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Home My WebLink About04-0143Register of Wills of CUMB aLA County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Louis Cannavine also known as , Deceased Nicholas G. McKelvey Social Security No. 188- 22- 7489 Petitioner(s), who is/are 18 years of age or older, apply(les) for: (COMPLETE 'A' or 'B' BELOW:) A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut or the Decedent, dated 03/04/2002 and codicil(s) dated None none named in the last Will of State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: none B. Grant of Letters of Administration (c.t.a.; d.b.n.c.ta; pendente lite; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Relationship Residence (COMPLETE IN ALL CASES:) Attach additional sheets if necessary, Decedent was domiciled at death in CUMBERLAND County, Pennsylvania with his/her last family or principal residence at 2100 Bent Creek Blvd. , Decedent, then 72 years of age, died 02/06/2004 Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (If not domiciled in PA) Personal property in Pennsylvania (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania Silver Spring Township (liststreet, number, and municipality) at Silver Sprins, PA (Location) 33,000.00 situated as follows: none letters in the appropriate form to the undersigned: Sic,;Inature Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of INicholas Go 4006 Landis Typedorprintednameandresidence McKelvey Road, Colle~eville, PA 19426 Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991) Oath of Personal Representative Commonwealth of Pennsylvania County of CUMBERLAND The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petitio~ are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s)will well and truly administer the estate a.~:ording to law. Sworn to or affirmed and subscribed X ~')/~/~ '--' .~ 'zW Nicholas G. McKeivey before me this/,_.~ day of No, Estate of Louis Cannavine Social Security No: 188- 22- 7489 AND NOW, ?~, / Deceased , ,;~:~_~, in consideration Date of Death: 02/06/2004 of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters ~ Testamentary ~] Of Administration (c.ta.; d.b.n.c.ta.; pendente lite; durante absentia; durante minoritate) are hereby granted to Nicholas G. McKelvey in the above estate and that the instrument(s) dated 03/04/2002 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters ........... $ Short Certificate(s) ..... $ Renunciation ........ $ Affidavits ( ) .... $ Extra Pages ( ) .... $ Codicil ........... $ JCP Fee .......... $ Inventory .......... $ Other ........... $ TOTAL ......... $ Prepared by the Pennsylvania Bar Association 70.00 6.00 10.00 Regi~er of s ~ Attorney: Edward P. Seeber, Esquire I.D. No: 76084 Address: JAMES, SMITH, DIETTERICK & CON.. 134 Sipe Avenue Hummelstown, PA 17036 Telephone: 717/533-3280 107, O0 Copyright (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991) his is to certify that the information here given is correctly copied from an original certificate of death du!y filed with me as Local R.egistrar. The original certificate will be forwarded to the State Vital Records Office for permanent f~ing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 9825888 No. Local Registrar // c~/ [.f~) ate-y COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH STATE FILE NUMI ~NT NAME OF DECEDENT (Firsk Middie~ Last) SEX J SOCIAL SECURITY NUMBER DALE OF DEATH (Month. Day. Year) .K ~ Louis Cannavine zMale[3. 188 -- 22 -- 7489 4.February 6, 2004 AOE ~L~,t a~.,,u.~) I U.OEn ~ ~E~E U,pg. 10AY DATE OF BIRm [ BIRTHPLACE (Ci~ and ~CE OF DEATH ~Che~ oNv ~e- ~e ~slmctioos ~ othe[ }idg} ,u. Cmrla~ m. Silver. Spr~ng ],.. ~dges At ~nt ~k ~. ..... m~ .... ~' , ._.,. M~te' . ' . . I . m Yes ~ No ~ m m,. ~ ,~ m c~ I ~v~c~ (Sped~) m .......... IAC~U~ ' X ' 17=. ~ Yes de~enl,ved~ Silver Spring ~. NicOlas G. ~avine ,,. Jose~ine Cin~e ~,.. NiColas G. ~el~y ~,.~ 4006 ~i~ R~d ~ll~eville~ PA 19426 m _ om,(~) ~ m.P~ 10~ 2004 =,=.~te O~ Hoaven C~t~[,u.~nicsb~9~ pA 17055 Yes D NO ~ Yes ~ No D Sum~ ~ Could not be del~d ~ PLACE OF INJURY- Al h~e. f .... ~.l, fa~. ~ ATI~ (~eL Ci~nown, Stole) LAST WILL AND TESTAMENT OF LOUIS CANNAVINE I, LOUIS CANNAVINE, having my legal residence at Twin Lakes Apt. g4417-A, Union Deposit Road, Harrisburg, Dauphin County, Pennsylvania, hereby declare this to be my Last Will and Testament, revoking all other Wills and Codicils heretofore made by me. ARTICLE ONE I declare that I am not married. ARTICLE TWO I have one child bom to me whose name is NICHOLAS G. MCKELVEY. ARTICLE THREE I direct the payment fi.om my estate of the expenses of my last illness and funeral as soon after my death as conveniently may be done. ARTICLE FOUR I intend to leave a memorandum which will direct the distribution of certain items of tangible personal property, and I request that my wishes as set forth in said memorandum be followed. To the extent that my tangible personal property is not disposed of by memorandum, I give all of the tangible personal property that I own at my death, including any household furniture and furnishings, automobiles, books, pictures, jewelry, art objects, hobby equipment and collections, wearing apparel, and other articles of personal and household use, equipment and ornament, and all insurance thereon to my son, NICHOLAS G. MCKELVEY, provided he survives me by thirty (30) days. If NICHOLAS G. MCKELVEY fails to survive me by thirty (30) days, such items shall be sold and the proceeds distributed with the residue of my estate. ARTICLE FIVE I direct my Executor to make the following specific distribution as soon as practical after my death: A. Two Thousand ($2,000.00) Dollars to LORA I. KELLY. IfLORA I. KELLY is not living at the time distribution is directed to be made, such distribution shall lapse and be distributed with the residue of my estate. ART~ I give the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate to my son, NICHOLAS G. MCKELVEY, provided he survives me by thirty (30) days. If NICHOLAS G. MCKELVEY fails to survive me by thirty (30) days, his share shall be distributed to his then living issue, per stirpes. ARTICLE SEVEN If any such descendant of mine has not reached legal age under the law of the jurisdiction in which that descendant is domiciled at the time of distribution under this Will, then distribution of his or her share shall be made instead to the custodian for that descendant under the Pennsylvania Uniform Transfer to Minors Act, and all provisions of that Act as they exist at the time of this my Last Will and Testament shall apply to the distribution. If necessary for legal transfer to that custodian, my Executor shall convert the assets in that descendant's share to cash or securities. ARTICLE EIGHT No beneficiary or remainderman under this Will or any codicil hereto shall have any right to alienate, encumber or hypothecate his or her interest in this Will in any manner, nor shall any interest of any beneficiary or remainderman be subject to claims of his or her creditors or liable to attachment, execution or other process of law. ARTICLE NINE Should the payment of expenses, claims and taxes from any Qualified Retirement Plan or Individual Retirement Account ("IRA") assets which comprise my estate cause my estate to be disqualified as a "Qualified Beneficiary," it is my intent, and I hereby direct that, to the extent practicable, no expenses, claims and taxes be paid from such Qualified Retirement Plan or IRA assets. ARTICLE TEN I appoint my son, NICHOLAS G. MCKELVEY, as Executor of my Will. If he is unable or unwilling to serve, then I appoint my niece, LORA I. KELLY, in his place and stead. I give to my Executor, in addition to and not in limitation of the powers given by law or by other provisions of this Will, the following powers with respect to settlement of my estate to be exercised from time to time in the discretion of my Executor, without further order or license of the Register of Wills or of any court: 1. To retain any property, pending distribution hereunder, to invest in or purchase any property without restriction to legal investments for fiduciaries, to distribute property in kind, to compromise claims, and to sell any property at public or private sale; 2. To borrow money from any person including any fiduciary acting hereunder, and to mortgage or pledge any real or personal property; 3. To engage in litigation and compromise, arbitrate or abandon claims; 4. To make distributions in cash, or in kind at current values, or partly in each, allocating specific assets to particular distributees on a non-prorata basis, and for such purposes to make reasonable determinations of current values; 5. To make elections, decisions, concessions and settlements in connection with all income, estate, inheritance, gift or other tax returns and the payment of such taxes, without obligation to adjust the distributive share of income or principal of any person affected thereby; 6. To invest and reinvest in every kind of property and investment which persons of prudence, discretion and intelligence acquire for their own accounts; 7. To manage, control, repair and improve all real property; 8. To procure and carry at the expense of the estate insurance of the kinds, forms and amounts deemed advisable by the Executrix to protect the Executrix and the estate against any hazard; 9. To pay all taxes, assessments, fees of the Executrix and all other expenses incurred in the collection, care, administration and protection of the estate; 10. To exercise such powers, herein conferred, after the termination of the trust estate until final distribution of the estate assets; and 11. To do all the acts, to take all the proceedings, and to exercise all the rights, powers and privileges which an absolute owner of the property would have, subject always to the discharge of their fiduciary obligations; the enumeration of certain powers in this Will shall not limit the general or implied powers of the Executrix; the Executrix shall have all additional powers that may now or hereafter be conferred on them by law or that may be necessary to enable the Executrix to administer the estate in accordance with the provisions of this Will, subject to any limitations specified in this Will. No bond shall be required of any fiduciary hereunder in any jurisdiction. No hereunder shall have any liability for any mistake or error of judgment made in good faith. fiduciary My Executrix shall receive reasonable compensation for services performed as determined by the court in which this Will is admitted to probate. ARTICLE ELEVEN I realize that Executors are given discretion by law to make various elections which affect the income and estate taxes payable by estates and beneficiaries, as well as the relative shares of beneficiaries, such as taking administration expenses as deductions for either estate or income tax purposes, selecting options for the payment of employee death benefits, electing to take a qualified terminable interest as part of the marital deduction, selecting alternate valuation dates, postponing the payment of taxes, filing joint income tax or gift tax returns and redeeming corporate stock. decisions made by my fiduciaries in any of these matters shall be binding upon, and not subject to question by, any affected persons. I rely upon my fiduciaries to take into consideration the total income and estate taxes payable by reason of their decisions including those payable by my survivors, and they are authorized in their discretion, but not required, to make adjustments between income and principal as a result thereof. ARTICLE TWELVE I direct that all estate, inheritance and other taxes in the nature thereof, together with any interest and penalties thereon, becoming payable because of my death with respect to the property constituting my gross estate for death tax purposes, whether or not such property passes under this Will, shall be paid from the principal of my residuary estate, and no person receiving or having a beneficial interest in any such property, whether under this Will or otherwise, shall at any time be required to contribute to or refund any part thereof; PROVIDED, however, that this direction shall not apply to the taxes on any property included in my estate solely because of a power of appointment thereover which I possess but have not exercised or on any qualified terminable interest or to any generation-skipping transfer taxes. IN WITNESS WHEREOF, I have at 4~'~gA/~-~t , Pennsylvania, this ~day of~tg~ ,200~,, set my hand and seal to this my Last Will and Testament, consisting of six (6) pages. LOUIS CANNAVINE t SIGNED, SEALED, PUBLISHED and DECLARED by LOUIS CANNAVINE, the above named Testator, as and for his Last Will and Testament, in the presence of us, who, at his request and in his presence, and in the presence of each other, have hereunto subscribed our names as wimesses. Residence Residence ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA : :SS: COUNTY OF DAUPHIN : We, LOUIS CANNAVINE, ,_~Lt.Sa~///7. ~ /~tz~,gDO/e and l~: l [O/F'~ ~7~ ~, C_~ ' I! Testator and witnesses, respectively, whose names are signed to the attached and foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instnkment as his last will and that he had signed willingly, and that he executed it as his free and voluntary act for the purpose therein expressed, and that each of the witnesses, in the presence and heating of the Testator, signed the Will as wimesses and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. TESTATOR ~WlTNESS Subscribed and sworn to and acknowledged before me by LOUIS CANNAVINE, the Testator, and subscribed and sworn to before me by ~tjr/~ fi/. ~ [t~_L/~Ek~/~. and /q~[ ~ '[t~~ ,wimesses, onthis ~- day of ~1~ , 200_~. Linda L. Fetterhoff, Notary Public Derry Twp., Dauphin .Coun~ty~^~ My Commissior~ E×pires Nov. 8, 2003 MEMORANDUM TO THE LAST WILL AND TESTAMENT OF LOUIS CANNAVINE It is my desire that the items listed below be distributed in-kind to the individuals whose name or names appear opposite the items listed: DATE LOUIS CANNAVINE LAST WILL AND TESTAMENT OF LOUIS CANNAVINE LAW OFFICE JAMES, SMITH, DU~ & CONNELLY, LLP P.O. BOX 650 HERSHEY, PENNSYLVANIA 17033-0650 CERTIFICATION OF NOTICE UNDER RULE 5.6(A) Name of Decedent: Louis Cannavine Date of Death: Will No.' February 6, 2004 Admin. No.: 2004-00143 TO THE REGISTER OF WILLS OF CUMBERLAND COUNTY: I certify that Notice of Estate Administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on March 8, 2004 · Name Address Lora I. Kelly Nicholas G. McKelvey 330 Hickory Road, Carlisle, PA 17013 4006 Landis Road, Collegeville, PA 19426 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: - no exceptions - Date: Signature: Name: Address: 0t: Zld 0[ [fVI,I ~. Telephone: Capacity: James, Smith, Dietterick & Connelly LLe 134 Sipe Avenue Hummelstown, PA 17036 (717) 533-3280 __ Personal Representative X Counsel for Personal Representative November 30, 2004 Glenda F. Strausbaug, Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 Re'- Estate of Louis Cannavine, deceased File No. 21-04-0143 Dear Ms. Strausbaug: Enclosed are the following documents to be filed for the above-referenced Estate: 1. An original and three (3) copies of the Pennsylvania Inheritance Tax Return. 2. An original and three (3) copies of the Inventory. 3. A check made payable to the "Register of Wills" in the amount of Eighteen Dollars ($18.00) representing the filing fee for the Return and Inventory. 4. A check made payable to the "Register of Wills" in the amount of Eight Hundred Forty-nine Dollars ($849.00) representing a payment towards the Pennsylvania Inheritance Tax. Please time-stamp the extra copies of the Return and Inventory and return them to me in the enclosed self-addressed, stamped envelope. If you have any questions, please feel free to contact me. Very truly yours, CheiL. Baker, CP Certified Paralegal Enclosures cc: Nicholas G. McKelvey, Executor THE .ES bECURITY FORMULA,, Cheryl L, Baker, CP Certified Paralegal clb@jsdc.com 134 SIPE AVENUE HUMMELSTOWN, PA 17036 MAILING ADDRESS PO BOX 650 HERSHEY, PA 17033 TOLL FREE 1 800 9423660 TEL 717 533 3280 FAX 7175337771 wwwlsdc corn COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OFINDIV~DUAL TAXES DEPT280601 HARRISBURG, PA 17128 0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV 1162 EX(11-96) NO. CD 004683 SEEBER EDWARD P 134 SIPE AVENUE HUMMELSTOWN, PA 17036 ...... fold ESTATE INFORMATION: SSN: 188-22-7489 FILE NUMBER: 2104-0143 DECEDENT NAME: CANNAVINE LOUIS DATE OF PAYMENT: 12/01/2004 POSTMARK DATE: 1 1/30/2004 COUNTY: CUMBERLAND DATE OF DEATH: 02/06/2004 ACN ASSESSMENT CQNTROL NUMBER AMOUNT 101 $849.00 TOTAL AMOUNT PAID: $849.00 REMARKS: SEAL CHECK# 6051 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-1500 EX + (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 171Z8-0~O1 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER COUNTYCODE YEAR DECEOENT'S NAME (LAST, FIRST, AND MIDDLE iNITIAL) SOCIAL SECURITY NUMBER D E Cannavine Louis 188-22- 7489 c E D E N T CAPB HpRL EpIO CRAC KOTM ES R E C A P I T U L A T I O N C o M T I 0 N DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-OD-YEAR) 02/06/2004 I 09/30/1931 F APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) NUMBER THIS RETURN MUST BE FILED IH DUFUC~,TE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 1. Original Return ~ 274~.. Supplemental Return 4. LimltadEstata . FuturelntarestCompromlse(dateofdeathafter t2-1Z-82) I~. Decedent Died Testate Decedent Maintained a Living Trust (Attach copy of Will) (Attach cop'/of Trust) [~9. LltigaUonProceedsRecelved r~10. SpousalPovertyCredit (date of death between 1Z-31-91 and 1-1-95) NAME Edward P. Seeber FIRM NAM E (I f Applicable) James, Smith, Dietterick & Connelly, LLP TELEPHONE NUMBER 717/533-3280 3 . Rem~lnderReturn (13dr~ot~t~f~3h S2 E, Federal EstataTax Return Required 0 8. Total Number of Safe Deposit Boxes 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 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-Probata Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) i'--I 11. Election to tax under Sec. 9113{A) (Attach Sch O) ~OMPLETE MAILING ADDRESS 134 Stpe Avenue Nummelst own, PA_ L7036 (1) No~e None (3) NOne (4) None 17,541.02 (0) 31,286,59 None 13,745.57 15,037.43 2,042.39 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subi®ct to Tax (Line 12 minus Line 13) (11) (12) (13). 17,079.82 14,206.77 (14) 14,206.77 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(aXl.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 x .0 0 (15) 0.00 12,206.77 x .0 45 (16) 549.30 X .12 (17) 0.00 2,000.00 x .15 (18) 300.00 19. Tax Due (19) 849.30 Copyright (c) 2000 form software only T he Lackner Group, Inc. Form REV- 1500 EX (Rev. 6-00) Decedent's Complete Address: $~H~ ADDRESS 2100 Bent Creek Blvd· CITY Mechanicsbur~ STATE ?^ ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) Total Credits ( A + B + C ) (Z) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Intarest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. ~f Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB) Make Che~k Payable to= REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ......................... ~m ~'~ b. retain the right to designate who shall use the property transferred or its income; ........... d. receive the promise for life of either payments, benefits or care? ................... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................ [] [] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............................................. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probata property which contains a beneficiary designation? ................................ [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS I$ YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 849.30 0.00 0.00 0.00 849.30 0.00 849.30 SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN Nicholas G. McKelvey DATE '--%/~ ,' J~ ~) ~^<,/ , 1110 Mer~ybrook Road /iq ...................... q SIGNATURE OF PREPARER OT~R THAN REPRESENTATIJ/E Jam DATE /, ,,...,, __ es, Smith, Dtetterick & Connelly, LLP / \ ..... . .... .............................................. ~.C.~.~:~,,,,,,:.....~!..,s,t~, PA 1.,7.036 ..... : ................. ['l/ ........................................ ~i"~i ................. ! ............... ! ............... i'"'i .................... i ...................................................... i .......... r'"i 'r "~ ~ 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(aXl)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(aX1.3)). A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (c) Z000 form software only The Lackner Group, Inc. Form REV- 1 ~[00 EX (Rev. · ~EV-1508 EX + (1-97) SCHEDULE E CASH, BANK DEPOSITS,& MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Louis Cannavine SS~ 188-22-7489 02/06/2006 Include the proceeds of litigation and the date the proceeds were received by the estate. All propel'(y jointly-owned with the right of survivorship must be disclosed on Schedule F. FILE NUMBER ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 272.60 2 3 Pennsylvania State Employees Credit Union - Savings Account No. 0188227489 - valued per letter dated 2/26/04 Pennsylvania State Employees Credit Union - Checking Account No. 0188227489 - valued per letter dated 2/26/04 Miscellaneous personal property - valued per Executor TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. 16,768.42 500.00 $ 17~541.02 Form REV-1508 EX (Rev. 1-97) · ,Ev-~5,oEx.(,-~) SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF Louis Cannavine SS~ 188-22-7489 02/06/2004 This schedule must be completed and filed if the answer to any of questions 1 through 4 on pa! · 2 is yes. FILE NUMBER DESCRIPTION OF PROPERTY % OF ITEM INCLUDE THENAMEOF THE TRANSFEREE THEIR DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE RELATIONSHIP TO DECEDENT AND THE DATE OI~ TRANSFER. NUMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1 Discovery Select Annuity 13,745.57 100.00~. 0.00 13,745.57 Contract No. E0200375 held by Prudential Financial - beneficiary is Nicholas G. McKelvey; valued per letter dated 11/2/04 TOTAL (Also enter on line 7, Recapitulation) $ 13,745.57 (If more space is needed, insert additional sheets of the same size) Copyright(c) 1996 form softwareonly CPSystems, lnc. Form REV-1510 EX (Rev. 1-97) ;~-~5;, ~x.o-s?) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF Louis Cannavine SS# 188-22-7489 02/06/2004 FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT 1 2 3 4 1 2 3 4 5 FUNERAL EXPENSES: Boscov's - burial clothing Gateway to Heaven - cemetery services Lacampana - funeral luncheon Malpezzi Funeral Home - funeral services 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 Pakl: Attorney's Fees James, Smith, Dietterick & Connelly, LLP Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent Probate Fees Register of Wills Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs Cumberland Law Journal - estate notice publication fee Nicholas McKelvey - reimbursement for hotel, food, gas & tolls Register of Wills - filing fees for Inventory & Tax Return The Sentinel - estate notice publication fee U-[~aul - rental of truck for removal of property TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 farm ~;ftwar® only CPSystems, Inc. 139.46 1,775.00 1,100.00 7,176.60 2,500.00 107.00 75.00 1,958.39 18.00 130.74 57.24 15,037.43 Form REV-1S11EX(Rev. 1-s~ R'EV- 151Z EX + (1-97) COMMONWEALTH OF PENNSYLVANIA iNHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Louis Cannavine SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, AND LIENS ssJ/~ 188-22-7489 02/06/2004 FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT Bridges at Bent Creek - retirement home bill Pennsylvania State Employees Credit Union - VISA Loan (L9) - valued per letter dated 2/26/04 2,000.00 42.39 TOTAL (Also enter on line 10, Recapitulation) $ 2,042.39 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, lnc. Form REV-1512 EX (Rev. 1-97) SCHEDULE j COMMONWEALTH OF PENNSYLVANIA ~NHEN~TANCE TAX NETURN BENEFICIAR RESIDENT DECEDENT Louis [88 - 22 - 7489 FILE NUMBER 1 Nicholas McKelvey 4006 Landis Road Collegeville, PA 19426 2 Lora I. Kelly 330 Hickory Road Carlisle, PA 17013 Son ESTATE Residue & Annuity 2,000.00 A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ~TRIBUTIONS ON LINE 13 OF ~ REV 150 :opyrlght (c)2000formsoftwareonl~?~-, ,. {If more space is needed, insert addition=l .~ ...... 70 COVER SHEET $ 0.00 Form REV-l$13 EX (Rev. 9-oo) Register of Wills of CUMBERLAND INVENTORY County, Pennsylvania Estate of Louis Cannavine No. j2/, Date of Death 02/06/2004 Deceased SociaI Security No. 188-22-7489 Nicholas G. McKelvey, Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/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 Attorney: Edward P. Seeber I.D. No.: 76084 Personal Representative Signature: NiCholas G. McKelvey Signature: Address: 134 Sipe Avenue Address: 1110 Merrybrook Road Hummelstown, PA 17036 Telephone: 717/533-3280 Description (See continuation page(s) attached) (Attach additional sheets if necessary) Collegevil~l~, PA 19426 Telephone: 610/489-4~1 c'~ Dated: c 3 Total: 17,541.02 NOTE: The Memorandum of real estate outside the Co~nwealth 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. REV- 1500 EX + COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 -- HARRISBURG, PA 17128-0601 D E C cAPB HpRL EpIO CRAc KOTK ES R E C A P I T U L A T I O N C O M A T I O N REV-1500 INHERITANCE TAX RETURI RESIDENT DECEDENT Cannavine Louis DATE OF DEATH (MM-DD.YEAR) I DATE OF BJRTH (MM-DO.YEAR) 02/06/2004 } 09/30/1931 (IF ~PLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE iNITIAL) X I. OrlginaIReturn Decedent Died Testate (Attach copy of Will) -FILE NUMBER OFF;CL4 L/USE ONLY 188- 22 - 7489 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~-;G!$¥,-H OF WILLS SOCIAL SECURITY NUMBER (Attach cop'/of Trust) [~9. LltigationProceedsRecelved [--]10. Spousal Poverty Credlt [] 11.ElectlontotaxuederSec. 9113(A) . NAME COMPLETE MAILING ADDRESS Edward P. Seeber FIRM NAM E (if Applicable) James, Smith, Dietterick & Conneily, LLP TELEPHONE NUMBER ' 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) (4) None 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 17,541.02 (Schedule E) 6. Jointly Owned Property (Schedule F) (6) None ] Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 13,745.57 (ScheduJe G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. 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) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(aX1.2) 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 134 Sipe Avenue Hummelst own, P~_ 17036 (1) No~te (2) None (3) Non e (8) 31,286.59 15,037.43 2,042.3q (11~ 17,079.82 (12) 14,206.77 (13~ x .0 0 (15) 12,206.77 x .0 45 (16) x .12 (17) 2,000.00 x .15 (14) 14,206.77 0.00 549.30 0.00 19. Tax DUB 19 300.00 20 :'" ........ ~ ......... ~'*'i .............................. ( ) 849 30 .... ~..~}l~,~i {{i .... :.~. ,{~ir'}.......... ',;..{!*'"{{i ...... ?.' .......... ;ii!! ....... Copyright (c) 2000 form software only T he Lackrmr Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: ADDRESS 2100 Bent Creek Blvd. CITY ISTATE IZIP Mechanicsbur~ PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments (1) 849.30 A. Spousal Poverty Credit S. Prior Payments C. Discount 3. Interest/Penalty if applicable TotalCredits(A+B+C) (2) 0.00 D. Interest E. Penaify Total Interest/Penalty ( D + E ) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference· This is the OVERPAYMENT· Check box on Page 1 Line 20 to request a refund (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 849.30 A. Enter the interest on the tax due. (SA) 0.00 B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SS) 849.30 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPR'IA~"~I~ ............. 1. Did decedent make a transfer and: a. retain the use or income of the property transferred; .......... Yes No b' retaintherighttodesignatewhoshallusethepropertytransferredorlts ~cor~;' : : : : : : : : : : ~ ~ 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-probata property which contains a beneficiary designation? ....... IF THE ANSWER TO ANY 0F'THE' ABOVE QUE$~ri0N$ iS ~E$,' ' [] [] YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. correct and complete, Declaration of preparer other than the persOnal representative is based on all Information of which preparer has any knowledge, SIGNATUREOFPERSONRESPONSIBLEFORFiLiNGRETURN Nicholas G McKelve,, ~-~ //~ , ~ /I "~ 11 ' J' DATE · -- , . ,, ~^<'/ , 10 Mer~ybrook Road SIGNATURE OF PREPARER OT~R TH ....... ;~ -~..-~.::~.- 5 ..... -~"r ..... "=~[.IA,~ James, Smith, Dietterick & Connelly, LLP ~ATE' /~ ~-~ ~ 134 Sipe Avenue · · .. -, .... , .,,,~ ,~, ,,=[e ~mposea on the net value of transfers to or for the use of the surv,wng 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 [72 P.S. 9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse is 0% from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even Jf the surviving spouse is the only beneficiary. For dates of death on or after Jury 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(aX1)]. 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(aXl.3)]. A sibling is defined, under Section 9102, as ' ' ' an ~ndw~dual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (c) Z00G form software only T he Lackner Group, Inc. Form REV-1500 EX (~ev. 6-00~ SCHEDULE E COMMONWEALTHOFPENNSYLVANIA JCASH, BANK DEPOSITS, & MISC. I INHERITANCE TAX RETURN RESrDENT DECEDEN? PERSONAL PROPERTY ESTATE OF Louis Cannavine SS_.~_i. 88- 22- 7489 02___2~._~/2004 FILE NUMBER include theproceeds of ifigation 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. NUMBER DESCRIPTION VALUE AT DATE OF D.~EAT H 1 Pennsylvania State Employees Credit Union - Savings Account No. 272.60 0188227489 - valued per letter dated 2/26/04 2 Pennsylvania State Employees Credit Union - Checking Account No. 16,768.42 0188227489 - valued per letter dated 2/26/04 3 Miscellaneous personal property - valued per Executor 500.00 TOTAL (Also enter on line 5, Reca~ (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software oniy CPSystem$, Inc. $ 17,541.02 ~=orm REV-1508 EX (Rev. 1-97) COMMONWEALTHOFP£NNSYLVANIA J INTER-VIVOS TRANSFERS & I '"HREFsRITDAENt~EDTEc~CERDEETNUTRN / MISC. NON-PROBATE PROPERTY ESTA.TE OF _ _ FILE NUMBER Louls Cannavine SS~/ 188 22 7489 02~2004 __This schedule must be completed and filed if the answer to an), of questions ] through 4 on page 2 is )'es. DATE OFDEATH EXCLUSION VALUE OFASSET ~F~PLICABL 1 overy SelecE ty~ Contract No. E0200375 held by Prudential Financial - beneficiary is Nicholas G. McKelvey; valued per letter dated 11/2/04 TAXABLE VALUE 3 TOTAL (Also enter on line 7, Recapifulation) $ (If more space' · · 13,745.57 Copyright(c) 1996 form software only CPSystems, Inc. IS needed, ~nsert addRional sheets of the same sJze) Form REV-'I$10 EX (Rev. 1-g7) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSE INHERITANCE TAX RETURN ADMINISTRA'riv~. [~ Lou~s C~v1~ SS~/ 188-22-7~89 ~004 FILENuMBER Debts of dec~ent must ~ ~epo~ on Sch~ule L ~TEM NUMBEN A. i 2 4 7. 1 2 3 4 5 FUNERA'-----~'EXPENSES: DESCRIPTION BOSCOv's . burial clothing Cateway to ~eaven - cemetery services Lacampana _ funeral luncheon Malpezzi Funeral Home - funeral services ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address ~ C~7 State Zip Year(s) Commission Paid: Attorney's Fees James, Smith, Dietterick & Connelly, LLp Family Exemption: (~f decedent's address ' . C~aimant ~s not the same as claimant's, attach explanation) Street Addr-~-ss City Relationship of Claimant to Decedent-T-'~-------~ State ~ Zip Probate Fees Register of Wills Tax Return Preparer's Fees O~erAdministrativeCos~ Cumberland Law Journal - estate notice publication fee Nicholas McKelvey _ reimbursement for hotel, food, gas & tolls Register of Wills - filing fees for Inventory & Tax Return The Sentinel _ estate notice publication fee U-haul - rental of truck for removal of property 139.46 1,775.00 1,100.00 7,176.60 2,500.00 107.00 75.00 1,958.39 18.00 130.74 57.24 (If more Copyrlg ht (c) 1996 form software only CPSYStems, Inc. needed, insert additional sheets of the same size) 37.43 Form REV-l$11 EX (Rev. COMMONWEALTHOFPENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN Louis Cannavine ~2004 Include unreimbursed medical eXpenses. ITEM NUMBEF 1 2 ~DESCRIPTION Bridges at Bent Creek ~ retirement home bill Pennsylvania State Employees Credit Union - VISA Loan (Lg) valued per letter dated 2/26/04 AMOUNT 42.39 TOTAL, (If more space is needed, insert addit~)nal sheets of the same size) Copydg ht (c) 1996 form software only CPSysterns, Inc. ,042,39 Form REV-1512 EX (Rev. 1-ST) REV- 1500 EX + (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. Z80601 HARRISBURG, PA 171;~g-0E01 D E C E D E N T cAPB HpRL EpIO CRAC KoTK ES cg R 5. E C A 6. P I T U 7. L A T 8. I O 9. N 10, REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEOENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL) Cannavine Louts DATE OF DEATH (MM- DD-YEAR} DATE OF BIRTH (MM-DD-YEAR) 02/06/2004 09/30/1931 IF APPLICABLE) SURVIVING SPOUSE'S NAME LAST, FIRST, AND MIDDLE INITIAL) C O M T I 0 N OFFICIAL USE ONLY FILE NUMBER COUNTYCODE YEAR NUMBER SOCIAL SECURITY NUMBER 188-22-7489 THIS RETURN MUST BE FILED IH DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 4; [~ e (date of death ~ 1. OrlginalReturn 2. Supplen~ntal Return .~. Remainder Return prior to 1;~-13-8Z) i Umlted Estate . Future Interest Compromise (date of death after 12-12-8Z) I;. Federal Estate Tax Return Required Decedent Died Testate Decedent Maintained a Living Trust ! 8. Total Number of Safe Dep~it Boxes (Attach copy of Will) (Attach copy of Trust) [] 9. LltigationproceedsReceived []10. SpousalPovertyCredlt [] I1. Election to tax under Sec. 9113(A) (data of death between 1;~-31-91 and 1-1-95) (Attach Sch O) NAME COMPLETE MAILING ADDRESS Edward P. Seeber FIRM NAME(If Applicable) 134 Sipe Avenue 3ames, Smith, Dietterick & Connelly, LLP Hummelstown, PA~17036 TELEPHONE NUMBER ~ 717/533-3280 , 1. Real Estate (Schedule A) (~) ' No~e ~ OFFICIAL USEONLY Z. Stocks and Bonds (Schedule B) (2) None 3. Closely Held Corporation, Partnership or (3) None Sole -Proprietorship Mortgages & Notes Receivable (Schedule D) (4) None Cash, Bank Deposits & Miscellaneous Personal Property (5) 17,541.02 (Schedule E) Jointly Owned Property (Schedule F) (6) None ] Separate Billing Requested Inter-Vivos Transfers & Miscellaneous Non-Probata Property (7) 13,745.57 (Schedule G or L) Total Gross Assets (total Lines 1-7) (8) 31,286.59 Funeral Expenses & Administrative Costs (Schedule H) (9) 15,037.43 Debts of Decedent, Mortgage Liabilities, & L~ens (Schedu)e I) (10) 2,0~2.39 11. Total Deductions (total Lines 9 & 10) (11) 17,079.82 12. Net Value of Estate (Line 8 minus Line 11) (12) ].4,206.77 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an elect~)n to tax has not been (13) made (Schedule J) 14. Net Value Subiect to Tax (Line 12 minus Line 13) (14) ].4,206.77 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(aX1.2) X 16. Amount of Line 14 taxable at lineal rate 12,206.77 x 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at coHataral rate 19. Tax Due 2,000.00 .0 0 (15) 0.00 .0 45 (18) 549.30 x .12 (17) 0.00 x .15 (18) 300.00 (19) 849.30 Copyright (c) ZOOO form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. ' Decedent's Complete Address: ISTREET ADDRESS 2100 Bent Creek Blvd. CITY Mechanicsbur~ STATE I ZIP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (~) Total Credits ( A + B + C ) (2) 3. interest/Penalty if applicable D. Interest E. PenaEy Total Interast;Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request · refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Emer the total of Line 5 + SA. This is the BALANCE DUE. (SB) 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; ......................... ~ ~ 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 Q AND FILE IT AS PART OF THE RETURN. 849.30 0.00 0.00 0.00 849.30 0.00 849.30 Under penalties of perjun/, 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 th;~n the personal representative is based on all InfOrl~atlon of which preparer h&s any knowledge. SlGNATUREOFPERSONRESPONSlBLEFORFILINGRETURN Nicholas G. McKelvey DATE < ...................... SIGNATUREOFPREPAREROT~RTHANREPRESENTAT~/E James, Smith, Utetterick & Connelly, LLt' DATE /J 134 Sipe Aven, e , ~ ~,~i~ ~i deat~ ~r after Jul~ 1, 1 ~4 snd before January 1, 1 g$$, the tax rate imposed on the net value of transfer~ 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 [f 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(aXl)]. The tax rate imposed on the net value of transfers to or for the use of the deceder;t's siblings is 12;/o [72 P.S. 9116(aXl.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (c} Z000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) , ~Ev-~sos EX + O-S?) COMMONWEALTH OFPENNSYLVANIA INHERITANCETAXRETURN RESIDENTOECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILENU~=CR Louis Cannavine 5S4~ 188-22-7489 02/06/2004 nclude the.proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH 272.60 Pennsylvania State Employees Credit Union - Savings Account No. 0188227489 - valued per letter dated 2/26/04 Pennsylvania State Employees Credit Union - Checking Account No. 0188227489 - valued per letter dated 2/26/04 Miscellaneous personal property - valued per Executor TOTAL (Also enter on line 5, Recapitulation) 16,768.42 500.00 $ 17,541.02 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software on¥ CPSyster~, In c. Form REV- 1508 EX (Rev. 1-97) ~Ev-ts,% EX*0-,?~ SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUM~P. Louis Cannavine SS~ 188-22-7489 02/06/2004 This schedule must be completed and filed if the answer to any of questions 1 throu, ~h 4 on page 2 is yes. DESCRIPTION OF PROF~H i'Y % OF INCLUDE THENAMEOF THE TRANSFEREE THEIR DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ITEM RELATIONSHIP TO DECEDENT AND THE DATE O~ TRANSFER. NUMBER ATTACH ACOPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1 Discovery Select Annuity 13,7~5.57 _00.00~. 0.00 13,745.57 Contract No. E0200375 held by Prudential Financial - beneficiary is Nicholas G. McKelvey; valued per letter dated 11/2/04 TOTAL (Also enter on line 7, Recapitulation) $ 13,74.5..57 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1510 EX (Rev. 1-97) ;~v-~s;~ E×*l~-sTI SCHEDULE H FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF Louis Cannavine SS~ 188-22-7489 02/06/2004 FILE _n~b~ of de""~"t must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT 1 2 3 4 1 2 3 4 5 FUNERAL EXPENSES: Boscov's - burial clothing Gateway to Heaven - cemetery services Lacampana - funeral luncheon Malpezzi Funeral Home - funeral services ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of personal Representative(s) Street Address city smta Zip Year(s) Commission Paid: Attorney's Fees James, Smith, Dietterick & Connelly, LLP Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address State Zip City Relationship of Claimant to Decedent Probate Fees Register of Wills Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs Cumberland Law Journal - estate notice publication fee Nicholas McKelvey - reimbursement for hotel, food, gas & tolls Register of Wills - filing fees for Inventory & Tax Return The Sentinel - estate notice publication fee U-Haul - rental of truck for removal of property TOTAL (Also enter on line 9, Recapitulation) 139.46 1,775.00 1,100.00 7,176.60 2,500.00 107.00 75.00 1,958.39 18.00 130.74 57.24 $ 15,037.43 (if more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV- 1 $11 EX (Rev. 1-97) ' R'EV-1512 EX * (1-97) COMMONWEALTHOFPENNSYLVANIA INHERITANCETAXRETURN RESIDENTDECEOENT ESTATE OF Louis Cannavine SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, AND LIENS SS# 18S-22-7489 02/06/2004 FILE ITEM NUMBER 1 DESCRIPTION Bridges at Bent Creek - retirement home bill Pennsylvania State Employees Credit Union ~ VISA Loan (L9) - valued per letter dated 2/26/04 TOTAL (Also enter on line 10, Recapitulation) AMOUNT 2,000.00 42.39 $ 2,042.39 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-15'I2 EX (Rev. 1-97) · R%EV_ 1513 EX * (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE T~*X RETURN RESIDENTOECEDENT ESTATE OF Louis Cannavine SS~ 188-22-7489 NUMBER I1. SCHEDULE J BENEFICIARIES 02/06/200/* NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE D STR BUTIONS [l~l~e o~lght s~u~al distrlb~lo~, a~ transfem u~er SR. 9 ~I.Z)] Nicholas McKelvey 4006 Landis Road Collegeville, PA 19426 Lora I. Kelly 330 Hickory Road Carlisle, PA 17013 ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. NON-TAXABLE DISTRIBUTIONS: RELATIONSHIP TO DECEDENT Do Not List Truste~(s) FILE Son Niece AMOUNT OR SHARE OF ESTATE Residue & Annuity 2,000.00 5 THRU 18, AS APPROPRIATEr ON REV 1500 COVER SHEET A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) Copyrig ht (c) 2coo form software only The Lackner Group, tnc. Form REV-1 $13 ~X (Rev. 9-0(3) Register of Wills of INVENTORY Estate of Louis Cannavine also known as County, Pennsylvania Date of Death 02/06/2004 , Deceased Social Security No, 188 - 22- 7489 Nicholas C. McKelvey, Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the foilowing 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/~Ne verify that the statements made in this Inventory are true and correct. I/~Ne understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 re~ating to unsworn falsification to authorities. Name of Attorney: Edward P. Seeber I.D. No.: 76084 Personal Representative.~ · Signature'. Ni6holas G. McKelvey Signature: Address: 134 Stpe Avenue Hummelstown, PA 17036 Telephone: 717/533-3280 Address: 1110 Merrybrook Road Colle~evil~e~ PA 19426 Telephone: 610/489-46~ 1 Dated: Description (See continuation page(s) attached) (Attach additional sheets if necessary) Total: 17,541.02 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 Sar Association Copyright (c) 1996 form software only CPSystems, Inc. Form ~RW-7 (199z) Date of Death: County: Louis Cannavine 02/06/2004 Cumberland INVENTORY CASH: Pennsylvania State Employees Credit Union - Savings Account No. 0188227489 - valued per letter dated 2/26/04 272.60 Pennsylvania State Employees Credit Union - Checking Account No. 0188227489 - valued per letter dated 2/26/04 16,768.42 PERSONAL PROPERTY: Miscellaneous personal property - valued per Executor 500.00 TOTAL RECEIPTS OF PRINCIPAL ............... 17,041.02 500.00 17,541.02 -1- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE *' BUREAU OF INDIVIDUAL:rrAXES' .... INHERITANCE TAX DIVISImI' -'./ .. PO BOX Z80601 HARRISBURG PA 171Z8-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT I ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-15~7 EX AFP <12-'" r\1 ....,J.v DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 02-21-2005 CANNAVINE 02-06-2004 21 04-0143 CUMBERLAND 101 Allount R_i Hed LOUIS r~jnD;-j '\' EDWARD A":SE'EBER JAMES EiAt 134 SIPE AVE HUMMELSTOWN PA 17 036 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLEI PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV :1!?'''.EX.AFir.r~1.:6J'r.NOT.fcE.OF.1NHEiYflN.CE.l'A)rA.pPRA:f'sEMENT~..ALt'bwlNCE.oR................- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF CANNAVINE LOUIS FILE NO. 21 04-0143 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. Re.l 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 G) 8. Tot.l Assets (1) (2) (3) (It) (5) (6) (7) .00 .00 .00 .00 17.541.02 .00 13.745.57 (8) NOTE: To insure proper credit to your account I submit the upper portion of this forll with your tax paYllent. 311286.59 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expanses/Adll. Costs/Misc. Expanses (Schedule H) 10. Debts/Mortgage liabilities/lians (Schedule I) 11. Tot.l Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequestsj Non~elected 9113 Trusts 14. Net Value of Est.te Subject to Tax (9) (10) 151037.43 2.042.39 (11) (12) (13) (14) 17.079.82 14.206.77 .00 141206.77 (Schedule J) I~ an assessment was issued previOUSly, lines 14, 15 and/or 16, 17, 18 and 19 will r~lect ~igures that include the total o~ Abb returns assessed to date. ASSESSMENT OF TAX: 15. AMount of Line 14 at Spousal rate (15) 16. AMount of Line 14 taxable at lineal/Class A rate (16) 17. AlIOunt of line lit at Sibling rate (17) 18. AMount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due X TS. NOTE: .00 X 12.206.77 X .00 X 21000.00 X 00 = 045 = 12 = 15 = (19)= .00 549.30 .00 300.00 849.30 DATE 11-30-2004 NUMBER CD004683 INTEREST/PEN PAID (-) .00 AMOUNT PAID 849.00 INTEREST IS CHARGED THROUGH 03-08-2005 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 849.00 .30 2.24 2.54 ~ . IF PAID AFTER DATE INDICATED I SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $11 NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)I YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) ';' ~t. f~ i~ C" ~-' o (,.:'.J :' '- ~..) ",,' >y I,j .: 15 <of, f , '" =3 -= -- -::0 = '- Q,) = Q) '" -=1:i):::J =._ 0 =cn..c: -=Q)1:: -=o::~ r- -= . 0 ~ -=..c:()Q)C") -= 0>>-.,- I = :::J ........ co C'0 =COC:::J~ =.0 ~ 0"0 -="'O(/)r- =~OQ,)~ -:U5-o"'<( - C ~ = . tIl 0 Il.. = L.L. ~.s:: ~ =tIlQ)1::.!!1 =-o..a:::JU) -=CEO= -:.!!1~()(ij -=0()~() ~ ~ c S';;::: w~ X~ ~[';i OI o.:~ w I 1\\11 '-,'111111)1111111 I ,\<(','111\ III' 111\ (llll' I' J~)C March 16, 2005 Glenda F. Strasbaugh, Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, P A 17013-3387 THE ESTATE SECURITY FORMIJLA.. Re: Estate of Louis Cannavine, deceased File No. 21-04-0143 Cheryl L. Baker, CP Certified Paralegal clb@jsdc.com Dear Ms. Strasbaugh: Enclosed is a check made payable to the "Register of Wills, Agent" in the amount of Two and 54/1 00 Dollars ($2.54) representing the additional tax for the above- referenced Estate. If you have any questions, please feel free to contact me. Very truly yours, Ch~~ Certified Paralegal c Enclosure 134 SIPE AVENUE HUMMELSTOWN, PA 17036 MAILING ADDRESS PO, BOX 650 HERSHEY, PA 17033 TOLL FREE 1,8009423660 TEL. 717.533.3280 FAX 717,533,7771 www.jsdc.com 'n :i:1JI-IClII >Cl~ c: 'e ~tI:I :::II l-t I-Ic::a m UlX....,.. :.. ~",;! c: '... ~g:iIi~ '0 ::c ... <..m ~'" 'z ~a c: <II :J>t:l .....-1 H :.. :i ... ;Z:ll: ~ t ~ , m:J> '-t. m '" "'''' ~ a.... ::z: N ~C r- .... t:l .. <.... ,... '" -om , E~ a 111I -l m-l ." ~ Q :J> a c> :... ~ z.... :II::J> r- '" .... :zc: m .... 'z m m > '''' '" X m I m \I> . '" . . . ." . i' :J> . ..... . .... . '" . <II .'" ",. D .", > '-t .. 'J :t- o.. n .... "',. 0 lz > ,. "'.... . m.. ..,. .... f!mz ",0 '0 :0:0 ...Z ':11: nm.... :l>lI: :", ;::l!i~ "'", .", !i!' m -t:l> . "'... .... \1>>0 '0 ...... "'-t :'" >.... z:z: zo.... -t '-t "''"'z 0 .... >,. 10 Z :l>n"ll""''' >j!im 0"11 .. ,. "II .z :I> n 0...:1> en:l> ..m.... ... . :0: zero-t-t-t m .... 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'" -t m ... :I> r- ~ -< '" '" c !l ", .... 0 z '" -t ~ -t " 0 ; COMMONWEALTH OF PENNSYlVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAKES DEPT. 280601 HARRISBURG, PA 17128.0601 REV.1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SEEBER EDWARD P 134 SIPE AVENUE HUMMElSTOWN, PA 17036 _uu_u fold EST A TE INFORMATION: SSN: 188-22-7489 FILE NUMBER: 2104-0143 DECEDENT NAME: CANNA VINE lOUIS DATE OF PAYMENT: 03/17/2005 POSTMARK DATE: 03/16/2005 COUNTY: CUMBERLAND DATE OF DEATH: 02/06/2004 NO. CD 005078 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $2.54 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK# 53159 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS $2.54 GLENDA FARNER STRASBAUGH REGISTER OF WillS ,.-----"'- . ~"'----.--.--._-~------ BUREAU OF INDIVIDUi'L{~~~D (HICE OF lNIEAITAHCE TAX DIVISitJi[ .~-' -- - - , PO lOX 280601' ' HAAAISIUAG PA 11121-0601 " COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE I:NHERI:TANCE TAX STATEMENT OF ACCOUNT '* , AEV-l~07 EX AFP (03-05) DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-18-2005 CANNAVINE 02-06-2004 21 04-0143 CUMBERLAND 101 _t _1tt..s LOUIS i '70n<; ^q P'A I?; ! 0 <.,.".\.,'_.; L ..> Ii '..... C'T:' EDWARD P"SEEBER JAMES ETAL 134 SIPE AVE HUMMELSTOWN PA 17036 I ! Ii PA~MENT TO: MAKE CHECK PAYABLE AND REMIT REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insu.... proper credit to your account" suait the upper portion of this fo..... with your :t.x ~....,t. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS 411I ' ................................................................................................................ REV-1607 EX AFP (03-05) ... INHERITANCE TAX STATEMENT OF ACCOUNT KKK ! ESTATE OF CANNAVINE LOUIS FILE NO.21 04-0143 ACN 101 DATE 104-18-2005 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE ~ED ESTATE. S BELDH IS A SUHNARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF AP LICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-21-2005 PRINCIPAL TAX DUE: 849.30 PAYMENTS (TAX CREDITS): ~ PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 11-30-2004 CD004683 .00 849.00 03-16-2005 CD005078 2.24- 2.54 i TOTAL TAX CREDIT i 849.30 BALANCE OF TAX DUE I .00 , INTEREST AND PEN. I .00 , TOTAL DUE ! .00 . IF PAID AFTER THIS DATE, SEE REVERSE I SIDE FOR CALCULATION OF ADDITIONAL INTEREST. I IF TOTAL DUE IS LESS THAN $1, ND PA~ IS REquIRED. IF TOTAL DUE IS REFLECTED AS A ''CREDIT"' ICR), YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FoRH FOR INSTRUCTIONS. ) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 1/04/2006 SEEBER EDWARD P 134 SIPE AVENUE HUMMELSTOWN, PA 17036 RE: Estate of CANNAVINE LOUIS File Number: 2004-00143 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. 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: 2/06/2006 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~~P/J_~~~ /'/ GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge ~z BUREAU OF INDIVIDUAL' TAXES INHERITANCE TAX DIVISION-- - PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT REV-1607 EX AFP (03-05) STEVEN J SCHIFFMAN ESQ SERRATELLI ETAL STE 201 2080 LINGLESTOWN RD HBG PA 17110 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 01-09-2006 DEIBERT 10-27-2004 21 04-1143 CUMBERLAND 101 ELEANOR R Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax payment. CUT ALONG THIS LINE -+ RETAIN LOWER PORTION FOR YOUR RECORDS +- --------------------------------------------------------------------------- REV-1607 EX AFP (03-05) *** INHERITANCE TAX STATEMENT OF ACCOUNT ... ESTATE OF DEIBERT ELEANOR R FILE NO.21 04-1143 ACN 101 DATE 01-09-2006 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 12-12-2005 PRINCIPAL TAX DUE: 3,151.00 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) *** SUMMARY OF ALL 005 PAYMENTS *** 12-14-2005 136.84 .00 12-14-2005 2.90- 3,017.06 TOTAL TAX CREDIT 3,151.00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 If IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR>, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. > g ,~, ."..r I~ ........'" I~. . ~.. f..\ Jd~ '~\ ~~. ~/ ~ 7"<'\ _.-: _.'1.__._... _....~~^,..!l1il_ _.J!: ~_____:1_ _~" ___ ~ .n_~'""I~~- .tr'"~(-;::~.!USit!..lt:.!l." lUll W~ lUilLSi UlL v IULlUl..itlUtClL' .ll.all..!l.U 'LAUlU.!i.ll.lLJ STATUS REPORT lJ1\JvER RULE 6.12 Name of Decedent: , , j~.cV\ So LtA"o Av \ (\'~ Date of Death: 'fi h~V'\R1 Co \ 2 OO~ jool' _ 0 0 \ L( 3 Estate No.: <; Pursuant to Rule 6.12 of the Supreme Court Orphans) Court Rules, I report the following with respect to completion ofllie administration of the above-captioned estate: 1. State whether administration of the ebtate is cOluplete: Yes IZJ No 0 2. If the answer is 1~ 0, state when the personal representative reasonably believes that the administration will be complete: 3. Ifthe answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the C6Urt7 . Yes 0 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 pa.."iies in interest? Yes 0 No 0 Date: .:J )\3) Ob c. Copies of receipts, releases, joinders and approval offonnal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report /r!~ 1; 111 ~ ~ Signature ~:" rJ l~hoL~5 G . Me ~t:)Vl: 1 Name ROAd \qLJ~lo I \ II.) M lc#~~ft .A..ddress CO\lfG'l:-vdt I A. lPlO 22.2 - L.J:2 4<0 ,...- Telephone No. ~a..~iJ......;:;r;-l..t-y". 11"'56 . v:......~....,....i D"'--~S~""~"';"~.'I.f';> -- r -... lL.l' J.. ~J.. ':'V.Ll.ul. ~.""ytJi....... ~J...u..a..:....!.. \ '-" o COi..lD.sel for personal representative V 1:-