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Home My WebLink About01-0855 PETITION FOR GRANT OF LETTERS Estate of NELLIE M. CHAMBERLIN No..cQl- 0 \ - 8 s.s- also known as NELLIE M. CHAMBERLIN I Deceased Social Security No. 205095382 CHALMER L. CHAMBERLIN and MARTHA COLDSMITH Petitioner(s). who islare 18 years rI age or older. appIy)ies) for : (COMPLETE "A" OR "B" BELOW:) @ A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut ORS named in the Last Will of the Decedent, dated 1/30/91 and codicil(s) dated State relevant circums1ances. e.g.. renunciation. death of executor. etc Except as follows. Decedent did not marry, was not divorced and did not have a chilcl born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incapacitated: o B. Grant of Letters of Administration (c.ta.. d.b.n.c.ta.: pendente lite, durante absentia: durante minoritate) Petitioner(s) after a proper search haslhave ascertained the Decedent left no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence I (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his/her last family or principal residence at 121 WALNUT BOTTOM RD., SHIPPENSBURG TOWNSHIP, SHIPPENSBURG, PA 17257 (list street, number and municipality) Decedent, then 91 years of age, died AUGUST 11 ,2001, at 121 WALNUT BOTTOM RD, SHIPPENSBURG, PA (Location) Decedent at death owned property with estimated values as follows: (if domiciled in PA All personal property ......................................... $ (if not domiciled in PA Personal property in Pennsylvania .................... $ (if not domiciled in PA Personal property in County .............................. $ Value of real estate in Pennsylvania ........................................................................................ $ Total ..................................................................................................................... $ 1,600.00 1,600.00 Real Estate situated as follows: Wherefore. Petitioner(s) respectfully request(s) the probate of the Last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: Typed or printed name and residence CHALMER L. CHAMBERLIN 5955 MICHAELE DR. ENOLA PA 17025 MARTHA COLDSMITH 1077 MAYAPPLE DR. SHIPPENSBURG PA 17257 \1-<6- 5' Oath of Personal Representative Commonwealth of Pennsylvania County of CUMBERLAND The Petitioner( s) above-named swear( s) and affirm( s) that the statements in the foregoing Petition are true and correct to the best of the knowtedge and belief of Petitioner( s) and that, as personal representative( s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law.-- Sworn to and affinned and subscribed - . . CHAL~ER'IL. CHAMBE~L1~ 7 I ~;.. before me th: 17TH day of . ~~ .JriL1-L-LL i::;~' L ~(b~THACOLDS. MITH \ MARY C LEWIS un._;&f~ (!~ DECREE OF REGISTER Estate of N~l-L1E M CHAMBERLIN also known as Deceased 21 - 01 - 855 No. Social Security No: 205095382 Date of Death: 8111/01 AND NOW, SEPTEMBER 18 2001 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters IX! Testamentary 0 of Administration ((c.ta.. d.b.n.c.t; penden1e lite; durante absentia; durante minoriate) are hereby gran~ to CHALMER L. CHAMBERLIN AND MARTHA COLDSMITH in the above estate and that the instrument(s), if any, dated JANUARY 30. 1991 described in the Petition be admitted to probate and filed of record as the Last Will of Decedent Attorney: SALLY J. WINDER 1.0. No: 24705 Address: 701 E KING ST. SHIPPENSBURG TOTAL .............................$ 39.00 Telephone: 717 532 9476 DATE FILED: 9/17/01 Mailed letters to attorney on 9-18-01 FEES Letters .................................... Short Certificates( s) ...... U. L.. Renunciation ....:..................... Extra Pages ( 2 ).. .. .. . :.. .. . .. I. T. R............................. ~......... JCP Fee ......~;......................... Inventory............................... . Other ........................ .............. $ 25.00 Register d Wills Y CLEWIS $ $ $ $ $ $ $ $ 3.00 h nn Signature 5.00 PA 17257 05.805 REV 9/86 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. Fee for this certificate, $2.00 p 7645529 ~ !42-00( Date ... 2Jff1 COMMONWEALTH OF PENNSYLVANIA e DEPARTMENT OF HEALTH e VITAL RECORDS CERTIFICATE OF DEATH TOWV!.llhip - ...-. --_..................." ._--_. MIlm--- 24. lot 27. _.: _...~ Injurteaor ~__I"""', Do __... _oI~ _.....-or.....atory arr.... _llf..ert lallure. U. __ _... -"..... .....1c..-fF_ _ar.....- ..........~- _.: OINoo.-_CIlIlIrIlullngIO_.1lul ""'-.........~___1l'I ""'" I. ',-0 U JIICIMlIAHOc:aIn~I'It'I'SICIAII""- bOlIl "'QrlClUf'Clrl\l__~IO_"'_1 To.. _01 MY~. _Iftecc_ 01"'_. _. _piece. __ to ..._., .........__r.. _.... DATE OF IHJUIlY (1.IonIh. o.y. _, rIME OF INJURY INJURY 1fT WOflK? DESCRltlE HOW INAJAY occu_o ~........... .. '- ................. I _. _UIIIIIJlUWG . ===:::..,ry :. ......... ~LMT _ .... AN AU10PIIY WEN: AImll'SY 'INOINOS l'E~m --.-..e JIMlR 10 COM'LETIOH OFCAUR 01' 0ERlt? - - _0 MIl ....0 MIlO -- ~- o ...................... o ~_..._ _ 0 MIlO ... .. .. -~oNIr_ ._..-1'MftICWI(Ph_.....,...,-"'___.-.-....~_....~....13I ,....._elMY~.____.....~I____ ......... ................................ ..... ,..... -...cAL DAlllNRRICOII<IN<<Il OIlllle bMIe of ..__1On .ncllor _....ioft. In "'Y oplnioft,...8111 -.. -..... ... ... . . ..., . .. .. . ................ . ... . '" )t.. REGISTRAR'S SlOHATUfIE AND Nt) D LAST WILL AND TESTAMENT I. NELLIE M. CHk~BERLIN. being of sound mind, memory and understanding, do make, publish and declare this my Last Will and Testament. hereby revoking all prior wills and codicils made at any time before by me. FIRST: I direct that all my funeral expenses be paid as soon as practical after my death. SECOND: I give and bequeath to my son, Chalmer L. Chamberlin, the sum of $8,000.00. If Chalmer L. Chamberlin should predecease me or if we should die in a common disaster. then in that event I give and bequeath the said sum of $8,000.00. to the wife of Chalmer L. Chamberlin, Mary Chamberlin, per stirpes. THIRD: I give and bequeath to each of my grandchildren, Gloria Coldsmith Gardner, Rick Coldsmith. Michael Coldsmith, and Kerry Chamberlin, the sum of $250.00. FOURTH: The rest and residue of my estate, be it real. mixed or personal. wherever and whenever situate, I give, devise and bequeath to my children, Chalmer L. Chamberlin and Martha Coldsmith, to share and share alike. in equal shares. per stirpes. FIFTH: I nominate and appoint my children, Chalmer L. Chamberlin and Martha Coldsmith. as the Executors of this my Last Will and Testament. H. ANTHONY ADAMS - ATTORNEY AT LAW - 128 EAST KING STREET, SUITE A - SHIPPENSBURG, PENNSYLVANIA 17257 IN WITNESS WHEREOF. I, NELLIE M. CHAMBERLIN, to this my Last Will and Testament. set my hand and official seal. this~day of January. 1991. {:!1dl'.R.. rWJ ( h~(SEAL) Sworn to and subscribed. declared and published by NELLIE M. CHAMBERLIN, as her Last Will and Testament, and so done in the presence of we the witnesses, who sign at her request, and in her presence, and in the presence of each other. "7 x{jt~u ?1-v CithL dc-C~ ..,.../.j ,\\~~cbb ~ COMMONWEALTH OF PENNSYLVANIA: :ss COUNTY OF CUMBERLAND I. NELLIE M. CHAMBERLIN, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament: and that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. '111~.~(7~~ Sworn to and acknowledged, before me, by NE~E M. CHAMBERLIN, the Testatrix. this . /'1+Y1 day of January, 1991. -lJ(} j P '/1(7J1(L/I 1.1 ~ \Aa5JfJ Notary Public I ~.~~~-'-;7;',~'-'~',::,-::>,;;:~'. -.... ........- "'--1 I ./ "f' ., . "" .- . , . .~., ' :~.: - . '.'.; ,::. .: .. " L' r ' , . ; :~~, _ , I ',' ., ........'. ",'."',:;f'l)l I ';,. " 'l ~.-c ~..~::... .:~ ;,(~-,.~.? -...". . ,,-' """ -"- ._.,...-~....,., -., ".-'-"'~-"'-~-'"'.""-"~-"""--"~-------' H. ANTHONY ADAMS - ATTORNEY AT LAW - 128 EAST KING STREET. SUITE A - SHIPPENSBURG. PENNSYLVANIA 172S7 I . COMMONWEALTH OF PENNSYLVANIA: :SS COUNTY OF CUMBERLAND We, H. Anthony Adams and Sharon Coleman Adams, the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law. do depose and say that we saw the Testatrix sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses, and that to the best of our knowledge and the Testatrix was at the time at least eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. Sworn to and subscribed before me by. H. Anthony Adams and Sharon Coleman Adams. the witnesses. this ~day of January, 1991. ~ iYVIw' ~\ I _ \ 'ilLL~ '-, rLll~ Notary Public f.~: ~'-~::.;::!~:~>',~~~i;C;2~=l ~~ ,,-, ....-..."-._.._.-........-".... .-~,... ..__._...,_-.,.a.,......_.....,....~.....-.. ...~......_......__....:.._.,.; H. ANTHONY ADAMS - ATTORNEY AT LAW - 126 EAST KING STREET, SUITE A - SHIPPENSBURG, PENNSYLVANIA 172S7 l & CERTIFICATION OF NOTICE UNDER RULE 5.6(al Name of Decedent NELLIE M. CHAMBERLIN Date of Death: 8/11/01 Estate No. 21 01 0855 SSN: 205095382 FileNo. Date Letters Granted: 9/18/01 Will or Administration No. 21 01 855 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 following beneficiaries of the above-captioned estate on 10/25/01 Address 5955 MICHAELE DR ENOLA 1 077 MAYAPPLE DR SHIPPENSBURG PA 17025 Name CHALMER L. CHAMBERLIN MARTHA COLDSMITH PA 17257 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: 10/25/01. ~~w~ SALLY J. WINDER Name (Please type or print) Address 701 EAST KING STREET PA 17257 0::;, I SHIPPENSBURG ? Telephone No. 7175329476 C'J P - ......... COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT WINDER SALLY J 701 E KING STREET SHIPPENSBURG, PA 17257 u______ fold ESTATE INFORMATION: SSN: 205-09-5382 FILE NUMBER: 21-2001- 0855 DECEDENT NAME: CHAMBERLIN NELLIE M DA TE OF PAYMENT: 11/02/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 08/11/2001 NO. CD 000476 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $64.15 I I I I I I I I TOTAL AMOUNT PAID: $64.15 REMARKS: SALLY J WINDER ESQUIRE CHECK# 9409 SEAL INITIALS: DO RECEIVED BY: REGISTER OF WILLS MARY C. LEWIS REGISTER OF WILLS -y/?-?- 6-./ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG I PA 171Z8-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX Recoraed Re'" ;.' s.-I.l.n... '. ~'" c:;' of VVilIs DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-17-2001 CHAMBERLIN 08-11-2001 21 01-0855 CUMBERLAND 101 .01 ole 27 A10:1 Z SALLV J WINDER 701 EKING ST SHIPPENSBURG PA g~~;iand col:O;;2 * REY-1547 EX AFP n2-00) NELLIE M Allount Rellitted ) CHANGED (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 9.321.60 .00 .00 (8) MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE1 PA 17013 CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~ RE-,,=is4j-Ex--AF,--fi2'':O()Y-NoYicE--oF-'rNHERITAiicE-YAX-A-PPRAisiMENi'~--Ai:.LOWAirCE-Cri----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF CHAMBERLIN NELLIE M FILE NO. 21 01-0855 ACN 101 DATE 12-17-2001 If an assessment was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. AlIOunt of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. AIIOunt of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due C D TS: AY EN DATE TAX RETURN WAS: (X) ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/AdII. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitab1e/Governllental Bequests; Non-elected 9113 Trusts 14. Net Value of Estate Subject to Tax NOTE: R C IPT NUMBER (-) PAVMENT MUST BE MADE BV 05-11-2002*. (9) (10) 7,821.01 .00 (11) (12) (13) (14) NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax pay.ent. 9,321.60 7 821 01 1,500.59 .00 1,500.59 (19)= .00 67.53 .00 .00 67.53 (Schedule J) .00 X 00 = 11500.59 X 045= .00 X 12 = .00 X 15 = AMOUNT PAID TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE .00 67.53 .00 67.53 . IF PAID AFTER DATE INDICATED1 SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)I YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) STATUS REPORT UNDER RULE 6.12 Date of Death: N~~~lf. 1Yl. ChAYr1~EJf,LLJ rly- JJ J ~fhJ ~ Admin. No.: 0\ - ~ 55 Name of Decedent: Will No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes [Xl No 0 I 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes NoD A-)f~f\)jf:7' LoI\~lO DoThfS b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes 0 NoD c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. ') ...JI ~ "j} _ Date:~O-6tj _rjj~~M~U~ Signature C n It h m r R k, r!, h ltiYl.g ~ R- L tS Name L ,~ \/ S9S ~ rn l C h A E E tv R ~ y e- !N~~A ~A ltt<J~ Address (717) 7~,".1 ;h~Ljg Telephone No. .,;~3 'td "0"-" nI1>'.., "" ;~\eueqUmo ':';fJa'!O LfJ: LLtf [2 lnr li'O. JoS/!k~!J() ~:;J2~B Capacity: ~ Personal Representative o Counsel for personal representative ,. REV-1500 EX . (&<<l) ~'\_~_s- REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT *' PENNSYlVANIA . DEP:::::UE DEPT. 280601 ~~G.PA171~1 DECEDENrS NAIooE (LAST. ARST. AND ..DOlE INITlAL) CHAMBERLIN NELLIE M. DATE OF DEATH (W-OO-VlS) I- Z W Q W (,) W Q DATE OF BIRTH (WIDVea) 0811112001 04124/1910 (IF APPUCABLE) SURVMNG SPOUSE'S NAIooE (LAST. ARST. AND ..DOLE INITIAL) OFRCIAI. USE eN.. y - t:.. --- FLE NUMBER ex \ - 0 \- C 0 8 S 5 '"'55lMTv"'COiiE'" -YEAR- - - iiiiiER- - SOCIAl SEaJRITY NU~R 205-09-5382 THI5 RETURN IIJST lIE FI.ED.. DUPlICATE WITH TIE REGISTER OF WILLS SOCIAl SECURITY NUIlIlER au to- ~~IO U DC~ au lLu :coo U DC...I till C 00 1. ~ilal Relum o 4. I.iniild EsIate o 6. Decedent Died TesIate (AII;Eh copy d WI) o 9. Uiga1ion Proceeds Received o 2. SuppIemen1al Return o 4a.Futureln1ereSt~(_d~"12-12~ o 7. Decedent Mai11ained a Living Trust (AII;Eh ClIpY d TrI.ISI) o 10. Spousal Poverty Credit to. d deaIh ~ 12-31-91 ;nj 1.1-95) o 3. Remai1def Return (cIIlIld"'pnar~ 12-1~ o 5. Federal EsIate Tax Relum Requied _ 8. Total Number of Safe Deposit Boxes o 11. EIedion ~ lax under See. 9113(A) lAlIil:Il ScII 0) 'DE SEC1ION MUST BE COIIPLETED. ALL CORRESPONDENCE AND CONF1DENTIAl. TAX INFORIIAllON SHOUlD BE ___ICU TO: NAJ.E COMPLETE MAIUNG ADDRESS SALLY J. WINDER 701 EAST KING STREET ARM tW.E (If Applicable) to- Z au Q z o IL 10 au DC DC o U TElEPHONE NUt.eER SHIPPENSBURG OFFICIAL USE ONLY z o 5 :;) l- ii: c( (,) w a::: 1. Real ESa1e (Schedule A) (1) 2. SD:ks and Bonds (Schedule B) (2) 3. Closely Hekl Corporation, Partnership or SoIe-ProplieDship (3) 4. MorMes & NoIBs RealivabIe (Schedule D) (4) 5. Cash. Bank Deposits & MisceIaneoos Personal Property (5) (Sd1eduIe E) 6. JoiltIy Owned Property (Schedule F) (6) o SeparaE BiIing Requesled 7. Inter.VIVOS Transfers & MisceIaneoUs ~ Property (7) (Schedule G or L) 8. Total Gross Assets (i>IaIli1es 1-7) 9. Funeral Expenses & Adminis1ra1ive Cosls (Schedule H) (9) 10. DebIs of Decedent. ~ Liabilities. & Liens (Schedule I) (10) 11. Total Deductions (toIaI Liles 9 & 10) 12. Net Value of EmIiI (Lile 8 minus Lile 11) PA 17257 ~ 9,321.60 .::t:> (8) 9.321.60 7,821.01 13. ChariIabIe and Govemmenlal Beques15lSec 9113 TIUS1S for which an eIedion 10 tax has not been (13) made (Schedule J) 14. Net V... Subjlc:t1D Tax (Lile 12 minus Lile 13) SEE INSTRIJCTIONS ON REVERSE SI)E FOR APPUCABLE RATES z o i= c( I- :;) a. :IE o (,) ~ I- 15. Amount of li1e 14 1axabIe at !he spousal lax raE, or transters under See. 9116 (a)( 12) 16. Amount of li1e 14 1axabIe at lineal ra1e x .0_ (15) 1,500.59 X .04.5 (16) 17. Amount of Lile 14 taxable at sibling rate X .12 (17) X .15 (18) (19) 18. Amount of li1e 14 1axabIe at coIIatefal rate 19. Tax Due 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < (11) (12) 7,821.01 1,500.59 (14) 1,500.59 67.53 67.53 Decedenfs Com lete Address: STREET ADORESS 121 WALNUT BOTTOM ROAD CITY SHIPPENSBURG Tax Payments and Credits: 1. Tax Due (Page 1 Uoe 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Disalunt STATE PA ZIP 17257 (1 ) 67.53 338 3. Interest/Penalty if applicable D. Interest E. Penaty Total Credits (A + B + C) (2) 3.38 TotaIlnterestJPenalty ( 0 + E) (3) 4. If Una 2 is greater than Uoe 1 + Uoe 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 10 request a refund (4) 5. If Uoe 1 + Uoe 3 is greater than Uoe 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) 8. Enter the total ci Uoe 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT PlEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN .X. IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income ci the property transferred; ........................................................................... 0 00 b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 00 c. retain a reversionary interest; or ...................................................................................................... 0 00 d. receive the promise fer life ci either payments, benefits or care? ............................................................. D 00 2. If death cx:curred after December 12, 1982, did decedent transfer property within one yeac of death without receiving adequate consideration?................ ......... ........... ........................ ...... ............................. D 00 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. D 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................. ......... ................ ................. ........ ..... ................... D 00 64.15 64.15 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPlETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. IAlder penaIli8& of~, I decIae I1at I hiM! exanined 1his reIUm, including llCCOIllllIlying schedules and staIemenIs. and Illhe best of my knowledge and belief. it is 1rue. correct and lXll11llele. 0ecIir.lli0n of pI1lpinr oIher lhcr1lhe personci Illp1ISeIIliiIi is based on all inbmaIion of which prl!pift!l" has alY knowledge. SlGNAru~~PER~RE~~~~GRETUR~ /J - ~/J CA~ pATE / ~~A~~~ IfltJ/t:tiJq ./7..l.,(P~ II (Io( ADORESS0'5~ J;rv;j~Jh 1).( fNf~ t4- ( . ~~0liU~TIVE, .. - DATEfl 1/ t 6 f 7~1 e ~j fr fPurfY~t~ fA 11)-t:;1 For dates ci death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.$. ~116 (a) (1.1) (i)). For dates ci death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1,1) (iill. The stalJJte does not exemot a mster to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural pcrent, an adoptive pcrent, or a steppa'ent ci the child is 0% [72 P.S. 99116(aX1.2)). The tax rate imposed on the net value of transfers to or fer the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(aX1)). The tax rate imposed on the net value of transfers to or fer the use of the decedenfs siblings is 12% [72 P.S. 99116(a)(1.3)). A sibling is defined, under Section 9102. as an individual who has at least one pcrent in common with the decedent, whether by blood or adoption. __D.~ * COMMONWEAI..TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATEOF CHAMBERLIN NELLIE M IrdJde the proceeds of IiIigation and the _the proceeds were received by the estate. All property jointly~ with the right of survivorship must be disdosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ALLFIRST bank checking account 00971~011-3 in the name of decedent 1,633.00 FIlE NUMBER 2. SHIPPENSBURG HEALTH CARE CENTER. personal account balance 340.00 3. ORRSTOWN BANK, burial trust account, balance as of date of death 7,348.60 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9.321.60 -.,"".,,.,, *' ccu.tONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATEOF FILE NUMBER CHAMBERLIN NELLIE M DebIs of decedent must be reported on Schedule L ITEM NUMBER A. DESCRIPTION AMOUNT 1. 2. FUNERAL EXPENSES: FOGElSANGER-BRICKER FUNERAL HOME, INC., funeral expense FUNERAl DONATION FOR RECEPTION OF FRIENDS AND FAMilY 6,701.90 100.00 B. ADMINISTRATIVE COSTS: 1. PersooaI Representative's Commissions Name of PeISOllal Representative (s) CHAlMER l. CHAMBERLIN 466.11 Social Security Numbef(s) I EIN Number of PefSOOal Representative(s) S1J1let Address 5955 MICHAElE DRIVE City ENOLA State P A Zip 17025 Year(s) Commission Paid: 2001 2. AIIDmey Fees SAllY J. WINDER 500.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Clainant ., Decedent 4. Probate Fees REGISTER OF WillS, letters $39, filing return $14 53.00 5. Aa;oumanl's Fees 6. Tax Return Prepare(s Fees 7. TOTAl (Also enter on line 9, Recapitulation) $ 7 821.01 (If more space IS needed, Insert additional sheets of the same SIZe) _~a.,~ '* cnAotONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER - ItIJ tlJl=l I 11= M RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. CHALMER L. CHAMBERLIN SON ONE-HALF NET 5955 MICHAElE DRIVE ENOLA. PA 17025 2. MARTHA COlDSMITH DAUGHTER ONE-HALF NET 1077 MAYAPPLE DRIVE SHIPPENSBURG, PA 17257 ENTER DOlLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET ll. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART n - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same SIZe) Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/08/2004 WINDER SALLY J 9974 MOLLY PITCHER HIGHWAY SHIPPENSBURG, PA 17257 RE: Estate of CHAMBERLIN NELLIE M File Number: 2001-00855 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 8/11/2004 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/08/2004 CHAMBERLIN CHALMER L 5955 MICHAELE DRIVE ENOLA, PA 17025 RE: Estate of CHAMBERLIN NELLIE M File Number: 2001-00855 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 8/11/2004 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Counsel Judge Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/08/2004 COLDSMITH MARTHA 1077 MAYAPPLE DRIVE SHIPPENSBURG, PA 17257 RE: Estate of CHAMBERLIN NELLIE M File Number: 2001-00855 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 8/11/2004 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Counsel Judge Name of Decedent: STATUS REPORT UNDER RULE 6.12 Date of Death: Will No.: Admin. No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes [] No [--] 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes [--1 No [i] Date: c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. ,('1l/.2 _. P~_. _ ~j~f~,~ &~,__., Signature Address Telephone No. Capacity: ~ Personal Representative ['~ Counsel for personal representative