HomeMy WebLinkAbout04-0640Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of
Deceased
LOIS LAVERTY
GRACE E. LAVERTY
Social Security No. 201-18-6260
(COMPLETE "A" OR "B" BELOW:)
[] A. Probate and Grant of Letters and aver that Petitioner is the Executrix named in the Last Will of the Decedent, dat,
Slale relevant circumstances, eg., renunciation, death of executor, etc
Except as follows, Decedent did not marry, was not divorced, and did not have a child bom or adopted after execution of the documents
victim of a killing and was never adjudicated incompetent: NONE
B. Grant of Letters of Administration
(d b.n.c.l.a.: pendente lite; durante absgaltia; durlulte minorilate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following
Name Relationship Residence
,'d April 6, 1988.
offered for probate; was not the
;pouse (if any) and heirs:
'
Decedent was domiciled at death in Cumberland County, Pennsylvania, with her last family or principal residence at 3002 Market Street, Camp Hill,
Pennsylvania 17011.
(list street, numbcr and municipality)
Decedent, then 77 years of age, died June 16, 2004, in Harrisburg, Dauphin County, Pennsylvania.
(Location)
Decedent at death owned property with estimated values as tbllows:
(If domiciled in PA) All personal property .................................................................................................................................. $170.000.00
(If not domiciled in PA) Personal property in Pennsylvania .............................................................................................................. $000000000
(If not domiciled in PA) Personal property in County ......................................................................................... ~ ............................... $000000000
Value of real estate in Pennsylvania ........................................................................................................................... : ............................ ~ ............................... $ 00000000
Total ..................................................................................................................................................................................... ............................... $170,000.00
Real Estate situated as lbllows: ~
Wherefbre, Petitioner respectfully requests the probate of the last Will presented with this Petition and the grant of letters in the appropriate fdrm to the undersigned:
I Signature Typed or printed name and residence
1102 Round Tree Place
Law~'enceville, NJ 08648
53864.1 6/21/04
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner above-named swears and affmm that the statements in the foregoing Petition are tree and correct to the best of the
knowledge and belief of Petitioner and that, as personal representative of the Decedent, Petitioner will well and n'uly administer the estate
according to law.
Sworn to and affirmed and subscribed
before me this ]22~q~day of
-~,=~fx.h , 2004.
Estate of Grace E. Laverty, deceased
Social Security No: 201-18-6260 Date of Death: ~~
AND NOW,,J,~ffe 2004, in consideration of the Petition on the reverse side hTer¢
having been presented before me,
on, satisfactory proof
IT IS DECREED that Letters Testamentary are hereby granted to Lois Laverty in the'above estate and that
the instrument dated April 6, 1988 described in the Petition be admitted to probate and filed of record as the last
Will of Decedent.
FEES
Letters ........................... $ '~2,3
Short Certificates..(4)... $ } '~' O0
Renunciation ................ $
Affidavit ( ) ................. $
Extramages( ) ............ $
Codicil .......................... $
JCP Fee ........................ * Iii()0
Invento~{~,~ ............. $
,,4~t'her.'...~. ........ b .......
TOTAL ................
Attorney:
I.D. No:
Address:
T~lephone:
Donn L. Snyder
06858
Penn National Insurance Tower
Two North Second Street, Seventh Floor:
Harrisburg, PA 17101
(717) 257-7552
53864.1 6/21/04
his 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 State Vital Records Office for permanent filing..,
WARNING: lt is illegal to duplicate this copy by photostat or photograph. ~_~"~<~ ~-//~)
Fee for this certificate, $2.00
No. '- - "
: H05 143 Rev. 2/87
Local Registrar
ate
NAME OF DECEDENT (First. Middle, Last)
AGE (Last Birthdey)
7 7 Yrs.
COUNTy OF DEATH
>hin
3002 Market Street
Camp Hill, PA 17011
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
SEX SOCIAL SECURITY NUMBER
Grace E. Laverty Female a. 201 - 18 -
DATE OF BIRTH
BIRTHPLACE (City ~
(Month, Day, Year) State or Foreign Country)
7-10-1926 r. Harrisbm '",'~' E] ~.~., E] ~o^[~ []
CITY, BORO, TWPOFDEATH FACILITYNAME(IfnO nsitu~ioo give street and ntmlbar) WAS DECEDENT
uehanna )ice of Central Penm
)OF BUSINESS/INDUSTRY EVER IN DECEDENI<,.i EDUCATION
U.S. ARMED FORCES?
Yes[] Nol~l ~-,2) o.,~,.)5+
DECEDENTS :le ~6,
ACTUAL 17& State PA e,, 17c. r'] Yes, decedent lived in
RESIDENCE decedent --
(See instructions live in a ,
on other side) t7b. Counll~[~~ township? 17d. [] No, decadent lived ,
within actual limits of._~:~3~L~
FATHER'S NAME (First, Middle, Last)
18.
Lois Laver
BudaJ [] Cmrnati~ [:~amoval from State []
DATE OF DISPOSITION
(Month, Day.
2~,,.June 22, 2004
LICENSE NUMBER
owMOTHER'S NAME (Fi/si, Midclfe, Maiden Surname)
n Stale
~o,~'.~}O~,~2~.n.d. T_r_ee P~ace' _~I
INAMk,AN-D-A-DDRESSOFFACILITY I re
J.~.410 J0 onesE3'cm'Eo,
LICENSE NUMBER
IMMEDIATE CAUSE (Final
disease o~ condition
resulting in death) ~
Sequemiatly #st co~itions
cause. Enter UNDERLYING
CAUSE (DIsease o~ i~ury
:e and p~aca stated
person who pronounces death. (Month. Day, Year)
LcieMANNER OF DEATH
Natl.~al,1~ Homicide
Accident[]
[]
WAS CASE REFERRED TO A
Yes
PART It:!
. i
OF DEATH?
DATE OF INJURY TIME OF INJURY
(Mo~h, Day, Year)
Yes• No~
M 30C. :
[] PI~CE OF INJURY-At home farm stme factory o~
3/~.0, etc. (Spec~½) ' '
28a. 28b.
~ ~oE IRil~eFb~eatl~GJNmYv~ _ _C~A ~N (?hysiCmn ce~tdy,ng cause of death whe~ anott~ ......
.... y Kn~meage, death occurred due to the cauea nd ~na~ra~n. na~s. ~P~ron°onced death ar~ completed item 23)
~e) a ...................................................... []
'PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both ~ de
To the beat of m knov~ · deb p/uno ~g athandcartifyingtocauseofdeath
y edg , th °~curred at the th'riB' date' Ind piece, and deb to the clueea(i) and man~)ner al elated ...................... [] /t
°MEDICAL EXAMINER/CORONER
NAME AND ADDRESS DF
bi/' II~J/~/ J OATEFlLED(Month, Day, Year)
DATE OF DEATH (Month. Day, Year)
June 16 2004
Ho
Remdence [] Omer
(Sperry) ~]
(Spec~y)
White
SURVIVING SPOUSE
] to death, but
, resulting in the underlying cause given in PART I
/ OCCURRED
' CAUSE OF DEATH
twp
city/boro
L Zip Code
r PA 17109
rt ,°pfAPA17109
(Month, Day, Year)
Q91-5770134
'~ EP~E~
'~ ~ FIDUCIARY'S BOND
(For Executors and all Administrators)
Grace E Laverty
ESTATE OF ' DECEASED
CASE NO ...................................................... DOCKET .................................................. PAGE ........................
That we, Lois Laver ty
.............................................................................................................................................................. principal,
and ERIE INSURANCE COMPANY of Erie, Pennsylvania, as Surety, are held and firmly bound unto
the ....... .C..o....m~...o. ~ .~..e...a..]: .t..h.....o...~...~.e..~9.s...y..]:. y...a.~.J:..a. ...................................................................... ~ ........................
for the use of those interested in the estate, in the sum of ($ 340,000
Three Hundred Forty Thousand
.................................................................................................................................................... ............ Dollars,
to be paid to the said .......C.9...m~...o..q..~..e..a...1..t.~...9.~...~.e...n..q.s..y..1. y...a..q.~..a. ....................................................................
to which payment, well and truly to be made, we bind ourselves, jointly and severally, for and in
the whole, our heirs, executors, administrators, successors and assigns, and each and every of them,
firmly by these presents.
7 3uly
SEALED WITH OUR SEALS and dated the ........................... day of ..........................IYear) ........... 2,004
THE CONDITION OF THIS OBLIGATION IS: That if the above bounden personal representatve,
Grace E. Laverty
or any of them, of the estate of .... . ......................................... deceased,
shall well arid truly administer the estate according to law, this obligation shall be void as to those
who shall so iadminister the estate; but otherwise, it shall remain in force.
Witness to signature of surety:
ERIE INSURANCE coMPANY
By:.
$F-27
ERIE
INSURANCE
COMPANY POWER OF ATTORNEY
~oOi~W~_L_L ,I~.,NB~Y~THES,EPRE. SE. NTS.: Th,attheE. RIE INSURANCE COMPANY, acorpomtiondul o ' dander .
onwea= o. ennsy,van,a, .ocs ner. y ma e, co=rote and appoint ;he
individually, its true and lawful Attorney-in-Fact, to make, execute, seal and deliver for and on its behalf, and as its act and
deed: any and all bonds and undertakings ofsuretyship, F_~[~[ ~ A ~ ~ "I'O ~ ~ ~ OF ~ ~
~ ~ ($~00,000.00) ....... ._,. ......
An. to. bind t. e ERI INSU .CE COMPANY thereby as fully and to the same e×tent as if s.chibo ds and unde kings
and omer writings ootigatory in the nature thereof were signed by the appropriate officer of the ERIE INSURANCE COM-
PANY and sealed and attested by one other of such officers, and hereby ratifies and confirms all that it~ said Attoruey(s)-in-
Fact may do in pursuance hereof.
The Power of Attorney is granted under and by authority of the following Resolution adopted by the Board of Directors of
ERIE INSURANCE COMPANY at a meeting held on May 8, 2002 at which a quorum was presented anti said Resolution has
not been amended or repealed:
"Resolved, that the President, or any Senior Vice President or Vice President shall have power and authority to: (a) Appoint
Attomey(s)-in-Fact and to authorize them to execute on behalf of the Company, bonds and undertakings, recognizances, contracts
of in. demnity and other writings obligatory in the nature thereof, and, (b) To remove any such Attorney-in-Fact at any time and
revolce the power and authority given to him; and
Resolved, that Attomey(s)-in-Fact shall have power and authority, subject to the terms and limitations of the Power of Attorney
issued to them, to execute and deliver on behalf of the Company, bonds and undertakings, reco mzances, on
and other writings obligatory in the nature themnf m~. .............· _ ~ '. g,. i . C acts of in&nmi
................ ,,........,,s no, necessary ,or t.e va,,.ity ofa*ybt% andunde E
rags, recognizances, contract of indemnity and other writings obligatory in the nature thereof."
This Power of Attorney is signed and sealed by facsimiles under and by virtue of the following ReSolu ion adopted by the
Board of D,irectors of.ERIE .I~4SURANCE COMPANY at a meeting held on the 8th day of May, 2002, at hich a quorum was
present ana said Resolution bas not been amended or repealed ~
"Resolved, that the signature of Jeffrey A. Ludrof, as President and Chief Executive Officer of the Company, i d the Seal of the
Company may be affixed by the following facsimiles on any Limited Power of Attorney for the execution o(l~oa~s, undertakings,
recogn[za. ~.ccs.4, co, nt?.cts~nd other writings in the nature thereof, and the signature ofJ. R. Van Gorder, as Sec tary of the Com-
pany, and [ne ~eai ottbe uompany may also be affixed by the following facsimiles to any certificate of any suc~r~imited Power of
Attorney and only under such circumstances, shall said facsimiles be valid and binding ~on Ihe Company."
IN WITNESS WHEREOF, the ERIE INSURANCE COM-
PANY has caused these presents to be signed by its President
and Chief Executive Officer, and its corporate seal to be hereto
affixed this 8th day of May, 2002.
STATE OF PENNSYLVANIA }s s.
COUNTY OF ERIE
On this 8th da), of May, A.D. 2002, before me personally came
Jeffrey A. Ludrof, to me known, who being by me duly sworn,
did depose and say: that he is President and Chief Executive
Officer of ERIE INSURANCE COMPANY, the corporation de-
scribed in and which executed the above instrument; that he
knows the Seal of said corporation; that the Seal affixed to the
said instrument is such corporate Seal; that it was so affixed by
order of the Board of Directors of said corporation and that he
signed his name thereto by like order.
CERTIFICATE
I, J. R. Van Gorder, as Secretary of the ERIE INSURANCE COM-
PANY, do hereby certify that the original POWER OF ATTOR-
NEY, of which the foregoing is a full, tree and correct copy, is
still in full force and effect as of the date below.
In witness whereof I have hereunto subscribed my name and
affixed corporate S~al of the Company by facsimiles pursuant to
the action of the Board of Directors of the Company,
this day of 20
.-- ~...',~ ¢o.., o~.
_--mi 1972 ~'~--
~i~'"--. ~'~,, ~, ~ · o..'/"~.~-? Pres'dent and3~'I ~
% ......: ...... ,,," ' Chie~l~xeea°tSve O~¢¢r
{ ~IY c°mmiSS~ontaer~P~ue~l~cUn e 27.2008
,," ~, A N C ~,'"%
°%,
.'"T.."~ *o". o ~-
:mt 1972 ~-o:_
~= '.... ...' ~
~' ~ Secreta
SF-57 5/04
WILL
"T, GRACE E. LAVERTY, of the Borough of Camp Kill,
Coumt~ of Cumberland, and Commonwealth of Pennsylv,ania,
do hereby declare this to be my last Will and Testlament
and hereby revoke any and all Wills and Codicils
previously made by me.
ITEM I: I give and bequeath my mother's
diamond ring to my sister, LOIS LAVERTY, of Princeton,
New Jersey.
ITEM II: I give and bequeath the sum of Ten
Thousand ($10,000.00) Dollars to The Pine Street
Presbyterian Church, Harrisburg, Pennsylvania.
ITEM III: All the rest, residue and remainder of
my estate, of whatever nature and wherever situate at
the time of my death, I give, devise and bequeath in
equal shares to my brothers, John T. Laverty, of
Durham, North Carolina, and David Laverty, of Norwell,
Massachusetts, and to my sisters, Esther Reece (Mrs.
Frank L. Reece) of Villa Hills, Kentucky, Lois Lav~rty,
of Princeton, New Jersey, and Martha Lavertyl, of
Laurens, South Carolina, per stirpes.
ITEM IV: Ail death taxes (not income taxes) that
may be assessed in consequence of my death, of whatever
nature and by whatever jurisdiction imposed, shall be
considered a part of the expense of the administration
of my estate, and my Executrix shall have the absolute
power in her discretion to pay the same at once whether
or not the law under which they are imposed permits the
postponement of payment of all or part of them to a
later date.
ITEM V: I hereby nominate and appoint my sister,
Lois Laverty, of Princeton, New Jersey, Executrix of
this my last Will.
IN WITNESS WHEREOF, I have hereunto set hand
and seal this 6th day of April , 1988, at th~ end
hereof, composed in all of three pages, includin~ the
self-proving attestation clause and signatureis of
witnesses.
E. LAVERT~
(.SEAL)
COMMONWEALTH OF PENNSYLVANIA:
: SS:
COUNTY OF DAUPHIN:
We, Grace E. Laver ty, the Testatrix and
Dorm L. Snyder and Judith C. Flqw~rs
the witnesses, whose names are signed to ~he attached
foregoing instrument, being first duly sworn, :do hereby
declare to the undersigned authority that the: Testatrix
signed, sealed, published, acknowledged, and deClared the
instrument as her Last Will and Testament; andi that she
signed willingly and that she executed it as her free and
voluntary act for the purposes therein expressedt and that
each of the witnesses in the joint presence of each other
and in the presence and hearing of the Testatrix, signed the
instrument as witness to her Last Will and Testament; and
that to the best of their knowledge the Testatrix iwas at the
time eighteen years of age or older, was of !sound and
disposing mind, memory and understanding, and ~a~ under no
constraint or undue influence.
Grace . Laver%y, ~ra~rix
JI~ITH 12. -FLOWER,S
Subscribed, sworn to and acknowledged before mei the
undersigned officer, by Grace E. Laverty, ! the
Testatrix, and subscribed and sworn to before me by
Donn L. Snyder ~nd Judith C. FlowersI
witnesses, in the presenC~ of each othe~ thi~ 6th
day of April 1988
Notary Public
__ .P~ON~A Fo IqZLLER, ~lotary Pub1 id;:
~ ~;o~ission Expires I~OV~ber~ 21i, 1~991~
1N RE: ESTATE OF
GRACE E. LAVERTY
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DWISION
No. 21-04-0640
CERTIFICATION OF NOTICE UNDER RULE 5.6(a}
Name of'Decedent: GRACE E. LAVERTY
Date of Death: JUNE 16, 2004
To the Register:
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 beneficiaries of the above-captioned estate on July 14,
2004:
Name Address
Lois Laverty
Martha Laverty
Esther Reece
John Laverty
Mark Laverty
Thomas Laverty
Michael Laverty
Pine Street Presbyterian Church
1102 Round Tree Place, Lawrenceville, NJ 08648
2514 Ann Street, Villa Hills, KY 41017
2514 Ann Street, Villa Hills, KY 41017
1508 Sycamore Street, Durham, NC 27707
38 Freeman Drive, Plymouth, MA 02360
108 Highland Street, South Hamilton, MA 01982
35734 Montrose Court, Round Hill, VA 20141
Third and Pine Streets, Harrisburg, PA 17101
Notice has been given to all persons known to the undersigned to be entitled thereto
under Rule 5.6(a)
Donn L. Snyder, Esquire
Saul Ewing LLP
Post Office Box 1291
Harrisburg, PA 17108-1291
Attorney for Estate
NOTICE OF ESTATE ADMiNISTRATION 1N ESTATE
THIS DOES NOT MEAN THAT YOU WILL RECEIVE
ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE.
Whether you will receive any money or property will
be determined wholly or partly by the decedent's will.
............ ' b by
............. .y ............. j ·, an_la.
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In re: Estate of Grace E. Laverty, Deceased
No. 21-04-0640
TO:
Lois Laverty
Martha Laverty
Esther Reece
John Laverty
Mark Laverty
Thomas Laverty
Michael Laverty
Pine Street Presbyterian Church
Please take notice of the death of decedent and the grant of letters to the personal
representative(s) named below.
The Decedent Grace E. Laverty, died on the 16th day of June 2004, a resident of
Cumberland County, Pennsylvania.
The Decedent died testate and her Will has been filed with the Office of the Register of
Wills of Cumberland County, Carlisle, Pennsylvania. (717) 240-6100.
Personal Representation: Lois Laverty, c/o the undersigned.
Saul Ewing LLP
Post Office Box 1291
Harrisburg, PA 17108-1291
Attorney for Estate
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENTOFREVENUE
BUREAU OFINOJVlOUAL TAXES
DEPT, 280601
HARRISBURG, PA 17128-O601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 004362
SNYDER DONN L
2 NORTH SECOND ST
7TH FLOOR
HARRISBURG, PA 17101
........ ford
ESTATE INFORMATION: SSN: 201-18-6260
FiLE NUMBER: 2104- 0640
DECEDENT NAME: LAVERTY GRACE E
DATE OF PAYMENT: 09/10/2004
POSTMARK DATE: 09/10/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 06/16/2004
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $20,000.00
REMARKS:
TOTAL AMOUNT PAID:
~20,000.00
SEAL
CHECK# 1008
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPI 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Z LAVERTY, GRACE E
LU -
t't DATE OF DEATH (MM-DB*YEAR) ~H
UJ (MM-DB-YEAR)
O 06-16-2004 I 07-10-1926
LLI (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST. AND MIDDLE iNITiAL)
N/A
[~ I onginatRetum ~ 2 SupplementetRetum
OFFICIAL USE ONLY
FILE NUMBER
21 04 064 0
SOCIAL SECURITY NUMBER
201-18-6260
THIS RE~RN MUST BE FILED IN DUPLICATE W~TH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
[] 6 DecedentDiedTestate(Ar~achcopyorW~ll) [] 7 DecedentMaintaineqaLiwhgTruat/A~achcopyCTrust)
~] 9 LrtJgatJon Proceeds Received [] 10 SpousaIPovertyCredit(dateofde~thbet~een12.31.gf ~,d1495)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX
5 Federal Estate Tax Return Required
8 Total Number of Safe Deposit Boxes
11. Election to tax under Sec 9113(A)
NAME
DONN L SNYDER,
SAUL EWING LLP
TELEPHONENUMBBR
717.257.7552
ESQUIRE
INFORMATION SHOULD BE DIRECTED TO:
COMPLETE MNLING ADDRESS
P.O. BOX 1291
HARRISBURG, PA 17108-1291
z
1 Real Estate (Schedule A) (1)
2 Stocks and Bonds (Schedule B) (2)
3. Closely Herd Corporation. Partnership or Sole-Proprietorship (3)
4 Mortgages & Nates Receivable (Schedate D) (4)
5 Cesh. Bank Deposits & Miscellaneous PersonaJ Properly (5)
(Schedate E)
6. JointJ¥ Owned Properly (Schedule F) (6)
[] Separate Billing Requested
7 inter-Vivos Transfers & Miscellaneous Non-Predate Properly (7)
(Schequle G or L)
8 Total Gross Assets (total Lines 1 - 7)
9 Funeral Expenses & Administrative Costs (ScheduJe H) (9)
10 Debts of Decedent, Mortgage Liabilities, & Liens (Schedate i) (10)
11 Total DeducBo~s (totat Lines 9 & 10)
12 Net Value of Estate (Line 8 minus Line 11)
13 Char~ble and Governmental Bequests/Sec 9113 TnJsts for which a~ election to tax has not been
made (Schedule J)
14 Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS FOR APPUCABLE RATES
0.00
178,881.53
13, 774.59
10,294.50
OFFICIAL USE ONLY
(8) 202,950.62
27,701.21
1,782.49
¢1) 29,483 .70
(12) 173,466. 92
(13) 10 000 00
(14) 163,466.92
15 Amount of Line 14 taxable at the spousat tax
rater o¢ tranafers under Sec 9116 (a)(12) (15)
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
19 Tax Due
(19)
20. ~ [CHECK HEREiFYOUARE REQUESTING AREFUND OFAN OVERPAYMENT1
XO
130,773.53 ×12
32,693.39 × 15
· > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
15,692.82
4,904.01
20,596.83
Decedent's Complete Address:
30~02 MARKET STREET
HILL
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
$. Prior Payments
C. Discount
0.00
20,000.00
1,000.00
Total Credits (A + B + C) (2)
3. Interest/Penalty if applicable
D. interest
E. Penalty
Total Interest/Penalty (B + E) (3)
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
(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.
Z;P17011
(1) 20,596.83
21,000.O0
403.17
0.00
Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred; ...................... Yes Ne
b re a n he dgh o des gna e who sba use he property transferred or its income; .................. [] [~
c. retain a reversionary interest; or .......................................... [] []
d. receivethepromiseforlifeofeitherpayments benefits or care? ..... [] []
2. If death °ccurred 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 secudty at his or her death? [] []
4. Did decedent own an Individual Redrement Account, annuity, or other non_probate property which
contains a beneficiary designation'~ .. . ....................... []
IF THE ANSWER TO ANY OF THE ABOVE QUE []
STIONS JS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under peqattJes of pe.jun4., I declare that I have examined this return, including eccornpany~ng schedules and statements, and to the best of my know~edge and belief, it is true, COfTeCt and complete
Declaration of prepare- other than the persona representative is based o~ ed info,'rnatio~ of w '
· . ~ h~ch preparer has anyknowledge
SrGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ~
ADDRESS
1102 ROUND TREE PLACE, LAWRENCEVILLE, NJ 08648
' ' URG, PA 17108-1291
DATE
1 O- /j - 04
DATE
lo->& -04
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 PS §9115 (a)(1.1)
For dates of death on or after January 1, 995. the tax rate imposed on the net value of transfers to or for the use of the survfving spouse is 0% [72 P S §9116 (a) (1 1) ii
The statute does not exemp a ransfer to a surviving spouse from tax. and the statutory requirements for disclosure of assets and filing a tax reture a~e ~till applicaN~ ev(~]'
f he surviving spouse is th~ only beneficiary.
For dates of death on or after July 1. 2000:
The tax rate imposed on the net value of transfers fTom 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 PS. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiades is 4.5%. except as noted in 72 P.& §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,
indiv]dua~ who has at least one parent in common with the decedent, whether by blood or adoption·as an
STF PA42021F 2
ESTATE OF
GRACE E. LAVERTY
All property jointly-owned with the right of survivomhip must be disclosed on Schedule R
FILE NUMBER
21-04-0640
ITEM
NUMBER
DESCRIPTION
AHERICAN EXPRESS FINANCIAL
AXP HIGH YIELD TAX EXEPT FUND -
24,931.804 SHARES @ $4.45
AMERICAN EXPRESS FINANCIAL
FIXED RETIREMENT ANNUITY
CLASS A
TOTAL (Also enter on line 2, Recapitulation)
STF PA42021 F4 If more space ~s needed insed additional sheets of the same size)
VALUE AT DATE
OF DEATH
110,946.53
67,935.00
$ 178,881.53
REV 1508 EX + (1-97) (I)
SCHEDULE E
COM' 'OR ^LTHOF, ENNS',LV^.,^ CASH, BANK DEPOSITS, & MISC.
ISC.INHERITANCE mX RETURN
ESTATE OF
GRACE E. LAVERTY FILENUMBER
21-04-0640
Include the proceeds of I ftJg at Jori 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.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
NUMBER DESCRIPTION ~LUE ~ DATE
OF DEATH
1. CROWN - FG 250 GUITAR
2. LADYIS 18K YELLOW GOLD - SIX SMALL DI~MMONDS - WEIGHT 3DWT 1GR.
3. 1998 FORD CONTOUR
4. REFUND - HOSPICE OF CENTRAL PENNSYLVANIA
5. NET RECEIPT PROM AUCTION OF MISC. ITEMS OF
FURNITURE - CLAUDE C. WOLFE AND ASSOCIATES
REFUND PENN TREATY INSURANCE CO.
REFUND - DONEGAL INSURANCE CO.
REFUND - READER'S DIGEST
REFUND - AARP
REFUND - PATRIOT-NEWS
REFUND - ALLSTATE INSURANCE
THE PIANO HOUSE - USED PI~NO
GOLDEN HORIZONS - FURNITURE
REFUND - VERIZON
REFUND - GOOD HOUSE KEEPING
REFUND - COMCAST
COMMERCE BANK
150.00
400.00
3,685.00
6,900.00
1,115.48
98.36
148.00
25.82
13.68
130.05
25.00
500.00
305.00
.28
5.83
252.09
20.00
TOTAL (Also enter on line 5. Recapitulation) $ 13, 774.
STFPA42021F 9 (If more space is needed, insert additional sheets of the same size)
ESTATE OF
GP~ACE E. LAVERTY FILENUMBER
21-04-0640
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVMNG JOINT TENANT(S) NAME ADORESS
RELATIONSHIP TO OECEDENT
A MARTHA p. LAVERTY
B. LOIS LAVERTY
2514 ANN STREET
VILLA HILLS, KY 41017
1102 ROUND TREE PLACE
LAWRENCEVILLE, NJ 08648
SISTER
SISTER
JOiNTLY-OWNED PROPERTY:
1. A 5/98 WAYPOINT BANK-ACCT NO. 3100005292 763.00 50% 381.5(
2. A. 8/03 WAYPOINT BANK-ACCT NO. 8978012927 1,543.00 50% 771.5{
3. B. 10/7' PA STATE EHPLOYEES CREDIT UNION 5.00 50% 2.5{
(51) SAVINGS ACCOUNT*
4. B. 10/7S PA STATE EMPLOYEES CREDIT UNION 18,278.00 50% 9,139 0C
(54) CHECKING ACCOUNT* '
*SISTER A WAS ADDED TO THESE
ACCOUNTS 6/15/04 A_ND IS THEREFORE
IGNORED FOR TAXABLE VALUES
TOT~(AlsoenteronlJne6, R~apitulation) $ 10,294.50
S TF PA42021F 10 the sam e size)
REV-1510 iX + (1-97)
COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS &
INHERITANCE TAX RETURN
FILE NUMBER
GP~ACE E. LAVERTY
21-04-0640
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
DESCRPTION OF PROPER-Y % OF
ITEM f~LUOE TF~ NAM E OF '[HF TRANSFEREE P~IR RELATIONSHIP TO DECEDENT AND THE BArE DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUF
NUMBER OF TRANSFER ATTACH A COPY OF TFL DEED FOR REAL ESTATE VALUE OF ASSET INTEREST (rF APFtlCAgLE
1 SEE ITEMS 3 AND 4, SCHEDULE F
TOTAL (A~so enter on line 7, Recapitulation) $
STF PA42021 F11 leets of the same size)
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & /
INHERITANC£ TAX aETURN ADMINISTRATIVE COSTS ~
FILE NUMBER
GP=ACE E. LAVERTY 21-04-0640
B
1.
ITEM
NUMBER
FUNERAL EXPENSES:
1.
8.
9.
DESCRIPTION
ADMINISTRATIVE COSTS:
Pereeqal RepresenattJve's Commissions
NameofPersonalReprese~tatJve(s) LOIS LAVERTY
Social Security Number(s) / EIN Number of Personal Representative(s)
StreatAddress 1102 ROUND TREE PLACE
city ~LAWRENCEVI LLE State NJ
Year(s) Commission Paid: 2004
Attorney Fees - SAUL EWING LLP
Fatally Exemption: (if decedent's address is not the same as claimant's, air ach explanation)
Claimant MARTHA LAVERTY
Zips08648
StreetAddress 3002 MARKET STREET
City CAMP HILL
Relationship of Claimant to Oeced~t SISTER
State PA Zip 17011
Probate Fees
Tax Return PrepareCs Fees
ERIE INSUN3LNCE BOND FOR EXECUTOR
STATE EMPLOYEES RETIREMENT SYSTEM REIMBURSEMENT FOR MONTHLY PAYMENT
LOIS LAVERTY - REIMBURSEMENT FOR MILEAGE & TOLLS
LOIS LAVERTY - REIMBURSEMENT FOR MINISTER & SINGER
LOIS LAVERTY - REIMBURSEMENT FOR FAMILY LUNCH
LOIS LAVERTY - REIMBURSEMENT FOR MILEAGE & TOLLS
UGI - FINAL BILL
CUMBERLAND LAW JOURNAL - ADVERTISING
PPL ELECTRIC UTILITIES CORP. FINAL
WAGGONER, FRUTIGER, CPA - RESEARCH TAX QUESTION
SAUL EWING LLP - REIMBURSEHENT FOR COPIES, ETC.
AMOUNT
10,000.00
10,000.00
3,500.00
278.00
1,012.00
1,187.52
570.00
275.00
58.65
428.02
3.04
75.00
23.44
185.00
105.54
TOTAL (Also enter on line 9, $
(if more space is needed, insert additional sheets of the same size) 27, 701.21
STF PA42021F 12
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
EBTATE OF
GRACE E. LAVERTY
SCHEDULEI
DEBTS OF DECEDEN~
MORTGAGELIABILITIES,& LIENS
FILE NUMBER
21-04-0640
Include unreimbursed medical expense~.
ITEM
NUMBER
2.
3.
4.
5.
6.
DESCRIPTION
7/6/04
7/6/04
7/22/04 -
7/22/04
7/22/04
7/3O/O4
JANET L. MILLER - CAMP HILL PERSONAL TAX
UGI CURRENT BILL
VERIZON - FINAL BILL
PPL ELECTRIC UTILITIES CORP. CURRENT
PA STATE EMPLOYEES CREDIT UNION VISA LOAN
PINE STREET PRESBYTERIAN CHURCH - PLEDGE
AMOUNT
14.70
21.56
60.61
60.62
1,125.00
500.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, inset[ additional sheets of the same size) 1, 7 8 2 . 4 L)
STF PA42021F 13
COMMONWEALTH OF PENNSYLVANIA SCHEDULE J
FILE NUMBER
GRACE E. LAVERTY 21-04-064
NUMBER
I,
1.
2.
3
4
5.
6
?
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPE~Y
TAXABLE DISTRIBUTIONS [include outdght spousal distributions, and trans~
under Sec. 9116 (a) (1.2)]
JOHN LAVERTY
1508 SYCAMORE STREET
DURHAH, NC 27307
ESTHER LAVERTY REECE
2514 ANN STREET
VILLA HILLS, KY 41013
LOIS LAVERTY (EXECUTRIX)
1102 ROUND TREE PLACE
LAWRENCEVILLE, NJ 08648
MARTHA LAVERTY
2514 ANN STREET
VILLA HILLS, KY 41017
~ARK LAVERTY
38 FREEMAiq DRIVE
PLYHOUTH, MA 02360
THOMAS LAVERTY
108 HIGHLAND STREET
SOUTH HAHILTON, MA 01982
HICHAEL LAVERTY
35734 HONTROSE COURT
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
BROTHER
SISTER
SISTER
SISTER
NEPHEW
NEPHEW
AMOUNT OR SHARE
OFESTATE
20%
20%
20%
20%
6.67%
6.67%
H.
ROUND HILL, VA 20141 NEPHEW 6.66%
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
B.C~RI~BLEANDGOVERNMEN~LDISTRIBUTIONS
PINE STREET PRESBYTERIAN CHURCH
THIRD AND PINE STREETS
HARRISBURG, PA 17101
TOTAL OF PART 1I - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
10,000.00
10,000.00
(If more space is needed, insert additional sheets of the same size)
STF PA42021F 14
AXP High Yield Tax-Exempt Fund Confirmation
*Please read important e×planations
and d&sclosures on last pages of
confirmation.
*This transaction was executed on a principal basis directly with the Fund.
*Other information regarding the execution of the transaction including the date and
time of the transaction will be furnished upon written request.
*Settlement date is the business day following the date of the transaction.
*Prices are rounded to the nearest one tenth of a cent. Sales charge amount is
included in the price.
*Many mutual fund companies offer sales load discounts to customers that have invested
over a certain dollar amount. These discounts may be calculated based on your current
)urchase or on your aggregate holdings, and may also include the holdings of your family
or household members. To ensure that you are obtaining all available discounts, you
should talk with your broker or financial advisor, or check the fund's prospectus or
weDslte.
Total Shares - Class A 24,931.804 Divs Yr-to-Date - Class A $0.00
Value per Share - Class A $4.450 Taxes Withheld Yr-to-Date $0.00
Value of Shares - Class A $110,946.53
Dividends Accrued - Class A $0.00
Account Value $110,946.53
Advisors Inc.
(717) 441-4801 70100AXPFinanciaiCenter
Page 2 of 3
C~30OOOOO8080 08/30/2004
PSEC
the financial IinkTM
July 27, 2004
Saul Ewing, Attorneys at Law
2 North Second Street, 7th Floor
Harrisburg, PA 17101-1604
Attn: Maronetta F. Miller
Grace E. Laverty, Deceased
SS # 201-18-6260
Dear Ms. Miller:
The following are the Date of Death Balance's for Grace E. Laverty's accounts with PSECU:
Account Date of Death Balances
Savings (S 1) $5.00
Checking (S4) $18,278.29
Visa Loan (Lg) $1,125.03
paid in full July 22, 2004
The account was opened October 15, 1977. The account was held jointly with Lois Laverty
from the date the account was opened and Martha P. Laverty was added to the account on
June 15, 2004.
Enclosed is a check payable to the Estate in the amount of $408.57, the remaining funds in
the account. This account is now closed.
If you have any questions, please contact me at (717) 234-8484 or toil-free at (800) 237-
7328, then press 6, extension 3120.
Sincerely,
Suzarme E. Fahr
Account Advisor
JUL 2 8 2004
PENNSYLVANIA STATE EMPLOYEES CREDIT UNION '
Main Address: I Credit Union Place, Harrisburg, PA 17110 2990 · (717) 234-8484 . (800) 237~7328
Mailing Address; PO. Box 67013, Herr sburg, PA 17106-7013 . (717) 777-2100 (TDD) . (800) 472-1967 (TDD)
Web Address: www.psecu.com
Savings federalty insured up to $100,000 by the National Credit Union Administration.
PAY. ESTATE OF GRACE E .SAVERTy
TO THE
CASHIER'S CHECK
PA STATE EMPLOYEES CREDIT UNION
& 2~ s 2~Jl" ~,&,
7/14/2004
SAUL EWING
2 NORTH SECOND ST 7TH FLR
HARRISBURG PA 17101-1604
The information which you requested on the account(s) of GRACE E LAVERTY
(Social Security Number 201-18-6260) is/are as follows:
Account Number
Class of Account
Date Opened
Principal Balance
Accrued Interest
Balance at Date of
Death
Account Ownership
Name of Joint
Owner, if any
Date Ownership
Was Established
Account Number
Class of Account
Date Opened
Principal Balance
Accrued Interest
Balance at Date of
Death
Account Ownership
Name of Joint
Owner, if any
Date Ownership
Was Established
3100005293 8978012927
CHECKING SAVINGS
051498 080703
763.13 I542.79
0.00 .12
763.13 1542.91
JTO JTO
MARTHA P MARTHA P
LAVERTY LAVERTY
051498 080703
Additional
Information
Requested
SENIOR SERVICES REP.
P.O. Box 1711. HARRISBURG, PENNSYLVANIA 17105-1711
Toll Free I'[~66~WAYPOINT (I-866/9E9-7646) - IN YORK AREA 717/815-4500 · ~ .......... ;_~ .......
Kelley Blue Book Used Car Values Page 1 of 2
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Pennsylvania · June 30, 2004
1998 Ford Contour LX Sedan 4D
Engine: 4-Cyl. 2.0 Liter
Trans: Automatic
Drive: Front Wheel Drive
Mileage: 30,000
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Consumer Rated Condition: Good
"Good" condition means that the vehicle is free of any major defects·
The paint, body and interior have only minor (if any) blemishes, and
there are no major mechanical problems. In states where rust is a
problem, this should be very minimal, and a deduction should be
made to correct it. The tires match and have substantial tread wear
left. A clean title history is assumed. A "good" vehicle will need some
reconditioning to be sold at retail; however major reconditioning
should be deducted from the value. Most recent model cars owned by
consumers fall into this category.
Private Party Value Search Local Listings for This Car $3,685
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WILL
I, GRACE E. LAVERTY, of the Borough of Camp Hill,
County of Cumberland, and Corc~onwealth of Pennsylvania,
do hereby declare this to be my last Will and Testament
and hereby revoke any and all Wills and Codicils
previously made by me.
ITEM I: I give and bequeath my mother's
diamond ring to my sister, LOIS LAVERTY, of Princeton,
New Jersey.
ITEM II: I give and bequeath the sum of Ten
Thousand ($10,000.00) Dollars to The Pine Street
Presbyterian Church, Harrisburg, Pennsylvania.
ITEM III: Ail the rest, residue and remainder of
my estate, of whatever nature and wherever situate at
the time of my death, I give, devise and bequeath in
equal shares to my brothers, John T. Laverty, of
Durham, North Carolina, and David Laverty, of Norwell,
Massachusetts, and to my sisters, Esther Reece (Mrs.
Frank L. Reece) of Villa Hills, Kentucky, Lois Laverty,
of Princeton, New Jersey, and Martha Laverty, of
Laurens, South Carolina, per stirpes.
ITEM IV: Ail death taxes (not income taxes) that
may be assessed in consequence of my death, of whatever
nature and by whatever jurisdiction imposed, shall be
considered a part of the expense of the administration
of my estate, and my Executrix shall have the absolute
power in her discretion to pay the same at once whether
or not the law under which they are imposed permits the
postponement of payment of all or part of them to a
later date.
ITEM V: I hereby nominate
Lois Laverty, of Princeton, New
this my last Will.
and appoint my sister,
Jersey, Executrix of
IN WITNESS WHEREOF, I have hereunto set my hand
6th April
and seal this day of
, 1988, at the end
hereof, composed in all of three pages, including the
self-proving attestation clause and signatures of
witnesses.
(SEAL)
C0~I0~ EArtH OF PENNSYLVADIA:
: SS:
COUN?¥ OF DAUPH ID:
We, Grace E. Laverty, the Testatrix and
Donn L. Snyder and Judith C. Flowers
the witnesses, whose names are signed to the attached
foregoing instrument, being first duly sworn, do hereby
declare to the undersigned authority that the Testatrix
signed, sealed, published, acknowledged, and declared the
instrument as her Last Will and Testament; and that she
signed willingly and that she executed it as her free and
voluntary act for the purposes therein expressed; and that
each of the witnesses in the joint presence of each other
and in the presence and hearing of the Testatrix, signed the
instrument as witness to her Last Will and Testament; and
that to the best of their knowledge the Testatrix was at the
time eighteen years of age or older, was of sound and
disposing mind, memory and understanding, and was under no
constraint or undue influence.
Grace~. Laver%y, P~ratrix
'DO~N ~L. Sr~fD~-- ~,xtness
J~ITH C. FLOWER Witness
Subscribed, sworn to and acknowledged before me, the
undersigned officer, by Grace E. Laverty, the
Testatrix, and subscribed and sworn to before me by
Donn L. Snyder and Judith C. Flowers
~itnesses, in the presence of each other, this 6th
day of April , 1988.
Register of Wills of cu , :L, ,tDounty, Pennsylvania
INVENTORY
Estateof Grace E. Laverty No. 21-04-0640
also known as Date of Death June 16, 2004
, Deceased Social Security No. 201 - 18 - 6280
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventor,/ 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 ~nventory 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 inventoW. I/We verify that the statements made in this InventoW are true and correct. J/We understand that
false statements herein are made subject to the penalties of ;tS. Pa. C.S. Section 4904 relating to unsworn falsification to
authorities.
Name of
Attorney:
ID. No.:
Address:
Telephone:
Dorm L. Snyder
06858
2 North Second Street, 7zh Floor
Harrisburg, PA 17101
(717) 257-7524
Personal Representative-
Dated: October/C, 2004
REAL ESTATE
PERSONAL ESTATE:
See Schedule B
See Schedule E
Description
Value
None
S178,881.53
I $ 13,774.59
I '
(Attach Additional Sheets if necessary)
Total: $192, 656 . 12
REV-1503 EX + {1-97) (I)
COMMO NVCbAI_TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GRACE E. LAVERTY
SCHEDULE B
FiLE NUMBER
21-04-0640
All properly jointly-owned with the right of survivorship must be disclosed on Schedule E
iTEM
NUMBER DESCRrPTION VALUE AT DATE
OF DEATH
STE PA42021F 4
AMERICAN EXPRESS FINANCIAL
AXP HIGH YIELD TAX EXEPT FUND -
24,931.804 SHARES @ $4.45
AMERICAN EXPRESS FINANCIAL
FIXED RETIREMENT ANNUITY
CLASS A
TOTAL (Also enter on line 2, Recapitulation)
(If mere space is needed, insert additional sheets of the same size)
110,946.53
67,935.00
$ 178,881.5{
COMMONWEALTHOF?ENNSYLVAN,A / CASH, BANK DEPOSITS, & MISC.
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF
Gl%ACE E . LAVERTY FILENUMBER
21-04-0640
rndude the proceed s of litigation and the date the proceeds were received by the estate All property jointly-owned with the dght of survivm'ship must be disclosed on Schedule E
NUMBER
VALUE AT DATE
OF DEATH
1 CROWN - FG 250 GUITAR
150.00
2. LADY'S 18K YELLOW GOLD SIX SMALL DIAMONDS - WEIGHT 3DWT 1GR. 400.00
3. 1998 FORD CONTOUR
3,685.00
4. REFUND HOSPICE OF CENTRAL PENNSYLVANIA 6,900.00
5. NET RECEIPT FROM AUCTION OF MISC. ITEMS OF 1,115.48
FURNITURE - CLAUDE C. WOLFE AND ASSOCIATES
6. REFUND - PENN TREATY INSURANCE CO. 98.36
7. REFUND - DONEGAL INSUP~ANCE CO.
148 . 00
8. REFUND - READER'S DIGEST
25.82
9. REFUND - AARP
13.68
10. REFUND - PATRIOT NEWS
130.05
11. REFUND - ALLSTATE INSUP~CE
25.00
12. THE PI/LNO HOUSE - USED PIANO
500.00
13. GOLDEN HORIZONS - FURNITURE
305.00
14. REFUND - VERIZON
.28
15. REFUND - GOOD HOUSE KEEPING
5.83
16. REFUND - COMCAST
252.09
17. COMMERCE BANK
20.00
DESCRIPTrON
TOTAL (Also enter on line 5. Recapituldior $
STF PA42021E 9 (If more space is needed, insert additional sheets of the same size) 1 3, 7 7 4. 5 g
COMMONWEALTH OF PENNSYLVANZA
DEPARTMENT OF REVENUE
NOTZCE OF ZNHERZTANCE TAX
APPRAZSEMENT, ALLOHANCE OR DZSALLONANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DEC ?.9 9: ! 0
CLERK OF
ORPH X'S COURT
SAUL EWl'I~I'G" LLP
PO BOX 1291
HB6 PA 17108
REV-X$47 EX AFP C09-0~)
DATE 12-27-200q
ESTATE OF LAVERTY GRACE E
DATE OF DEATH 06-16-200q
FZLE NUMBER 210q-O6qO
COUNTY CUMBERLAND
ACN 101
Amoun~ Rami~ad I
MAKE CHECK PAYABLE AND REMXT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 1701~
CUT ALONG THZS LZNE ~ RETAZN LOWER PORTZON FOR YOUR RECORDS ~
REV-15&? EX AFP [01-033 NOTZCE OF ZNHERZTANCE TAX APPRAZSEMENT~ ALLOWANCE OR
DZSALLOWANCE OF DEDUCTZONS AND ASSESSMENT OF TAX
ESTATE OF LAVERTY GRACE E FZLE NO. 210q-O6qO ACM 101 DATE 12-27-200q
TAX RETURN HAS: ( ) ACCEPTED AS FILED (X) CHANGED SEE ATTACHED NOTICE
RESERVATZON CONCERNZNG FUTURE ZNTEREST - SEE REVERSE
APPRAZSED VALUE OF RETURN BASED ON: ORTGTNAL RETURN
1. Real Es~a~a (Schedule A) (1)
2. S~ocks and Bonds (Schedule B) (2)
$. Closely Held S~ock/Par~:nershlp Tn~:ares~: (Schedule C) ($)
~. Mor:kgages/Mo~:es Receivable (Schedule D) (~)
g. Cash/Bank Deposits~Misc. Personal Propar~y (Schedule E) ($)
6. Jointly Owned Propar~y (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. To,:al Assa~s
APPROVED DEDUCTZONS AND EXEMPT:iONS:
9. Funeral Expensas/Adm. Cos~s/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Ra~urn
178~881.55
.00
15277q.59
10229q.50
.00
.00 NOTE: To insure proper
cradi~ to your account,
sub. i~ ~he upper por~ion
.00 of ~his for. wi~h your
~ax payment.
(8)
2q,201.21
15.
lq.
NOTE:
202,950.62
1~782.q9
(11) 26.983.70
(12) 176,966.92
Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15)
Na~: Value of Es~a~:a Sub.~ac~: ~:o Tax (lq)
Zf an assessment ~as issued previously, lines 1~, 15 and/or 16, 17,
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
1.6. Amoun'l: of Line lq a~ Spousal re~a (15)
16. Amoun~ of Line lq ~axebla a~ Lineal~Class A ra~e (16)
17. Amoun~ of Line lq a~ Sibling ra~:a (17)
18. A.oun~ of L~ne lq ~axeble et Collateral/Class B ra~a (18)
19. Principal Tax Due
TAX CREDZTS:
PAYMENT I RECEIPT
DATE NUMBER
09-10-200q. CDOOq$62
10-$0-2001 CDOOq6ZZ
10,000.00
166,966.92
AMOUNT PATD
20,000.00
57.2q
TOTAL TAX CREDZT [ 21,105.89
BALANCE OF TAX DUEI 132.83CR
ZNTEREST AND PEN. I .00
TOTAL DUE [ 1~2.85CR
( ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS REQUZRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDZT" (CR), YOU MAY BE DUE ~_~
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) ~\
1,0q8.65
.00
.00 x O0 = .00
.00 x Oq5= .00
155,752.qq x 12 = 16,287.89
51,25q.q8 X 15 = q,685.17
(19)= 20,975.06
DISCOUNT (+)
INTEREST/PEN PAID (-)
IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
18 and 19 N111
REV-1470 EX (8-88)
INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG, PA 17128-0601
DECEDENTS NAME FILE NUMBER
Grace E. Laverty 2104-0640
REVIEWED BY ACH
Destiny S.R. Brown 101
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
The claim for the family exemption has been disallowed. The claimant must be a spouse
or if no spouse, a parent or child living in the same household as the decedent as of the
date of death.
Row Page 1
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 1712B-0601
DONN L SNYDER ESQ
SAUL EWING LLP
PO BOX 1291
HBG PA 17108
CONNONNEALTH OF PENNSYLVAN/A
DEPARTNENT OF REVENUE
ZNHERZTANCE TAX
STATEMENT OF ACCOUNT
DATE 12-27-200q
ESTATE OF LAVERTY
DATE OF DEATH 06-16-200q
FILE NUHBER 21 OR-06~O
COUNTY CUHBERLAND
ACN 101
Amoun~c Remi'l:'l:ed
RE¥-1607 EX &FP (12-04)
GRACE E
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
NOTE: To insure proper credi~ ~o your accoun~c, submit: ~he upper por~/on of ~:his for. wi~h your ~ax peymen~c.
CUT ALONG THIS L/NE ~ RETAIN LOWER PORTION FOR YOUR RECORDS
ESTATE OF LAVERTY GRACE E FILE NO. 21 0~-06~0 ACN 101 DATE 12-27-200q
THIS STATEHENT 1S PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACH ZN THE NAHED ESTATE. SHOWN BELOW
/S A SUHMARY OF THE PR/NC/PAL TAX DUE, APPL/CATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, /F APPLICABLE,
A PROJECTED /NTEREST F/GURE.
DATE OF LAST ASSESSHENT OR RECORD ADJUSTHENT: 12-27-200~
PRINCIPAL TAX DUE: .......................................................................................
PAYHENTS CTAX CREDITS):
20,975.06
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID ¢-)
09-10-ZOOq
10-30-ZOOq
CDOOq$6Z
CDOOq612
1,0q8.65
.00
ZO,O00.O0
57.2q
IF PAID AFTER TH/S DATE, SEE REVERSE
S/DE FOR CALCULATION OF ADD/TIONAL /NTEREST.
TOTAL TAX CREDIT
21,105.89
BALANCE OF TAX DUE 132.85CR
ZNTEREST AND PEN. .00
TOTAL DUE 152.85CR
( /F TOTAL DUE ZS LESS THAN $1,
NO PAYMENT IS REQUIRED.
/F TOTAL DUE IS REFLECTED AS A 'CRED/T' (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE S/DE OF THIS FORM FOR /NSTRUCTIONS. )
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Grace E. Laverty
Date of Death: June 16,2004
Register File No. 21-04-0640
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion ofthe administration of the above-captioned estate:
1. State whether administration of the estate is complete: Yes ~ No
2. If the answer to #1 is No, state when the personal
representative reasonably believes that the administration
will be complete:
3. If the answer to # 1 is Yes, state the following:
a. Did the personal representative file a final
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? Y es ~ No_
d. Copies of receipts, releases, joinders and
approvals of formal or information accounts may
be filed with the Clerk of the Orphans' Court
and may be attached to this report. (attached)
Date: February 23, 2005
ONN L. SNYDE , ESQ
SAULEWINGLLP
POST OFFICE Box 1291
Harrisburg, PA 17108-1291
717.257.7552
; i, :
... .
1 (......-;
:-:; C: iu'
<J
54463.9 2/22/05
uf
IN RE: THE ESTATE OF
IN THE COURT OF COMMON PLEAS
GRACEE.LAVERTY,DECEASED
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-04-0640
SATISFACTION AND AWARD
The undersigned, hereby acknowledge that Lois Laverty, Executrix of the Estate of Grace E.
Laverty, deceased, has distributed to the undersigned an automobile valued at Three Thousand Six
Hundred Eighty Five Dollars ($3,685.00) and cash in the amount of Twelve Thousand Nine
Hundred Ten and 21/100 Dollars ($12,910.21) as full payment of all sums due pursuant to the
Estate of Grace E. Laverty, directs and authorizes the Clerk of the Orphan's Court Division to mark
satisfied of record the award which may be made in his individual favor.
IN WITNESS WHEREOF, the undersigned has caused these presents to be executed this
7t1... day of -:f~... --1 ,2005.
Witness:
/ .
0'" 1l~ct;z(Lrr-r-
JACQUELINE A. HEFELFINGER
NOTAfW PU3L1C OF NEW JERSEY
C~)r:1:,',:;~,ion Expires 07/23/07
1119811 2/2/05
IN RE: THE ESTATE OF
IN THE COURT OF COMMON PLEAS
GRACEE.LAVERTY,DECEASED
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-04-0640
SATISFACTION AND AWARD
The undersigned, hereby acknowledge that Lois Laverty, Executrix of the Estate of Grace
E. Laverty, deceased, has distributed to the undersigned cash in the amount of Sixteen Thousand
Five Hundred Ninety Five and 211100 Dollars ($16,595.21) as full payment of all sums due
pursuant to the Estate of Grace E. Laverty, directs and authorizes the Clerk of the Orphan's Court
Division to mark satisfied of record the award which may be made in his individual favor.
./ IN WI~SS WHEREOF, the undersigned has caused these presents to be executed this
I day of--\ ~/~;J ,2005.
Witness:
.~l=~:y~~'\
~L1~_ 0 ~Zif
By: MARTHALAVERTY
Social Security No. J?l-3~-2S Lj~
111981.1 2/2/05
INRE: THE ESTATE OF
IN THE COURT OF COMMON PLEAS
GRACEE.LAVERTY,DECEASED
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-04-0640
SATISFACTION AND AWARD
The undersigned, hereby acknowledge that Lois Laverty, Executrix of the Estate of Grace
E. Laverty, deceased, has distributed to the undersigned cash in the amount of Sixteen Thousand
Five Hundred Ninety Five and 21/100 Dollars ($16,595.21) as full payment of all sums due
pursuant to the Estate of Grace E. Laverty, directs and authorizes the Clerk of the Orphan's Court
Division to mark satisfied of record the award which may be made in his individual favor.
ID
IN WITNESS WHEREOF, the undersigned has caused these presents to be executed this
dayof ~l"O ,2005.
Witness:
1l~
By:
i\
111981.12/2/05
INRE: THE ESTATE OF
IN THE COURT OF COMMON PLEAS
GRACEE.LAVERTY,DECEASED
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-04-0640
SATISFACTION AND AWARD
The undersigned, hereby acknowledge that Lois Laverty, Executrix of the Estate of Grace
E. Laverty, deceased, has distributed to the undersigned cash in the amount of Sixteen Thousand
Five Hundred Ninety Five and 21/100 Dollars ($16,595.21) as full payment of all sums due
pursuant to the Estate of Grace E. Laverty, directs and authorizes the Clerk of the Orphan's Court
Division to mark satisfied of record the award which may be made in his individual favor.
,-'"
A
IN WITNESS WHEREOF, the undersigned has caused these presents to be executed this
day of -r e b ,2005.
Witness:
~,,\ C,,-e(
Z/
.1~,^-N~<4 '
q'c~,00
By:
~(~~ ,~~/~~.
ES~HER~ECE ) 9;2 -;2;2.- J6/FJ
SOCIal Secunty No.
111981.1 212105
IN RE: THE ESTATE OF
IN THE COURT OF COMMON PLEAS
GRACE E. LAVERTY, DECEASED
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-04-0640
SATISFACTION AND AWARD
The undersigned, hereby acknowledge that Lois Laverty, Executrix of the Estate of Grace
E. Laverty, deceased, has distributed to the undersigned cash in the amount of Six Thousand One
Hundred Ninety Eight and 40/100 Dollars ($6,198.40) as full payment of all sums due pursuant to
the Estate of Grace E. Laverty, directs and authorizes the Clerk of the Orphan's Court Division to
mark satisfied of record the award which may be made in his individual favor.
/;. IN WITNESS WHEREOF, the undersigned has caused these presents to be executed this
(/ day of rdlt.c.I#i;J ,2005.
Witness:
~,/f (?~
I
By:
;//!..A ~..
MARK LAVERTY
Social Security No. "3 Y'~'" (). - ) ~ ~ ~
111981.1212105
IN RE: THE ESTATE OF
IN THE COURT OF COMMON PLEAS
GRACEE.LAVERTY,DECEASED
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-04-0640
SATISFACTION AND AWARD
The undersigned, hereby acknowledge that Lois Laverty, Executrix of the Estate of Grace
E. Laverty, deceased, has distributed to the undersigned cash in the amount of Six Thousand One
Hundred Ninety Eight and 40/1 00 Dollars ($6,198.40) as full payment of all sums due pursuant to
the Estate of Grace E. Laverty, directs and authorizes the Clerk of the Orphan's Court Division to
mark satisfied of record the award which may be made in his individual favor.
I IN j WITNESS WHEREQ]1, the undersigned has caused these presents to be executed this
7 vJ)yof p-~/fUl{Xr2005.
Witness:
J.
(,
? / I;
/./' /~lq
\_/
/
,/,/'
By:
/ftYjlt1 v~~>
MICHAEL LAVERTY" (I _ ....
Social Security No. o}; (-0 7 50 13
111981.1 212105
IN RE: THE ESTATE OF
IN THE COURT OF COMMON PLEAS
GRACEE.LAVERTY,DECEASED
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-04-0640
SATISFACTION AND AWARD
The undersigned, hereby acknowledge that Lois Laverty, Executrix of the Estate of Grace
E. Laverty, deceased, has distributed to the undersigned cash in the amount of Six Thousand One
Hundred Ninety Eight and 40/1 00 Dollars ($6,198.40) as full payment of all sums due pursuant to
the Estate of Grace E. Laverty, directs and authorizes the Clerk of the Orphan's Court Division to
mark satisfied of record the award which may be made in his individual favor.
. ~ IN WITNESS WHEREOF, the undersigned has caused these presents to be executed this
,8 - day of ~ ttA..rY ,2005.
Witness:
By:
n c--.----
~7LAV€iTY9 --
Social Security No. (') I, ~ ~v - 17,<:> 3
~O-J~- ~
1119811 212105
INRE: THE ESTATE OF
IN THE COURT OF COMMON PLEAS
GRACEE.LAVERTY,DECEASED
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21-04-0640
SATISFACTION AND AWARD
The undersigned, hereby acknowledge that Lois Laverty, Executrix of the Estate of Grace
E. Laverty, deceased, has distributed to the undersigned cash in the amount of Ten Thousand
Dollars ($10,000.00). as full payment of all sums due pursuant to the Estate of Grace E. Laverty,
directs and authorizes the Clerk of the Orphan's Court Division to mark satisfied of record the
award which may be made in his individual favor.
.., i P IN WrTNE S WHEREOF, the undersigned has caused these presents to be executed this
~ day of 'e, ,t.t.4.A.-'. ,2005.
Witness:
i
NOTARIAL SEAL
~lRGltML MANNING, ., NIle
.....~ Ben. CUmbIdII..at.
My CoMmtnlan ___ fib. 2. 2001
By:
~tti
~ W. ~,
PINE ST T CHURCH
EINNo. 21-llf33 Db?
f>1'--E.S. - B- h 0 F
T~sTffS
\ \ \981.1 2/2105
Cll~l ,Ct' ~ (l'-lQ rt~1
f.
04-~40
f,;~ Cetl'fI..tL
?cu-d U', ~1-U2
,r:D'J
I ~~;~s~"::~~:,:~.~~~~;:_'"" ,~O . '''"' .m=
iii!! Toll Free 1-800-458-0811 . Fax (814) 870-3126. www.erieinsurance.com
ERIE.
Obligee
I
I Date of Mailing I March 4, 2005
Principal
I
I
I
Commonwealth of Pennsylvania Lois Laverty
Cumberland County Orphans Court Penn National Ins. Plz.
1 Courthouse Square 2 N. 2nd St., 7th Floor
Carlisle, PA 17013 Harrisburg, PA 17101-1619
L ~ L -.J
NOTICE OF CANCELLATION OR NON-RENEWAL
EFFECTIVE
STANDARD DATE TYPE OF BOND BOND NUMBER BOND AMOUNT
TIME
12:01 A.M. 6-30-05 Executor Bond Q90 8061387 H $340 000.00
It is our desire to terminate this bond and we hereby give notice that the liability of the Erie Insurance
Company will cease 6-30-05 .
The reason for this action is:
o Principal's Request 0 Agent's Request
o Other (See explanation below.)
Q Bond Term Expired
cc: Agent M7082 Gieseler & Joyce Ins. Af3., u.c
Sincerely,
~~~i~
Chief Executive Officer
EIG-2301 9/02
OBLIGEE
BUREAU OF INDIVIDUA1/1'~ES~-
INHERITANCE TAX OIYIStOl'C"-:': ._ .
PO BOX Z80601
HARRISBURG PA 171Z8-060i
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
'*
REY-IU7 EX AFP (12-D4)
DONN L SNYDERESQ
SAUL EWING LLP
PO BOX 1291
HBG PA 17108
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
01-31-2005
LAVERTY
06-16-2004
21 04-0640
CUMBERLAND
101
GRACE
E
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 paYllent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
ft~:r&~~.!5r.A~J..rGl~.6!'.......i;..irA~!~~~lr~l)t.~fl"~A~.b".l~1:60~...j;i.....................
ESTATE OF LAVERTY GRACE E FILE NO.21 04-0640 ACN 101 DATE 01-31-2005
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED 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: 12-27-2004
PRINCIPAL TAX DUE:,
20.973.06
PAYMENTS (TAX CREDITS):
~
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
09-10-2004 CD004362 1.048.65 20.000.00
10-30-2004 CD004612 .00 57.24
01-12-2005 REFUND .00 132.83-
TOTAL TAX CREDIT 20.973.06
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER THIS DATE. SEE REVERSE
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" (CRl.
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. l
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2110601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 04- 0640
04140935
10-20-2004
REV-154! EX ." n'-Oll
TYPE OF
ACCOUNT
o SAVINGS
IX] CHECKING
o TRUST
o CERTIF .
ST
EST. OF: GRACE E LAVERTY
S.S.NO. 201-18-6260
DATE OF DEATH 06-16-2004
'04 ~'n\l 5~~JX '1 (J CUMBERLAND
. I\tUV ~ I; . t
;V~ a--.J-~ ~.
- a-5"JHAnnwJ V
PA 17011 Vi H~:~\HiH S J K, \
Jl-JDJ7
1" ", >',
MARTHA
APT 2
3002 MARKET
CAMP HILL
P LAVERTY
REMIT PAYMENT AND FORMS TO:
REGISTER OF WIllS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
WAY POINT BANK has provid..d th.. DBpart....nt with th.. infoNlation listed b..low which has b....n used in
calculating the pot..ntial tax due. Th..ir records Indlcat.. that at the death of the above dec..dent, you w..r.. a jolnt own..r/b..naflciary of
this account. If you f....l this inforBation is incorract, please obtain writt..n correction fro. tha fInancial institution, attech a COpy
to this forJl and r.turn it to the above addr..ss. This account is taxable in accordanc. wIth the Inheritanc.. T..x laws of the CO.Jlonw.elth
or "..nnsylvani,.. ~.Hons --1/ H an.........od by callIng (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 3100005293 Date 05-14-1998
Established
Account Balance
Percent Taxlilble
AMOUn~ Subject to
Tax Ra~e
Potential Tax Due
x
763.13
50.000
381.57
.15
57.24
TAXPAYER RESPONSE
To insure prop..r credit to your account, two
(2) copies of this notice .ust aCCOJlpany your
pay.ant to the Relllst..r of Wills. "ake check
p.yable to: "Register of Wills, Agent".
x
NOTE: If tax paYllllnts are aade within th.....
(3) aonths of the decadent.s d.te of death,
you allY d..duct a SZ discount of the tax due.
Any inheritance tax due will beeo.e delinquent
nine (9) months aftar th.. date of death.
Tex
PART
ill
The above inforaatlon end tax due is correct.
1. You aay choose to reait p.YBent to th.. Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you .ay check box "An and return this notlce to the Register of
Wills and an officlal ass.ssaent will be issugd by the PA Depart.snt of Revenue.
B. E:J The above asset has been or will be reportsd end tax paid with the PennSYlvania Inheritanca Tax return
to b.. filed by the dscedsnt.s r.presentative.
C. c=J The .bov. inloraation is incorrect and/or debts and deductions wer.. paid by you.
You .ust co.plate PART [!] and/o... PART ~ b.low.
[CHECK ]
ONE
BLOCK
ONLY
PART
~
TAX RETURN - COMPUTATION OF
lINE 1. 08~e Established 1
2. Account Balance 2
3. Percent Taxable 3 X
4. Amount Subject to Tex 4
5. Debts and Deductions 5
6. Anount Taxable 6
7. Tax Rate 7
8. Tax Due 8
TAX ON JOINT/TRUST ACCOUNTS
If you indicat. a different tax rate, ple.se state your
relationship to decedent;
X
PART
[!]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on line 5 of Tax Co.putation>
I
$
Under penalties of perjury, I declare that the
co.plet. to the best of ny knowledge and belief.
:i7;':~Gfju~
facts I have reported above are true, correct and
......
HOME (
WORK (
TELEPHONE
)
)
NUMBER
DAT~
GENERAL INFORMATION
1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicabla IntBrBSt basad on infar.ation
subaittsd by the financial institution.
Z. Inheritance tax beca.es delinquent nina .onths aftar tha dacadant.s data of daath.
3. A joint account 15 taxable avan though tha dacedant's naaa was added as a .attar of canveniance.
4. Accounts (inCluding those hald batwaan husband and wifa) whIch the dacadent put in joInt na.a5 within ana ysar prior to
daath ara fully taxable as transfars.
5. Accounts astablishsd jointly batwaan husband and wifa .ora than ana yaar prior to daath ara not taxabla.
6. Accounts hald by a dacsdant "In trust for" anothar or athars ara taxabla fUlly.
REPORTING INSTRUCTIONS - PART
1
- TAXPAYER RESPONSE
1. BLOCK A - If ths Infor.atIon and coaputation in tha notica ara corract and daductians ara not baing clai.ad, placa an "X"
in block "A" of Part 1 of tha "Taxpaysr Response" saction. Sign two coplas and subait the. with your chack for the B80unt of
tax to tha Ragistar of Wills of tha county indicatad. Tha PA Dapartaant of Ravanua wIll issua an official assessBent
(fora REV-1548 EX) upon rscaipt of the return froa tha Ragistsr of Wills.
Z. BLOCK B - If the assat spacifisd on this notica has baan or will ba raportad and tax paid with tha PannsYlvania Inheritance
Tax Return filed by ths dacadant.s rapresantativa, placa an "X" In block "B" of Part 1 of the "Taxpayar Rasponsa" section. Sign one
copy and return to the PA Dapart.ant of Ravenua, Buraau of Individual Taxes, Dept 2&0601, Harrisburg, PA 171Z&-060I in the
envelope provided.
3. BLOCK C - If tha notica inforaation Is incorrect and/or daductions are baing claiaed, check block "C" and coaplsta Parts 2 and 3
according to the instructions below. Sign two copies and subait tha. with your check for tha ..aunt of tax payabla to the Register
of Wills of the county Indicated. Tha PA Depart.ant of Ravanus will issua an official assassaant (for. REV-lS48 EX) upon racalpt
of tha raturn frOB tha Ragistar of Wills.
LINE
1. Enter
NOTE:
TAX RETURN. - PART
2
- TAX COMPUTATION
tha data tha account originally was astabllshed or titlad In the aannar axlsting at data of death.
for a dacedant dying after 12/12/&2: Accounts which the dacedant put in joint n..as within ana (1) yaar of daath ara
taxable fully as transfers. Hawaver, thara is an exclusion not to excaad $3,&00 par transfaraa rsgardless of the valua of
the account or the nunbar of accounts hald.
If a doubla astarisk (RR) appears befora YDur first na.a In tha address portion of this natica, tha $3,000 .xclusion
alreadY has been deductad frOB tha account balanca as raportad by tha financial institution.
Z. Entar the total balanca of th. account including intarast accruad to tha data of death.
3. Tha parcant of tha account that is taxabla for aach survivor is daterainad as follows:
A. The percant taxable for joint assats astablishad _ors than ana Yaar prior to tha dacadant.s death:
DIVIDED BY TOTAL NUMBER Of DIVIDED BY TOTAL NUMBER Of X 100 PERCENT TAXABLE
JOINT OWNERS SURVIVING JOINT OWNERS
ExaBpla: A joint assat reglstarad In tha na.a of tha decadant and two othar persons.
1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) = .167 X 100
16.7X (TAXABLE fOR EACH SURVIVOR)
B. Tha parcant taxabla for assets craatad within one yeer of tha decadant.s death or accounts owned by tha dacadent but hald
in trust for anothar individuBl(s) (trust baneficiaries):
1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT
OWNERS DR TRUST BENEfICIARIES
X 100
PERtENT TAXABLE
Exaapla: Joint aCCDunt re"istarad In the na.a Df tha dacadant and two athar parsons and astablishad within ons year of dsath by
the decadent.
I DIVIDED BY 2 (SURVIVORS) = .50 X 100 50X (TAXABLE FOR EACH SURVIVOR)
4. Tha a.ount Subject to tax (llna 4) is detarminad by aultiplylng tha account balanca (lina 2) by tha parcant taxabla (lina 3).
5. Entsr tha total of tha dabts and daductlons listed In Part 3.
6. Tha aaount taxabla (line 6) Is datarainad by subtracting the dabts and deductions (lina 5) froa tha a.ount sUbjsct to tax (line 4).
7. Enter ths appropriata tax rate (1lna 7) as detar.lnad balow.
Dat. of D..th Spouse lin..l Sibling Collateral
07101/94 to 12131/94 3r. 6r. 15r. 15r.
01101195 to 06/30/00 Dr. 61. 157- lSr.
07/01/00 to present 07- It.Sr.- 121. lSr.
"Tha tax rata 1aposed Dn the nat VIIlua of tr8l'lsfers fro. a dacaasad chIld twenty-ana years of alia or Y
oungar at
daath to or fDr tha usa Df a natural parant, an adoptiva parent, Dr a stapparant of the child Is OX.
Tha linaal class of hslrs includas grandparants, parents, children, and linaal dascandants. "Childran" Includas natural chlldran
wheth.r or not they have baen adoptad by others, adoptad childran and stap children. "Linaal dascandentsw Includas all children of tha
natural parents and thair descendants, whathar or not thay hava bean adopted by othars, adoptad dascandants and their dascendants
and stap-dascandants. "Siblings" are d.finad as indIviduals who hava at l.ast ana parant in co..on with tha dacadant, whethar by blood
or adoption. Tha "Collataral" class of hairs Includas all othar beneficlarias.
CLAIMED DEDUCTIONS - PART
3
DEBTS AND DEDUCTIONS CLAIMED
Allowabla dabts and deductions are detarminad as follows:
A. You lagally ara responsibla for pay.ant, or tha estate subjact to adainistratIon by a personal reprasantatlva Is insufficiant
to pay tha deductibla iteas.
B. You actually paid tha dabts after da.th of tha decadant and can furnish proof of pay.ant.
C. Dabts being clalaad aust ba ite.lzad fully in Part 3. If additional spaca Is neadad, use plain paper & l/Z" x II". Proof of
payaent aay ba raquestad by tha PA Departaant of Ravanua.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT 280601
"ARRISBURG. PA 17128-0601
REV-1162 EX( 11-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
LA VERTY MARTHA P
2514 ANN ST
VI L LA HI L L S I K Y 41 01 7
-- -~ Uh fold
ESTATE INFORMATION: SSN: 201-18-6260
FILE NUMBER: 2104-0640
DECEDENT NAME: LAVERTY GRACE E
DATE OF PAYMENT: 11/09/2004
POSTMARK DATE: 10/30/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 06/16/2004
NO. CD 004612
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
04140935 I $57.24
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECK# 1044
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$57.24
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS