HomeMy WebLinkAbout09-03-10Pa. O.C. Rule 6.12 STATUS REPORT
REGISTER OF WILLS OF CUMBERLAND
COUNTY, PENNSYL~JANIA
Name of Decedent: BEVERLY SAMPLE
Date of Death: FEBRUARY 9, 2009 File Number: 2109-0176
',
Pursuant to Pa. O.C. Rule 6.12, 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 :.................... ~ Y'es ®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:
c.
d.
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a. Did the personal representative file a final account with the Court? ....... ~~es ~No
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
nformaleTto they artiesnn interest? an account ....... • . • .. , • ...... , . ~y~es ~No
Y P
Copies of receipts, releases, joinders and approvals of formal or informal acco~ntS may be
filed with the Clerk of the Orphans' Court and may be attached to this report. '~
Si e ojPers Filing this Form
Capacity: QPersonal Representative Counsel
JEAN D. SEIBERT
Name of Person Filing this Form
109 LOCUST STREET
Address
HARRISBURG, PA 17141
717-236-9301
Telephone
Form RW-/0 rev. /0.13.06
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA ORPHANS' COURT DIVISION
N0.2109-0176
FIRST AND FINAL ACCOUNT
3anie A. Jackson, Executrix
For
ESTATE OF BEVERLY SAMPLE, Deceased ',
Date of Death:
Date of Appointment of Executrix:
Date of Advertisement of Letters:
The Sentinel
Cumberland Law Journal
Account Stated To:
March 26, 2009,
and
March 27, 2009,
and ~
~ 9, 2009
20, 2009
2, 2009
9, 2009
3, 2009
0, 2009
2010
I
Purpose of Account: Janie A. Jackson, Executrix, offers this account to acquaint interested
parties with the transactions that have occurred during her administration.
The account also indicates the proposed distribution of the estate.
It is important that the account be carefully examined. Requests for additional inforn~ati~n
or questions or objections can be discussed with: ',
Janie A. Jackson
6631 Conway Road
Harrisburg, PA 17111
OR
Jean D. Seibert, Esquvre
WION, ZULLI & SEIBERT
109 Locust Street
Harrisburg, PA 17101
(717) 236-9301
__ 1
SUMMARY OF ACCOUNT
Fiduciary
Current Acquisition
Page Value Value
Principal I~
63
91 ~
1
Inventory Amount 3 ,
.
$
8
Receipts subsequent to Inventory 4 9,573L53
Less Disbursements:
Debt of Decedent 5 $4,053.17
Funeral Expenses 5 329.00
Administration Expenses 6 1,672.78
Federal and State Taxes 6 7,000.00 j
Fees and Commissions 6 4,375.00
Total Disbursements $17,429.5
Principal Balance before Distribution $56,058. 6
Distribution in Kind 7 10,655. 0
$45,403. 6
Income i~
Receipts 8 $508.410
Less Disbursements 9 4446.1
$62.214
~
Combined Balance on Hand ~~
$45,466.0
2
RECEIPTS OF PRINCIPAL
Assets Listed in Inventory F'~duciary
(Value as of date of death) Acquislitic~n Value
M&T Bank Checking Account No. 9838681964 $2,989.02
Accrued Interest 0.71
&T Bank Certificate of De osit No. 31003917029538
M p 7,23.24
Accrued Interest !, 445.45
To ota
Y 10,25.00
~
Rings ~,
~, 1~~~~30.00
Income Tax Return 2008 ~1,a07.00
Federal Retirement Pension (Janie Jackson, Beneficiary gave to Estate) ', X70.70
Comcast Refund ',16.41
Rent Reimbursement I,
~ 4'41.00
Debt owed to estate for rent paid by decedent's estate for
Beneficiary, Benjamin F. Jackson after lease for decedent had ended ' 6166.65
631191'5.18
Totallnventory $
3
RECEIPTS SUBSEQUENT TO INVENTORY
North Cazolina Mutual Insurance (Janie Jackson, Beneficiary gave to Estate
Federal Group Life Insurance (Janie Jackson, Beneficiary gave to Estate
Deposit
Proceeds from sale of VA property
PA Inheritance Tax Refund
Federal Income Tax Refund
$1,176.00
6,765.81
3.78
772.14
I', 1 X3.39
', $72.41
9, .73.53
4
DISBURSEMENTS OF PRINCIPAL
Debts of Decedent
Outstanding checks from DOD balance $61.28
$20.00, 17.28 and 24.00
03-09-09 PPL 60.14
03-09-09 CAC- Ambulance 813.00
03-19-09 East Pennsboro Ambulance Service 607.20
03-17-09 West Shore EMS 558.04
03-19-09 VGM Homelink 364.50
03-20-09 Verizon 57.61
04-08-09 Travelers Car Insurance 470.00
04-03-09 The Apartment Store -Rent March 441.00
04-02-09 James Hess, CPA -Income Tax 76.00
OS-O1-09 Pinnacle Health Hospitals 360.00
OS-04-09 VGM Homelink 11.00
OS-26-09 Debbie Lupold, TC -Personal Tax 4.90
09-14-09 VGM Homelink 135.50
10-14-09 Holy Spirit Hospital 33.00
Funeral Expenses
06-08-09 Hooper Memorial
5
$329.00
$,0$3.17
$3219.00
Administration Expenses
02-15-09 Register of Wills -Probate Fee $204.00
04-03-09 The Apartment Store -April's Rent 441.00
04-30-09 Register of Wills -Short Certificates 8.00
OS-21-09 Register of Wills -Exemplified Copy of Will 40.00
OS-21-09 Cumberland Law Journal- Advertising 75.00
OS-21-09 The Sentinel- Advertising 208.78
07-09-09 Register of Wills -Exemplified Copy of Will 40.00
07-14-09 Travelers Auto Insurance 220.00
07-30-09 Penn Dot- Registration 36.00
09-25-09 Travelers Auto Insurance 225.00
11-10-09 Register of Wills -Filing Fee (WZS) 15.00
04-12-10 James Hess, CPA 85.00
08-23-10 M&T Bank Charge 5.00
Reserve to pay postage, copies, etc. 70.00
Federal and State Tax
OS-12-09 Register of Wills, Agent- $7,000.00
PA Inheritance Tax
Fees and Commissions
11-12-09 Wion, Zulli & Seibert ~/a Attorney's fee $2,187.50
Reserve to pay remaining'/2 Attorney's fee 2,187.50
Total Disbursements of Principal
Principal Balance on Hand
~1,~72.78
$~/,OI00.00
$4~37~.00
$17~72g.95
$56,p5$.76
6
DISTRIBUTIONS IN KIND
Toyota
Rings
$10,525.00
130.00
$10,655.00
7
_I
RECEIPTS OF INCOME
02-13-09 Interest on M&T Bank Checking Account No. 9838681964 $0.87
02-23-09 Interest from M&T Certificate of Deposit No. 31003917029538 482.24
03-13-09 Interest on M&T Bank Checking Account No. 9838681964 :31
03-23-09 Interest on M&T Bank Checking Account No. 9849093506 1;90
04-23-09 Interest on M&T Bank Checking Account No. 9849093506 ', 2.p1
OS-22-09 Interest on M&T Bank Checking Account No. 9849493506 2.b7
06-23-09 Interest on M&T Bank Checking Account No. 9849093506 ' 2.49
07-23-09 Interest on M&T Bank Checking Account No. 9849093506 ' 1.96
08-21-09 Interest on M&T Bank Checking Account No. 9849093506 1.90
09-23-09 Interest on M&T Bank Checking Account No. 9849093506 12. ~ S
10-23-09 Interest on M&T Bank Checking Account No. 9849093506 ',1.96
1
11-23-09 Interest on M&T Bank Checkin Account No. 9849093506
g '2.00
12-23-09 Interest on M&T Bank Checking Account No. 9849093506 '1.87
01-22-10 Interest on M&T Bank Checking Account No. 9849093506 '1.87
02-23-10 Interest on M&T Bank Checking Account No. 9849093506 0.95
03-23-10 Interest on M&T Bank Checking Account No. 9849093506 0.34
04-23-10 Interest on M&T Bank Checking Account No. 9849093506 10.3!9
OS-21-10 Interest on M&T Bank Checking Account No. 9849093506 p.3S
06-21-10 Interest on M&T Bank Checking Account No. 9849093506 b.4~1
07-21-10 Interest on M&T Bank Checking Account No. 9849093506 p.316
OS-23-10 Interest on M&T Bank Checking Account No. 9849093506 D.3$
Total Receipts of Income $5018.410
8
i
DISBURSEMENTS OF INCOME
02-09-09 Credit for interest accrued as of date of death on M&T
Checking Account No. 9838681964 $x.71
02-09-09 Credit for interest accrued as of date of death on M&T
Certificate of Deposit No. 31003917029538 44~.4~
$44 .116
9
PROPOSED DISTRIBUTIONS
Current Value Fiduciary
Acquisition Value
Diane Napier $9,093.20 $9,093.20
Bernice Childs 9,093.20 9,093.24
Lucy M. Jones 9,093.20 9,093.20
Benjamin F. Jackson 8,426.55 8,426.55
Debt owed to estate 666.65 666.65
Janie A. Jackson 9,093.20 9,093.20
$45,466.00 $45,466.00
10
Janie A. Jackson, Executrix of the ESTATE OF BEVERLY SAMPLE, deceased, hereby
declares under oath (penalties of perjury) that she has fully and faithfully discharged the duties
of her office; that the foregoing First and Final Account is true and correct anal fully discloses all
significant transactions occurring during the accounting period; that all known claims against the
estate have been paid in full; that, to her knowledge, there are no claims now ~ut~tanding against
the estate; and that all taxes presently due from the estate have been paid.
. ~--t
anie A. Jackson, Executrix
Subscribed and sworn to
before me this ~SR~.,,day of
~c. o ,,,~ , 2010.
Notary Pub
My
COMMp~-L7H OR PENN~~U
NOTARIAL SEAL
DEB81 SUE MIDDAUGH, Not ~PubGc
o~p r~ty
hin
City of Harri ~u ~~~ 25, 2013
Cotmn~~+
12
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
COMMONWEALTH OF PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE ESTATE OF
BEVERLY SAMPLE : N0.2109-0176
Deceased
RECEIPT AND RELEASE AGREEMENT ~I
WHEREAS, Beverly Sample died testate on February 9, 2009; and III,
WHEREAS, Janie A. Jackson was appointed as Executrix of the Estate of Bev l~ Sample
and Letters Testamentary were granted to Janie A. Jackson on February 20, 2009 by e Register of
Wills of Cumberland County, Pennsylvania; and
WHEREAS, Benjamin F. Jackson had the opportunity to examine the acco ting of the
Executrix and hereby waives any right to demand the filing of a formal court accoun ' g ~y Janie A.
Jackson and approves the acts and transactions of the Executrix in the administration f the Estate;
and I
WHEREAS, it is the desire of the parties hereto that distribution of the balanc of~' principal
and income be made without the formality of the filing of an accounting in the above- ef~renced
Court, or any other court having jurisdiction; and
WHEREAS, Janie A. Jackson is willing to make such distribution upon receip~ oi±the Release
and indemnification provided for in this Agreement.
NOW THEREFORE, KNOW ALL MEN BY THESE PRESENTS that the un er~igned
does hereby request Janie A. Jackson to make final distribution of the balance of the E ta$e without
the filing of an accounting for audit and approval by the court having jurisdiction. Th undersigned,
in consideration of the payment and delivery to her/him of the following:
To BENJANIIN F. JACKSON, the following amount: Ili,
Cash in the total amount of $8,426.55. ~!,
the receipt of which is hereby acknowledged, for herself/himself, her/his heirs, person
representatives, successors and assigns does remise, release, quit-claim and forever dis haMrge Janie
A. Jackson, individually, and as Executrix aforesaid; her successors and assigns, of an from all
actions, suits, payments, accounts, claims and demands whatsoever or by reason then f, and from
any suit, payment, claim or liability arising from the administration of the Estate, and er~by agrees
that any court having jurisdiction may by its decree dischazge Janie A. Jackson as Ex utr~x.
The undersigned further agrees to indemnify and hold harmless Janie A. Jackson, as
Executrix, from and against any and all claims, loss, liability or damage which he ma}~ suffer or to
which he/she maybe subjected by reason of the settlement of the account and the dist~ibtttion of
assets of the said Estate without approval of the court having jurisdiction. In consideration of the
distribution to the undersigned of the property described above, the undersigned agree tci pay Janie
A. Jackson, as Executrix, any amount up to the value of the property which the under 'geed received
from the Executrix as his/her bequest that may be necessary in the future to discharge ~ liabilities
of the Estate.
The undersigned further declares that it is his/her intention to be legally bound by the
execution of this Agreement and to bind his/her heirs, personal representatives, succe sops and
assigns.
IN WITNESS WHEREOF, the undersigned has hereunto set his/her hand and ~eap, this
day of ~, 2010. ',
WITNESS:
Commonwealth of Pennsylvania
County of
SS
On this _~ day of , 2010, before me, a Notary Pu lid,
personally appeared BENJAMIN F. JACK N, known to me (or satisfactorily proven) to be the
person whose name is subscribed to the within Receipt and Release Agreement and ac o~pvledged
that he/she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my d an eal.
My Commission Ex~tires:
F COMMONWEALTH OF P~ ~
NOTARIAL SEAL
DEBBI SUE MIDDAUGH, Notar
City of Harrisburg, Dauphin C
Commission Expires October
3
4
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
COMMONWEALTH OF PENNSYLVANIA
ORPHANS' COURT DIVISION
IN 'THE ESTATE OF
BEVERLY SAMPLE : N0.2109-0176
Deceased .
RECEIPT AND RELEASE AGREEMENT
WHEREAS, Beverly Sample died testate on February 9, 2009; and
WHEREAS, Janie A. Jackson was appointed as Executrix of the Estate of Bev ly Sample
and Letters Testamentary were granted to Janie A. Jackson on February 20, 2009 by th~Register of
Wills of Cumberland County, Pennsylvania; and ',
WHEREAS, Diane Napier had the opportunity to examine the accounting of th Executrix
and hereby waives any right to demand the filing of a formal court accounting by Janie .Jackson
and approves the acts and transactions of the Executrix in the administration of the Es e;'and
WHEREAS, it is the desire of the parties hereto that distribution of the balance ~ f principal
and income be made without the formality of the filing of an accounting in the above-re~fer~nced
Court, or any other court having jurisdiction; and
WHEREAS, Janie A. Jackson is willing to make such distribution upon receipt ~f tie Release
and indemnification provided for in this Agreement.
NOW THEREFORE KNOW ALL MEN BY THESE PRESENTS that the and si ed
does hereby request Janie A. Jackson to make final distribution of the balance of the Est te' without
the filing of an accounting for audit and approval by the court having jurisdiction. The dlersigned,
in consideration of the payment and delivery to her/him of the following:
To DIANE NAPIER, the following amount:
Cash in the total amount of $9,093.20.
the receipt of which is hereby acknowledged, for herselflhimself, her/his heirs, personal
representatives, successors and assigns does remise, release, quit-claim and forever disc az~e Janie
A. Jackson, individually, and as Executrix aforesaid; her successors and assigns, of and orn all
actions, suits, payments, accounts, claims and demands whatsoever or by reason thereof,!, and from
any suit, payment, claim or liability arising from the administration of the Estate, and he~eb~ agrees
that any court having jurisdiction may by its decree dischazge Janie A. Jackson as Executrix.
The undersigned further agrees to indemnify and hold harmless Janie A. Jackson, as
Executrix, from and against any and all claims, loss, liability or damage which he may Suffer or to
which helshe maybe subjected by reason of the settlement of the account and the distribution of
assets of the said Estate without approval of the court having jurisdiction. In consideration of the
distribution to the undersigned of the property described above, the undersigned agrees',to ay Janie
A. Jackson, as Executrix, any amount up to the value of the property which the undersi ~d received
the Executrix as his/hex b uest that ma be necessary in the future to discharge ay $iabilities
from eQ y
of the Estate.
The undersigned further declares that it is his/her intention to be legally bound l~y the
execution of this Agreement and to bindhis/her heirs, personal representatives, success rs and
assigns.
IN WITNESS WHEREOF, the undersigned has hereunto set his/her hand and seal this
__~____-day of _~ 2010. '~
WITNESS:
Commonwealth of Pennsylvania
SS
County of ,
On this ~ day of 2010, before me, a Notary Pu lia,
personally appeared DIANE NAPIER, kno to me (or satisfactorily proven) to be the er~on
whose name is subscribed to the within Receipt and Release Agreement and acknowled ed that
he/she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I herE
NOTARIAL SEAL
DEBBI SUE MIDDAUGH, Notary F
City of Harrisburg, DauPh~ C ~ui
Jh Comrtxssion Ex~es October ~
My Commission Expires: ',
__ _ __
_ _ - - r
._J
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
COMMONWEALTH OF PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE ESTATE OF .
BEVERLY SAMPLE : N0.2109-0176
Deceased
RECEIPT AND RELEASE AGREEMENT
WHEREAS, Beverly Sample died testate on February 9, 2009; and
WHEREAS, Janie A. Jackson was appointed as Executrix of the Estate of Beve~ly i5ample
and Letters Testamentary were granted to Janie A. Jackson on February 20, 2009 by the Register of
Wills of Cumberland County, Pennsylvania; and
WHEREAS, Janie A. Jackson had the opportunity to examine the accounting o the
Executrix and hereby waives any right to demand the filing of a formal court accountin b}~ Janie A.
Jackson and approves the acts and transactions of the Executrix in the administration of the Estate;
and
WHEREAS, it is the desire of the parties hereto that distribution of the balance f principal
made without the formali of the filin of an accountin in the above-re~er~nced
and income be ty g g
Court, or any other court having jurisdiction; and
WHEREAS, Janie A. Jackson is willing to make such distribution upon receipt c~f tie Release
and indemnification provided for in this Agreement.
NOW THEREFORE, KNOW ALL MEN BY THESE PRESENTS that the and
does hereby request Janie A. Jackson to make final distribution of the balance of the E:
the filing of an accounting for audit and approval by the court having jurisdiction. The
in consideration of the payment and delivery to her/him of the following:
To JANIE A. JACKSON, the following amount:
Cash in the total amount of $9,093.20,
the receipt of which is hereby acknowledged, for herselflhimself, her/his heirs, personal ~~',
representatives, successors and assigns does remise, release, quit-claim and forever disc are Janie
A. Jackson, individually, and as Executrix aforesaid; her successors and assigns, of and r4i all
actions, suits, payments, accounts, claims and demands whatsoever or by reason thereof,'an~i from
any suit, payment, claim or liability arising from the administration of the Estate, and hereby agrees
that any court having jurisdiction may by its decree discharge Janie A. 3ackson as Execut'~ix
The undersigned further agrees to indemnify and hold harmless Janie A. Jacksom, as
Executrix, from and against any and all claims, loss, liability or damage which he may ~ui~'er or to
which he/she maybe subjected by reason of the settlement of the account and the distribution of
assets of the said Estate without approval of the court having jurisdiction. In consideration of the
distribution to the undersigned of the property described above, the undersigned agrees to pay Janie
A. Jackson, as Executrix, any amount up to the value of the property which the undersi e~i received
from the Executrix ashis/her bequest that may be necessary in the future to discharge y liabilities
of the Estate. '~
The undersigned further declares that it is his/her intention to be legally bound b the
execution of this Agreement and to bind his/her heirs, personal representatives, success rs'and
assigns.
IN WITNESS WHEREOF, the undersigned has hereunto set his/her hand and sal this
~r~day of 2010.
WITNESS:
~~
Janie A. Jackson
Commonwealth of Pennsylvania
SS
County of Dauphin
On this ~ ~ day of , 2010, before me, a Notary Pu1bli ,
personally appeared JANIE A. JACKSON, own to me (or satisfactorily proven) to b thl~e person
whose name is subscribed to the within Receipt and Release Agreement and acknowl gel that
he/she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my and and seal.
Notary Publi
My Commission Expires:
NOTARIAL L
DEBBI SUE MIDDAUG , N tary PutS~
Cite of Harrisburg, D i County
Rv Commission Expires r 25, 1
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
COMMONWEALTH OF PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE ESTATE OF
BEVERLY SAMPLE : N0.2109-0176
Deceased
RECEIPT AND RELEASE AGREEMENT
WHEREAS, Beverly Sample died testate on February 9, 2009; and
WHEREAS, Janie A. Jackson was appointed as Executrix of the Estate of Bev ly Sample
and Letters Testamentary were granted to Janie A. Jackson on February 20, 2009 by th Register of
Wills of Cumberland County, Pennsylvania; and
WHEREAS, Lucy M. Jones had the opportunity to examine the accounting of th$ Executrix
and hereby waives any right to demand the filing of a formal court accounting by Jam~A. Jackson
and approves the acts and transactions of the Executrix in the administration of the Est to and
WHEREAS, it is the desire of the parties hereto that distribution of the balanced oflprincipal
and income be made without the formality of the filing of an accounting in the above-referenced
Court, or any other court having jurisdiction; and
WHEREAS, Janie A. Jackson is willing to make such distribution upon receip~ of the Release
and indemnification provided for in this Agreement.
NOW THEREFORE, KNOW ALL MEN BY THESE PRESENTS that the un er~igned
does hereby request Janie A. Jackson to make final distribution of the balance of the E~ta~e without
the filing of an accounting for audit and approval by the court having jurisdiction. Th~ undersigned,
in consideration of the payment and delivery to her/him of the following:
To LUCY M. JONES, the following amount:
Cash in the total amount of $9,093.20.
the receipt of which is hereby acknowledged, for herself/himself, her/his heirs, personal
representatives, successors and assigns does remise, release, quit-claim and forever dis~h~rge Janie
A. Jackson, individually, and as Executrix aforesaid; her successors and assigns, of an from all
actions, suits, payments, accounts, claims and demands whatsoever or by reason thereq'f, ~nd from
any suit, payment, claim or liability arising from the administration of the Estate, and herby agrees
that any court having jurisdiction may by its decree discharge Janie A. Jackson as Exe~utr~iac.
The undersigned further agrees to indemnify and hold harmless Janie A. Jacksan, as
Executrix, from and against any and all claims, loss, liability or damage which he may suer or to
which he/she maybe subjected by reason of the settlement of the account and the distr~,bution of
assets of the said Estate without approval of the court having jurisdiction. In consideraltion of the
distribution to the undersigned of the property described above, the undersigned agreed to spay Janie
A. Jackson, as Executrix, any amount up to the value of the property which the undersilgn~d received
from the Executrix as his/her bequest that maybe necessary in the future to discharge a~ny~~,liabilities
of the Estate. '
The undersigned further declazes that it is his/her intention to be legally bound ~y the
execution of this Agreement and to bind his/her heirs, personal representatives, succes$or$ and
assigns. ';
I
IN WITNESS WHEREOF, the undersigned has hereunto set his/her hand and sjeal', this
Z~ day of /4'y ~ , , 2010. '
SS:
Lucy M. nes
Commonwealth of Virginia
SS
County of ~~~5~`~'c n,s c--
On this Z b day of ~ ~ 5 , 2010, before me, a Notary lid,
personally appeazed LUCY M. JONES, known to me (or satisfactorily proven) to be th person
whose name is subscribed to the within Receipt and Release Agreement and acknowl ged that
he/she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and seal.
\``~aUUUU~rlgq~i t`
```~~` MATr~ ~i,,~ ~
\~ ..~:~ COMM~~Iy~~``9~~ ~ Notary Public
~ <~~~ a; N
'L•~ ~~ ~'
o~o~ ~~~UUU ~ My Commission Expires: c~ ., a 'Z-ot
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
. COMMONWEALTH OF PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE ESTATE OF
BEVERLY SAMPLE : N0.2109-0176
Deceased ''
RECEIPT AND RELEASE AGREEMENT
WHEREAS, Beverly Sample died testate on Februazy 9, 2009; and
WHEREAS, Janie A. Jackson was appointed as Executrix of the Estate of B~
and Letters Testamentary were granted to Janie A. Jackson on February 20, 2009 by
Wills of Cumberland County, Pennsylvania; and
,ly Sample
Register of
WHEREAS, Bernice Childs had the opportunity to examine the accounting of e~Executrix
and hereby waives any right to demand the filing of a formal court accounting by Janie .Jackson
and approves the acts and transactions of the Executrix in the administration of the Est te; and
WHEREAS, it is the desire of the parties hereto that distribution of the balance
and income be made without the formality of the filing of an accounting in the above-r
Court, or any other court having jurisdiction; and ~ .
WHEREAS, Janie A. Jackson is willing to make such distribution upon receipt ~f tihe Release
and indemnification provided for in this Agreement.
NOW THEREFORE, KNOW ALL MEN BY THESE PRESENTS that the and signed
does hereby request Janie A. Jackson to make final distribution of the balance of the Es ate without
the filing of an accounting for audit and approval by the court having jurisdiction. The ndersigned
in consideration of the payment and delivery to her/him of the following:
To BERNICE CHILDS, the following amount:
Cash in the total amount of $9,093.20.
the receipt of which is hereby acknowledged, for herself/himself, her/his heirs, personal
representatives, successors and assigns does remise, release, quit-claim and forever disc ge Janie
A. Jackson, individually, and as Executrix aforesaid; her successors and assigns, of and o~n all
actions, suits, payments, accounts, claims and demands whatsoever or by reason thereo aid from
any suit, payment, claim or liability arising from the administration of the Estate, and h eb,~y agrees
that any court having jurisdiction may by its decree dischazge Janie A. Jackson as Exec tri*.
The undersigned further agrees to indemnify and hold harmless Janie A. Jackson, as
Executrix, from and against any and all claims, loss, liability or damage which he may duffer or to
which helshe may be subjected by reason of the settlement of the account and the distrit~ution of
assets of the said Estate without approval of the court having jurisdiction. In consideration of the
distribution to the undersigned of the property described above, the undersigned agrees o pay Janie
A. Jackson, as Executrix, any amount up to the value of the property which the undersi ed received
from the Executrix as his/her bequest that maybe necessary in the future to discharge y liabilities
of the Estate. ~ ~
The undersigned further declares that it is his/her intention to be legally bound b~ the
execution of this Agreement and to bind his/her heirs, personal representatives, success rs and
assigns. 'i
~jWITNESS THEREOF, the undersigned has hereunto set his/her hand and se~l xhis
~~=~~'" day of 7~j- C~ ~ (~ ~7`^ , 2010.
SS:
....-
d I
i
ernice Childs
State of Maryland .
SS
County of
On this ay of 6 , 2010, before me, a Notary lic,
personally appeazed BERNICE C DS, known to me (or satisfactorily proven) to be a person
whose name is subscribed to the within Receipt and Release Agreement and acknowl geci that
he/she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my d and seal.f~~ ', ~--~
Y~
otary Public
M Commission Ex Tres: I~ ,/ c~
y p /j, ~O ~~---- ~--L~ / r~