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HomeMy WebLinkAbout04-0177PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of also known as Deceased. Social secumy No. o~© 0 ~c/-?c/~-~ No. ? To: Register of Wills for the County of Commonwealth of Pennsylvania in the The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl 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 h last family or principal residence at at Decendent, then years of age, died County, Pennsylvania, with (list street, number and municipality) ' bo,o Y , vr , Decendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not dOmiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: Petitioner after a proper search ha__ the following spouse (if any) and heirs: Name ascertained that decedent left no will and was survived by Relationship Residence Iq~ ~ la~e_. ~rl~ ,~ i~. THEREFORE, petitioner(s) res~.ctfully request(s) the grant of letters of administration in the appropriate form to the undersigned. OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF The petitioner(s) above-named swear(s) or affirm(s), that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this day of 19__ Register No. Estate of ,Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW 19 , in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to in the estate of FEES Letters of Administr~ion ..... $ Short Certific~es( ) .......... $ Renunci~ion ................ $ $ TOTAL__ Filed ..................... Register of Wills t0: ~ d 0~ B3J ~.~o~. (sup. ct. ~.D. $ ADDRESS 19~[i}A;~ ZC ~;:: :~ A.D. - PHONE RENUNCIATION The undersigned f_~i/~,1 of the above decedent, hereby renounce(s) the right to administer thc estate and respectfully ask(s) that Letters WITNESS handthis //¢7 dayof ~__~{~l~/"y .21)~9v (Signature) (Address) (Signature) (Address) (Address) his is to certi~ that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 999106O No. Local Registrar Date COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH · Esther K. l~:x:x~w , F ~ ' ' ' 71 v... , Se tember ~ · ~r~o I ~rlzsle I ~rlisle R~ional M~ical CenP~ I~ ~.~ I,~, ' ' ' ]'" ~m's"~m ~ ~. ~. ~.z,~ I~c~'s -. Wi~w ,,. 213 Sr~ck Church R~d Neville PA 17241 [~ ~ u~r ~ford ,t ~tt O. Kessi~er Matthew Moomaw Leonora Larson I~NFORM~M_T~ ~ A.O(~ES.t (,S~'W. C~/Tomm. S~m, Zip 231 Brzck Church Road, Newville PA 17241 Green Hill Cemtery I,,t Waynesboro PA Name of Decedent: Date of Death: c~ Will No. To the Register: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Admin. No. .~ I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on : Name %m'4 Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: Signature Address Capacity: ~ Personal Representative Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT, 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD REV-1162 EX(11-96) 0048O4 MOOMAW MATTHEW S 213 BRICK CHURCH ROAD NEWVILLE, PA 17241 ........ fold ESTATE INFORMATION: SSN: 200-24-1458 FILE NUMBER: 2104-01 77 DECEDENT NAME: MOOMAW ESTHER K DATE OF PAYMENT: 01/06/2005 POSTMARK DATE: 01/06/2005 COUNTY: CUMBERLAND DATE OF DEATH: 02/03/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $8,516.80 REMARKS: TOTAL AMOUNT PAID: MATTHEW S MOOMAW 98,516.80 SEAL CHECK//1047 INITIALS: SK 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 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT LU Z Z O Q. o3 uJ O (.) DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Moomaw, Esther K. DATE OF DEATH (Mk~DD-YEAR) I DATE OF BIRTH (M~DD-YEAR) 02-03-2004 I 09-17-1932 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) n/a [] 1. Odgina]Retum [] 2. Supplemental Return [] 4a. Future Interest Compromise (dete of death alta' 12-12-62) [] 7. Decedent Maintained a Living Trust (Attach copy of Trust) [] 10. Spousal Poverty Credit (date of death betwe~n12-31-91 and1-14IS) OFFICIAL USE ONLY FILE NUMBER COUNTY CODE YEAR I~MSER SOCIAL SECURITY NUMBER 200-24-1458 THIS RETURN MUST BE FILED IN DUPLICATE WI'ITl THE REGISTER OF VVILLS SOCIAL SECURITY NUMBER [] 4. Limited Estate [] 6. Decedent Died Testate (Attach copy of Wil) [] 9. Litigation Proceeds Received ] 3. Remainder Return (date of death prior to 12-13-82) [] 5. Federal Estate Tax Return Required __ 8. Total Number of Safe Deposit Boxes [] 11. Election to tax under Sec. 9113(A) ra,~ch Sch O) THIS SECTI~ MUST BE COM P~TED. ALE CORRESPONDENCE:AND CONFIDENTi~ TAX INFORMATION S~U~ BE DIRECTED TOi: NAME I COMPLETE MAILING ADDRESS Jeffrey S. Cohick 1 390 Alexander Spring Rd. FIRM NAME(If Apptcable) Cohick & Associates Carlisle PA 17013 TELEPHONE NUMBER 717/249-5321 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 9 2,12 3.3 5 3. Closely Held Corporation, Partnership or Sole-Proprietorship {3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 18,4z~r~. 0 5 (Schedule E) Joinlly Owned Property (Schedule F) (6) [] Separate Billing Requested Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) Total Gross Ass~ (total Lines 1 - 7) Funeral Expenses & Administrative Costs (Schedule H) (9) Debts of Decedent, Mortgage Liabilities, & Uens (Schedule I) (10) Total Beducfions (total Unes 9 & 10) Ne{ Vat ue of Estata (Line 8 minus Line 11) 13. ~1: 8. O 9. n, 10. 11. 12. 13. 14. 16. 17. ~O~ 18. X 19. 20. Charitable end Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) Ne{ Value Subject to Tax (Line 12 minus Une 13) 86,652.70 OFFICIALr~SE ONLY (8) 197,220.10 7,889.00 1,407.44 (11) 9,296.44 (12) 187,923.66 (13) (14) 187,923.66 SEE INSTRUCTIONS FOR APPLICABLE RA'IES Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) Amount of Line 14 taxable at lineal rate Amount of Line 14 taxable at sibling rate Amount of Line 14 taxable at collateral rate Tax Due X .0 (15) 187,923.66 x.o 45 (16) 8,456.56 X .12 (17) X .15 (18) (19) 8,456.56 [], J CHECK HERE IFYOU ARE REQUESTING A REFUND OFAN OVERPAYMENT I > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < STFPA42021F.1 ' Decedent's Complete Address: STREET ADDRESS 213 Brick Church Road crrY Newville STATE PA Iz'P 17241 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Pdor Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty 60,24 (1) Total Credits (A + B + C) (2) Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the dilference. This is the TAX DUE. (3) (4) (5) (5A) (5B) A. Enter the interest on the tax due. 8,456.56 60.24 0.00 8,516.80 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 8,5 16,80 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? ....................................................... 1~ []. IF THE ANSWI~R TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of pa'jun/, 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. Dedaratioa of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON R.E,~PONS[BLF,, FOR FILING RETURN ADDRF.~S y//N 2~' Brick Church Road ewville PA 1724'l DATE SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 390 Alexander Spring Road, Carlisle, PA '170'13 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. {}9116 (a) (1.1)(i)]. For dates of death on or after January 1, 1995, the tax rate im posed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. {}9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. {}9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. {}9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. STFPA42021F.2 REV-I'503 EX + (1-97) (0 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Moomaw, Esther K. SCHEDULE B STOCKS & BONDS I FILE NUMBER 21-04-00177 NI property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 2826.355 shs..lennison Utility Fund Class B @9.26 1031.668 shs. 3ennison Value Fund Class B @16.07 8468.68 shs. Dyden High Yield Fund Class B @5.83 TOTAL (Also enter on line 2, Recapitulation) 26,172.05 16,578.90 49,372.40 92,123.35 (If mom space is needed, insert additional sheets of the same size) STF PA42021F.4 REV-1508 EX + (1.97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Moomaw, Esther K. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-04-00177 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-<~wned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 2. 3. 4. 5. 6. 7. 8. Cornerstone Federal Credit Union - account #112-01 Cornerstone Federal Credit Union - account #112-07 Cornerstone Federal CFedit Union - account #112-18 PA Dept of Revenue - 2003 income tax refund Social security benefit for February, 2003 1997 Chevrolet Minivan 1976 Mercedes Benz 240D United American Insurance Co. - uneaFned health insurance premiums PA Department of Treasury - unclaimed property payments TOTAL (Also enter on line 5, Recapitulation)~ 1,024.50 4,830.81 2,007.25 7.00 1,048.00 6,475.00 2,500.00 195.59 355.90 18,444.05 (If more space is needed, insert additional sheets of the same size) STF P^42021F.9 RE~'-1510 EX + (1-97)(I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Moomaw~ Esther K. SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY I FILE NUMBER 21-04-00177 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERLY % OF ITEM INCLUOE TFE NAME OF THE TRANSFFREE, THEIR RELA'¢IONSHIP TO DECEDENT AND THE DATE DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER OF TRANSFER. ATTACH A COPY OF TI-E DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF ~I~E) 4. Prudential Financial - nonqualifed annuity contract #E0039621 55,661.80 100 55,661.8C 2. Prudential Financial - IRA account #E0020985 30,990.90 100 30,990.9C Beneficiaries on items 1-2 are children of deceased , TOTAL (Also enter on line 7, Recapitulation) $ 86,652.7~, (If more space is needed, insert additional sheets of the same size) STF PA42021F. 11 REV"'-1511 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN . RESIDENT DECEDENT ESTATE OF Moomaw, Esther K. SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS I FILE NUMBER 21-04-00177 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. 1. FUNERAL EXPENSES: Wagners Memorials - headstone ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Sodal Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not Ihe same as claimant's, attach explanation) Claimant Marl:hew S. Moomaw Zip Street Address 231 Brick Church Road city Newville State PA Relationship of Claimant to Decedent son Probate Fees Accountant's Fees Tax Return Preparer's Fees Register of Wills - probate fees and filing inheritance tax return Zip 17241 TOTAL (Also enter on line 9, Recapitulation) 410.00 3,500.00 3,000.00 719.00 260.00 7,889.00 (If more space is needed, insert additional sheets of the same size) STF PA42021 F.12 REV-~512 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Hoomaw, Esther K. SCHEDULEI DEBTS OF DECEDEN% MORTGAGE LIABILITIES,& LIENS FILE NUMBER 21-04-00177 Include unreimbursecl medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 2. 3. 4. 5. 6. United States Treasury - 2003 federal income tax Discover Card - balance due Peco Energy - utility service Wickard's Garage - auto repairs Sprint - telephone service Sedlock Surgery - professional services TOTAL (Also enter on line 10, RecapitulaJion) 984.00 94.94 66.00 71.50 91.00 100.00 1~407.44 (If more space is needed, insert additional sheets of the same size) STF PA42021F,13 REV:1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Moomaw Esther K. SCHEDULE J BENEFICIARIES FILE NUMBER 21-04-00177 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. II. 1. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Matthew S, Moomaw Michael S. Moomaw Cynthia Anne Moomaw Smith Anthony A. Moomaw son son daughter son 1/4 residue 1/4 residue 1/4 residue 1/4 residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE none B, CHARI~BLEANDGOVERNMEN~LDISTRIBUTIONS none TOTAL OF PART Il - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) STF PA42021F.14 I'NVENTORY REAL AND PERSONAL ESTATE OF Esther K. Moomaw, Deceased Late of o,-./-/'77 Upper Frankford Township, Cumberland County, PA Date of death: February 3, 2004 Social Security Number 200-24-1458 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 2826.355 shs. 3ennison Utility Fund CI B @9.26 1031.668 shs. 3ennison Value Fund CI B @16.07 8468.68 shs. Dryden High Yield Fund CI B @5.83 Cornerstone Federal Credit Union Account #112-01 Cornerstone Federal Credit Union Account #112-07 Cornerstone Federal Credit Union Account #112-18 PA Dept of Revenue - 2003 tax refund Social Security benefit for February 1997 Chevrolet Minivan 1976 Mercedes Benz 240D United American Insurance Co. - unearned medical insurance premiums PA Dept. of Treasury - unclaimed property payments Total $ 26,172.05 16,578.90 49,372.40 1,024.50 4,830.81 2,007.25 7.00 1,048.00 6,475.00 2,500.00 195.95 355.90 COMMONWEALTH OF PENNSYLVAN~[A : : COUNTY OF CUMBERLAND .. SS MATTHEW S. MOOMAW, being duly sworn according to law, deposes and says that he is the Administrator of the Estate of ESTHER K. MOOMAW, Deceased; that the foregoing schedules constitute a complete inventory and appraisement of the real and personal estate of ESTHER K. NOOMAW, deceased, except real estate outside the Commonwealth of Pennsylvania and that the figures opposite each item of real and personal estate in the foregoing schedules are determined and stated by the undersigned to be the fair value of said items as of the date of the decedent's death. Sworn, to and subscribed before me this ~'+/~ day of .~anuary, 2005. MA'ITI'HEW S. MOOIVlAV~' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE '* BUREAU OF INDIVIDUAl/~rAXE$T' INHERITANCE TAX DIVISioN.. . PO BOX Z80601 HARRISBURG PA 171Z8-0601 -. .. NOTICE OF INHERITANCE TAX APPRAISEMENT 1 ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1541 EX AFP 112-041 18 ". I 7 f !.. ,L.!.. " j l ':i DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-14-2005 MOOMAW 02-03-2004 21 04-0177 CUMBERLAND 101 ESTHER K C\I "'...+'""I,u tLth{\ ORPHJ\!\fS JEFFRE't~j\'~1lJJ:K,C: COHICK & ASSOCS 390 ALEXANDER SPG RD CARLISLE PA 17013 Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE1 PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ RE-Y =r!?;'1'-Ex--1.FP--CBr=cJ!"-Noi'-icE-oF-INHErtifl'N-cE-l-Ax-APPRA-isEit-EN'~--1.[tOWANCE-OR------._----- - -_. DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MOOMAW ESTHER K FILE NO. 21 04-0177 ACN 101 DATE 03-14-2005 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets U) (2) (3) (4) (5) (6) (7) .00 92.123.35 .00 .00 18.444.05 .00 86.652.70 (8) NOTE: To insure proper credit to your account 1 submit the upper portion of this forll with your tax payment. 1971220.10 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) UO) 71889.00 1.407.44 U1> (2) (3) (4) 9.296 44 1871923.66 .00 1871923.66 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: 15. Allount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due .00 X 00 = .00 1871923.66 X 045 = 81456.56 .00 X 12 = .00 .00 X 15 = .00 (9)= 81456.56 ~ TAX CREDITS: (+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 01-06-2005 CD004804 60.24- 81516.80 TOTAL TAX CREDIT 81456.56 BALANCE OF TAX DUE .00 INTEREST AND PEN. .66 TOTAL DUE .66 . IF PAID AFTER DATE INDICATED 1 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) 1 YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17'013 Phone: (717) 240-6345 Date: 1/05/2006 MOOMAW MATTHEW S 213 BRICK CHURCH ROAD NEWVILLE, PA 17241 RE: Estate of MOOMAW ESTHER K File Number: 2004-00177 Dear Sir/Madam: It has corne 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: 2/03/2006 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~~~ GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Counsel Judge ~:t IN THE COURT OF COMMON PLEAS OF DAUPHIN COUNTY, PENNSYLVANIA IN RE: ORPHANS' COURT DIVISION ESTATE OF ESTHER K MOOMAW NO. 21-04-00177 DECEASED 2-3-04 STATUS REPORT UNDER RULE 6.12 Name of Decedent: ESTHER K MOOMAW Date of death: 2/3/2004 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_X_ No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to NO.1 is Yes, state the following: a. Did the personal representative file a formal account with the Court? Yes No X 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 No X d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of Orphans' Court and attached hereto. I /s; /o(~ { { 7flI.~0(~ signfure: ~: Name: Address: MATTHEW S MOOMAW 213 BRICK CHURCH ROAD NEWVILLE. PA 17241 717/249-5321 Personal Representative Telephone: Capacity: ~