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HomeMy WebLinkAbout03-0021 PETITION FOR PROBATE and GRANT OF LETTERS //] / kstate of HAROLD a. DeROLPH, No. l/l/~"~also known as HAROLD J. DeROLPH ~:~ ~ To: Register of Wills for the , Deceased. County of CUMBERLAND in the Social Security No. 298223S30 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the executrix named in the last will of the above decedent, dated ,lanuary 251 200t and codicil(s) dated NONE (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decedent was domiciled at death in CUMlaERL&ND County, Pennsylvania, with h is last family or principal residence at 38t t Candle Light DriveI Hampden Township~ Camp HillI Pennsylvania (list street, number and municipality) Decedent, then 74 years of age, died 1/5/03 , at Select Specialty HospitalI 503 N. 21st Street~ Camp HillI PA 17011 Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never ajudicated incompetent: Decedent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ 52,000.00 (If not domiciled in Pa.) Personal property in Pennsylvania $ 0.00 (If not domiciled in Pa.) Personal property in County $ 0.00 Value of real estate in Pennsylvania $ 0.00 situated as follows: WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters TESTAMENTARY thereon. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) Margaret ~. DeRolph, 3811 Candle Light Drive - Camp Hill PA 17011 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Swom to or affirmed an.d, ~ubscribed DECREE OF PROBATE AND GRANT OF LETTERS AND NOW I - ~)-l~ ~00~ , in consideration ofthe petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated 11~'5101 described therein be admitted to prob~,te and filed of record as the last will of HAROLD J. DeROLPH.~I~ //~/,~ ~ and Letters 7®stamentary are hereby granted to MARGARET A, DeROLPH Register of Wills FEES Probate, Letters, Etc ......... $ J l 5-0~ MURREL R. WALTERS, III 024849 Short Certificates ( ,3 ) ...... $ c~. ~)C) ATTORNEY (Sup. Ct. I.D. No.) '~ .~,,% D.~~. '. .... $ ~P' 0 0 54 EAST MAIN STREET ~TC~ $ ~ ~).00 MECHANICSBURG PA 17055 TOTAL_ $ It~O0 ADDRESS Filed.. ! .~. '~0.'~.. .............. {7'7} 697..4650 PHONE "lis is to certiO,' that the inlbrmation here given is correctly copied fi'om an original certificate of death duty l.oc:J Rcgistrar.'The original Cel-tificatc will be fb~arded to the State Vital Records Office for permanent fi WARNING: It is illegal to duplicate this copy by photostat or photograph. [.,,,,,, ~~1 ~?~/ Local Registrar No. ~ Date ~ 2Jr7 COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH STATE ~ILE NUMBER NAME OF OECEOENT (F~rsl M~Ole. L~) ,. H~old J. DeRolph, ~. [~__M~e ,. 298 -- 22 -- 3830 ~. Janu~y 5, 2003 ~. _ , ~ ,. 9-18-1928 Col~b~, OH "~' ~. Cumb~lm~d ~. E~t Pennsboro [,~.,~o~ .... ~,,. White O~C~NrS~U.~,~SS(~.C~.~.Z~C~ [~CE~,*'S Pennsylvania ,..~ ~.~ Hampd~ 3811 Candle Ligh~ Drive ~s,~ - ,,. C~p Hi~, PA 17011 ~o~,~, ,~.~. Cumberland '~"~** ~'~ ,,. H~old B. DeRolph l'" Elizabeth C. Rath ~. M~q~et A. DeRol)h ~ 3811 Candle Light Drive, C~p Hill, PA 17011 ~'~ ~ - Jana~. 8, ~005 ,,~.Penn~tfgvanga Clem~oatf l*,~. ~ag~b~g, PA 17109 13~. O~/~ 1 ~. la~. ~- I~. I~, ,. i~. I~. I~. , I~- ,, - 'MEDIAL ~AMINE~C~ONER (,~2 il ~ ~ Pdnl ~~ /' LAST WILL AND TESTAMENT BE IT REMEMBERED THAT I, HAROLD J. DEROLPH a resident of Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my LAST WILL AND TESTAMENT, hereby revoking any and all Wills and Codicils previously made by me. I I declare that I am married to MARGARET A. DEROLPH, and that I have three (3) children, MARY C. DEROLPH, HAROLD J. DEROLPH, JR., and JOHN R. DEROLPH. II I direct that all my just debts and funeral expenses shall be paid from my residuary estate as soon as practicable after my decease. III I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. IV I give, devise and bequeath all my property, whether real or personal, wherever situate, including any property over which I may have a power of appointment to my wife, MARGARET, provided that she survives me by thirty (30) days. V If my wife, MARGARET, shall predecease or fail to survive me by thirty (30) days, I give, devise and bequeath all of my property, whether real or personal, wherever situate, including any property over which I may have a power of appointment to my children, MARY, HAROLD, and JOHN, in equal shares, per stirpes. VI It is my desire that MURREL R. WALTERS, III be retained as attorney for estate administration purposes because he is well acquainted with my affairs. VII I nominate, constitute and appoint my wife, MARGARET A. DEROLPH, as Executrix of this LAST WILL, to serve without bond. If my wife is unable or unwilling to act in that capacity, then I nominate, constitute and appoint my son, HAROLD J. DEROLPH, JR., as Executor of this LAST WILL, to serve without bond. IN WITNESS WHEREOF, I, HAROLD J. DEROLPH, have set my hand to this LAST WILL this ,,~,f" day of ~,,_o ,2001. Signed, sealed, published and declared by the above-named HAROLD J. DEROLPH, as and for his Last Will and Testament, in the presence of us, ~tffo, at his request and in his presence, and in the presence of each other, have/l~(ereunto subscribed our names as witnesses. . ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA : SS. COUNTY OF CUMBERLAND : I, HAROLD J. DEROLPH, Testator, whose name is si~T~ed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my LAST WILL; that I signed it as my free and voluntary act for the purposes therein expressed. ~-IXROLI~. D E'R~I~PH Sworn or affirmed to and acknowledged before me by HAROLD J. DEROLPH, Testator, this ~ff ~- day of ~~ ~ , 2001. Notary Public Dlalle M. $ ':" ~ ?~', ~ubllC J Mechanicsbur~ F ",be, ~d Col~_ J My Coltirtlisslor ! :~ -, ,~ 22, 2004 J AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA : SS. COUNTY OF CUMBERLAND : the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as his LAST WILL, that HAROLD d. DEROLPH signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the be;~t o,9,f-our knowledge, the Testator was at the time 18 years of,~ge or m~re, of so/flj~ mind and under no constraint or undue influence. ~ .~~ ,,~//~/~ Sworn or affirmed to and acknowledged before me this ~P~- day of ~ ,2001. Notary Public 3 j Notarial Seal J , Diane M. Smith, Notary Public J ~veCn..anicsburg Bo_ro, Cumberland Courtly j y uommiss~on ~-xpires june 22, 2004 HAROLD J. DEROLPH MURREL R. WALTERS, III ATrORNEY AT LAW 54 EAST MA1N STREET MECItANICSBURG, PENNSYLVANIA 17055 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Harold J. DeRolph, Sr. Date of Death: January 5, 2003 Will No. 2003-0021 Admin. No. 21-03-0021 To the Register: I certify that notice of (beneficial interest) 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 April 21, 2003 Name Address , Margaret A. DeRolph 3811 Candle Light Drive // Camp Hill, PA 17055 // Notice has now been given to all persons entided thereto under ~e 5.6(~cept: None Date: April 21, 2003 54 East Main Street Mechanicsburg, PA 17055 (717) 697-4650 Capacity: __ Personal Representative X Counsel for personal representative Cumberland County Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 12/01/2004 WALTERS MURREL R III 54 E MAIN STREET MECHANICSBURG, PA 17055 RE: Estate of DEROLPH HAROLD J File Number: 2003-00021 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: 1/05/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, GLENDA FARNER STP~ASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION STATUS REPORT UNDER RULE 6.12 Name of Decedent: HAROLD J. DeROLPH, SR. Date of Death: January 5, 2003 Esl:ate No.: 2003-00021 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 (date) 3. If the answer to No. 1 is yes, state the following: A. Did the personal representative file a final account with the court? Yes No X B. The separate Orphans' Court No. (if any) for the personal representative's account is: (Not Applicable in Dauphin County) C. Did the personal representative state an account informally to the parties in interest: Yes X No Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Cour/t/find may be attached to this report. ~~ MURREL R. WALTERS, III, E~UIRE 54 East Main S~eet Mechanicsburg, PA 17055 717-697-4650 Capacity: Personal Representative __X__ Counsel for Personal Representative REV-1500 EX + (&-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY '* I- Z W o W U w o W I- ll:~1I) U O::ll: wg;u :I:o::g U a..m a.. <C z o i= 0( ..oJ ::) !:: D- o( U W ~ z o i= 0( I- ::> D- :E o U ~ I- FILE NUMBER 21 -03 o 0 2 1 ""CoUNTY'CoDE ---YEA~ - - NuMsER- - DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER DEROLPH, SR. DATE OF DEATH (MM-DD- Year) HAROLD 2 9 8 - 2 2 - 3 830 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS J. DATE OF BIRTH (MM-DD-Year) 01/05/2003 09/18/1928 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 1Kl1. Original Return D 4, Limited Estate IKl 6. Decedent Died Testate (Attach copy 01 Will) D 9, Litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise (date 01 death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach copy ofTrust) D 10. Spousal Poverty Credit (date 01 death between 12-31-91 and 1-t-95) D 3. Remainder Return (date 01 death prior!o 12-13-82) D 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Sch O) I- Z W C Z o a.. II) w 0:: 0:: o U NAME MURREL R. WALTERS III FIRM NAME (If Applicable) COMPLETE MAILING ADDRESS 54 EAST MAIN STREET TELEPHONE NUMBER 717-697-4650 MECHANICSBURG PA 17055 OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) g C., 51,400.00 ..,;~.' c:; c:.~.. CJ 51,400.00 605.00 50,795.00 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 50,795.00 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 50,795.00 X 0.00 (15) 0.00 16. Amount of Line 14 taxable at lineal rate X _(16) X .12 (17) X .15 (18) (19) 0.00 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: S1'REET ADDRESS 3811 CANDLE LIGHT DRIVE CITY STATE PA ~ CAMP HILL ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check to: REGISTER OF WILLS, AGENT 0.00 0.00 0.00 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 of the property transferred; ........................................................................... D IX] b. retain the right to designate who shall use the property transferred or its income; ........................................ D IX] c. retain a reversionary interest; or ...................................................................................................... D IX] d. receive the promise for life of either payments, benefits or care? ............................................................. D IX] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................. D IX] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. D IX] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... D IX] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ADDRESS ....c " PA 17055 DATE (' tJ of c. 0 ""'7 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exempt a transfer 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 parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116{a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~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, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (6-98) '. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF DEROLPH. SR. FILE NUMBER HAROLD J. 21 03 Include the proceeds of litigation and the date the proceeds were received by the estate, All property jointly-owned with right of survivorship must be disclosed on Schedule F. 0021 ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 38,000.00 CITIZENS BANK SAVINGS ACCOUNT 2. NATIONWIDE IRA - BENEFICIARY - MARGARET .I. DEROLPH 13,400.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 51,400.00 REV-1511 EX + (12-99) 'W COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER DEROLPH. SR. HAROLD J. 21 03 0021 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. CREMATION SOCIETY OF PENNSYLVANIA - PREPAID B ADMINISTRATIVE COSTS: 1 Personal Representative's Commissions Name of Personal Representative (s) MARGARET J. DEROLPH (COMMISSION RENOUNCED) Social Security Numbe~s)/EIN Number of Personal Representative(s) Street Address 3811 CANDLE LIGHT DRIVE City CAMP HILL State P A Zip 17011 Year(s) Commission Paid: 2. Attorney Fees MURREL R. WALTERS III, ESQUIRE 350.00 3. Family Exemption: (If decedent's address is not the same as claimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees REGISTER OF WILLS - CUMBERLAND COUNTY 155.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 505.00 (If more space is needed, insert additional sheets of the same size) REV-1512 EX;- (6-98) '* SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DEROLPH. SR. FILE NUMBER HAROLD J. 21 03 0021 Include unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH BURICK AZIZKHAN INTERNAL MEDICINE ASSOCS. MEDICAL 100.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 100.00 RC'.'''~8<'I~'' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES DEROLPH SR. HAROLD .1. FILE NUMBER 21 n~ RELATIONSHIP TO DECEDENT Do Not List Trustee(s) 0021 AMOUNT OR SHARE OF ESTATE 1. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] MARGARETJ.DEROLPH 3811 CANDLE LIGHT DRIVE CAMP HILL, PA 17011 WIFE 100% NUMBER I. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRIS8URG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE ~-'- "MDTICE OF INHERITANCE TAX AP~r~EMENT, ALLOWANCE OR DISALLOWANCE OF D~DUCTIONS AND ASSESSMENT OF TAX -'.j *' REV-1547 EX AFP (06-05) DATE 01-14-2008 ESTATE OF DEROLPH SR HAROLD J DATE OF DEATH 01-05-2003 FILE NUMBER 21 03-0021 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 03-14-2008 ( See reverse side under Objections) A.ount Remittedl l MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 f~!_~~~~~_!~!~_~!~~______~___~~!~!~_~Q~~~_~Q~!!Q~_~Q~_!Q~~-~~~Q~~~--~-------------------- REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF DEROLPH SR HAROLD J FILE NO. 21 03-0021 ACN 101 DATE 01-14-2008 ,~ ..... ( , ,,, )" r MURREL R WALTERS I I I 54 E MAIN ST MECHANICSBURG PA 17055 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 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) (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 51.400.00 .00 .00 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 8. Total Assets (8) 51,400.00 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (9) CIO) 505.00 100.00 (11 ) CI2) CI3) Net Value of Estate SUbject to Tax CI4) 601i.00 50,795.00 .00 50,795.00 11. 12. 13. 14. Total Deductions Net Value of Tax Return Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: PAYMENT DATE CI9)= .00 .00 .00 .00 .00 RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID (-) CIS) 50,795.00 X (16) .00 X CI7) .00 X CI8) .00 X AMOUNT PAID 00 = 045 = 12 = 15 = TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE .00 .00 .00 .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. ('-L IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DU~ U A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)