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Home My WebLink About04-0673 PETITION FOR PROBATE and GRANT OF LETTERS also known as To: Register of Wills for the ~ Deceased. County of Social Security No. ~ ~- ~- ~6 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older ~ the execut~ in the last wilt of the above decedent, dated ~ o ~ ~ ~ ~ ~ ~d codicil(s) dated in the named ,19. (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in (l~, ~ L,n--~.~ County, Pennsylvania, with h [~ last f~ily or principal residence a~c ~ (list strut, number ~d muncipality) ~en~, th~n ~ yea~ of age, died ~%~ '~,~ 1~ at ~ ~ C'~ >c~.~c[~ ~_~ ~. ....... '-. , ~ Except as follows, decedent did not marry was n~' n~-~ 7,~¢tv~ ~/., /~,cf . ,, ~ u,vurcca ann ~lO not have a child born or ~opted after execution of thc will offered for probate; was not the victim of a killing and was adjudicated incompetent: never ~cendent 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 situated as follows: WHEREFORE, petitioner(s) respectfully renuest(s) the pr~obate of the last will and codicil(s) presented herewith and the grant of letters t~eron. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) OATH OF PERSONAL REPRESENTATIVE ~'~:' COMMONWEALTH OF PENNSYLYANIA · COUNTY OF ~ ~ ~ ~Xc-~,_9~ ~c,o)~ ~ ~ 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. Sworn to or affir _ and suhscribed ta.a befor~ne, this . ]C~'% day of ~ WILL of John C. Palmer, Jr. I, Jolm C. Palmer, Jr. of Cumberlattd, Pennsylvania, all other Wills. declare~is to be my Will mad revoke ARTICLE I I authorize my Personal Representative to pay such sums as my Personal Representative deems proper for my cremation or burial and interment, including the disposition of the ashes orthe acquisition of any burial site and the erection and engraving of monuments and markers, regardless of any limitation fixed by statute or rule of court and without order of court. (A) My Personal Representative shall make the following dism~outions to the following in~wations, and to the following persons who survive me: 1992 Jeep Cherokee to my sister - Kathy Leib; coin collectioin to Ashley N. Kelly and Kaitlyn M. Kelly, my neices - equally; all of my Pittsburg Steelers memon~oila. Mark Hubbard, all personal items in the gargage of my mothers house goes to the Boy Scoutrs of America - Keystone Chapter. (B) My Personal Representative shall distn~oute the rest of my tangible personal property not disposed of in Paragraph (A) of this Article II, or all of my tangible personal property if there are no specific bequests oftangfole personal property, as a part of the rest of my estate. ARTICLE HI I give the rest of my property to the following beneficiaries in the following proportions: A.) Shall be given to my mother - Doris Palmer. ARTICLE 1V The provisions in this Will for the distn~oution of my estate shall be supplemented by the following: (A) My Personal Representative shall pay all taxes (including inheritance taxes) owed because of my death (including any interest and penalties) out of the residue of my estate. My Personal Representative shah create out of the residue a separate fund for the purpose of paying state inheritance taxes in the amount necessary to pay said inheritance taxes. The payment of the taxes shall be made regardless of whether the taxes are owed on property passing under this Will or outside of this Will and regardless of whether the taxes are owed by my estate or by any beneficiary. My Personal Representative shall not be entitled to reimbursement from any beneficiary for the payment of the taxes. (B) Each beneficiary shah be deemed not to have sarvived me unless the beneficiary is living on the thirtieth day al~er the date of my death. (C) Whenever any beneficiary of my estate is under a legal disability or, in the judgment of my Personal Representative, is for any reason unable to apply any distribution to the beneficiary's own best advantage, my Personal Representative may nevertheless make the distribution directly to the beneficiary or to the conservator of the beneficiary's property or to a person with whom the beneficiary resides at the time of the distribution in whatever manner my Personal Representative shall deem best. In the alternative and if the beneficiary is under twenty-one years of age, my Personal Representative may, in the discretion of my Personal Representative, distribute the property to a custodian for the beneficiary under a Uniform Transfer or G-~ to Minors Act. The receipt by the beneficiary, conservator, custodian or other person of any distn"oution so made shall be a complete discharge to my Personal Representative regarding the distribution. ARTICLE V In addition to the existing authority of my Personal Representative, my Personal Representative may: (A~ Sell or grant options with respect to any real or personal property in such manner, for such purposes, for such prices, and upon such terms, credits and conditions as nmy be deemed advisable. (B) Make any dix4~ion or dism~outiun of my residuary estate in money or in other property or partly in both upon the basis of fair market value and cause any share to be composed ofmuney, property or undivided fractional share in property, different in kind from any other share. (C) Permit any beneficiaries of my estate to use any tangl~ole personal property or real property, without paying any rent, without giving any bond or security and without liability for any loss or damage. My Personal Representative shah not be liable or responsible for any injury to, consumption of or loss of any such property so used. (D) Take charge of any real property as part of the probate administration of .my estate for such period as my Personal Representative shall dete~mine; collect any income therefrom; and pay the taxes and expenses thereot~ including the cost of keeping such prnperty in adequate condition and repair, in the m0nner and to the extent that my Personal Representative shall deem advisable. ARTICLE VI (A) Iappoint Karen L. Kelly - my sister, as Personal Representative of my estate. If such Personal Representative shall fail to qualify or cease to act as Personal Representative, I appoint the following persons or bank or trust company as alternate or successor Personal Representative to serve in the order specified below, and if the first alternate Personal Representative shall fail to qualify or cease to act as Personal Representative, the second alternate Personal Representative shall serve as Personal Representative. Kathrya Le~b - First alternate Frank H. Kelty, EA - Second alternate To the extent perm~ed by law, my Personal Representative shall be authorized, in the discretion of my Personal Representative, to have my estate adm/nistered without adjudication, order or direction of the court having jurisdiction over my estate. hereunder. No bond or surety shaH be required of any Personal Representative serving (42) Throughout this Will the use of any gender shall be deemed to include all genders, and the use of the singular the plural, and vice versa. The terms "child" and "descendant" shall include an adopted person and such adopted person's descendants, i~ but only ~ the adopted person is not more than twelve years of age on the date of the court order granting such adoption. (D) At the date of execution hereot~ I have the following children who are now living: None. (E) The appointment ora corporate Personal Representative shall include the appointment of its successor or successors by any merger, conversion or consolidation. (F) While serving hereunder, the corporate Personal Representative shah receive compensation for its services according to its published schedule of charges in effect at the time such services are rendered. the Testator, sign my name to this instrument this ~ ~' day of and being first duty sworn, do hereby declare to the undersigned authority that I sign and execute this instrument as my will end that I sign it willingly (or willingly direct another to sign for me), that I execute it as my fi'ee and voluntary act for the purposes expressed in the ~ and that I am eighteen years of age or older, of sound mind, and under no constraint or undue influence. ~ohn C. Plainer, Jr. We, the witnesses, at the Testator's request, sign our names to this instrument, being first duly sworn, and do hereby declare to the undersigned authority that the Testator signs end executes this instrument as the Testators will and that the Testator signs it willingly (or willingly directs another to sign for the Testator), and that each of us, in the presence and hearing of the Testator, hereby signs this will as witness to the TestatoPs signing, and that to the best of our knowledge the Testator is eighteen years of age or older, of sound mind, and under no constraint or undue influence. Witness State of County of We, the Testator and the wim¢~, -respectiveiy, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as the Testators will and that the Testator had signed willingly (or willingly directed another to sign for tha~Testator), and that the Testator executed it as the Testatur's f~ee and voluntary act for the purposes expressed in the wi/l, and that each of the witnesses, in the pr. esence and hearing of the Testator, ~md at the request of the Testator, signed the will as w~tness and that to the best of the witnesses' knowledge the Testator was at that time eighteen years of age or older, of sound mmd, and under no constraipt or ~due influence. John {~Plamer -- Witness Wimess Wimess Subscribed, sworn to and acknowledged before me by, John C. Hamer, Jr., the Testator, and subscribed and ~worn to before me by ~)~'~ t~m,,~ , and ](a.t'~.,v//1~ ' , witnesses, this day of (Seal) 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: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 zOo3, No. ~ ~Date 52 Vr, Dauphin Co. ,picture framing 4006 Gettysburg Rd. ^cTu^t RESIDENCE Camp Hill, PA 17011 is, m~, John C. Palmer,sr. Karen Kelly 2004 Local Registrar 2 G 2004 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH John C. Palmer, Jr. 94 -44 ~036 's ~,~ ~hite . ~004 , Cmll~rlit.,'l~, PA17070 ~p ~t. 324 H~i Ave. Year) ~ERFORMED? CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Date of Death: Q9 - a 3- {~k'l To the Register: I certify that notice of (beneficial interest) g~lj~ltll.l~t~ 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 : Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Signature 7 Telephone( )'")1"3 Capacity: ~ Personal Representative Counsel for personal representative Cumberland County - Reglster Ot Wllls One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 4/25/2006 KELLY KAREN L 240 POPLAR AVENUE NEW CUMBERLAND, PA 17070 RE: Estate of PALMER JOHN C JR File Number: 2004-00673 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. 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 is due by: 6/23/2006 please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, IA I ~ 1~-,j~wJ G~ner St~- Clerk of the Orphans' Court cc: File Counsel Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 .- Name of Decedent: ~hf\ C-. 5?o....\iY\.Qf' --Sr~ I Date of Death: ~ ,- d 3 - oy Estate No.: 9../ - 0 t.{ - &;7 ~ 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 ~l}pther administration of tl?-e estate is complete: Yes l!j No 0 ~/ -~JO~ 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 person~e~sentative file a final account with the Court? Yes 0 No LY" b. The separate Orphans' Court No. (if any) for the personal representative's account is: iJ J A c. Did the person~resentative state an account informally to the parties in interest? Yes lfll No 0 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. ~J :3 J 0 &/ 'Cn,WIn Signature ~ l(QO~ \ Date: KQ~, Name ,JCHJ Address L. Kel\1 ?~\Qr ~ f\JL p~ '~: :;. , . Capacity: lll-IJ4-IS~ 3~ yephone No. 6 Personal Representative o Counsel for personal representative ll\ RE: ESTATE OF PALMER JOHN C JR ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO. 2004-00673 NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A HEARING P~URSUANT TO RULE 6.12, SUPREME COURT ORPHANS' COURT RULE Personal Representative: KELLY KAREN L Counsel for Personal Representative: Date of Decedent's Death: 6/23/2004 Date of Delinquency Notice: 7/11/2006 The undersigned, Glenda Famer-Strasbaugh, Clerk of Orphans' Court, in accordance with Rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of Common Pleas of Cumberland County, that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status Rep0l1 required by Rule 6. 12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orphans' Court Rules was given on the above date and that the ten (10) day notice to file the Status Report has expired. Accordingly, in accordance with Rule 6.12 the Court is hereby notified of such delinquency and the undersigned requests that a Court conduct a hearing to detem1ine whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. Date: 7/24/2006 ~dL~~~~ . ,~/ Glenda Farner Strasbaugh Clerk of the Orphans' Court Distribution: Personal Representative Counsel for Personal Representative Estate File A hearing is scheduled October 2. 2006 (aU I A.M. in Courtroom NO.3. If the Status Report is filed prior to automatically be cancelled. ... . Glenda Farner Strasbaugh Register of Wills and Clerk of Orphans' Court Marjorie A. Wevodau First Deputy Kirk S. Sohonage, Esq Solicitor Register of Wills and Clerk of the Orphans' Court County of Cumberland One Courthouse Square Carlisle, PA 17013 (717) 240-6345 FAX (717)240-7797 - INVOICE Bill To: InvoiceNo: Invoice Date: Estate of: Estate No: 988 8/4/2006 TOHNPAl1vIER TR 21-04-0673 KELLY FINANOAL SERVICES INC 400 BRIDGE ST JA NEW CUMBERLAND, P A 17070 Qty 1 Fee Description Additional Probate Fee Total $20.00 20.00 Total: $20.00 --- ~-- ,0 r'I~(){)(jJ ~1 / /~~I ,u1.-,tf I" ~)~ ct - Checks should be made payable to the Register of Wills. Terms: Net 30. Please return one copy of this invoice with your payment. Thank you. _J 15056041169 REV-1500 EX (06-05) PACep3rtrrent of Revenue Bureau of Individual Taxes FQ E'Dx 28C€01 f-Brrisburg, PA 17128-C601 ENTER DECEDENT INFORMATION BELOW Soc al Security Number Date of Death OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT 0).1 Ol( (~'73 Date of Birth 194.44.8036 06232004 08261951 Decedent's Last Name Suffix Decedent's First Name PALMER JR JOHN MI C (If Applicable) Enter Surviving Spouse's Information Below SpolJse's Last Name Suffix Spouse's First Name MI SpolJse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FilL IN APPROPRIATE BOXES BELOW [Xl Original Return 0 2. Supplemental Return 0 3. Remainder Return (date of death prior to 12-13-82) 0 4 limited Estate 0 4a Future Interest Compromise (date of 0 5. Federal Estate Tax Return Required death after 12-12-82) 0 6 Decedent Died Testate 0 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death 0 11 Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number FRANK H. KELLY, EA 717.774.7536 Firm Name (If Applicable) REGISTER OF WILLS USE ONLY KELLY FINANCIAL SERVICES, INC. First line of address 400 BRIDGE STREET Second line of address City or Post Office State ZIP Code DATE FILED NE:;\I CUMBERLAND PA 17070 Correspondents e-mail addressFRANKKELLY@KELLYTAX.COM Under penalties of perjury, I declare that I have examined thiS return, including accompanying schedules and statements, and to the best of my knowledge and belief, It IS Vue, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE A~'f~~:. . /\yY-U,o"l (If '" , \ s~cy. TURE l ADD'<E " ,,-. " '-1(, DATE PLEASE USE ORIGINAL FORM ONLY Side 1 L_ 15056041169 15056041169 --1 _J 15056042160 REV-1500 EX Decedents Name JOHN C PALMER JR RECAPITULATION 1. Real estate (Schedule A) . 2. Stocks and Bonds (Schedule B) . 3 Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 3. 5 Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 4 Mortgages & Notes Receivable (Schedule D) . 4. 6 Jointly Owned Property (Schedule F) D Separate Billing Requested 7 Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) D Separate Billing Requested 8 Total Gross Assets (total Lines 1 - 7) . 9 Funeral Expenses & Administrative Costs (Schedule H) . 10 Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . 11. Total Deductions (total Lines 9 & 10) . 12 Net Value of Estate (Line 8 minus Line 11). 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) . 14 Net Value Subject to Tax (Line 12 minus Line 13) 10. 11. 12. 13 14. Decedent's Social Security Number 194.44.8036 2. 5 10,666.00 6. 7. 0.00 8. 10,666.00 12,849.00 6,923.00 19,772.00 (9,106.00) 9 (9,106.00) TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15 Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(12) x .0 16. Amount of Line 14 taxable at lineal rate x .0 17. Amount of Line 14 taxable at sibling rate x .12 18 Amount of Line 14 taxable at collateral rate x .15 19 TAX DUE 15. 16. 17. 18. 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L. 15056042160 0.00 D 15056042160 --.J REV-1500 EX Page 3 File Number 2 1 - 0 4 - 6 7 3 Deced.~nt's Complete Address: DECEDENT'S NAME JOHN C PALMER JR STREET ADDRESS 4006 OLD GETTYSBURG ROAD CITY 1 STATE I ZIP CAME' HILL PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 0.00 Total Credits (A + 8 + C) (2) 0.00 3. Intere,tlPenalty 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. Fill in box on Page 2, Line 20 to request a refund. (4) 0.00 5 If Line 1 I Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due 8. Enter the total of Line 5 -i- 5A. This is the BALANCE DUE. (5A) (5B) 0.00 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 a. retain the use or income of the property transferred; . b. retain the right to designate who shall use the property transferred or its income; . c. retain a reversionary interest; or . d receive the promise for life of either payments, benefits or care? 2. If death occurred 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 security at his or her death? . 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . Yes D D D D No lli1 o o o D D lli1 lli1 [Xl D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent [72 PS s9116(a)(U.)(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 zero (0) percent [72 PS S9' 16(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 zero (0) percent [72 PS s9116(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 four and one-half (45) percent, except as noted in 72 PS S9116(1.2) [72 PS S9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. s9116(a)(U)]. 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-1502 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE - - ESTATE OF FILE NUMBER JOHN C PALMER, JR 21-04-673 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchange between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITE~ NUMElER DESCRIPTION VALUE AT DATE OF DEATH NONE I TOTAL (Also enter on line 1, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 8 STOCKS & BONDS ESTATE OF JOHN C PALMER, JR FILE NUMBER 21-04-673 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMI3ER DESCRIPTION VALUE AT DATE OF DEATH NONE ~ , TOTAL (Also enter on line 2, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRI ETORSHI P ESTATE OF FILE NUMBER JOHN C PALMER, JR 21-04-673 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMI3ER DESCRIPTION VALUE AT DATE OF DEATH NONE TOTAL (Also enter on line 3, Recapitulation) S (If more space IS needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) COM~10NWEAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF JOHN C PALMER, JR 1. Name of Corporation N ON E FILE NUMBER 21-04-673 State of Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer 1.0. Number Business Reporting Year 3. Type of Business Product/Service 4. ST OCK TYPE TOTAL NUMBER OF PAR VALUE NUMBER OF SHARES VALUE OF THE Voting/Non-Voting SHARES OUTSTANDING OWNED BY THE DECEDENT DECEDENT'S STOCK 1m on $ erred $ Con Pre! Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? If yes, Position Annua[ Salary $ . DYes DNa Time Devoted to Business 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness S .. DYes DNo 7. Was there life insurance payable to the corporation upon the death of the decedent? . . DYes D No If yes, Cash Surrender Value $ Net proceeds payable S Owne' of the policy 8. Did the decedent sell or transfer any stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes D No If yes, D Transfer D Sale Number of Shares Transferee or Purchaser Consideration S Date Attach a separate sheet for additional transfers and/or sales 9 Was there a written shareholder's agreement in effect at the time of the decedent's death? . If yes, provide a copy of the agreement. . . DYes DNo 10. Was the decedent's stock sold? If yes, provide a copy of the agreement of sale, etc. . . . . . . . . . . . . . DYes D No 11. Was the corporation dissolved or liquidated after the decedent's death? . . . . . . . . . . DYes D No [f yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? . . . . DYes D No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been ~,ecured, attach copies D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of diVidends paid each year. List those declared and unpaid. G Any other Information relating to the valuation of the decedent's stock (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF JOHN C PALMER, JR 1. Name of Partnership NONE FILE NUMBER 21-04-673 Date Business Commenced Address Business Reporting Year City State Zip Code 2. Federal Employer 1.0. Number 3 Type of Business Product/Service 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ B. PARTNER NAME PERCENT PERCENT BALANCE OF OF INCOME OF OWNERSHIP CAPITAL ACCOUNT 5. A. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? If yes, provide amount of indebtedness $ .......... DYes DNo 8 Was there life insurance payable to the partnership upon the death of the decedent? . . . . . . . . . . . . 0 Yes 0 No If yes, Cash Surrender Value S Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31..82? DYes DNo Transferee or Purchaser If yes, DTransfer DSale Percentage transferred/sold Consideration S Date Attacr a separate sheet for additional transfers and/or sales. 10 Was there a written partnership agreement in effect at the time of the decedent's death? . . . . . . 0 Yes 0 No If yes, provide a copy of the agreement. 11 Was the decedent's partnership interest sold? . . . . . . . DYes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? . . . . . 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? If yes, explain DYes DNo 14. Did the partnership have an interest in other corporations or partnerships? . . . .. . DYes DNo If yes. report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s If real estate appraisals have been secured, attach copies o Any other information relating to the valuation of the decedent's partnership interest. I SCHEDULE D MORTGAGES & NOTES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT --- -- -- --------- -------------------- -------- ESTATE OF REV-15CJ7 EX+ (6-98) JOHN C PALMER, JR FILE NUMBER 21-04-673 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMI3ER DESCRIPTION VALUE AT DATE OF DEATH NONE TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-15G8 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JOHN C PALMER, JR FILE NUMBER 21-04-673 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. ITEM NUM[3ER 1. 2. 3. DESCRIPTION M&T BANK CHECKING 67195040 M&T BANK SAVINGS 15004208556992 PERSONAL PROPERTY TOTAL (Also enter on line 5, Recapitulation) I $ (If more space is needed, Insert additional sheets of the same size) VALUE AT DATE OF DEATH 9,569 922 175 10,666.00 REV~1509 EX+ (6~98) COMr~ONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF JOHN = PALMER, JR FILE NUMBER 21-04-673 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A NONE B. C JOINTLY-OWNED PROPERTY: LETTER DATE DeSCRIPTlO~ %OF DATE OF DEATH ITeM FOR JOINT I,ADE INCLUDE NAME OF . NUMBeR OR SIMiLAR DATE OF DeATH DEWS VALUE OF NUMBER 'B,A~T JOI~T IDENTIFYING NUV,BEil FOR VALUE OF ASSET INTEREST DECEDE,~T S INTEReST 1 A. I I I I I I I i I I I _L~ I TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF JOHN C PALMER, JR FILE NUMBER 21-04-673 DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDEIH AlID DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST [IF APPlIcAaLEI VALUE 1, IRA - PUTNAM FUNDS - 3706 100 3,706 0.00 I I I I I I I I I I I I i L TOTAL (Also enter on line 7, Recapitulation) $ 0.00 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. (If more space is needed, insert additional sheets of the same size) REV-1511 E.<+ (12-99) N,^ I COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT - - -- ----- ---.--..---- --------.-----..- ESTATE OF JOHN C PALMER, JR SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS n_ I _ FILE NUMBER 21-04-673 Debts of decedent must be reported on Schedule I. ITEM NUMBER A 1 DESCRIPTION FUNDERAL EXPENSES MUSSLEMAN FUNERAL HOMES, INC, LEMOYNE PA AN OLDE TOWNE FLORIST NCE CUMBERLAND PA CASKET SPRAY 2. B. ADMINISTRATIVE COSTS Personal Representative's Commissions Name of Personal Representative(s) KARE N L KE L L Y Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 240 PO PLAR AVE City NEW CUMBERLAND Year(s) Commission Paid 2 0 0 6 State P A ZIP 1 7 0 7 0 2. Attorney Fees 3 Family Exemption (If decedent's address is not the same as claimant's, attach explanation) Claimant DORI S L PALMER Street Address 4006 OLD GETTYSBURG ROAD City CAMP HILL Relationship of Claimant to Decedent MOT HE R State P A ZIP 1 7 0 11 4. Probate Fees Accountant's Fees 6. Tax Return Preparer's Fees 7. 8. PREP OF FINAL FEDERAL, STATE AND LOCAL TAX RETURN WAKE AND FOOD EXPENSES - COAKLEYS TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) AMOUNT 5,579 194 533 3,500 1,500 275 1,268 12,849.00 REV-15~2 EX+ (12-03) COMr~ONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF JOHN C PALMER, JR FILE NUMBER 21-04-673 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including un reimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUEAT DATE OF DEATH L . MBNA ANDREWS & PATEL, CAMP HILL PA FRANK KELLY - HANDICAPPED HANDRAIL TO HOUSE 4,937 25 1,961 -, -':=1. TOTAL (Also enter on line 10, Recapitulation) $ 6,923.00 (If more space is needed. insert additional sheets of the same size) REV~ 1513 EX+ (9~OO) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES 1. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec.9116(a)(1.2)] DORIS L. PLAMER 4006 OLD GETTYSBURG ROAD CAMP HILL PA 17011 FILE NUMBER 21-04-673 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE ESTATE OF JOHN C PALMER, JR NUMBER I MOTHER 100% 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART Il- 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) REV-15-,4 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ..1 RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN _~he_ck Box 4 onl3~V-1~QQS:over Sheet) ESTATE OF JOHN C PALMER, JR FILE NUMBER 21-04-673 This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. [Xl WiI I o Intervivos Deed of Trust o Other I LIFE ESTATE INTEREST CALCULATION I NAME(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH LIFE ESTATE IS PAYABLE NONE o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which life estate is payable 2. Actuarial factor per appropriate table. Interest table rate - 03 1/2% 06% 010% OVariable Rate 3. VaIUl~ of life estate (Line 1 multiplied by Line 2) $ % s I ANNUITY INTEREST CALCULATION I NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which annuity is payable 2. Check appropriate block below and enter corresponding (number) Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) OQuarterly (4) OSemi-annually (2) OAnnually (1) 3 Amount of payout per period 4. Aggregate annual payment, Line 2 multiplied by Line 3 5 Annuity Factor (see instructions) Interest table rate - 0 31/2% 06% 010% OVariable Rate 6 Adjustment Factor (see instructions) 7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period paycut is at end of period, calculation is: Line 4 x Line 5 x Line 6 . s OMonthly (12) OOther( ) $ % s If using variable rate and period payout IS at beginning of period, calculation is: (Lin.~ 4 x Line 5 x Line 6) ~ Line 3 s NOTE The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18 (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L REMAINDER PREPAYMENT OR INVASION OF TRUST PRINCIPAL FILENUMBER 21-04-673 REV-1644 EX+ (3-04) I. ESTATE OF Pi"lLMER JOHN C (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on B. Name(s) of Life Tenant(s) or Annuitant(s) NONE (Date) Date of Birth Age on date of election Term of years income or annuity is payable C Assets: Complete Schedule L-1 1. Real Estate. $ 2. Stocks and Bonds . . . . . . . . . $ 3. Closely Held Stock/Partnership ....... . $ 4. Mortgages and Notes. . . . $ 5. Cash/Misc. Personal Property. . $ 6. Total from Schedule L-1 . . . . ...... . 0 Credits: Complete Schedule L-2 1. Unpaid Liabilities . . . . . . . . $ 2. Unpaid Bequests $ 3. Value of Unincludable Assets. . ...... . $ 4. Total from Schedule L-2 . . . . . . . . . . . . . . . S E Total Value of trust assets (Line C-6 minus Line 0-4) .. . $ - . . . $ F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (Line E x Line F) (Also enter on Line 7, Recapitulation) .................... $ III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) or Annuitant(s) Date of Birth Age on date corpus consumed Term of years income or annuity is payable C. Corpus consumed D. Remainder factor (see Table I or Table II in Instruction Booklet) E. Taxable value of corpus consumed (Line C x Line D) (Also enter on Line 7, Recapitulation) . . . . . . . . . $ . . $ REV-1647 EX+ (9-00) SCHEDULE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT (Check_B~x 4a on Re,,-1500 Cover Sheet) ESTATE OF FILE NUMBER JOHN C PALMER, JR 21-04-673 This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. [Xl Will 0 Trust 0 Other '1BenCfid",e, r I r i ~ 11. F'or decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. o Unlimited right of withdrawal 0 Limited right of withdrawal ~iEXPlanation of Compromise Offer: I NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY '1. N/A 2. :3. ~. :5. IV. Summary of Compromise Offer: 1. Amount of Future Interest. . . . . . . . . . . . $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) $ 3 Value of Line 1 passing to spouse at appropriate tax rate Check One 0 6%, 0 3%, 0 0% ............ $ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One 0 6%, 0 4.5% $ (also include as part of total shown on Line 16 of Cover Sheet) 5 Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) $ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) $ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) :;; (If more space is needed, insert additional sheets of the same size) REV-16, 8 EX (11-99)(1) SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA INHE:RITANCE TAX DIVISION (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) ESTATE OF I FILE NUMBER JOHN C PALMER, JR . 21-04-673 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. I PART I - CALCULATION OF GROSS ESTATE I 1 Taxable Assets total from line 8 (cover sheet) . 1. 2. Insurance Proceeds on Life of Decedent .... . .... . 2. 3. Retirement Benefits ... . ... . 3. 4. Joint ,!'Issets with Spouse 4. 5. PA Lcttery Winnings 5. 6a Other Nontaxable Assets: list (Attach schedule if necessary). 6a. 6b. 6c. 6d 6. SUBTOTAL (Lines 6a, b, c, d) 6. 7. Total Gross Assets (Add lines 1 thru 6) 7. 8 Total Actual Liabilities. 8 9. Net Value of Estate (Subtract line 8 from line 7) 9 If line 9 IS greater than $200.000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II I PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income Tax I Return for decedent and spouse.) Income 1. TAX YEAR: 19 2 TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse. 1 a. 2a. 3a. b Decedent 1b. 2b. 3b. c. Joint 1c. 2c. 3c. d Tax hempt Income 1d 2d. 3d. e. Othe' Income not listed above 1e 2e. 3e I. Total 11. 21. 31. 4. Average Joint Exemption Income Calculation 4a. Add ,Joint Exemption Income from above: (11) + (2f) + (3f) (~3) 4b. Average Joint Exemption Income If line 4(b) is greater than $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part III. I PART J II - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT ESTATES I I i 1 I ~ E 5 Insert amount of taxable transfers to spouse or $100,000, whichever is less. 2. 3 Multiply by credit percentage (see instructions) . This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. For ~~onresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedents gross estate. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. . 4. 5. In Re: Estate of PALMER JOHN C JR ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLV ANIA NO. 2004-00673 NOTICE OF FAILURE TO FILE STATUS REPORT Persona] Representative: KELL Y KAREN L Counsel for Personal Representative: Date of Decedent's Death: 6/23/2004 The Orphans' Court record indicates that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court ()qJhans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Repoli. I t' the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of such delinquency and the undersigned will requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. Date I".. ~. .,/.') .~, /) .~1/1i/l...i ,i~L<::..::.. - '~...".". A::L;/t/ll.(t:4f.;: .~..o'tk;' . ,vt. 7110/2006 Glenda Farner Strasbaugh Clerk of the Orphans' Court Distribution: Personal Representative Counsel for Personal Representative Estate File Register of\vills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name of Decedent: Date of Death: Estate No.: Pursuant to Rule 6.12 ofthe Supreme Court Orphans' Court Rules, I repOli the following with respect to completion of the adrr1inistration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes 0 No 0 2. If the answer is t-ro, strrte \vhen the p~r~onal representative reasonably believes that the administration will be complete: 3. If the answer to No. I is Yes, state the following: a. Did the personal representative file a fmal account with the Court? Yes 0 No 0 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 panies in interest? Yes 0 No 0 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 tlUs report. Date: Signature Name Address Telephone No. Capacity: 0 Personal Representative o Counsel for personal representative <l> ~ ~ .~ c: ~ 1ii <l>"O 0 ~~ '0 00 ~ o ci "' 0 ~z DO ", ~ E ~ ~~ E .0 ,g ~ c-o ~ "0 :2! 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[. ,.. t:....;? ;~.i~rrl i ~.... ~ 2 I d e();' :!5 o Z9~~ ~ '< ::> ~.<-- (. .J-LID 'l) ,7) .J 09-12-2006 PALMER JR 06-23-2004 21 04-0673 CUMBERLAND 101 APPEAL DATE: 11-11-2006 ( See reverse side under Objections) ~ount R..ittedl I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE~ PA 17013 CUT ALONG THIS LINE -+ RETAIN LOWER PORTION FOR YOUR RECORDS 4- iiv:is47-ix-AFP-ioi:osi-NOTIci-oF-INHEiITANCE-TAX-APPRAISEMENT:-AiioNANCE-oi--------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX JOHN C FILE NO. 21 04-0673 ACN 101 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA .,Q.PARTMENT OF REVENUE , C'::C~,MOTICE OF INHERITANCE TAX ~~,APPRA~SEHENT~ ALLOWANCE OR DISALLOWANCE J' ~:\ '-OF DEDUCTIONS AND ASSESSHENT OF TAX I' t L.,~, {'" f"', C" : ,,,,V DATE ESTATE OF DA TE OF DEATH FILE NUMBER COUNTY ACN f J FRANK H KELLY KELLY FINANCIAL 400 BRIDGE ST NEW CUMBERLAND '- SRVCS PA 17070 ESTATE OF PALMER JR *' REV-1547 EX AFP (06-05) JOHN C TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED DATE 09-12-2006 RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Reel Estete (Sch~le A) 2. Stocks Md Bonds (SchIlcIule B) 3. Clo..ly H.ld StocklPertnership Interest (Schedule C) 4. HortgegeslNotes Receiveble (Schedule D) S. Cesh/Benk Depos1tslHisc. Personel Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Tr.nsfers (Schedule G) 8. Totel As..ts (1) (2) (3) (4) (S) (6) (7) .00 .00 .00 .00 10.666.00 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Fwwrel Expen..s/AdII. CostslHisc. Expen..s (Schedule H) 10. Debts/HOrtgege Liebilities/Liens (Schedule I) 11. Tot.l Deductions 12. Net Velue of Tex Return 13. Cheriteble/GovernD8ntel Bequests; Non-elect.d 9113 Trusts 14. Net Velue of Estete Subject to Tex 12~849.oo (9) (10) 6.923.00 (11) (12) (13) (14) (Schedule J) NOTE: To insure proper credit to your eccount~ sub111t the upper portion of this fOr. with your tax paYll8nt. lo~666.oo ]Q.77' 00 9~lo6.oo- .00 9~lo6.oo- NOTE: I~ an assesSBent was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will r~lect ~igures that include the total of ~ returns assessed to date. ASSESSMENT OF TAX: lS. AIIount of Line 14 .t Spousel rate (1S) . 00 X 00 = . 00 16. AIIount of Line 14 texllble .t Lineal/Class A rete (16) .00 X 045 = .00 17. A.ount of Line 14 at Sibl1ng rate (17) .00 X 12 = .00 18. A.aunt of Line 14 taxeble et Collateral/Cless B rete (18) .00 X 15 = .00 19. Principal Tax Due (19)= .00 . . DATE INTEREST/PEN PAID (-) AMOUNT PAID NUMBER TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ( IF TOTAL DUE IS LESS THAN $1~ NO PAYMENT IS REQUIRED. D IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR) ~ YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) · IF PAID AFTER DATE INDICATED~ SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.