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HomeMy WebLinkAbout07-15-10 (2) REV 1737-1 EX + (6-08) ~ pennsylvania NONRESIDENT DECEDENT DEPARTMENT OF REVENUE AFFIDAVIT OF DOMICILE PO BOX z8o6oi HARRISBURG, PA 1128-0601 This affidavit must be completed and sworn to by a person having personal knowledge of these facts, preferably by a surviving spouse or member of the decedent's family. Name of Decedent Date of Death Joseph A. Cuccarese 01 /15/2010 Legal Address at Time of Death: Street Address CityBorough State ZIP Code 2362 Country Lane Poland OH 44514 The following information is submitted in support of the statement that the above individual was not domiciled in the Commonwealth of Pennsylvania at the date of death. 9. Names and addresses of the decedent's surviving spouse and members of hislher immediate family: Name and Relationship to Decedent Victoria E. Cuccarese -Wife Street Address City/Borough State ZIP Code 2362 Country Lane Poland OH 44514 Name and Relationship to Decedent Caren Purcell -Daughter Street Address CityJBorough State ZIP Code 2082 Knollwood Street Poland OH 44514 Name and Relationship to Decedent Carla Patti -Daughter Street Address City/Borough State ZIP Code 219 Clingan Road Struthers OH 44471 2. Did the decedent ever live in Pennsylvania? (8[ Yes ^ No If yes, during what periods? From 2004 to date of death Decedent maintained a townhome in Penn~lvania solel~_for use durin~~the work week __ 3. Did the decedent spend time in Pennsylvania during the five years preceding death ? ~ Yes ^ No If yes, during what periods and at what address(es)? ~..,,, Decedent owned a townhome at 4085 Darius Drive, Enola PA 17025 since 2004 ~ -~ . ~ ~'~' ~ ~~ ~ '` 4. What was the nature of decedent's place(s) of residence during the five years immediately preceding death? = ~; =.'~- cat ~ = Indicate whether decedent resided in a house or apartment and whether it was rented or owned by the decedent, and/or whet~;eF~sc~edent r~sided i~i,~ F y.a hotel or the home of relatives or friends. -; ~-~~ T.~ , ~ ' ~~:.; Decedent owned the townhome ~ ~ - ~ r.~ %= ~-:- - _ Y .~- ~ , ~PD 5. Was the decedent employed during the five years preceding death? ~ Yes ^ No If yes, list the name(s) and address(es) of employer(s). Rite Aid Corporation 30 Hunter Lane, Camp Hill, PA 17001 6. Did the decedent leave a wi!!? Rli Yes ^ No If yes, state the court that admitted the will to probate and the date admitted, and attach a copy (including all codicils} arnd a certificate of issuance of letters testamentary. Admitted in Cumberland County on June 22, 2010. Will and Short Certificate attached 7. If the decedent did not leave a will, has an administrator of the estate been appointed? ^ Yes ^ No If yes, state the court that appointed the administrator and the date of appointment, and attach a certificate of the issuance ot` letters of administration. 8. At any time during the last five years did the decedent execute a will, codicil, trust indenture, deed, mortgage, lease or any other document in which the decedent was described as a resident of Pennsylvania? ^ Yes >t1 No If yes, describe such document. NONRESIDENT DECEDENT AFFIDAVIT OF DOMICILE (continued) Page 2 9. Did the decedent pay a tax on income or on intangible praperty to any state, county or municipality during the last five years? If yes, where and when was it paid? ~ Yes ^ No Federal, state and local taxes paid in Ohio. Copies of last tax return attached. 10. To what regional office of the Internal Revenue Service did the decedent forward his federal income tax returns during the last five years preceding death? Kansas City, MO 64999-0002 11. At the time of death, did the decedent own, individually or jointly, any interest in real property, including lease-holds, or tangible personal property located in Pennsylvania? ¢~ Yes ^ No If yes, describe the property in detail. 4085 Darius Road, Enole PA 17025, which is the townhome identified above 12. In what business activities was the decedent engaged during the last five years preceding death? Indicate whether decedent was employed or otherwise engaged in the business, and state the names and the addresses of the persons, firms or corpora- tions with which the decedent had such business affiliations (Except for employer listed in #5). None 13. What is the estimated gross value of the decedent's estate, exclusive of real property and tangible property located outside of Pennsylvania? $165,000.00, consisitng almost entirely of the above-mentioned real property 14. At the time of death, did the decedent own or operate an automobile? ~ Yes ^ No If yes, in which state was it registered? Ohoi. See copy of registration and drivers license attached, noting residence of Ohio 15. At the time of death, was the decedent a member of a church or any other organization ? j~ Yes ^ No If yes, provide the name and address of the church or any other organization. St. Nicholas Church 764 Fifth Street, Struthers, OH 44471 16. State the purpose or reason the decedent owned real property in Pennsylvania. Decendent worked for Rite Aid Corporation, whose headquarters are located in Cumberland County. 17. Include any other information you wish to submit in support of the contention that the individual was not domiciled in Pennsylvania at the time of death. If more space is needed, use additional sheets of paper of same size. Decedent owned the real proeprty solely for use during the work week, as his job required him to be present at Rite Aid's corporate offices in Cumberland County. Decedent had no other connection to Pennsylvania. wame or rerson compietmg Attfdavit Relationship to Decedent Victoria E. Cuccarese Wife street Raaress City State ZIP Code 2362 Country Lane Poland OM 44514 Under penalties of perjury, I declare that based on my personal knowledge of the decedent, the information provided on this form is true, correct and complete. Signature of Person Completin~g°Affida/vi~t Date ~- ~ w ~ l~/~--~ ~~ 1 ~ ~~~ v ,~ 3t3£~~tt:?~t~t ~~~~~~~ ~~#1.. t, Yom. *~~ !~1~:;;EJ3;3ft# ~` P~,3F?~ PRl{~ ~r'+~. 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