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HomeMy WebLinkAbout03-0439Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS ADNINISTRATION C.T.A. Estate of Beatrice Warren Cooley also known as No. ,Al-o$ -o ? Jeannine Cooley Jones , Deceased Social Security No. 009-28-0196 petitioner(s), who is/are 18 years of age or older, app~y('le$) (COMPLETE "A" OR "B" BELOW:) A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut__ named in the Last Will of the Decedent, dated June 15, 1973 and codicil(s) dated Except as follows, Decedent did not marry, was not divorced, and did not have a child bom or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: B. Grant of Letters of Administration c.t.a. (c.t.a., d.b.n.c.t.a,: pendente lite; durante absentia; durante mtnodtate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Relationship Residence Stephen Warren Cooley Son 19 Tobacco Terrace, Palmyra, VA 22963 Jeannine Cooley Jones Daughter 208 North High Street, Newburg, PA 17240 (COMPLy- I I= IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, P~nnsylvania, with his/her last family or principal residence at 121 Walnut Bottom Road, Shippensbum, PA 17257 ( S~, ~oon~l~.~.'--~L~ ~ (liet stme{, number and municipality) ~ I ~ - ~ I~ Decedent, then 91 years of age, died _.May 2 ,20 03 , at Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (If not domiciled in PA) Personal preperty in Pennsylvania (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania Total Real Estate situated as follows: None Shippensburq, Cumberland County, Pennsylvania (Lo~tion) $0.00 $ $ $ 0.00 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: Signature Typed or printed name and residence J Jeannine Cooley Jones, 208 North High Street, Newburg, PA 17240 Fora1 R~N-1 Page I of 2 (Dauphin County- Rev. 9/92) Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above-named swear(s) and afffirm(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 representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to and affirmed and subscribed before me this 23rd day of May ,20.03 DECREE OF REGISTER Estate of Beatrice Warren Cooley also known as , Deceased No. 21-2003-0439 Social Security No: 009-28-0196 Date of Death: May 2, 2003 AND NOW, June ll~J-~ ,20 03 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters [] Testamentary [] of Administration c.t.a. (c. La.; d.b.n.c.t; pen~ente lite; durante absenfia; durame minod~ate) are hereby granted to Jeannine Cooley Jones in the above estate and that the instrument(s), if any, dated June 15, 1973 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. $. 9.00 Register of WiJ~ FEES Letters ........................... Short Certificate(s)...3. ...... Renunciation ...... .(..Z..! ...... $ 5.00 Affidavit ( ) ................. $ Extra Pages (1) ............ $ 3.00 Codicil .......................... $ JCP Fee ........................ $ 10.00 Inventory & Tax Forms...$ Other ............................ $ TOTAL ................ Mailed letters to Arty on .6./2L1/2003,~ c - , ~-- FonnRW-1Page2of2(Daupnin ounty- er. $ 45.00 DATE FILED: Attorney: David H. Martineau, E~uire I.D. No: 84127 Address: 3211 North Front Street PO Box 5300; Harr sburg, PA 17110-0300 Telephone: (717) 238-8187 Jupe llth, 2003 21-2003-439 RENUNCIATION In Re Estate of To the Register of Wills of Beatdce Warren Cooley Cumberland , deceased. County, Pennsylvania. The undersigned, Stephen Warren Cooley: son , of (Relationship) (Capacity) the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters Testamentary be issued to Jeannine Cooley Jones . Witness my hand this c,~ day of ~('i% ,20 03. ~-~' (Signature)~ Stephen Warren Cooley 19 Tobacco Terrace: Palmyra: VA 22963 (Address) (Signature) (Address) (Signature) Swom to or affirmed and subscribed before me this gO day of ~ ,20 0'~. ~6tacy Public My Commission ExPires: ~0. ~0, ~ · Doctjtrtent ii: 26100it~ ~.' (Address) REGISTER OF WILLS OF COUNTY OATH OF SUBSCRIBING WITNESS codicil ~ ' (each) a subscribing witness to the will presentedXl~erewith, (each) being duly qualified according to law,'~ ose(s) and say(s) that ~ present and saw the testat '",.~ , sign the same and that ~ signed as a witness at the request of testat'"~ in h presence and (in the presen'e~ of each other) (in the presence of the other subscribing Mt. ness(es)). Sworn to or affirmed and subscribed before me this day of 19 21-2003-439 Register \~Name) (Address) (Name) (Address) REGISTER OF WILLS OF Ct~nberland COUNTY OATH OF NON-SUBSCRIBING WITNESS Jeannine Cooley Jones (~) a subscriber hereto, (mmic) being duly qualified according to law, depose(s) and say(s) that she is familiar with the signature of Beatrice Warren Cooley , codicil testatrix of -- ' the .~'~, presented herewith and codicil that she believes the signature on the ~s in the handwriting of Beatrice Warren Cooley to the best of nv] knowledge and belief. Sworn to or affirmed and subscribed before me this 23rd day of  May ~ 2003 Donna M. Otto, 1st Deputy/ Register (Name)~ (Address) (Name) (Address) codicil "~ h) a subscribing w~ness to the C°w~i~ilpresen~ herewith, (each)bein~d '' ~ ' uly qualified ac~rdlng to l~epose(s) and say(s)~ XX~X ~X~ present ~od saw, as a witness at the e presence of thex other subsc~ng witness(es)). ~ ~ ~\ Swo~ and subscribed ~xfore xx~ ~ me this xX. dayX~ f ~",,~ (Name) ~ .... ~ XX ~\ 19 XX ,, ~X ~ ~ c- ' ~!~ Register 21-2003-439 (Name) (Address) REGISTER OF WILLS OF Cunberland COUNTY OATH OF NON-SUBSCRIBING WITNESS Om~) a subscriber hereto, (~t~) being duly qualified according to law, depose(s) and say(s) that He is familiar with the signature of Beatrice Warren Coo] o~y , codicil testatrix of ( -- ' ) the ~presented herewith and ~...c.~dicil that He believes the signature on th~s in the handwriting of Beatrice Warren Cooley Sworn to or affirmed and subscribed before day of (~me) his 28th M~ ~ .D ~ 2003 ..... / ~" '~..~ (Name) (Address) his is to certi~, 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 fbr this certificate, $2.00 P 9286806 No. "~ocal RegYsstrar/ · / Dat/e H105.143 Rev. 2/87 PERMANENT BLACK INK COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH DEc ..... , ............... SEX 'ALSECuj.T LT ..... OATEOF d ~. S~ippensburg ~p .Shippensburg Health' Care Center ,~,~.~,,~..i~. ' ,. ~ite ~,.Telephone Operator ,~. State Hpspital u. "'~ '~ ,a. ~'~ 12 0-~*~ 4 ~. Widowed 121 Walnut Bottom Road ,s. Shippensbur~, PA 17257 ,,.H. William Warren IOECEDENT'S ACTUAL RESIDENCE Pennsylvania ~ ~7c.1~ ~.~, ShiDpensburq Cumberland ~*P? l?d.~ ~m~Ne' ~1~ ~. Ho~e Cemetery ~ Waterbury, Vermont INAME AND A~ORE~ O¢ FACILITY ~.Fogelsanger-Bricker ~H, PO Box 336, Shi~p~D~h~ PA 17257 LICENSE NUMEER DATE SIGNED ~ CASE REFERRED TO MEDICAL EXAMINER/CORONER? DUE TO (OR AS A CONSE OUEN. CE OF): I MANNER OF DEATH DATE OF INJURY TIME CF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. [] NoO LICENSE NUMBER IOATE S4GNED ( , Day. ~earl NAME ~D AD.ESS ~ PERSON WHO COMPLIED CAU~ DATE FILED (M~h Oay, ~arl ' 21-2003-439 I, BEATRICE WARREN COOLEY, of the town of Waterbury, county of Washington, state of Vermont, being of sound and disposing mind and memory, do make, publish and declare the following to be my last will and testament and I hereby pressly revoke and declare null and void any other will or instrument in writing in the nature of a will heretofore made by me. ART ICLE I I direct my executor, hereinafter named, to pay all funeral expenses and the cost of the administration of my estate to be paid out of my residuary estate as soon as practicaSle after my death. ART ICLE I I All the rest, residue and remainder of my estate~ wherever the same is situated, whether real, personal or mi×ed, which I may die seized and possessed or to which I may be in any ways entitled at the time of my decease, I give~ devise and bequeath to my husband, FRANKLIN CARPENTER COOLEY, if living at the time of my death~ should my husband, FRANKLIN CARPENTER COOLEY, predecease me, I give~ devise and bequeath said rest, residue and remainder of my estate in equal shares to my son, STEPHEN WARREN COOLEY, of Ale×andria~ in the state of Virginia, and my daughter, JEANNINE COOLEY JONES, of Woodland, in the state of Maine, and if either my s on~ STEPHEN WARREN COOLEY, or my daughter, JEANNINE COOLEY JONES, predecease me, then to their issue surviving, in equal shares, per stirpes. ART ICLE I I I If my husband, FRANKLIN CARPENTER COOLEY, and I shall die under such circumstances that there is not sufficient evidence to determine the order of our deaths or if he shall die within a period of ninety (90) days after the date of my death, then all bequests~ devises and provisions made herein to or for his benefit shall lapse; and my estate shall be ad- ministered and distributed, in all respects, as though my said husband, FRANKLIN CARPENTER COOLEY, had not survived me. ART ICLE IV I nominate and appoint my son, STEPHEN WARREN COOLEY, to be executor of this will. I request that my son, STEPHEN WARREN COOLEY, shall not be required to furnish any surety or sureties upon his official bond, if he be appointed as executor of my estate under this will. IN WITNESS WHEREOF, I, the said BEATRICE WARREN COOLEY, hereunto set my hand and for the purposes of identification I have initialed each of the two (2) pages of this wills this fifteenth day of 3une~ A.D. One Thousand Nine Hundred and Seventy Three at Montpelier, Vermont. BEATRICE WARREN COOLEY /~-~ Signed and declared by the said BEATRICE WARRF~N COOLEY as and for her last will and testament in our presence who, at her requests in her presence, and in the presence of each others have hereunto subscribed our names as witnessess .this fifteenth day of Junes A.D. One Thousand Nine Hundred and residing at residing at residing at CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent · Date of Death ' Will No. · Beatrice Warren Cooley May 2, 2003 2003-00439 Admin. No.: To the Register: I hereby certify that notice of beneficial interest 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 July 17, 2003 . Nallle Stephen W. Cooley Jeannine Cooley Jones Address 19 Tobacco Terrace; Palmyra, VA 22963 P.O. Box 37; Newburg, PA 17240 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Date: Signature Name David H. Martineau, Esquire Address 3211 North Front Street Telephone Capacity: X P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 __ Personal Representative Counsel for Personal Representative 284644-1 REV-1500 EX (6-OO) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER COUN]Y CODE YEAR M, JMDER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURFrY NUMBER Z COOLEY, BEATRICE W. 009-28-0196 ~ DATE OF DEATH (MM-DD-YEAR) DATE Of BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPUCATE WITH THE LU REGISTER OF VVlLLS O 05-02-2003 06-05-1911 III (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURrF'Y NUMBER LLI Z n W [] 1. Original Return [] 4. Umited Estate [] 6. Decedent Died Testate (A~achcopy of Wil) [] 9. Utigation Proceeds Received [] 2. Supplemental Return [] 4a. Future Interest Compromise (da~eofdeathaffer 12-12-82) [] 7. Decedent Maintained a Uving Trust (Attach copy of Trust) [] 10. Spousal Poverty Credit (da~e of d~h betwee, 12-31-91 and 1-I-95) [] 3. RemainderReturn(dateofdeathprbrto12.13-~z) [] 5. Federal Estate Tax Return Required __ 8. Total Number of Safe Deposit Boxes [] 11. Election to tax under Sec. 9113(A) (Attach Sch O) : "rHm SECTi~ M~ BE GOMPLETED; ~E CORRE$~EN~E ~D GONm~i~ TAX]N ~ S~UED ~ m B~O: NAME DAVID H. MARTINEAU FIRM NAME (if App~cable) METZGER, WICKERSHAM, KNAUSS & ERB, TELEPHONE NUMBER (717) 238-8187 ~ COMPL~E ~ILING ADDRE~ ~3211 NORTH FRONT STREET p~P.O. BOX 5300 II4___~RRISBURG, PA 17110-0300 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) 1,361.10 (Schedule E) 6. JoinUyOwned Property(Schedule F) (6) [] Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 6, 0 2 1.41 (Schedule G or L) 8. Total Gross Ass~ (total Lines 1 - 7) (8) 9. Funeral Expenses &Administrative Costs (Schedule H) (9) 3,2 3 3.0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 146,704.42 11. Total Deductions (total Lines 9 & 10) (11) 12. Net Value of Estate (Line 8 minus Une 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) NOt Value Subject to Tax (Une 12 minus Line 13) 7,382.51 149,937.42 (142,554.91) 14. (14) ( 142,554.91 ) SEE INSTRUCTIONS FOR APPUCABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due x .0__ (15) O.OO x.o 45 (16) O.00 x .12 (17) x .15 (18) (19) 0. 00 20. [] 1 CHECK HERE IF Y~E~EQUESTI~ ~ ~EFUND OF ~ OVERPAyME~ I STF PA42021F.1 Decedent's Complete Address: ISTREET ADDRESS 121 WALNUT BOTTOM ROAD C~Y SHI PPENSBURG ISTATE PA Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Pdor Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. IziP 17257 (1) o. oo (3) (4) (5) (5A) (5B) 0.00 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 0.0 0 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSVVER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS AS PART OF THE RETURN. 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ........................................ [] [] b. retain the fight 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 alter 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? ....................................................... [] IF THE ANSVVER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT 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 frue, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI~NATURE{]/~...~.j~.~.OF PERS..ON RESPONSIBLE~..~. jFOR FILIN~G{/~_~ ~.-~RETURN , DATE /~::]D-RESS ...... ~ ~:2'- - - ' JEANNINE COOLEY JONES, 208 NORTH SI~E Of PREPARER OTHLN~<I~IVE ,DATE ADDRESS ' ' ' DAVID H. P.O. BOX PA 17110 HIGH ST., NEWBURG, PA 17240 MARTINEAU, 3211 NORTH FRONT ST., 5300, HARRISBURG, 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 RS. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a su~ving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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 RS. {}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. STF PA42021F.2 REV-1502 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE A REAL ESTATE FILE NUMBER Ail 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 exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real pmpety which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL (Also enter on line 1, Recapitulation) $ (If mom space is needed, insert additional sheets of the same size) STF PA42021F.3 REV-1503 EX + (1-97) (I) I I SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS iNHERITANCE TAX RETUEN RESIDENT DECEDENT ESTATE OF FILE NUMBER COOLEY, BEATRICE W. All property jointly.owned with the right of suwlvorshlp must be disclosed on Schedule K ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAl. (Also enter on line 2, Recapitulation)$ (If more space is needed, inser/additional sheets of the same size) STF PA42021F.4 REV-1504 EX + (1-97)(I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE C CLOSELY.HELD CORPORATION, PARTNERSHIP or SOLE.PROPRIETORSHIP FILE NUMBER Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest d ~he decedent, other then a sole-proprietorship, See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER DESCRIPTION 1. TOTAL (Also enter on line 3, Recapitulation) VALUE AT DATE Of DEATH (If more space is needed, insert additional sheets of the same size) STF PA42021F.5 REV-1505 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT FILE NUMBER Name of Corporation Address City 2. Federal Employer I.D. Number 3. Type of Business State Zip Code Product/Service State of Incorporation Date of Incorporation Total Number d Shareholdem Business Reporting Year TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting / Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all dghts and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? If yes, Position 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ 10. 11. 12. [] Yes [] No Annual Salary $ []Yes E~No nme Devoted to Business Was there life insurance payable to the corporation upon the death of the decedent? [] Yes [] No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was pdor to 12-31-827 []Yes []No If yes, []Transfer []Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet fo~ additional b'ansfers and/or sales. Was there a written shareholder's agreement in effect at the time of the decedenrs death? [] Yes [] No If yes, provide a copy of the agreement. Was the decedent's stock sold? [] Yes [] No If yes, provide a copy of the agreement of sale, etc. Was the corporation dissolved or liquidated alter the decedenrs death? [] Yes [] No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. Did the corporation have an interest in other corporations or partnerships? [] Yes [] No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedenrs 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 secured, 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 decedenrs stock. STF PA42021F.6 REV-1506 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT FILE NUMBER Name of Partnemhip Address City 2. Federal Employer I.D. Number 3. Type of Business 4. Decedent was a [] General State Zip Code Date Business Commenced Business Reporting Year Product/Sen/ice [] Limited partner. If decedent was a limited partner, provide initial investment $ PERCENT OF PERCENT OF BALANCE OF PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? [] Yes [] No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? [] Yes If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy [] No 9. Did the decedent sell or transfer an interest in this partnership within one year pdor to death or within two years if the date of death was pdor to 12-31-827 [] Yes [] No If yes, [] Transfer [] Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a wdtten partnership agreement in effect at the time of the decedent's death? [] Yes [] No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? []Yes [] No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedenrs death? [] Yes [] 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? [] Yes [] No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? [] Yes [] No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax retums (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. D. Any other information relating to the valuation of the decedent's partnership interest. STFPA42021F.7 REV-1507 EX + (1-97)(I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE D MORTGAGES & NOTES RECEIVABLE FILE NUMBER All property jointly.owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) STF PA42021F.8 REV-1508 EX + (1-97) (I) COMMCNWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE E CASH, BANKDEPOSITS,& MISC. PERSONALPROPERTY FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of suwivomhip must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1,361.10 CHECKING ACCOUNT CHEVY CHASE BANK 6200 CHEVY CHASE DRIVE LAUREL, MD 20707 ACCOUNT NO. 855901088 TOTAL (Also enter on line 5, Recapitulation) $ 1,3 61.10 (If more space is needed, insert additional sheets of the same size) STF PA42021F.9 REV-1509 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUBBER 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 JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE Include name of fimndal institulion and bad( acco~ number or sirnibr identi~ng numbe~ DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT Attach deed forjoinOy.,hetd realestate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation)$ (If more space is needed, insert additional sheets of the same size) STF PA42021F. 10 REV-1510 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY I FILE NUMBER This schedule must be completed and filed if the answer to any d questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF ['rEM INCLUDE ~HE NAME OF TI-E TRN'4SFEREE, ~IR RELATIONSHIP TO DECEDENT AND 'I}IE DA'rE DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER OF '[RANSFER. ATrACH A COPY OF TI.E DEED FOR REAL ESTA'[E. VALUE OF ASSET INTEREST (IF APPLICABLE) 1. SAVINGS ACCOUNT 9,021.41 100 3,000 6,021.4] ORRSTOWN BANK 77 EAST KING STREET SHIPPENSBURG, PA 17057 ACCOUNT NO. 703002812 TRANSFEREE: JEANNINE COOLEY JONES RELATIONSHIP TO DECEDENT: DAUGHTER DATE OF TRANSFER: 11/04/2002 TOTN. (Also enter on line 7, Recapitulation)$ 6, 0 2 1.4 '] (If mom space is needed, insert additional sheets of the same size) STF PA42021 F.11 REVo1511 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 5. 6. 7. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is no~ the same as claimant's, attach explanation) Claimant Zip. St]'eet Address City Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees PUBLICATION OF NOTICE State Zip TOTAL (Also enter on line 9, Recapitulation) $ 3,000 57 176 3,233.00 (If more space is needed, insert additional sheets of the same size) STF PA42021F.12 REV-1512 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. 145,357.27 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM P.O. BOX 8486 HARRISBURG, PA 17105-8486 SHIPPENSBURG HEALTH CARE CENTER 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 MEDICAL BILLS SHIPPENSBURG HEALTH CARE CENTER 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 TELEPHONE BILLS 1,277 70.15 TOTAL (Also enter on line 10, Recapitulation) $ 146, 704.42 (If more space is needed, insert additional sheets of the same size) STF PA42021 F.13 REV-1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY BEATRICE W. SCHEDULE J BENEFICIARIES FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE [. o TAXABLEDISTRIBUTIONS[includeoutdghtspousaldi~dbutions, andtmn~m und~Sac. 9116(a)(l.2~ JEANNINE COOLEY JONES 208 NORTH HIGH STREET NEWBURG, PA 17240 STEPHEN WARREN COOLEY 19 TOBACCO TERRACE PALMYRA, VA 22963 DAUGHTER SON 50% 50% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 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) STF PA42021 F.14 REV-1514 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on Rev-1500 Cover Sheet) FILE NUMBER 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 on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. [--~Will 1--11ntervivos Deed of Trust I--1Other NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE [] Life or [] Term of Years __ [] Life or [] Term of Years__ [] Life or [] Term of Years__ [] Life or [] Term of Years__ 1. Value of fund from which life estate is payable 2. Actuarial factor per appropriate table Interest table rate - [] 3 1/2% [] 6% 3. Value of life estate (Line 1 multiplied by Line 2) [] 10% []Variable Rate % NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE [] Life or [] Term of Years__ [] Life or [] Term of Years __ [] Life or [] Term of Years__ [] Life or [] Term of Years__ 1. Value of fund from which annuity is payable 2. Check appropriate block below and enter corresponding (number) Frequency of payout - [] Weekly (52) [] Bi-weekly (26) [] Quarterly (4) [] Semi-annually (2) [] Annually (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 []3 1/2% I'-] 6% [] 10% Adjustment Factor (see instructions) $ [] Monthly (12) []Other ( ) [] Variable Rate % Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 × Line 5 × Line 6 $ If using variable rate and pedod payout is at beginning of pedod, calculation is: (Line4 x Line5 × Line 6) + Line3 $ 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, 15, 16 and 17. (If more space is needed, insert additional sheets of the same size) STF PA42021F. 15 REV-1647 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on Rev-1500 Cover Sheet) FILE NUMBER 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 retum. [] Will [] Trust [] Other Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a dght 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 exemises such withdrawal dght. [] Unlimited right of withdrawal [] Limited right of withdrawal Explanation of Compromise Offer: 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 CheckOne [--]6%, r-]3%, []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 []6%, [--14.5% ................................. $ (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) STF PA42021F. 16 REV-1649 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF COOLEY, BEATRICE W. SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 9113 (A) of the Inheritance & Estate Tax AcL If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar amangement meets the requirements of Section 9113 (A), and: a. The trust or similar arrangement is listed on Schedule O, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule O, then the transferors personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule O, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. DESCRIPTION VALUE Part A Total $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. DESCRIPTION Part B Total $ (If more space is needed, insert additional sheets of the same size) STF PA42021F. 17 VALUE I~ BEATRICE WARREN COOLEY, of the town of Waterbury~ county of Washington,'state of Vermont~ being of sound and disposing mind and memory, do make~ publish and declare the following to be my last will and testament and I hereby ex- pressly revoke and declare null and void any other will or instrument in writing ~n~h~na~ure of a will heretofore made by me. ARTICLE I I direct my executor, hereinafter named, to p~y all funeral expenses and the cost of the.administration of my estate to be paid out of my residuary estate as soon as practicaSle after my death. ART IC LEI I All the rest, residue and remainder of my estate, wherever the same is situated, whether real~ personal or mixed, which I may die seized and possessed or to which I may be in any ways entitled at the time of my deceas~ I give, devise and bequeath to my husband~ FRANKLIN CARPENTER COOLEY~ if living at the time of my death, should my husband, FRANKLIN CARPENTER COOLEY, predecease me, I give, devise and bequeath said rest, residue and remainder of my estate in equal shares to my son, STEPHEN WARREN COOLEY, of Alexandria, in the state of virginia, and my daughter, 3EANNINE COOLEY JONES, of Woodland, in the state of Maine, and if either my son, $TEPHEN WARREN COOLEY, or my daughter, JEAN]WINE COOLEY JONES, predecease me, then to their issue surviving, in equal shares~ per stirpes. ARTICLE Iii If my husband, FRANKLIN CARPENTER COOLEY, and I shall die under such circumstances that there is not sufficient ~/~ residing at evidence to determine the order of our deaths or if he shall die within a period of ninety (90) days after the date of my death, then all bequests~ devises and provisions made herein to or for his benefit shall lapse; and my estate shall be ministered and distributed, in all respects~ as though my said husband, FRANKLIN CARPENTER COOLEY, had not survived me. ART IOLE IV I nominate and appoint my son~ STEPHEN WARREN COOLEY, to be executor of this will. I request that my son~ STEPHEN WARREN COOLEY, shall not be required to furnish any surety or sureties upon his official bofid, if he be appointed as executor of my estate under this will~' IN WITNESS WI~EREOF, I, the said BEATRICE WARREN COOLEY, hereunto set my hand and for the purposes of identification I have initialed each of the two (2) pages of this will, this fifteenth day of June~ A~D. One Thousand Nine Hundred and Seventy Three at M0ntpeller, Vermont. L'SBEATRICE WARREN COOLEY signed and declared by the said BEATRICE WARRF~N COOLEY as and for her last will and testament in our presence who~ at her request; in her presence~ and in the presence of each other, have hereunto subscribed our names as witnesses, .this fifteenth day of June~ A.D. One Thousand Nine Hundred and Seventy Three. Name: COOLEY, BEATRICE Tax ID: 009-28-0196 Res ID: 00323 Status: CLOSED 05112103 Account Type: Transferring Allowance: $ 30.00 Date Opened: 09/08/98 Restraints: NO TRANSACTIONS AT ALL Account #: 855901088 Current Balance: $ 0.00 Statement Date: 06/19/03 Status Reason: DECEASED 05102/03 Account Date Description Debit Credit Reject Balance Batch Record Seq Credited Ol/Ol/O3 01/03/03 01/03/03 01/21/03 01/21/03 01/31/03 01/31/03 02/03/03 02/03/03 02/19/03 02/19/03 02/28/03 02/28/03 03/03/03 03/03/03 03/19/03 03/24/03 03/31/03 03/31/03 04/03/03 04/03/03 04/17/03 04/30/03 04/30/03 05/02/03 05/02/03 05/05/03 05/12/03 05/12/03 OPENING BALANCE US TRSRY 303SOC SEC CARE COST AUTO WDL INTEREST PAID 0.59 TELEPHONE CHARGES 23.35 STATE OF VERMONT PEN 110.95 CARE COST AUTO WDL 80.95 US TRSRY 303SOC SEC CARE COST AUTO WDL INTEREST PAID 0.66 Care cost due STATE OF VERMONT PEN 110.95 CARE COST AUTO WDL 80.95 US TRSRY 303SOC SEC CARE COST AUTO WDL 1277.00 INTEREST PAID 0.02 CLOTHING 60.00 STATE OF VERMONT PEN 110.95 CARE COST AUTO WDL 80.95 US TRSRY 303SOC SEC CARE COST AUTO WDL 1277.00 INTEREST PAID 0.01 STATE OF VERMONT PEN 110.95 CARE COST AUTO WDL 80.95 US TRSRY 303SOC SEC CARE COST AUTO WDL 1277.00 TELEPHONE CHARGES 70.15 CLOSING INTEREST 0.01 TO CLOSE ACCOUNT 13.96 1080.04 1277.00 2031.44 1277.00 1277.00 1277.00 1277.00 1277.00 1880.65 3157.65 2077.61 2078 20 2054 85 2165 80 2084 85 3361 85 2084 85 2085.51 54.07 165.02 84.07 1361.07 84.07 84.09 24.09 135.04 54.09 1331.09 54.09 54.10 165.05 84.10 1361.10 84.10 13.95 13.96 0.00 20103 0 20103 0 0934376646 40121 0 8B581P 012003 11 0934376743 20131 0 20131 0 0934376646 20203 0 20203 0 0934376646 40219 0 8A468P 1/29/03 1 0934376743 20228 0 20228 0 0934376646 20303 0 20303 0 0934376646 40319 0 8A833P 031903 2 0934376743 20331 0 20331 0 0934376646 20403 0 20403 0 0934376646 40417 0 20430 0 20430 0 0934376646 20502 0 20502 0 0934376646 8B328P W050503 1 0934376743 101088 0 101088 0 0934376743 Page: 1 REV-1549 EX (9-00) COMMO.WE^'T. OF PE..S.'VA.I^ NOTICE OF DECEDENT DEPARTMENT OF REVENUE .u.E^. o.,.D,V,OU^. TAXES ACCOUNT STATUS DEPT. 280601 HARRISBURG, PA 17128-0601 (717) 787-8327 NAME: (Last) Cc,~t ~.¥ ...................................... ~---(~"~"' ~-~. (First) ....~,i ] (Middle Initil DECEDENT SOCIAL SECURITY NUMBER dF DE~-~'¥ - -~-~X~'-~"~'I~ D~-~- (Mon-~ .................. i~i ..... '~ ADDRESS OF DECEDENT: ............ -'7 .................. ; ..... ~ .......... ~ ........ C~ ............. ~ ~ ~ NAME OF FINANCIAL INSTITUTION · ~ j ............ ADDRESS , CI~ , STATE ZIP CODE INFORMATION TELEPHONE NUMBER - Check bilk if na~-~address change TYPE OF ACCOUNT: I ACCOUNT NUMBER ACCOUNT ~ Joint Savings ~ Joint Checking ~ 'lnTmstFo~ ~ Joint~meCed~icate Il INFORMATION ACCOUNT BA~NCE (Include interest to date of death) ] ORIGINAL DAT~C~~ABLIS~I~ t / COPY OF ACCOUNT T~%E AS IT APPEARS ON SIGNATURE CARD OR CERTIFICATE OF OEPOSlT P~CE CHECK IN BLOCK BELOW ~ACCOU~T WAS ESTABLISHED BY A T~NSFER OF FUNDS FROM ANOTHE~ ACCOUNT THAT WAS REGISTERED IN IF AVAI~BLE THE NAMES OF THE SAME JOINT OWNERS AND ENTER THE DATE ORIGINALLY ESTABLISH~. ~ Rollover Account - Date Originally Eslablished .A~E (Last) (First) {~iddle Initial} OFFICIAl USE JOINT ADDRE~ SURVlVO~ ~ ~ X . ~ PERCENT TAXABLE ~.mc~.~ c~~ ~~ s~ z,.co~ INFORMATION ~ ~ ! 9 ~q b TAX RATE RE~T]ON~HIP TO DEC~NT SURVIVOR'S S~IAL ~ECURI~ NUmBeR ' NAUE (Last) (First) (Mi~e ~.~,,~) OFFICIAL USE JOINT ~DDRESS ONlY PERCE~T~XA~Lt suRvIvo~ BENEFICIARY CITY STATE ZIP CODE INFORMATION TAX RATE RE~T~O.SHe ~O DEC~D~r SURWVO.'S SOCIAL SECUa~ NUUSER NAME (Last) (Fi=t) (Middle Initial) OFFICIAL USE ONLY JOINT ADORESS ............. SU~IVOR PERCE~T TAX~BL~ BENEFICIARY CI~ ~ STATE ZIP CODE INFORMATION TAX RATE RE~TIONSHIP TO DECEDE~ SURVIVOR,S SOCIAL SECURI~ NUMBER NAME (~st) (Fi=t) (Mille ~.iaa~) OFFICIAL USE ONLY JOINT ADDRESS PERCENT TAXABLE SU~IVOW BENEFICIARY Cl~ STATE ZIP CODE INFORMA~ON TAX RATE ~E~TIONSHIP TO DECEDENT SURVIVOR'S SOCIAL SECUR~ NUMBER :)rmatlon Is true, correct and complete. 'TI MOTHEA MOOSE Register of Wills of Cumberland County, Pennsylvania Estate of also known as INVENTORY Beatrice W. Coole.v , Deceased No. 2003-00439 Date of Death May 2:2003 Social Security No. 009-28-0196 Jeannine Cooley Jones I.D. No.: 84127 Address: 3211 Nor[h Front ~tr~.~.t: PO Box .~30{3 Hnrd.~hurg: PA 17110-0.3i30 Personal Representative(s) of the above Estate, deceased, vedfy that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We vedflj that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unswom falsification to authorities. ,?//~;nnine Cooley Jones ~ 208 North High Atr~.e.t: NP. wbu~ PA 17240 Dated .~-~7'~ ~ ~ ~ Telephone: (717) 238-8187 Description Chevy Chase Bank, Checking Account ~-855901088 (Attach Additional Sheets if necessary) Value $ 1,361.10 Total: $ 1,361.10 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory, Form RW-7 (Dauphin County) - Rev. 9/92 STATUS REPORT UNDER RULE 6.12 Name of Decedent : Date of Death : Will No. 2003-00439 Beatrice Warren Cooley May 2, 20O3 Admin No. 21-03-0439 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: State whether administration of the estate is complete: Yes X 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: ao Did the personal representative file a final account with the Court? Yes No The separate Orphans' Court No. (if any) for the personal representative's account is: in interest? c. Did the personal representative state an account informally to the parties Yes No d. Copies of receipts, releases, j oinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Family Agreement - Waiver of Account attached Signature V8 "o3 puelJaqu.~l~O c;Z: Zld OZ Tlr ~. Name David H. Martineau, Esquire Address 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 Telephone Capacity: X (717) 238-8187 __ Personal Representative Counsel for Personal Representative 308858-1 In the matter of the : ESTATE OF : BEATRICE WARREN COOLEY, : Deceased. : IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 2003-00439 FAI~III,¥ AGR1ZI~.MENT - WAIVF, R OF A(X2OIINT This Agreement entered into this 10 day of zri,~, y ~ :d , 004,,~ and between Jeannine Cooley Jones, in her capacity as Administralrix, C.T.A.~f the Ea~dte of ~ce Warren Cooley, deceased, and Stephen Warren Cooley and Jeannine ey Jo_ones, m;gl~ary legatees of the estate. > :~ ~3 C~ BACKGROUND 1. Beatrice Warren Cooley ("Decedent") died on May 2, 2003, a resident of Cumberland County, leaving a Will dated June 15, 1973. 2. Decedent's Will was admitted to probate by the Register of Wills of Cumberland County, Pennsylvania, on June 11, 2003. 3. Steven Warren Cooley, named as Executor of Decedent's Will, renounced kis fight to admirdster the estate on May 20, 2003 and Letters o£ Administration, C.T.A. were issued to Jean_trine Cooley Jones on June 11, 2003. 4. Decedent, having died a widow, named her only two surviving children, Stephen Warren Cooley and Jeannine Cooley Jones, as the sole residuary legatees. 5. The Administratrix advertised the grant of Letters of Administration, prepared and filed an Inventory and Appraisement of Decedent's Property and prepared and filed a Pennsylvania Inheritance Tax Return and federal and state income tax returns as required, and paid the 308433-1 appropriate taxes thereon. 6. There are no general legatees named in Decedent's Will. 7. Decedent's gross probate estate consisted of only one bank account, held at Chevy Chase Bank, 6200 Chevy Chase Drive, Laurel, Maryland: $1,361.10. 8. estate. 9. 10. I1. 12. Account No. 855901088, containing The administrative costs of administering the estate exceeded the gross probate The gross liabilities of the estate (not including administrative costs) consisted of: Shippensburg Health Care Center: $ 1,347.15 Pennsylvania Department of Public Welfare: $145,357.27 Decedent's estate is insolvent. Sh/ppensburg Health Care Center's claim has been fully satisfied. The Pennsylvania Department of Public Welfare has not been paid any sum and has acknowledged the insolvency of Decedent's estate in its letter dated April 1, 2004, attached hereto as Exhibit "A". ! 3. The Administralrix has completed the administration of the estate. 14. Both Stephen Warren Cooley and Jeannine Cooley Jones desire that this Family Agreement be filed in lieu of filing an accounting in the Orphan's Court Division of the Court of Common Pleas of Cumberland County. 15. Stephen Warren Cooley and Jeannine Cooley Jones have been given the opportunity to review the books and records of the Administratrix and based upon such opportunity or examination, they have determined that they have sufficient information to make an informed 308433-1 decision to waive their fight to an accounting. AGREEMENT In consideration of the willingness of the Administmtrix to terminate the estate in accordance with the terms of the Will without the protection afforded to her by a formal adjudication of an Administratix's account, Stephen Warren Cooley and Jeannine Cooley Jones, the undersigned beneficiaries, individually and with respect to their heirs, personal representatives, successors and assigns, do hereby: 1. Acknowledge that we have read this Agreement and represent that the facts set forth above are true and correct to the best of our knowledge, information and belief; 2. Acknowledge that we are familiar with the provisions of Decedent's Will; 3. Waive the filing of a formal account of the administration of this estate, with respect to receipts and payments from the income and principal thereof, in any court which has jurisdiction, in particular, the Orphan's Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania; 4. Acknowledge that we are not entitled to the distribution of any property, real personal or mixed, fi'om Decedent's estate; 5. Wan'ant that we know of no outstanding and unsatisfied claims against the estate, except for the above referenced claim of the Pennsylvania Department of Public Welfare; 6. Absolutely and irrevocably release and discharge Jeannine Cooley Jones, Administratrix C.T.A. of the Estate of Beatrice Warren Cooley, Deceased, her personal representatives, heirs, successors and assigns, from any and all actions, liabilities, claims and demands, including specifically but not limited to liability arising in connection with any mistake of 308433-1 fact or law, or negligence or careless act or omission in connection with the administration and distribution of assets of the estate without a formal court accounting and adjudication; 7. Understand that this Agreement may be signed in counterpart originals, all of which together shall be deemed to constitute one original; and 8. Agree that this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, we agree and intend to be legally bound hereby and have signed this Agreement this ! o day of ~-u.~ ~f ,2004. WITNESS: WITNESS: WITNESS: Stephen Warren Cooley, Beneficiary feannine Cooley Jones, Be~ciary eannine Cooley J~-nes, Ad~stratdx, C.T.A. 308433-1 STATE OF COUNTY : SS. : Onthis, the Io dayof4,~o, xV , Anne Domini 2004, before me, the undersigned officer, personally appeared JEANNINE COOLEY JONES, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same both individually and as Administratrix, C.T.A. of the Estate of Beatrice Warren Cooley, for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and seal. Notary~l~c ~ ~-- -- Notarial Seal Roger D. Leeper, Notary Public Greene Twp. Frank n County My Corem ssion Expires June 18, 2oo5j Member, Pennsylvania Assooation of Notades STATE OF ~0~, uS g'& ~94,tx~ COUNTY OF lz',qO~t~ : SS. Onthis, the lO dayof ~"'T~xt~ , Anne Domini 2004, before me, the undersigned officer, personally appeared STEPHEN WARREN COOLEY, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. IN WlTNESS WHEREOF, I hereunto set my hand and seal. Notafia Seal Roger D. Leepor, Notary Public Greene Twp., Franklin County My Commission Expires June 18, 2005 Member, PennsyNania Association of Notaries 308433-1 METZGER WICKERSHAM PC DAVID H MARTINEAU ESQUIRE 3211 N FRONT $~ PO BOX 5300 '~ ~i?~ HARRISBURG PA I7110-0300 COMMONWEALTH OF PENNSYLVANI~ DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY UABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HASRISBURG, PA 17105=~486 April 1, 2004 Re: BEATRICE COOLEY CIS #: 860142286 SSN: 009-28-0196 Date of Death: 05/02/2003 Dear Attorney Martineau: Pursuant to your correspondence dated March 26, 2004, regarding the above-referenced estate, the Department recognizes the estate to be insolvent. Please notify us of any change in circumstances which may affect the insolvency of the estate. Thank you for your cooperation in this matter. If you have any questions, please contact me. Sincerely, Barbara A. Fellows Claims Investigation Agent 717-772-6613 717-705-8150 FAX ~ BUREAU OF ZNDTVZDUAL TAXES TNHERTTANCE TAX DTVTSZON DEPT. 180601 HARRTSBURG, PA 17118-0601 DAVID H MARTINEAU HETZGER ETAL PO BOX 5500 HOG CONNON#EALTH OF PENNSYLVANIA DEPARTNENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAZSEHENT] ALLONANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSMENT OF TAX Re .............. r_:f DATE ESTATE OF DATE OF DEATH FILE NUHBER COUNTY ACN 05-15-2004 COOLEY 05-01-Z005 21 05-0439 CUHBERLAND 101 REV-1;q? EX AFP COl-DS) BEATRICE ~ Amount Remit~md I PA 17:110 MAKE CHECK PAYABLE AND RENTT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS ~ DZSALLONANCE OF DEDUCTIONS AND ASSESSNENT OF TAX ESTATE OF COOLEY BEATRICE FILE NO. :>1 03-0439 ACN 101 DATE 03-15-2004 TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Es~a~e (Schedule A) 2. S~ocks and Bonds (Schedule B) $ Closely Hold S~ock/Par~nership Zn~erms~ (Schedule C) Mor~gages/No~os Receivable (Schedule D) $ Cash/Bank Deposi~s/Nisc. Personal Proper~y (Schedule E) 6 Jointly Ownmd Proper~y (Schedule F) 7 Transfers (Schedulm G) 8 To*al Asse*s APPROVED DEDUCTZONS AND EXENPTZONS: 9. Funeral Expensms/Adm. Cos~s/H1sc. Expanses (Schedule H) 10. Dob~s/Nor~gage LiebLl1*ies/Liens (Schedule Z) 11. To,al Doduc*ions 12. No* Value of Tax Re*urn (1) (2) ($) (5) (6) (7) 11361.10 O0 O0 NOTE: To insure proper O0 credit ~o your account, O0 submi~ ~he upper portion O0 of ~his form with your ~ax payment. (9) 61021.41 (B) (10) 3,Z33.00 15. NOTE: ASSESSNENT OF TAX: 15. Aeoun~ of Line lq at Spousal ra~e 16. Amoun~ of Line lq *axablm a~ Lineal/Class A ra~m 17. Amount of Line lq a* Sibling ra~a 18. Amoun~ of Line lq ~axablo a~ Collateral/Class B ra~e 19. Pr/nc/pal Tax Due TAX CREDITS: PAYMENT RECEIPT DISCOUNT DATE NUMBER INTEREST/PEN PAID (-) 146~70q.q2 (11) (12) 7,382.51 149.9~7.42 141,554.91- Charitable/governmental Bequests; Non-elected 9115 Trusts (Schedule J) (13) Ne~: Value of Estate Sub~ec~: ~o Tax (lq) Zf an assessment ~as lssued previously, lines lq, 15 and/or 16, 17, reflect figures that include the total of ALL returns assessed to date. .00 142,554.91- IF PA[D AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADD/T/ONAL /NTEREST. 18 and 19 will (15) .00 x O0 = .00 (16) .00 x 045= .00 (17) . O0 x 12 = . O0 (18) .00 x 15 = .00 (19)= . O0 AMOUNT PAID TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE .00 .00 .00 .00 ( IF TOTAL DUE IS LESS THAN $1) NO PAYMENT ZS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A "CREDIT' (CR)z YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RESERVATION: PURPOSE OF NOTICE: PAYNENT: REFUND (CR): OBJECTIONS: ADHIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December Il, 1982 -- if any futura interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonaealth hereby expressly reserves the right to appraise and assess transfer /nharitance Taxes at the lamful Class 8 (collateral) rate on any such futura interest. To fulfill tho requirements of Section ZI~O of the Inheritance and Estate Tax Act, Act Z$ of ZOO0. (TI P.S. Section 91q0). Detach the top portion of this Notice and submit with your payment to the Register of Nills printed on the reverse side. --Hake check or money order payable to: REGISTER OF HILLS, AGENT A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-IS13). Applications ara available at the Office of the Register of Hills, any of the Z3 Revenue District Offices, ar by calling the special lq-hour answering service for forms ordering: 1-800-36Z-Z050; services for taxpayers with special hearing and / or speaking needs: 1-800-~qT-30ZO (TT only). Any party in interest not satisfied eith the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object aithin sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17ilS-lOll, OR --eIection to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 171Z8-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-IS01) for an explanation of administratively correctable errors. any tax due is paid within three (3) calendar months after the decadant's death, a five percent (SI) discount of the tax paid is allowed. The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payaanto Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .00016~. Ail taxes which became delinquent on and after January 1, 198Z will bear interest at a rate which mill vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOOq ara: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor ~ ZOZ .0005q8 ~)'~S-1991 11Z .000301 ~ 9Z .O00Zq7 1983 16Z .000~38 1992 9Z .O00Z~7 ZOOZ 6Z .00016~ 198~ 11Z .000301 1993-199~ 7Z .00019Z 2003 5~ .000137 1985 13Z .000356 1995-1998 9Z .0002~7 2004 ~Z .000110 1986 IOZ .O00Z7~ 1999 7Z .00019Z 1987 IOZ .OOOZ7~ ZOO0 7Z .00019Z --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Hotice, additional interest must ba calculated.