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HomeMy WebLinkAbout02-0706PETITION FOR GRANT OF LETTERS OF ADM:[NISTRATION F.'state of S`~IN J. GROSSMAN also known as Deceased. Social Security No. 202-46-6723 No. 2 ~ - 0 ~ ' ~ ~ ~D To: Register of Wills for the County of ~g~~r.A» in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/~ 18 years of age or older, appl ies for letters of administration on the estate of (d.b.n.; pendente liter durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in Cumberland County, Pennsylvania, with h i G last family or principal residence at 862 CarlHmm~e Maror~ dpt_ 3108 Carlisle, Cumberland County, PA (list street, number an<l municipality) Decendent, then 47 years of age, died July 22 ,fig 2002 , at North Middleton Township, Cumberland County, PA . 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: 4,000.00 Petitioner. after a proper search ha S ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name Relationship Residence Jessica N. Grossman Dau hter 1504 Timber Chase Drive Mec anics urg, PA 7 5 THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. H N 1504 Ti,~nber Chase Drive a~ Mechanicsburg, PA 17050 C G O ~ .~ Ha d w. ~° / ~% ~_ JFSSI N GR'.OSSMAN a ~o OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF ss 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 d truly administer the estate according to law. ~ "7 Sworn to or affirmed and subscribed -'~' ,~ before me this ?=~a _ day of essica u ~.UGUST ~ 2002 w "~ I~ _ a MAR C S R gister l ~ No. 2 ! -o ~.-1d~ E~~'ate of sTEVEiv J • GROSSMAN ,Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW AUGUST 7 ~ 2002, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that .Jessica N. Grossman is/entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to _ Jessica N. Grossman in the estate of --~~~ J. Grossman FEES Letters of Administration ..... $ 25 _ ~~ Short Certificates( ) .......... $ 15 _ ~~ Renunciation ................ $ ~~ $ 5_nn TOTAL $~ s.n~ Filed .. $-.7.-00.2 ......... A. D. 19 atty picked up On 8-7-2002 t ~'R C ~I~te~ister o Will Heather D. toyer, Esquire I.D. # ORNEY (Sup. Ct. I.D. No.) 4431 N. Front St., 3rd Floor ADDRESS Harrisburg, PA 17110 PHONE 717-234-2401 IlO5.RO5 REV 91R~ This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the Stare Viral Records Office for permanenr''filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. H I OS I J4 Rev 1/91 8482913 N o. fvPE-PRINT IN PLHMANENT DL ACKINK ~,f l'. i rl. ~1 c w ~\~ I i w .) t] f Fee for this certificate, $2.00 -,1~, - ~ ~+~-C 2 Local Re istrar ~ f/ Date COMMONW EALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (Coroner) NAME OF DECEDENT (FuW, Mgoy. lav) SE% SOCUL SECURITY NUMBER DATE OF DEATH IM«kh. Day. Year) ,. Steven J Grossman ,. Male ,. ocoa2 - Ye - 6~a3 ., July 22, 2002 AGEILesl Bvaraey) UNDERI YEAR UNDER7DAY DATE OF&RTH BIR7HPLACEICily ergo PLACE OF DEATH(CM Ck WyOrr-ase uamrctrmaan oelar Wet Mr%aM Daya Nan MkIMN IM«ah, DaY•WerJ SNIe«Foreign COUnkyl NOSpITAL: OTHER: 47 vra Au 31 1954 g' • / ~ Inpatl.«^ FRIOuIWINm^ DW^ any ^ w i ^ s ~ ~ S. Qrf/3OUr T. a 0erru pe ~ay) N. - COUNTY OF DEATH fT1; DEATH FACILITY NAME pl n« Inslgaiprl, give akrNi ono mrmlw) YMS DE EOEM OF HISPANIC ORIGINT MCE - ArMncan IrWian, Black, WMa, Nc. Cumberland North Middleton State Game Lands PAR 944 "°~""~"yp~•~"YG°^•"• +spe°dY) ' t • W A h rAkan. Pu•rl0 Ricer, •LC. W Y ~ - ' ab. Ea.' W. 10 . DECEDENT'S USUAL OCCUPRION KB/D OF BUSINES INDUSTRY MR9 DECEDENT EYER IN DECEDENT'SEDUCATION MARITAL STATUS~MarMa SURVIVING SPOUSE U S ARMED FORCEST - 1 ' . . rng noel IGrva kind d v+Oh 0«wour Mvr NarrlW, WiAOwIW, (11 wr1e, give maiden rurM) of vvprkirp el•; ao noluNr aa.) ~ r ^' Elsm•Ma71S•OOrldarY Dw«c•o 1SP•cdYl _ vea^ No (P12) .e«+ .. j~ U 5(,LR/~YO.C ,1,F_A/~StI7Ef2M ) //O/-!£D n•. 1 . 1 . 1 . ~ 1s. • DECErDENT'S MAILING ADDRESS (firer, GiN/fown, St/al~e. Zip Coos) r( y CQ.e~ cuY~n£ • p~YOQ DECEDENT' ACTUAL 17a. SUn• ~G- 170.^ YN, tleOpMMMwoin Nvp " n UPT 3/a B ~ . RESIDENCE (sp inrnunane w.M. . G / 7 0 /3 . 2 L ~ r P.; «, aver artla) ,./ /3 F2 ~G1n)J b""'~ip4 RL :, C "O r ~ ~A C "/f m°~ii , -J ... u. C a . u c~m 170. caps 17d.L' 1 w iln in i M °r .~rw cn n,om FATHER'S NAME IFer, MiaW. Lase MO7HER'6 NAME (Far, Mitlde, Meiaen SurMmel ,,. Jarncs G/eo ss.7Ta~ t,, S00.n ~~c ~' a/1~,a i/Y INFORMANT'S NAME (Type'Prvrq INFORMANT'SMAIUNG ADDRE (Skeet, CkyrTOwn, Slre. ZrpCoaa) za..- fSSicta., 6'2oS5/17aAY' ./Sat T/ir/B£.e Chru~ DR;v.~ /y)iL-hc.n.c:~;<~~. fn_ /7u3o METHOD OF DISPOSTION DATE OF DISPOSITION PUCE OF DISPOSITION-Namsd C•mrary, C''+emetory LOCATION-Cily77own. Stale, Zp COae BurWQ Crsmatim^ Mmpvr from Siew^ (MorOh, DaY. Yaer) orgner Plat ~r2M /~yf/~/~ /'~_ /70/r' DOnaign^ Olhr lspecyyl ^ / 6 0 d 7 0"1 z_ ~°~%9 6r~~~r mfnr. ~ 2K 7r - z/J ~ x1.. :LD. a lc, ...- < w.x,- ~ 21 . SIGNXTUR FUNS LSERVICE IC SEED PERSON ACTING AS HUCH LICENSE NUMBER 9 N SAND ADDRESS OF FACILITY /VET / .~unfrrRC °,u. Z]~ "°~" n`'r"„ xze. D v/3 6 8Y' ,~ ' xxa. -~ '-- Y1e. ~Y v / ~ cx.-.4 eT s7 ~'a-n ~ "~/~. i 7 v // Camille nem923ec0 wMncMilying 1otMD..idmy knowNage, daeih rx%urraa at lne lime. sale end place sl•lea. LK:ENSE NVMBER DATE SIGNED pnysm u: rl« avadada ai lim• of aeon to cent PeuN cl Oaalh. (SpMlure a«l Title) iMl,rllrl, DeY yeUr) x0•. 510. xxe. ' Trams 2e-26 mustwcomplelW Dy TIME Of DEATH prg, DATE PRONOUNCED DEAD IMOnih, Day, Year) NMSCASE IiEFERREDTO ME AL EXAMINEWCOAONER9 •. parson woo wonourrsa gain. ~. 2:15 A. M zE. July 22, 2002 wa NoL7 1]. PApT 1: EMar Hle aipalp, inluM• «rxmplcrkn• which CerWa IM Walh. DO MI enl•r the moos of ayirq, auto e5 <aralac a respirrory attar, ehOCk Or npn lellw•. rApproalmre PART II: Other agndrGm cunadrune coninuuung ro seem. Da LNl pdy °rN GUN «I taco llM' iknarvrOMV•p n«rasuni lne un0erl i rp in y rp cauN gwan rn PART I. IYYEOUITE CAt18E (FnW toner •M Wam `~,,,;,~d;~~-. a Gunshot to Head i e DUE 70 (Oil AS A CONSEQUENCE OFT'. ~ S•pre«irly kN NrrdtlaM D. r Aany, 4arfrrp t°klurr•di•t• DUE 70108 ASA CONSEQUENCE OF): GuN. Ear UNDERLYING CAUSE IIJraasN«iryury 0 ' mrumi.Na•vrra DUE TO (OR A9ACONSEOUENCE OF): -'----`~~--~ resunvp m tlplhl LMT - a. WAS AN AUTOPSY WERE AUTOP FlNDOKIS MANNER OF DEATH DATE OFINJURY TIME OF INJURY INJURY AT WORKT DESCRIBE HOW INJURY OCCURRED PERFOFiMEO7 N/A47a3LE PRIORTO (Mrnin, Day, Yeer) COMPLETKYN OF CAUSE Aprx. Self-inflicted gunshot oFDEYirHT ""oral ^ "°"iiCtle ~, July 22, 2002 "` ~] "°~ -handgun r~ Arxia•M ^ PerMirq lnvpligalion ^ W. b. 2' 15 A M. W ^ N ~ Y ^ N ^ _ - s o p O PLACE GFINJURY-AL hap,l•rm. rr•M, hcbry. oaica LOCATION (Shea, G,IYNnwrl. :;Imel swow ~ Couwrwllleaelermin.a ^ an eic ls «.n ) , ~a g, p y . parking Lot t. 94 Carlisle, PA zN :Eb. z CERTIFIER (Check «yy «wl BKiNrVt1RE 'CERi1FY1NG PNYSK,AN tPnysruan candying Guse d tleatlr when anan« physvaan has pawunreU tleeln antl ccanyla W 11«ri 13) ^ Coroner ToiM D••t of my knorwq., a••M O•cumdaw LO lM pup(•1 •ram•nMra•a4t•o .......................................... ........... lib LICEN MBER GATE SIGNEDIMrma, Goy. fi:.,rl •PQONOUNGNO AND CERTIFYING PHYSICIAN Ph aGaln b°N 1 Y' prorwuruangtlealhantlGrldYm9locausnMtleelh) TO LM Dpi of my knOw4op•, M•M occurrW M LM iMM, aaU, w PI•c•, aM oW la tM GrIrlNel •na m•nMr •. •qt•0 .......................... ^ ~ Jul 22 2002 1C. Ole. y 7 NAME AND ADORiESS OF PERSON WHO COMPLETED GAUSS OF DEATH ' Iltam 27)Typ•miPdm Michael L. Norris, Coroner MEDICAL EXAMINER/CORONER ' OnIMOa•IarN•annlnaUOn.MIOrMV.Mlytbn,LnmyoplMOn,LbtlhocturrWaltMtim•,dab,anapla0•,antlouaotMGUSN.I.ntl 6375 Basehore Road, Suite #1 1,..m.nn.,..n.ta .................................................................................................. ,,. Mechanicsburg, Pa. 17050 REGI 'S SIGNQURE AND NUMBER I I,~ ~ DATE FlLED(Manar Oay,KNI) ~ ~ ~ [! CI 7 I I33. / \ rx.1QA',~T R Jul ~ J\ trC~Cttl+~ Dl~~2GL.l ,~ 1,. U y / ~ ~ ~ ~ J ~ r C..: i CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Steven J. Grossman Date of Death: July 22, 2002 No. 2002-00706 TO THE REGISTER: I certify that notice of benef cial interest required by Rule 5.6(a) of the Orphans Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on Friday, August 30, 2002: Name Address Jessica N. Grossman 1504 Timber Chase Drive Mechanicsburg, PA 17055 and Centre Plaza 00408-1 5032 Centre Avenue Pittsburgh, PA 15213 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: NONE Date: August 30, 2002 SMIGEL, ANDERSON & SACKS, LLP ~ ~--_ _ By: ~„ Ileather D. Royer, Esquir ID# 76327 4431 North Front Street, 3ra Floor Harrisburg, P.A 17110-1709 (717) 234-2401 Attorneys for Personal Representative Register oT Wills of Dauphin County, r'l~nnsytvania INVENTORY Estate of STh'VEIV J. GROSSMAN also known as Deceased No. 2002-00706 Date of Death 7/22/02 Social Security No. 202-46-6723 JESSICA N, GROSSMAN 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: Heather D. Royer, Esq. I.D. No.: 76327 Address: Telephone 4431 N. Front St., 3rd Fl, Harrisburg, PA 17110 717-234-2401 Personal Representative: Jessi ) Grossman ~q Dated ! ~~ ~~ Description 1. Personal property sold at auction on 9-21-02 2. Sale of guns/bows and arrows 3. Sale of Fuji Discovery 17" bike 4. Sale of Futon 5. Waypoint Bank Checking Account - #10026938 6. Sale of 1983 Ford Bronco -SALVAGE 7. Sale of 1983 Ford Mustang 8. Final paycheck 9. 2002 Income Tax Refund 10. Ellie Insurace Exchange -claims on vehicle 11. Ellie Insurance Exchange -claims on vehicle 12. Erie Insurance Group - Premitm refund Value $ 1,322.75 $ 800.00 $ 200.00 $ 75.00 $ 209.80 $ 100.00 $ 6,700.00 $ 2,267.99 $ 833.00 $ 359.62 $ 296.56 $ 115.00 Total: $ 13, 279.72 )Attach Additional Sheets if necessary) 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 [he total of the In vei,tory _~- Rw-s SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or Uansfers under Sec. 9116 (ax1.2) 16. Amount of Line 14 taxable at firteal rate COh1hI0N'PJ~ALTH OF ~~ ~\ L,,, Y- 1 V V V PENNSYLVANIA y~~~~ CE?ARTt~tEN7 OF REVENUE INHERITANCE TAX RETURN FILE NUMBER DEPT. 280601 01 _ 02 00706 HARRISBURG, PA 17128-06 ,.. RESIDENT DECEDENT ~«;~r ~~~ YES - ~:u~E~ - - DECED'cVT-S NAME (LAST, FIRST, A,~ID MtDOIE INITIAL) SOCIAL Sc'CURITf NUti18ER Z C~06SMAN, STEUII~I J. ~ 2 0 2 - 4 6 - 6 7 2 3 W ~ DATE OF DEATH (Mht-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE W 7-22-02 8-31-54 REGISTER OF WILLS U L!J (IF APPLICABLE) SURVIVING SPOUSE'S `1AME (LAST, FIRST, AND MIDDLE {NIT{AL) SOCIAL SECURITY NUMBER ~ N/A - w ®1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return lcxa or seam vna b rz•r}e~ ~ a ~ ~ 4. Limeted Estate ~ 4a. Future Interest Compromise taac. ordom aner rz•rz~azl ~ 5. Federal Estate Tax Return Required ~ a m ~ 6. Decedent Died Testate (xaad+ wvr orwa) ~ 7. Decedent Maintained a Living Trust (AmcA copy d r~l 0 8. Total Number Of Safe Deposit Baxes < ~ 9. U6ga6on Proceeds Received ~ 10. Spousal Poverty Credit (mU ordnm DeMen rzar•9i arW r-1.95) ~ 11. Election to tax older Sec. 9t13(A) qa~a, srs of THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: ~ w NAME COMPLETE MAILING ADDRESS _ Heather D. Ro er Es 4431 North Front Street, 3rd Floor ° W S~MIG~QE, t~r~ND~EZSON & SACS{S Harrisburg, PA. 17110 z ° U .3~L~? 234N 201 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sde-Proprietorship (3) 4. Mortgages S Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (s) - 13, 279.72 Z (Schedule E) 0 6. Jointly Owned Property (Schedule ~ (6) _. Separate Billing Requested ~ 7. Inter-Yrvos Transfers & Miscellaneous Non-Probate Property m I- (Schedule G or L) a ~ (e) 13, 279.72 Q 8. Total Gross Assets (total lines 1-7) W 9. Funeral Expenses 3AdminisUa6ve Costs (Schedule H) (s) 12, 360.52 ~ 10. Debts of Decedent, Mortgage LiabrTities, d Liens (Schedule ~ (10) 1 , 432.21 11. Total Deductions (total L'snes 9 810) (11) 13, 792.73 12. Net Value of Estate (Line 8 minus Line 11) (12) . 13. Charitable and Governmental BequestsJSec 9113 Trusts for which an election to tax has not been (13) , made (Schedule J) Net Value Subject to Tax (line 12 minus line 13) 14 INSOLVF3~IT (14) . _ Z a I- a U 17. Amount of Line 14 taxable at sb8ng rate 18. Amount of Line 14 taxable at collateral rate ,~ _ •~, ~ ~ '>,, "L o c~i ~ cnn 19. Tax Oue x .0 _ (t5) x .o _ (1s) x .12 (17) x ,15 (18) (19) INSOLVFIVT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Complete Address: ST~~'3~ G¢RESS Wynne Manor B 310 Carlisle, PA 17013 CITY STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) _0_ 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (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. 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. Enter the total of Line 5 + 5A This is the BALANCE DUE. (5B) -0- Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN TFIE 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, 1962, did decedent transfer property within one year of death without receiving adequate cansideration? ........................................................................................................ ...... ^ 3. Did decedent own an 'in trust for or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETUf2N, UnCer penaAes of pe ' , I declare at I have examined ttws return, including acconpanying schedules and statements, and to the best of my Icwwledge and bebef, d is true, correct and complete. Declaration of rer er Ih a personal representative is based on aq information ar which preparer has arty knowkdce. SIGNA R ESPONSIBLE FOR FILING RETURN BgATE S/~~~o 3 ~ ~,~D ~ 7iv,-, b~e~- ~c~s-e- ,C~ ~'~ ~-,-, ~ c<s ~ u v~ i°.9 / 70.0 SIGNA~1 E OF PREPARER O~fE~R~tif1N-IESENTATIVE _ .DATE .....,,.. ~ I<~/ f /a S ADDR S T~-~ 4431 N. Front St., 3rd F r, Harrisburg, PA 17110 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) (~). 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 ezemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and Bing a tax return are still applicable even rf 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 I`cr the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2}j. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefiaaries is 4,5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1}j. The tax rate imposed on the net value of Vansfers to or for the use of the decedent's siblings is 12% (72 P.S. §9116(a)(1.3)i. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ~~~ SCHEDULE E COMAIONWEALTHOFPENNSnVANIA CASH, BANK DEPOSITS, ~ MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIOEN7 QECEOENT ESTATE OF FILE NUMBER STEVEN J. GROSSMAN 2002-00706 Include the proceeds of litigation and the dale the proceeds were received by the estate. All property jointlyowned with the right of survivorship must 6e disclosed an Schedule F. ~/AIUE AT DATE ITEtuI NUti18ER DESCRIPTION OF DEATH t. Personal property sold at auction on 9-21-02 $ 1,322.75 2. Sale of guns/bows and arrows $ 800.00 3. Sale of Fuji Discovery 17" bike $ 200.00 4. Sale of Futon $ 75.00 5. Waypoint Bank Checking Account - #100269638 $ 209.80 6. Sale of 1983 Ford Bronco for SALVAGE - $ 100.00 7. Sale of 1983 Ford Mustang $ 6,700.00 8. Final paycheck $ 2,267.99 9. 2002 Income Tax Refund $ 833.00 10. Erie Insurance Exchange -Claims on vehicle $ 359.62 11. Erie Insuraoe Exchange -claims on vehicle $ 296.56 12. Erie Insurance Group -Premium refund $ 115.00 TOTAL (Also enter on {ine 5, Recapitulation} ` = 13, 279.72 (It more space is needed, insert additional sheets of the same size} ~~ .~~~ COtr1A1pN5NEALTH OF PENNSYl.VANU INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF - FfLE NUMBER STEVEN J. GROSSMAN ?nn~_nn7n~ Debts of decedent must be reported on Schedule 1. ITEM AMOUNT NUMBER DESCRIPTION A. FUNERAL EXPENSES: ~. Neill Funeral Home, Inc. 4,598.60 2. Gingrich Memorials and Headstone 1,400.00 3. Luncheon after F~meral -Snapper's Bar & Grill 497.25 4. Flowerama 44.48 ~, ADMINISTRATIVE COSTS: ~ - Personal Representative s Commissions Name of Personal Representative (s) Social Security Number(s) ! EtN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2 Attorney Fees Srtu-9e1, Anderson & Sacks 5, 000.00 3, family EzempGon: (N decedent s address i5 not the same as daimant s, attach explanation) Claimant NSA SUeel Address City Slate Tp Relationsfiip of Claimant to Decedent 4 Probate Fees - Ctunberland County (~ourt HOtLSe Reglste:C of Wills 55.50 5 Accountants Fees - GreellWdlt & Company 100.00 6 Tax Return Preparers Fees ~, Advertising Expense -Auction and sale of Mustang $ 152.30 8. Auctioneer's Commission $ 198.41 9. Advertising Expense -Legal Ad $ 191.48 10. Appraisal Fee -Apartment and Personalty $ 100.00 11. PA Dept. of Transportation -Duplicate Title FeE~ $ 22.50 TOTAL (Also enter an line 9, Recapitulation) S 12, 360.52 SCHEDULE H FUNERAL EXPENSES 8 ADMINISTRATIVE COSTS If more space is needed, insert additional sheets of the same :size) aei-su Ec • u.,n m COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, $ l DESCRIPTION FILE NUMBER 2002-00706 AMOUNT • PP&L (Electric bill) $ 96.97 2. Lisa Neidig -Reimbursement for car stereo $ 157.38 3. Sprint (Telephone bill) $ 98.90 4. US Healthworks -Medical Records $ 4.50 5. Omega Medical Labs $ 48.00 6. Mullens Towing & Recovery (1983 Ford Bronco) ~ $ 100.00 7. Post Office box rental fee $ 19.00 8. Commonwealth of PA (accident report) $ 8.00 9. Heckendorn's Auto Body Re: Mustang repairs and deductible) $ 576.43 10. Ford Mustang inspection, maintenance, towing & registration $ 184.44 11. Postage and photocopies $ 30.54 12. CTCB - 2002 Local Income Tax payment $ 63.05 13. Progressive Insurance on Mustang $ 45.00 STF`VEN J. GROSSMAN Include unreimbursed medical expenses. ITEM NUMBER 1 TOTAL (Also enter on tine 10, Recapitulation) ~ s 1 , 432.21 (If more space is needed, insert additional sheets of the same size) • RkV-4UEa •tl'9.1 (~ COMMONWEALTH OF PENNSYLVANIA WHERITANCE TAX RETURN RESIDE?t7 DECEDENT SCHEDULE) BENEFICIARIES ESTATE OF F1LE NUMBER ~'I'EVIIJ J. GRQSSMAN 2002-00706 RELATION:>HIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECENING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS (uidude outright spousal distributions) 1. Jessica GYosstttan Daughter 100$ c/o 1504 Timber Chase Drive Mechanicsburg, PA 17055 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II• NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II • ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 15~~0 COVER SHEET I s (If more space is needed, insert additional sheets of the same si~:e) AUCTION SETTLEMENT SHEET Settlement for: Steven J. Grossman Estate Total prnceeds from the sale of personal property Ezpenses: Commission of 15•/. on total gross sales $198.41 Advertising: $132.30 Rentals Total Ezpenses Total Due Seller Date of Settlement: 09-24-02 Escrow Check #: o~Q~~.S S. Brian 1V~agaro ~~~ ~~~ EnoL, PA. 17025-1912 717.732.790 Sellers Signature: $ NC 5330.71 Thank you for the opportunity to serve you and your auction needs. Brian Ma o Auctioneer ~ ` Sak Date: 09-21-02 $1322.75 <$330.71 $992.04 J -_ ~ I ~ A Wa o~nt © yP BANK LOOK i=OR US. WE'lt GET YOU THERE. 09~'03l2002 SMIGEL ANDERSON & SACKKS X31 N FRONT ST 1-L4RRISBURG PA 17110-1709 The information which you requested on the account(s) of STEVEN GROSSMAN~ ;Social Security Number 202-46-6723) islare as follows: account Number 100269638 Class of Account CHECKING Date Opened llrorol Principal Balance 209.80 accrued Interest _ 3alance at Date of 209.80 Death -account Ownership SOLE dame of Joint Dwner, if any Date Ownership Was Established account Number lass of Account Date Opened ?rincipal Balance Accrued Interest balance at Date of Death Account Ownership - '~ame of Joint Jwner, if any Date Ownership ryas Established additional Stn rely, .nformation requested ? KA Y UN SENIOR SERVICES REP. P.O. BOX 1711. HARRISBURG. PENNSriVANIA 17105-1711 ~! - GEC -°2' COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. IZS0601 HARRISI3URG, PA 171zs-DbDl NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX pFF [01-03) DATE 1.1-24-2003 ESTATE OF GROSSMAN STEVEN J DATE OF DEATH 07-22-2002 FILE NUMBER 2'1 02-0706 - COUNTY CUMBERLAND HEATHER D ROYER ESQ ACN 101 SMIGEL ETAL Amount Remitted 4431 N FRONT ST 3RD F HBG PA 17110 MAKE CHECK PAYADLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HDUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS -~ REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT' OF TAX ESTATE OF GROSSMAN STEVEN J FILE N0. 21 02-0706 AI:N 101 DATE 11-24-2003 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 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4l .00 of this form with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 13,279.72 tax payment. 6. Jointly Owned Property (Schedule F) (6) .0 0 7. Transfers (Schedule Gl (7) .00 8. Total Assets (g) 13,279.72 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 12,360.52 10. Debts/Mortgage Liabilities/Liens (Schedule Il (10) 1,432.21 11. Total Deductions (11) ~ .79 .7 12. Net Value of Tax Return (1P) 513.01- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) •0 0 14. Net Value of Estate Subject to Tax (l4) 513.01- NOTE: if an assessment was issued previously, lines 14, 15 and~~or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) •00 X 00 = .00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) .00 X 045 . .00 17. Amount of Line 14 at Sibling rate (17) .00 X 12 - .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 - .00 19. Principal Tax Due t19)= .00 TeY f_RFTITTC~ DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE; .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE t IF TOTAL DUE IS LESS THAN 51,, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" [CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RESERVATION: Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class 8 Ccollateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right tc appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. PURPOSE OF NOTICE: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.S. Section 9140). PAYMENT: Detach the top portion of this Notice and submit with your payment to the Register of Wills printed an the reverse side. --Make check ar money order payable to: REGISTER OF NILLS, AGENT REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office of the Register of Wills, any of the 23 Revenue District Offices, or by calling the special 24-hour answering service for forms ordering: 1-800-362-2050; services for taxpayers with special hearing and / or speaking needs: 1-800-447-3020 (TT only). OBJECTIONS: Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown an this Notice must abject within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: Factual errors discovered on this assessment should be addressed in writing ta: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Past Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent° CREV-1501) far an explanation of administratively correctable errors, DISCOUNT: If any tax due is paid within three (3l calendar months after the decedent's death, a five percent (5%) discount of the tax paid is allowed. PENALTY: The 15% tax amnesty man-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time Period as you would appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine C9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six C6%) percent par annum calculated at a daily rate of .000164. All taxes which became delinquent an and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2003 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 1982 20% .000548 1987 9% .000247 1999 7% .000192 1983 16% .000438 1988-1991 11% .000301 2000 8% .000219 1984 11% .000301 1992 9% .000247 2001 9% .000247 1985 13% .000356 1993-1994 7% .000192 2002 6% .000164 1986 10% .000274 1995-1998 9% .000247 2003 5% .000137 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. STATUS REPORT UNDER RULE 6.12 Name of Decedent: ~S 7 -6~.-'~'~ D ~' ~ 1'~- ~ ~ ~ Date of Death: d ZZ Z 6 d ~- ~~ `~' ~~~ ~ Z°d Z.-EY~•74 Will No.: /U Admin. No.: ~' i,C7 ~ '' (~O ]~ (,o Pursuant to Rule 6.12 of the Supreme Court Orphans' Court F:ules, I report the following with respect to completion of the administration of the above-captioned estate: 1. to whether administration of the estate is complete: Yes 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.b~d the personal representative file a final account with the Court? Yes _ No [] b. The separate Orphans' Court No. (if any) for the personal representative's account is: ~ ~ ~ ~ ~V ; ~ d ~ Z - a ~ ~ Q c. Did the personal represe alive state an account ' ormally to the parti s in interest? Yes n N °~ ~ i,r~ , `~`~ ~,~' S~ ~~~~ c. Copies of receipts, releases, joinders d approval f formal or~~~ informal accounts may be filed with Clerk of thf;. Orphans' Court and maybe attached to this report. D ate: ~ / g ! x ~ ~' ~' /'-~---..._.. afore e~SSI Cam- ~ • ~ C' o ~ rc~(~. ~. Name ~ ~ ~ ~ T; r,~,~ C~.a~-e., ~ ~ Address C'~~ ~ i7 72-~•q~6g~ Telephone No. Capacit~ Personal Representative Counsel for personal representative STATUS REPORT UNDER RULE 6.12 Steven J, Grossman Name of Decedent: Date of Death: July 22, 2002 Will No.: 2002-00706 Admin. No.. 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 ~ 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 final account with the Court? Yes _ No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes II No c. Copies of receipts, releases, joinders and approval oi° formal or informal accounts may be filed with the Clerk of the. Orphans' Court and maybe attached to this report.. Date: 2G l G =_-~ ,_ Signature rw a. ~- cv ---, o _ .,. ~ ry ..i Heather D, Royer, Esq, Name 4431 North Front St., 3rd Fl, Harrisburg, PA 17110 Address 717-234-2401 Telephone No. Capacity: Il Personal Representative Counsel for personal representative