changes in Investment Holdings INCOME Receipts: This Account 7 19.98 Net Gain (or Loss) on Sales 0.00 or Other Disposition --------------- 19.98 Less Disbursements 0.00 --------------- Balance Before Distribution 19.98 Distributions to Beneficiaries 0.00 --------------- Income Balance on Hand 8 19.98 Investments Made Changes in Investment Holdings COMB INED BALANCE ON HAND 10,188.34 --------------- --------------- SCHEDULE A RECEIPTS OF PRINCIPAL Fiduciary Acquisition Value ----------- CASH: - - - - 04/23/04 Cash in Decedent's possession. 537.00 04/23/04 Cash in Decedent's possession. 660.00 04/23/04 M&T Bank, - Checking Acct. 10,184.77 #40390411-principal balance as of D.O.D. -------------- 11,381. 77 PERSONAL PROPERTY: ----------------- 04/23/04 1982 Plymouth Reliant 0.00 automobile, - carried at no value (car was inoperable and could not be driven without substantial repair; Estate had to pay $75.00 to have car towed to junkyard for disposal) . 04/23/04 Liberty Mutual Insurance Co., 5,052.26 - proceeds of life insurance paid to Decedent's Estate. 04/23/04 Liberty Mutual Insurance Co., 5,265.00 - proceeds of life insurance paid to Decedent's Estate. 04/23/04 Protective Life Insurance Co., 47.68 - refund of premium. 04/23/04 Two .357 Smith & Wesson 100.00 handguns. -------------- 10,464.94 -1- SUBSEQUENT PRINCIPAL RECEIPTS: ----- -- - - -- ---- ------ - ---- --- 04/28/04 u. S. Treasury, - Social 978 . 00 Security monthly payment. OS/26/04 U. S. Treasury, - Social 978.00 Security monthly payment. -------------- 1,956.00 -------------- TOTAL RECEIPTS OF PRINCIPAL............... 23 ,802. 71 ------------- ------------- -2- SCHEDULE B GAINS AND LOSSES ON SALES OR OTHER DISPOSITIONS - PRINCIPAL Gain Loss - - - - - - - - 01/11/05 Two .357 Smith & Wesson handguns. - sale of two .357 Smith & Wesson handguns. Net Proceeds 100.00 Fid. Acq. Value 100.00 0.00 --- - -- - - - -- -- - - - - - ------ ---- TOTAL GAINS AND LOSSES/PRINCIPAL.... ....... 0.00 0.00 LESS LOSS............................. 0.00 -------------- NET GAIN OR LOSS. . . . . . . . . . . . . . . . . . . . . . . . . . . 0.00 -------------- -------------- -3- SCHEDULE C DISBURSEMENTS OF PRINCIPAL SCHEDULE C-l DEBTS OF DECEDENT ----------------- 04/23/04 Holy Spirit Hospital, - 2,877.50 account payable, medical. 04/23/04 Protective Life Insurance 1,271.15 Co. , - loan against life insurance policy. 04/23/04 Quantum Imaging, - account 198.00 payable, medical. -------------- TOTAL DEBTS OF DECEDENT........... . . . . . . . . . . . . . . . . . . 4,346.65 SCHEDULE C-2 FUNERAL EXPENSES ---------------- 08/03/04 Myers Funeral Horne, - funeral 4,200.00 expense. -------------- TOTAL FUNERAL EXPENSES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,200.00 SCHEDULE C-3 ADMINISTRATION EXPENSES - - - - - ----- - ---- --- - - --- 06/24/04 Cumbereland Law Journal, - 75.00 advertising Letters. 06/24/04 Register of Wills, - probate 74.00 Estate. 07/06/04 The Patriot-News, - 84.70 advertising Letters. 07/26/04 Colony House Restaurant, - 720.00 rent for May, June and July, 2004. -4- 07/30/04 Colony House Restaurant, - 920.00 repairs to apartment. 10/26/04 Register of Wills, - Short 3.00 Certificate. 11/09/04 M&T Bank, - reimbursement for 978.00 Social Security overpayment. 12/17/04 Register of Wills, - Short 3.00 Certificate. 01/19/05 Register of Wills, - filing 30.00 Inventory and Appraisement. 05/16/05 Reserve, - for final expenses 250.00 (filing Account, Releases" etc. ). -------------- TOTAL ADMINISTRATION EXPENSES....... ................ 3,137.70 SCHEDULE C-5 FEES AND COMMISSIONS -------------------- 01/20/05 Marlin R. McCaleb, Esq., - 1,950.00 attorney's fees. -------------- TOTAL FEES AND COMMISSIONS... ........ .... .... ....... 1,950.00 -------------- TOTAL DISBURSEMENTS OF PRINCIPAL. ......... ...... .... 13,634.35 -------------- -------------- -5- PRINCIPAL BALANCE ON HAND Current Value Fiduciary Acquisition 11 Units Description or as Noted Value PNC Bank 10,168.36 10,168.36 --------------- --------------- 10,168.36 10,168.36 =============== =============== -6- SCHEDULE G RECEIPTS OF INCOME SCHEDULE G-2 INTEREST ------------ PNC Bank, --------- 06/28/04 0.14 07/13/04 0.72 08/11/04 1.21 09/13/04 1.55 10/12/04 1.44 11/09/04 1.40 12/13/04 2.08 01/11/05 1. 81 02/08/05 1. 94 03/10/05 2.50 04/12/05 2.76 05/11/05 2.43 -------------- 19.98 -------------- TOTAL INTEREST INCOME..................... 19.98 -------------- -------------- TOTAL RECEIPTS OF INCOME.................. 19.98 -------------- -------------- -7- INCOME BALANCE ON HAND Current Value Fiduciary Acquisition if Units Description or as Noted Value PNC Bank 19.98 19.98 --------------- --------------- 19.98 19.98 =============== =============== -8- AFFIDAVIT Marlin R. McCaleb hereby certifies and says: that I am the Administrator of the Estate of Chesley D. Ham, Deceased; that I am the Accountant herein; that I have fully and faithfully discharged the duties of my office; that the foregoing accounting is true, correct and complete; that the attached list or schedule (* ) contains the names, addresses and amounts due unpaid creditors having given notice of their claims; that the attached list or schedule (**) contains the names and addresses of all persons interested in the distribution of the said Estate; that there are no unpaid claimants or persons interested in the distribution of the Estate who have given notice to the Administrator and who are not listed herein; and that the facts set forth in the foregoing Account are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. , Section 4904, z:1?~tion to authorities. Date: May 17, 2005 Marll R. McCaleb Administrator * UNPAID CREDITORS None ** PERSONS INTERESTED IN ESTATE: l. Commonwealth of Pennsylvania c/o Warren Klunk Department of Revenue Bureau of Individual Taxes Dept. 280603 Harrisburg, PA 17128-0603 -9- STATEMENT OF PROPOSED DISTRIBUTION BY MARLIN R. McCALEB, ADMINISTRATOR OF THE ESTATE OF CHESLEY D. HAM, LATE OF THE BOROUGH OF MECHANICSBURG, PENNSYLVANIA, DECEASED MARLIN R. McCALEB, Administrator of the Estate of Chesley D. Ham, Deceased, proposes to distribute the balance of said Estate in his hands, to wit: $10,188.34, in accordance with Section 2103(6) of the Probate, Estates and Fiduciaries Code of Pennsylvania (20 Pa.C.S. 2103 (6) ) , as follows: TO: Commonwealth of Pennsylvania 10,188.34 c/o Warren Klunk Department of Revenue Bureau of Individual Taxes Department 280603 Harrisburg, PA 17128-0603 TOTAL TO BE DISTRIBUTED: $10,188.34 AFFIDAVIT MARLIN R. McCALEB, hereby certifies and says: that he is the Administrator of the Estate of Chesley D. Ham, Deceased; and that the facts set forth in the foregoing Statement of Proposed Distribution are true and correct to the best of his knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S., Section 4904, relatii;~n to authorities. Date: May 17, 2005 Marlin R. McCaleb Administrator ~Ji!~lfUfJ ~ iUfi'~'aJ ~JilJfd!fi ~~~ir!'llh ~~f 'lfj i~- II 1"1 Sll II I U-ffl:! 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Z (Jl ~ >-3 c:: ::t: H ( H ::tI :D' :D" 0 Q :s; Z ~ ~ PUftr N !"t i'll ~ !1.11 If I j \;JIII11'h ., II i llli ~ ~ ~ lihil!f. , l!l!ftlfi~ l3~~~1~ 3ft_.,.,.1il._ Cumberland. councy - Ke~J.:::;L.t:.L V.L ....L.u....;:> One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 3/07/2006 MCCALEB MARLIN R 219 E MAIN STREET MECHANICSBURG, PA 17055 RE: Estate of HAM CHESLEY D File Number: 2004-00528 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 I, 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: 4/23/2006 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, ~~AJ~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Personal Representative(s) V7r Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name of Decedent: Chesley D. Ham Date of Death: April 23, 2004 Estate No.: 21-04-0528 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 1X1 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 fil No 0 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 IXl No 0 Date: 03/09/06 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. i..~ ~ Signature ~ 6') Marlin R. McCaleb Name 219 East Main Street Mechanicsburg, PA 17055 Address 717/691-7770 f:::J Telephone No. r"~_~~;h.. \...-apa'-'u] . n D"'..,,".....nl DAT'\"A"A~+ot~"TO LJa 1. '-'L.:)VU.UL .L'-,",PL"''''''LJ.l.U.&.L t' '-' o Counsel for personal representative ~}