HomeMy WebLinkAbout03-0198PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
~'$1.t¢ o.f'~<~}{l[~ /~t¥~¢'~ ~ NO.
also known as To:
Social Security No. ~ ~3 1 - ~0 " '3 ~D~c~eased'
Register of Wills for the
County of
Commonwealth of Pennsylvania
Thc g~tition of the undersigned respectfully represents that:
in the
Your I~etitioner(s), who is/are 18 years of age or older, appl i¢ ~
(d.b.n.; p~nd~nte llte; dtlrante absentia; dtJrflntc minorit~tc)
the above decedent.
for letters of administration
on the estate of
Decendent was domiciled at death in __~txm J~ er lan d
· County,, Pennsylvania, with
last familyorprincipalre$idenccat~LLB ~x3s ~l. ~r ¢,~ ~t.~ {,J o : m ]P vi~l~ ~ f ~ ~ ~ ~T
(list str~, number and muni~pnli~) ] ~ '
Decendent, then Z~ ye~s of age, di~ p~,~P.U ~y I~ , ~ SO0 ~.
Dccendent at death owned property with estimated valu~ as folllows:
(If domiciled in Pa.) All personal property $
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled iu Pa.) Personal property in County $
Value of real ~state in Pennsylvania $_
situated as follows: "~
7.-00, oo
Petitioner__ after a proper search ha_~_, ascertained that decedent left no will and was survived by
the following spouse {if any) and heirs:
Na~ne Relationship Residence
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
¢OVNTY Or ss
The petitioner(s) above-named swear(s) or affirm(s)that the
statements in the foregoing petition arc true and correct to the best
of the knowledge and belief of pctltloner(s) and that as personal
representative(s) of the above decedent petitioner(s) will well and
truly adminisxer the estate according to law.
o
Sworn to or ,affirmed and subscribed r'
I~fore me this ~-~ ~'~-/ day of [
AND NOW _ ~z~, ~ ~ in consideration of the petition on
the reverse side hereof, sa~t~ll~actory proof ha~_been presented before me,
IT IS DECREED that ~~~.
is/are emitled to Lette~of~Admi~istra~o~, and in accord with such finding, Letters of Administration
FEES
Let£crs of Administration ..... $_~ ~::~
Short Certificates( )
',l~u~qc!9~n ................ $ /z~. ~.
· ~ TOTAL $
Filed .... ~x.~ff. .......... A.D.
ATTORNEy (Sup. Cl. I,D. No.)
ADDRESS
"~# '7 7 & ( 7~t 7._r
PHONE
RENUNCIATION
In Re Estate of Kelly H. Alvarez, deceased
To the Register of Wills of Cumberland County, Pennsylvania
be
The undersigned
of the above
decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that~
Letters of Administration
issued to Ta~y Fairchild
WITNESS Fr~I handthis ~ ~- dayof f~(t~c, zp/ ,20z: ¢
Amado Alvarez
(Address)
~ (Address) (Signature)
2982 Ocean Shore Blv / ~/3~
Flagler Beach, FL 32136
RENUNCIATION
In Re Estate of Kelly H. Alvarez, deceased
To the Register of Wills of Cumberland County, Pennsylvania
The undersigned Geraldine M. Miller, mother of the above
decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that
Le~ers of Administration
be issued to Ta~my Fairchild
WITNESS rn.{ hand this ~ day of ~ ,20 ,~ 3
~Y28 North Front Stree't, Apt. 2'
Wormleysburg, PA 17043
his is to certify that the information here given is correctly copied fi'om an original certificate of death duly filed with [nc Ets
l,ocal Registrar. The original certificate will be fbrwardcd to thc State \/ital Records OffSet ~'or pcrmane:~t filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph·
Fee fbr this certificate, $2.00
Local Registrar d
No. Date
NAME OF DECEDENT (First, Mid(lie, Last)
Kelly
AGE (Las; Birthday} UNDER 1 YEAR
Months Days
23 Yr,.
COUNTY OF DEATH
Cumberland
DECEDENT'S USUAL OCCUPATION
Care
628 North Front Street
Wormleysburg, PA 17043
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
STATE FILE NUMBER
ITM ISOCIAL SECURITY NUMBER
Alvarez zFemale ,. 181-60-3204
I UNDER~ DAY DATEO~SIRTH II~D. 12, 1979j @ m/pi 5.5 I
Mi ..... '--et. S ..... For~gn C ...... ) HOSPITAL: OTHER:
West Shore U.S.~,ED~ONCES? {S~dv only h~ a~ade ~Oel~
Humane Society . ,3. (0.,a 12 ~"~+) J,.Never Married ~.
ACTUAL 17.. ~,t. Pennsylvania ~ ,7~ Yes. ~ce~nl lived in
Amado Alvarez
D~E OF DE~H (M~lh, Day, Y~)
February [8, 2003
Residence [] (Specify) .~[
RACE - American Indian. Black, While.
(S~ec~fy)
White
SURVIVING SPOUSE
(ti ~,ile, g~ve maiden name)
East Pennsboro
MOTHER'S NAME (Fr;:d M,ddte, Malde~ ~rname)
I,,. Geraldine M. Miller
IINFORMANT'S MAILIN (i ADDRESS ~r~l, C~wn. ~ate, Zip C~e)
]~.628 North Front Street Wormleysburg, PA 17043
IPL~E ~ DISPOSITION - Name of Cemmer~ Cremal~ I L~ION * Ci~wn, Slate, Zip Code
,,~ Mt. Olivet Cemetery ,,d New Cumberland, PA 17070
~MEANDAODRESS~ClL~ in
Zimmerm~n-Auer Funeral Home, c.
122c. Ald~ .rnn,mto~n Road Harrisburg. PA 17109
twp
c~ylboro
Geraldine M, Miller
METHOD OF DISPOSITI
~N
Burial ~] CrsmatioFI [] Removal from Stele []
Don&Lion [] Ol~r (SpecifyI
2-25-2003
, death occurred at the time, date and place slated
personltems 24-26who pronounce~mu8 be com.n~*addealh, by TIME OF DEATH Ap rx. DAT~ PRONOUNCED DEAD (Mor4h, Day, Year)
]:00 F. a I~*. February' 18, 2003
r~,,~th~ ~ ,. Multiple Traumatic Iniuries
s~.n,m~.~.s b. Motor Vehicle Crash
LICENSE NUMBER DATE SIGNED
(Month. Day. Year)
23b. 23e.
V~RSCASEnrFCP~,~.DTOME lC EXAMINER/CORONER?
,il. ~ No[::]
d I
WAS AN AUTOPSY IWERE AUTOPSY FINDINGS IMANNER OF DEATH IDATE OF INJURY ITIME OF INJURY INJURY AT WORK? DE
PERFORMED? AVAILABLE PRIOR TO M SCRIBE HOW INJURY OCCURRED.
ICOMPL.,O~O. OAU.E I __ I'o~th.D~,.'~,,~0 I Apr,[. I ,,[U.belted rear seat pass-
OF DEATH? Natural U Hompclde [] Yes
] I __ " [ Feb 18,2003 I [] ao~ lenger in multi-vehicle
! '"
nc n ~ ena ys~ckan has p,- i [ p~eled ttefn 23) / ¢ ~
CENSENUMBER '/' ' ~ IDATESIGNEDIMo~qth Day ¥ )
· PRONOUNCING AND CERTIFYING PHYSICIAN (PhyS~k~q both proncxmcing death and c~sr Idyir~ to cause o~ death} ' '
T°~-~fmv~"~-~p~`~-~h~==~-t~-~d~t~-~-~-~)~ndm~"~-r~-~-t-a L~ ~ I=~d February 2003
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
'MEmCALEXAMINER/CORONER [ilem27)Type°rPrintMichael L. Norrisj Coroner
~hab~a~f~xam~ti~na~d~nveat~gat~n~nr~¥~p~n~n~death~ccurredatthe~rne~dat~andp~¢e~nddu~t~hacau~e~)~nd ~G( 6375 Basehore Road, Suite
manner al stated .................................................................................................
3~' ~ ~=. Mechanicsburg, Pa. [7050
REGISTRAR'S SIGNATURE AND NUMBER
~///~'~; / ~ ~,:....,, :)ATE FILED (Mo~th, Day. Year)
". I /o'r' r I 5 3
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: KEI-,LV ~. hLV_a_RE Z
Date of Death:
FEBRUARY 18~ 2003
Will No. Admin. No. 2003- 00198
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on 6/23/03 .
Name Address
Geraldine M. 'Miller 328 North Front Street, Apt. 2,
Amado Alvarez 1205 S. 28th Street, Harrisburg,
Harrisburg,PA
PA
Notice has now been given to all persons entitled thereto under Rule 5.6(a) e~c/e~t N/A
Date: 6/23/03
Signatur~~,~.~
Name LESLIE M.
FIELDS, ESQUIRE
Address831 MARKET STREET/P.O. BOX 222
LEMOYNE, PA 17043
Telephone '~ 17) 761 - 2121
Capacity: __
X
Personal Representative
Counsel for personal representative
ESTATE OF KELLY H. ALVAREZ,
Deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2003-00198
: PA No. 21-03-0198
PETITION FOR APPROVAL OF PARTIAL SETTLEMENT OF
WRONGFUL DEATH AND SURVIVAL CLAIMS
AND NOW comes the Petitioner, Tammy Fairchild, Administ~'atrix of t~? Estate of
Kelly H. Alvarez, by and through her attorney, Leslie M. Fields respectfully r(~esenting
the following: ~?
1. Petitioner is Tammy Fairchild, Administratrix of the Estate of Kelly H.
Alvarez, Letters of Administration having been granted on March 5, 2003. Petitioner is the
adult sister of Kelly H. Alvarez, deceased, who died as a result of a multi vehicle collision
which occurred on February 18, 2003 in Camp Hill, Cumberland County, Pennsylvania.
2. The collision was caused by the negligence of Alvin L. Boyer, a Michigan truck
driver, and resulted in extensive property damage and personal injuries to approximately
ten (10) individuals in addition to the decedent. Mr. Boyer was insured by Republic
Western Insurance Company with a single limit policy of $1,000,000.00 dollars to cover
all claims for personal injury and property damage.
3. After extensive negotiations, all known personal iniury and property damage
claims have been settled with Republic Western Insurance Company, with the instant
Estate to receive $625,000.00 dollars in settlement of the wrongful death and survival
claims, of which $150,000.00 (present value) is to be structured as set forth in paragraph 6
below. The remainder of the $1,000,000.00 policy limit will then be exhausted with the
exception of $93,500.00. This $93,500.00 dollar fund will be retained by Republic
Western Insurance Company for the payment of any as yet undisclosed personal injury or
property damage claims until thirty (30) days after the expiration of statute of limitations, or
until March 21, 2005. Any amounts remaining of that fund will then be paid to the Estate
pursuant to an additional petition for court approval to be filed at that time. A copy of the
release and settlement agreement with Republic Western is attached hereto as Exhibit "A".
4. In addition to the $625,000.00 dollar payment from Republic Western
Insurance Company, the full policy limits of a stacked under insured motorist policy,
totalling $200,000.00 have been offered by State Farm Insurance Company, which has
also consented to the terms of the settlement with Republic Western described above. A
copy of their offer to settle is attached hereto as Exhibit "B".
5. The Commonwealth of Pennsylvania, Department of Revenue, has approved
an allocation of the proposed settlement in this case with the gross amount of $660,000.00
being allocated to the wrongful death claim and $165,000.00 to the survival claim as set
forth in their letter, a copy of which is attached hereto as Exhibit "C".
6. Tile sole heir and beneficiary in this case is Geraldine Miller, the mother
of the decedent. As set forth in paragraph 3, Ms. Miller desires to structure part of the
proceeds of the settlement as a uniform qualified assignment with a cost of $150,000.00 to
be placed with Pacific Life and Annuity Company, as set forth in their Uniform Qualified
Assignment and Release, a copy of which is attached hereto as Exhibit "D". This will
provide payments to Geraldine Miller commencing 9/1/2004 in the amount of $577.00
monthly for 10 years followed by the payment of $150,000.00 on 9/1/2014.
8. Counsel has been retained pursuant to a contingent fee agreement providing
for counsel fees in the amount of 33 1/3 percent plus litigation costs. Costs to date are in
the amount of $1,127.00. The inheritance tax department has indicated that counsel fees
and costs are to be deducted consistent with their allocation which would result in counsel
fees and expenses on the wrongful death claim of $220,901.60 and counsel fees and
expenses in the amount of $55,225.40 on the survival claim, which Petitioner feels is fair
and reasonable.
WHEREFORE, Petitioner respectfully prays that this Court issue an Order as follows:
a. approving the settlement with Republic Western for amount of $625, 0000,
with $150,000 being in the form of a uniform qualified assignment as set
forth above;
b. approving the settlement with State Farm for the policy limits of
$200,000.00;
c. approving the allocation of the settlement as $660,000.00 to the wrongful
death claim and $165,000.00 to the survival claim; and
d. approving payment for counsel fees and expenses on the wrongful death
claim in the amount of $220,901.60; and
e. approving payment for counsel fees and expenses on the survival claim in the
amount of $55,225.40.
FULL AND FINAL RELEASE
For and In Consideration of the sum of FOUR HUNDRED SEVENTY FIVE
THOUSAND DOLLARS ($475,000.00) paid to us directly in hand as well as the
Periodic/Structure Payments outlined below (present value of $150,000.00), paid by
REPUBLIC WESTERN INSURANCE COMPANY ("INSURER"), TRANS-RITE GLOBAL
LOGISTICS and ALVIN BOYER (hereinafter DEFENDANTS), the receipt of which is
hereby acknowledged, we, Geraldine Miller and Tammy Fairchild, being of lawful age and
duly authorized to act on behalf of the Estate of Kelly Alvarez, hereby fully and forever
release, acquit and discharge the said INSURER, DEFENDANTS, AND ANY AND ALL
OTHER PERSONS, FIRMS, PARTNERSHIPS, CORPORATIONS AND GOVERNMENTAL
ENTITIES which are or might be claimed to be liable to us, the Estate of Kelly Alvarez, her
heirs, administrators, executors, successors and assigns from any and all actions, causes
of action, claims, compensatory damages, punitive damages and demands of whatsoever
kind or nature which have been or could have been asserted now or at any time in the
future, on account of any and all known and unknown injuries, losses and damages
sustained or received on or about the lSth day of February, 2003, arising out of or in any
way related to a motor vehicle accident on Route 581 in Camp Hill, Pennsylvania, for which
injuries, losses and damages we claim the said DEFENDANTS to be legally liable. It being
understood and agreed that the acceptance of said sum is in full accord and satisfaction of
a disputed claim and that the payment of said sum is not an admission of liability, it is also
understood that this Release does not discharge or waive any potential
underinsured motorist claim that the Estate of Kelly Alvarez may attempt to pursue.
It is further agreed as a condition to the release and settlement of all claims to this
matter that the balance of the $93,500 remaining on the liability cQverage of the
Defendants will be held in the escrow account of Dickie, McCamey & Chilcote, P.C. and
that any other outstanding personal injury and/or property damage claims or suits arising
out of this accident will be settled and satisfied from the $93,500 referenced above.
Thirty (30) days after the passing of the statute of limitations if there is any residual
remaining after the satisfaction of all property damage and personal injury claims then the
balance will be paid to Attorney Leslie Fields to distribute.
We hereby declare that we fully understand the terms of this settlement; that the
amount stated herein is the sole consideration of this release and that we voluntarily
accept said sum for the purpose of making a full and final compromise, adjustment and
settlement of all claims resulting or to result from said accident.
It is expressly understood and agreed that this release and settlement is intended to
cover and does cover not only all now known injuries, losses and damages, but any future
injuries, losses and damages not now known or anticipated, but which may later develop or
be discovered, including all the effects and consequences thereof.
In consideration of the release set forth above, the Insurer on behalf of the
Defendants agrees to pay or cause to be paid, periodic payments made according to the
schedule as follows (the "Periodic Payments"):
effective unless it is in writing and delivered to the Insurer or the Insurer's Assignee. The
designation must be in a form acceptable to the Insurer or the Insurer's Assignee before
such payments are made.
Geraldine Miller acknowledges and agrees that the Defendants and/or the Insurer
will make a "qualified assignment", within the meaning of Section 130 (c) of the Internal
Revenue Code of 1986, as amended, of the Defendants' and/or the Insurer's liability to
make the Periodic Payments set forth above to Pacific Life & Annuity Services, Inc. ("the
Assignee"). The Assignee's obligation for payment of the Periodic Payments shall be no
greater than that of Defendants and/or the Insurer (whether by judgment or agreement)
immediately preceding the assignment of the Periodic Payments obligation.
Any such assignment, if made, shall be accepted by Geraldine Miller without right of
rejection and shall completely release and discharge the Defendants and the Insurer from
the Periodic Payments obligation assigned to the Assignee. Geraldine Miller recognizes
that, in the event of such an assignment, the Assignee shall be the sole obligor with
respect to the Periodic Payments obligation, and that all other releases with respect to the
Periodic Payments obligation that pertain to the liability of the Defendants and the Insurer
shall thereupon become final, irrevocable and absolute.
The Defendants and/or the Insurer, itself or through its Assignee reserve the right to
fund the liability to make the Periodic Payments through the purchase of an annuity policy
from Pacific Life and Annuity Company ("annuity issuer"). The Defendants, the Insurer or
the Assignee shall be the sole owner of the annuity policy and shall have all rights of
ownership. The Defendants, the Insurer or the Assignee may have annuity issuer mail
payments directly to the Payee. Geraldine Miller shall be responsible for maintaining a
current mailing address for Payee with annuity issuer.
The discharge of the obligation of the Defendants, Insurer and/_or Assignee to make
each Periodic Payment described in Section 2 of this Agreement, if by check, shall occur
upon the mailing of a valid check, on or before the due date, in the amount due to the
Payee's address as shown in the Assignee's records, or, if by Electronic Funds Transfer
(EFT), upon the electronic transferring of such payment, on or before the due date, to the
Payee's bank account as shown in the Assignee's records.
It is further understood by us and our attorneys that all medical liens, subrogation
claims, workers compensation liens, insurance liens/subrogation claims, and all
liens/subrogation claims from any governmental body or program that relate to benefits
paid to the Estate of Kelly Alvarez or expenses incurred by the Estate of Kelly Alvarez of
whatsoever kind arising out of the above-referenced motor vehicle accident or relating in
any way to treatment received for injuries and/or damages arising therefrom, shall be
satisfied, settled and/or resolved by us. All such claims, liens, and expenses are solely our
responsibility and the satisfaction of any such claim is a material condition/term of this
Agreement.
It is further agreed that we and our attorneys will indemnify and defend the
Defendants from and against any such liens, claims and subrogation actions asserted by
any insurer, workers' compensation carrier, health care provider or governmental body, to
the fullest extent permitted by law, including attorney's fees, should any demand be made
against the Defendants.
IT IS FURTHER UNDERSTOOD AND AGREED THAT ALL PARTIES TO THIS RELEASE
INCLUDING BUT NOT LIMITED TO DEFENDANTS, OUR FAMILY, OUR ATTORNEYS AND OTHER
REPRESENTATIVES, SHALL DECLINE COMMENT ON ANY ASPECT OF THIS CASE OR
SETTLEMENT TO ANY PERSON, OR TO ANY MEMBER OF THE NEWS MFDIA, AND SHALL NOT
EITHER DIRECTLY OR INDIRECTLY DISCLOSE OR REVEAL TO ANY PERSON, OR IN ANY WAY
PUBLICIZE OR CAUSE TO BE PUBLICIZED IN ANY NEWS OR COMMUNICATIONS MFDIAj INCLUDING
BUT NOT LIMITED TO NEWSPAPERS, MAGAZINES, JOURNALS, RADIO OR TELEVISION, THE FACTS
OF THIS CASE, THE EXISTENCE OF THIS SETTLEMENT, OR THE TERMS AND CONDITIONS OF THIS
SETTLEMENT. THIS PARAGRAPH IS INTENDED TO BECOME PART OF THE CONSIDERATION FOR
SETTLEMENT OF THIS CLAIM.
It iS further understood and agreed that this is the complete release agreement, and
that there are no written or oral understandings or agreements, directly or indirectly
connected with this release and settlement that are not incorporated herein.
This agreement shall be construed that wherever applicable the use of the singular
number shall include the plural number and shall be binding upon and inure to the
successors, assigns, heirs, executors, administrators, and legal representatives of the
respective parties hereto.
We have carefully read the foregoing with the assistance of legal counsel of our
choosing and know and understand the contents and meaning thereof and sign the same
as our free act and will.
It is understood and agreed that this Full and Final Release is being executed and
shall be construed and enforced pursuant to Pennsylvania law. Even if there is some
action or claim asserted in a jurisdiction other than Pennsylvania regarding the subject
matter of this Full and Final Release, it is agreed that Pennsylvania law will govern the
interpretation and application of this Release.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
,2004.
Witnesses:
__ _ day of
Tammy Fairchild, Administratrix of the
Estate of Kelly Alvarez
[SEAL]
¢~:atdin~ Miller
State of ~/~y?v~ni~ )
) SS:
County of_~¢~/e,,Ccf/(]/ )
On this ZS~'~_ day of _.~7~/~/
,2004, before me personally appeared Tammy
Fairchild and Geraldine Miller to me known to be the persons named in and who executed the
above release and acknowledged that Tammy Fairchild and Geraldine Miller executed same as
their free act and deed. Witness my hand and notarial seal the date aforesaid.
My commission expires /f/~,~//' ¢ ,20 ~. .
State Farm Insurance Companies
July 6, 2004
Leslie Fields, Esq.
Costepeulos Fester & Fields
PO Se× 222
Lemoyne, PA 17043-0222
115 Limekiln Road
PO Box 257
New Cumberland PA 17070-0257
RE:
Your Client:
Our Insured:
Our Claim No.:
Date ef Less:
The Estate of Kelly Alvarez
Geraldine Miller
38-K137-039
February 18, 2003
Dear Hs. Fields:
This follows our conversation this date in reference to your
client above. This will confirm that we will offer our
underinsured policy limits of $100,000 on each of two policies to
your client. We will require Court Approval of the Wrongful
Death and Survival Actions. Upon reciept of an original copy of
the Court Approval, we will issue our draft. Should you have any
questions, feel free to call me at the number listed below.
Sincerely,
James J. Ramsey ~
Claim Representative
(717) 774-9074
State Farm Mutual Automobile Insurance Company
HOME OFFIC~IS 91710_0001
State Farm Insurance
July 6, 2004
Leslie Fields, Esq.
Costopoulos Foster & Fields
PO Box 222
Lemeyne, PA 17043 0222
Companies
State Farm insurance
115 Limekiln Road
PO Box 257
New Cumberland PA 17070 0257
RE:
Your Client:
Our Insured:
Our Claim No.:
Date of Loss:
The Estate of Kelly Alvarez
Geraldine Miller
38-K135-837
February 18, 2003
Dear Ms. Fields:
This follows our conversation this date in reference to your
client above. This will confirm that we will offer our
underinsured policy limits of $100,000 on each of two policies to
your client. We will require Court Approval of the Wrongful
Death and Survival Actions. Upon reciept of an original copy of
the Court Approval, we will issue our draft. Should you have any
questions, feel free to call me at the number listed below.
Sincerely,
James J. RamseyJ
Claim Represen~fative
(717) 774 9074
State Farm Mutual Automobile Insurance Company
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAl_ TAXES
DEPARTMENT 280601
HARRISBURG, PA 17128-0601
Telephone
4/16,/2004 REVISED
Leslie M Fields, Esquire
Constopulos et al
PO Box 222
Lemoyne, PA 17043-0222
717-783-0972
717-783-3467 (fax)
~dib e r t ((3 s ta tc .1~a.u s (e-mail)
Re: Estate of Kelly Alvarez
File Number: 2103-0198
Dea~ Ms. Fields:
The Department of Revenne has received a letter concerning the Petition for Approval of Settlement Claim
to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been
forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the
actions.
Pursnant to the letter, the 23 -year-old-decedent died as a result ora motor vehicle accident. Decedent is
survived by the decedent's parents.
Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no
objection to the proposed allocation of the gross proceeds of this action, $ 660,000.00 to the wrongful death claim
and $ 165,000.00 to the survival claim. Proceeds ora survival action are an asset includcd in the decedent's estate
and are sut~ject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs
and Ii:cs must be deducted in the same percentages as the proceeds are allocated, in re Estate of Men'wnan, 669
A.2d 1059 (Pa. Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this matter. As the
Department has no objections to the Petition, an attorney from the Depamnent of Revenue will not be attending any
hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from
this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the
Department may take in any other proposed distribution of proceeds of a ;wongful death / survival action.
Inheritance Tax Division
Burean of Individeal Taxes
Uniform Qualified Assignment and Release
"Claimant"
"Assignor"
"Assignee"
"Annuity Issuer"
"Effective Date"
Geraldine Miller
Republic Western Insurance Company
Pacific Life & Annuity Services, Inc.
Pacific Life and Annuity Company
This Agreement is made and entered into by and
between the parties hereto as of the Effective Date with
reference to the following facts:
A. Claimant has executed a settlement agreement or
release dated , 2004
(the "Settlement Agreement") that provides for the
Assignor to make certain periodic payments to or for
the benefit of the Claimant as stated in Addendum
No. 1 (the "Periodic Payments"); and
The parties desire to effect a "qualified assignment"
within the meaning and subject to the conditions of
Section 130(c) of the Internal Revenue Code of
1986 (the "Code").
NOW, THEREFORE, in consideration of the foregoing
and other good and valuable consideration, the parties
agree as follows:
The Assignor hereby assigns and the Assignee
hereby assumes all of the Assignor's liability to make
the Periodic Payments. The Assignee assumes no
liability to make any payments not specified in
Addendum No. 1.
The Periodic Payments constitute damages on
account of personal injury or sickness in a case
involving physical injury or physical sickness within
the meaning of Sections 104(a)(2) and 130(c) of the
Code.
The Assignee's liability to make the Periodic
Payments is no greater than that of the Assignor
immediately preceding this Agreement. Assignee is
not required to set aside specific assets to secure
the Periodic Payments. The Claimant has no rights
against the Assignee greater than a general creditor.
None of the Periodic Payments may be accelerated,
deferred, increased or decreased and may not be
anticipated, sold, assigned or encumbered.
The obligation assumed by Assignee with respect to
any required payment shall be discharged upon the
mailing on or before the due date of a valid check in
the amount specified to the address of record.
This Agreement shall be governed by and
interpreted in accordance with the laws of the State
of Colorado.
The Assignee may fund the Periodic Payments by
purchasing a "qualified funding asset" within the
meaning of Section 130(d) of the Code in the form of
an annuity contract issued by the Annuity Issuer. All
rights of ownership and control of such annuity
contract shall be and remain vested in the Assignee
exclusively.
The Assignee may have the Annuity Issuer send
payments under any "qualified funding asset"
purchased hereunder directly to the payee(s)
specified in Addendum No. 1. Such direction of
payments shall be solely for the Assignee's
convenience and shall not provide the Claimant or
any payee with any rights of ownership or control
over the "qualified funding asset" or against the
Annuity Issuer.
Assignee's liability to make the Periodic Payments
shall continue without diminution regardless of any
bankruptcy or insolvency of the Assignor.
9
In the event the Settlement Agreement is declared
terminated by a court of law or in the event that
Section 130(c) of the Code has not been satisfied,
this Agreement shall terminate. The Assignee shall
then assign ownership of any "qualified funding
asset" purchased hereunder to Assignor, and
Assignee's liability for the Periodic Payments shall
terminate.
10. This Agreement shall be binding upon the respective
representatives, heirs, successors and assigns of
the Claimant, the Assignor and the Assignee and
upon any person or entity that may assert any right
hereunder or to any of the Periodic Payments,
11. The Claimant hereby accepts Assignee's
assumption of ail liability for the Periodic Payments
and hereby releases the Assignor from all liability for
the Periodic Payments.
Assignor: Republic Western Insurance Company
Assignee: Pacific Life & Annuity Services, Inc,
Title:
Authorized Representative
Title:
Authorized Representative
Claimant: Geraldine Miller
Approved as to Form and Content:
Leslie M Fields, Esq.
National Structured
Set;t;lemen~s
Trade Association
Addendum No. 1
Description of Periodic Payments
Periodic Payments:
P~y~hl~ fn ~¢,r~ldin~ Miller
Commencing 9/1/2004
$577 per month for 10 years only
$150,000 on 9/1/2014
Beneficiary: Tammy Fairchild, William Fairchild and Terry Fairchild, equally or to their
respective Estates
Geraldine Miller may request in writing that the Assignee change the beneficiary
designation under this agreement. Any change of the beneficiary designation will only be
made with the Assignee's consent. Assignee's decision will be final. Assignee will not be
liable for any payment made prior to receipt of the request or so soon thereafter, that
payment could not reasonably be stopped.
Initials
Claimant:
Assignor:
Assignee:
Printed in USA
UQAR ED 4 88
VERIFICATION
I, Tammy Fairchild, Adminstratrix of the Estate of Kelly H. Alvarez, do hereby verify
that the statements made in the foregoing document are true and correct. I understand that
any false statements herein are made subject to the penalties of 198 Pa. C. S. Section 4904,
relating to unswom falsification to authorities.
Date:
Tammy FairChild, Administratrix of
the Estate of Kelly H. Alvarez
ESTATE OF
KELLY H. ALVAREZ,
Deceased
: IN THE COURT OF COMMON PLEAS OF
· CUMBERLAND COUNTY, PENNSYLVANIA
· NO. 21-03-0198
IN RE: PETITION FOR APPROVAL OF PARTIAL SETTLEMENT OF
WRONGFUL DEATH AND SURVIVAL CLAIMS
ORDER OFCOURT
AND NOW, August 9, 2004, hearing on the Petition for Approval of
Partial Settlement of Wrongful Death and Survival Claims is set for
Wednesday, August 18, 2004, at 3:30 p.m. in Courtroom 3.
By the Court,
'-'-72; ~'-~-~ Leslie M. Fields, Esquire
'%~_...? (.~ Costopoulos, Foster & Fields
_, ~/ 831 Market Street
-;~, (,. PO Box 222
' ~i ? Lemoyne, PA 17043
ESTATE OF KELLY H. ALVAREZ,
Deceased
1N THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2003-00198
PA No. 21-03-0198
ORDER
AND NOW, this day of ,2004, upon
~ . ' 0 Wron ful Death and Survival
consideration of the Petition for Approval of Partml Settlement of g
Claims, it is ORDERED as follows:
a. The settlement with Republic Western in the amount of $625,000.000, with
$150,000.00 being in the form ora uniform qualified assignment is approved;
b. The settlement with State Farm for the policy limits of $200,000.00 is approved;
c. The allocation of the settlement as $660,000.00 to the wrongful death claim and
$165,000.00 to the survival claim is approved;
d. Payment of counsel fees and expenses on the wrongful death claim in the amount
of $220,901.60 to Costopoulos Foster & Fields is approved; and
e. Payment of counsel fees and expenses on the survival claim in the amount of
$55,225.40 to Costopoulos, Foster & Fields is approved.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 004377
FIELDS LESLIE M
831 MARKET STREET
LEMOYNE, PA 17043
...... fold
ESTATE INFORMATION: SSN: 181-60-3204
FILE NUMBER: 2103-01 98
DECEDENT NAME: ALVAREZ KELLY
DATE OF PAYMENT: 09/14/2004
POSTMARK DATE: 09/03/2004
COUNTY: CUM BERLAN D
DATE OF DEATH: 02/18/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $4,260.00
TOTAL AMOUNT PAID:
$4,260.00
REMARKS:
SEAL
CHECK# 1212
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
COMMONWEALTH OF
PENr~YLVANIA
DEPARTMENT OF REVENUE
DEPT. 28060i
HARRISBURG, PA 17128-060i
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
-o 0_1
COUNTY CODE YEAR NUMBER
X
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Alvarez, Kelly H.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
02/18/2003 12/12/1979
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
181-60-3204
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
[]1. Odginal Return
[~4. Limited Estate
~-'~ 6. Decedent Died Testate (A~Ch copy of wi~)
[~]9. Litigation Proceeds Received
NAME
Leslie M. Fields, Esquire
FiRM NAME (IfApplicabJe)
Costopoulos, Foster & Fields
TELEPHONE NUMBER
(717) 76~-2121
r-~2. Supplemental Return [] 3. Remainder Retum (date of death pr~to 12-13-82)
[] 4a. Future Interest Compromise (date of deaa after 12-12-82) [] 5. Federal Estate Tax Retum Required
[~7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes
[] 10. Spousal Poverty Credit (da~e of death between 12-31-91 a~d 1-1-95) [] 11. Election to tax under Sec. 9113(A) I^t~ch Sch O)
COMPLETE MAILING ADDRESS
831 Market Street
P.O. Box 222
Lemoyne, PA 17043
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
~] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
9.
Total Gross Assets (total Lines 1-7)
Funeral Expenses & Administrative Costs (Schedule H) (9)
Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)(10)
Total Deductions (total Lines 9 & 10)
Net Value of Estate (Line 8 minus Line 11)
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) (14)
109,774.60
(8)
15,096.60
(11)
(12)
(13)
09,774.60
5,096.50
94,678.10
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2) x .0 __ (15)
16. Amount of Line 14 taxable at lineal rate 94,678.10 x .0 __ (16)
17~ Amount of Line 14 taxable at sibling rate x .12 (17)
I8 Amount of Line 14 taxable at collateral rate ...... x .15 (18)
19. Tax Due (19)
94,678.10
4,260.00
Decedent's Complete Address:
STREET ADDRESS
628 Norht Front Street
CTY.
worm eysourg
I STATEpA
7043
Tax Payments and Credits:
1~ Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
4,260.00
4,260.00
4,260.00
Total Credits ( A + B + C ) (2)
3. Interest~Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE, (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income 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 secudty 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 ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT
AS PART OF THE RETURN,
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 true, 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
ADDRESS
t EPARER OT~ESENTATIYE DATE
, ~_ ~ 09/02/04
, Lemoyne, PA 17043
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 RS. {9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. {9116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 RS. {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 RS. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. {9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX+ (6-98)
COMMONV~'cALTH OF PENNSYLVANIA
iNHERITANCE TAX RETURN
RESI DENT DECEDENT
SCHEDULE E
C..ASfl, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Kelly H. Alvarez 21-03-0198
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property Jointly-owned with right of survivorship muat be disclosed on Schedule F.
iTEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
net proceeds of litigation, after deducting 33.3% counsel fees and expenses - see letter from Department
of Revenue and Court Order - attached. Procoeds wore received on August 27, 2004.
109,774.60
TOTAL (Also enter on line 5, Recapitulation) $
(If mom space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Kelly H. Alvarez
FILE NUMBER
Debts of decedent must be reported on Schedule 1.
DESCRIPTION AMOUNT
ITEM
NUMBER
5.
6.
7.
FUNERAL EXPENSES:
Zimmerman Auer funeral home - funeral services
Brachendorf Memorial - grave stone
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
. State Zip
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Geraldine Miller
Street Address 628 North Front Street ~ same as decedent
City Wormleysburg State PA
Relationship of Claimant to Decedent Mother
.Zip 17043
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
8,234.50
3,318.00
3,500.00
44.00
TOTAL (Aisc enter on line 9, Recapitulation) $ 15,096.50
(If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPARTMENT 280601
HARRISBURG, PA 17128-0601
Telephone
4/16/2004
Leslie M Fields, Esquire
Constopulos et al
PO Box 222
Lemoyne, PA 17043-0222
REVISED
717-783-0972
717-783-3467 (fax)
j dibert(c~state.pa.us (e-mail)
Re: Estate of KellyAlvarez
File Number: 2103-0198
Dear Ms. Fields:
The Department of Revenue has received a letter concerning the Petition for Approval of Settlement Claim
to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been
forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the
actions.
Pursuant to the letter, the 23 -year-old-decedent died as a result of a motor vehicle accident. Decedent is
survived by the decedent's parents.
Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no
objection to the proposed allocation of the gross proceeds of this action, $ 660,000.00 to the wrongful death claim
and $ 165,000.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate
and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. {}8302; 72 P.S. {}{}9106, 9107. Costs
and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669
A.2d 1059 (Pa. Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this matter. As the
Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any
hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from
this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the
Department may take in any other proposed distribution of proceeds of a wrongful death / survival action.
Business & Trust Valuation Manager
Inheritance Tax Division
Bureau of Individual Taxes
ESTATE OF KELLY H. ALVAREZ, : IN THE COURT OF COMMON PLEAS
Deceased : CUMBERLAND COUNTY, PENNSYLVANIA
:
: No. 2003-00198
: PANo. 21-03-0198
ORDER - -
AND NOW, this [ g/'~' ~ ~/{_~,1~ 1
day of ' ,2004, upon
consideration of the Petition for Approval of Partial Settlement of Wrongful Death and Survival
Claims, it is ORDERED as follows:
a. The settlement with Republic Western in the amount of $625, 000.000, with
$150,000.00 being in the form of a uniform qualified assignment is approved;
b. The settlement with State Farm for the policy limits of $200,000.00 is approved;
c. The allocation of the settlement as $660,000.00 to the wrongful death claim and
$165,000.00 to the survival claim is approved;
d. Payment of counsel fees and expenses on the wrongful death claim in the amount
of $220,901.60 to Costopoulos Foster & Fields is approved; and
e. Payment of counsel fees and expenses on the survival claim in the amount of
$55,225.40 to Costopoulos, Foster & Fields is approved.
BY THE COURT:
A TRUE COPY FROM RE(~ORD / Fo J.
In Testimony wherof:l hereunto
set my hand and the seal
BUREAU OF TNDTVTDUAL TAXES
TNHERXTANCE TAX DTV~STON
PO BOX 180601
HARR/SBURG, PA 17118-0601
COHMONNEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTZCE OF ZNHERZTANCE TAX
APPRAZSEHENT, ALLO#ANCE OR DZSALLOHANCE
OF DEDUCTIONS AND ASSESSNENT OF TAX
LESLIE M FIELDS ESQ u*'-.~, L~:~
COSTOPOULOS ETAL
PO BOX 222 ~
LEMOYNE P~A, 17045
DATE
ESTATE OF
DATE OF DEATH
FILE NUHDER
COUNTY
ACN
REV-I~I7 EX AFP
12-06-2004
ALVAREZ KELLY H
02-18-2005
21 05-0198
CUHBERLAND
101
Amount RoeAtted d
MAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGISTER OF gILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LANE ~ RETAIN LONER PORTION FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLONANCE OR
DZSALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF ALVAREZ KELLY H FILE NO. 21 05-0198 ACN 101 DATE 11-06-200~.
TAX RETURN #AS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATION CONCERNZNG FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN DASED ON: ORIGINAL RETURN
1. Roe1Estoto (Sohedulo A)
2. Stocks and Bonds (Schodule B) (2)
$. Closely Hold Stock/Partnership Interost (Schodulo C) ($)
~. Nortgagos/Notes RocoAvoblo (Schodulo D) (~)
5. Cash/Bank DoposAts/NAsc. Porsonol Property (Schodulo E)
6. Jointly Ownod Proporty (Schedulo F) (6)
7. Transfers (Schodulo G) (7)
8. Tote! Assots
APPROVED DEDUCTIONS AND EXEHPTZONS:
9. Funoral Exponsos/Ado. Costs/MAsc. Expenses (SchoduZo H] (9)
10. Debts/Mortgago LAobilitAos/L/ons (Schodulo Z) (10)
11. Total Doductions
12. Not Valuo of Tox Roturn
15.
1~.
CharAtablo/Governeontol Boquosts; Non-oloctod 9115 Trusts (Schodulo J)
Net Value of Estoto Subjoct to Tax
.00
.00
.00
.00
109;774.60
.00
.O0
(8)
15,096.60
.00
NOTE: To insure proper
credit to your account,
submit tho upper portion
NOTE:
of th/s for. with your
tax payeont.
109,774.60
(11) 15.096.50
(12) 94,678.10
(15) . O0
(lr~) 94,678.10
Zf an assessment ,as lssued previously, lines 1~, 15 and/or 16, 17, 18 and 19 ,111
re~lect ~igures that /nclude the total o~ ALL returns assessed to date.
ASSESSHENT OF TAX:
1S. Amount of Lino 1~ st Spousol rate (15)
16. Amount of LAne 1~ taxablo at LinooX/CXoss A roto (16}
17. Amount of LAne 1~, at SAblAng roto (17)
18. Amount of L/no 1~ taxablo at Collatorol/Closs B rote (18)
19. Prlnc/pal Tax Duo
D/SCOUNT (+)
INTEREST/PEN PAID (-)
TAX CREDTTS:
PAYtlENT
DATE
09-05-2004
· O0 x O0 = . O0
94,678.10 x 045= 4,260.00
· O0 x 12 = . O0
· O0 x 15 = . O0
(19)= 4,260.00
ANOUNT PAID
4,260.00
KECEXPT
NUHBER
CD004577
BALANCE OF UNPAID INTEREST/PENALTY AS OF
ZF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
.0O
09-04-2004 TOTAL TAX CREDIT J 4,260.00
BALANCE OF TAX DUEl .00
ZNTEREST AND PEN. 140.84
TOTAL DUE 140.84
( ZF TOTAL DUE ZS LESS THAN $1, NO PAYHENT ZS REQUIRED. ~
ZF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR), YOU NAY BE DUE
A REFUND· SEE REVERSE SADE OF THIS FORH FOR INSTRUCTIONS.)
RESERVAT/DN: Estates of decedents dying on or before December 12, 1982 -- if any future 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 Comaonaealth hereby expressly reserves the right to appraise and assess transfer inheritance Taxes
at the lawful Class B (collateral) rate on any such futura interest.
PURPOSE OF
NOT[CE: To fulfill the requirements of Section 21~0 of the inheritance and Estate Tax Act, Act 25 of 2000. (72 P.S.
Section 91~0).
PAYHENT: Detach the top portion of this Notice and submit with your payment to the Register of #ills printed on the reverse side.
--Hake check or money order payable to= REGISTER OF NilES, AGENT
REFUND (CR): 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-1315). Applications ere available
online at eww.rsvenua.stata.pa.us, any Register of Hills or Revenue District Office, or free the Department's
[fi-hour answering service for fores orders: 1-800-361-Z050; services for taxpayers with special hearing and/or
speaking needs: 1-800-~q7-3010 (TT only).
OBJECTIONS: Any party in interest not satisfied with the appraisment, allowance or disallowance of deductions or assessment of tax
(including discount or interest) as shown on this Notice may object within 60 days of tho date of receipt of this notice
by filing one of the following:
A) Protest to the PA Department af Revenue, Board of Appeals. You may ob]act by filing a protest online at
wwN.boardofappaais.state.pa.us an or before the expiration ef the sixty-day appeal period, in order for
an electronic protest to ba valid, you must receive a confirmation number and processed date free the
Board of Appeals wabsita. You amy also send a written protest to PA Department of Revenue, Board of Appeals
P.O. Box 181011, Harrisburg, PA 17118-1011. Petitions may not be foxed.
B) Election to have the matter determined at the audit of the account of the personal representative.
C) Appeal to the Orphans' Court.
ADMIN-
iSTRATiVE
CORRECTIONS: Factual errors discovered on this assessment should bo addressed in writing to: PA Department of Revenue,
Bureau of individual Taxes, ATTN: Post Assessment Review Unit, P.O. Sox 180601, Harrisburg~ PA 17118-0601
Phone (717) 787-6505. Sam page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-1501) for an explanation of administratively correctable attars.
DISCOUNT: [f any tax due is paid within three (3) calendar months after the dacadent's death, a five percent (51) discount of
the tax paid is allowed.
PENALTY: The 15Z tax amnesty non-participation penalty is computed on tho total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the and of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same tiaa period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST: 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 payment. Taxes which became delinquent before January 1, 1981 bear interest at the rate of
six (61) percent per annum calculated at a daily rate of .00016fi. All taxes which became delinquent on and after
January 1, 1981 will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOOq are:
Interest Daily Interest Daily Interest
Daily
Year Rate Factor Year Rate Factor Year Rate Factor
~ [OX .OOOSq8 ~'~6-1991 111 .000301 ~ 9Z .O00Zq7
1983 162 .000q38 1992 9Z .O00Zq7 ZOOZ 62 .00016~
198fl 112 .000501 199~-199& 72 .OOOlgZ 2003 52 .000137
1985 132 .000356 1995-1998 92 .O00Zfi7 ZOOq qZ .000110
1986 10Z .O00Z7q 1999 71 .00019Z
1987 101 .OOO27q ZOOO 7Z .000191
--Interest is calculated as follaws:
INTEREST = BALANCE OF TAX UNPAXD X NUHBER OF DAYS DELINQUENT X DAXLY 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. [f payment is made after the interest computation date shown on the
Notice, additional interest lust be calculated.
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 1/10/2005
FIELDS LESLIE M
831 MARKET STREET
LEMOYNE, PA 17043
RE: Estate of ALVAREZ KELLY
File Number: 2003-00198
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing will become delinquent on: 2/18/2005
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
cc:
File
Personal Representative(s)
Judge
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL ~f.:-:,r,[:i r<::::r\: r:C
INHERITANCE TAX DIVISION i i~\....'" '".:_ ,} \/. ' ;\.-L 1...-1
PO BOX 2806111 'I ! '~'
HARRISBURG~ PA 17128-0601
INHERITANCE TAX
RECORD ADJUSTMENT
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DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
12-29-2004
ALVAREZ
02-18-2003
21 03-0198
CUMBERLAND
101
CL::F:I<.
ORPi--"~
LESLIE M F~~PSESQ
COSTOPOULOS ETAL
PO BOX 222
LEMOYNE PA 17043
Allount R..ltted
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REV-159SEXAFPC09-04)
KELLY
H
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, submit the upper portion of this for.. with your tax payment.
CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV: is'9:i-iif-iiFP-rilFo3y-----ji.-ii,jHERi:YiiNcE-TA-i-RE-CORO--iiiij-USTHENT-iiii----------------------- - - ----
ESTATE OF ALVAREZ
KELL Y
H FILE NO. 21 03-0198
ACN 101
DATE
12-29-2004
ADJUSTHENT BASED DN:
VALUE OF ESTATE:
ADMINISTRATIVE CORRECTION
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. Hortgages/Notes Receivable (Schedule DJ
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Administrative Costs/
Miscellaneous Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequestsj Non-elected
14. Net Value of Estate Subject to Tax
III
(21
(31
(41
(51
(61
(71
.00
.00
.00
.00
109,774.60
.00
.00
(BI
(91 15,096.60
1101 .00
(111
1121
9113 Trusts (Schedule J) (13)
1141
TAX:
15. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rete
17. Amount of Line 14 at Sibling rat.
18. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
.OOX 00 =
94,678.10 X 045=
.OOX 12 =
.OOX 15 =
1191
1151
1161
1171
1181
109,774.60
15,096.50
94,678.10
.00
94,678.10
.00
4.260.51
.00
.00
4,260.00
.C~CH ,.., AHDUNT PAID
DATE NUHBER INTEREST/PEN PAID (-I
09-03-2004 CD004377 .00 4,260.00
09-14-2004 WRITE OFF .00 140.84
TOTAL TAX CREDIT 4.260.00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
.
IF PAID AFTER DATE INDICATED, SEE REVERSE
FDR CALCULATIDN DF ADDITIONAL INTEREST.
IF TDTAL DUE IS LESS THAN $1, ND PAYHENT IS REQUIRED.
IF TDTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YDU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FDRH FDR INSTRUCTIONS. I
~':::.{-.
REV-1470EX(6-B8)
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INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENTS NAME
KELLY H ALVAREZ
FILE NUMBER
Dianne McClain
ACN
2103-0198
101
REVIEWED BY
ITEM
SCHEDULE NO.
EXPLANATION OF CHANGES
The Notice of Inheritance Tax Appraisement, Allowance or Disallowance of Deductions
and Assessment of Tax has been adjusted to reflect an abatement of interest since the
assets were proceeds of litigation.
ROW
PaQe 1
.
Register of Wills of Cumberland County
STATUS REPORT UNDER RULE 6.12
N f D d t Kelly Alvarez
ame 0 ece en :
Date of Death: February 18, 2003
Estate No.: 2003-00198
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes 0 No IZl
2. lfthe answer is No, state when the personal representative reasonably believes that
the administration will be complete: May 2005
3. If the answer to No. I is Yes, state the following:
a. Did the personal representative file a final 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 parties in
interest? Yes 0 No 0
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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. , ~_ ~' . , ~. "
February 24 ?lbs--" ~~. L
Date: . -. //- ~/ . ~~ .
///-/ Signatuje
Leslie M. Fields. Esq.
Name
831 Market Street
Lemoyne, PA 17043
Address
(717) 761-2121
Telephone No.
Capacity:
o Personal Representative
Qg Counsel for personal representative
eft
ESTATE OF KELLY H. ALVAREZ,
Deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2003-00198
PA No. 21-03-0198
PETITION FOR APPROVAL OF FINAL SETTLEMENT OF
WRONGFUL DEATH AND SURVIVAL CLAIMS
AND NOW comes the Petitioner, Tammy Fairchild, Administratrix of the Estate of
Kelly H. Alvarez, by and through her attorney, Leslie M. Fields respectfully representing
the following:
1. Petitioner is Tammy Fairchild, Administratrix of the Estate of Kelly H.
Alvarez, Letters of Administration having been granted on March 5, 2003. Petitioner is the
adult sister of Kelly H. Alvarez, deceased, who died as a result of a multi-vehicle collision
which occurred on February 18, 2003 in Camp Hill, Cumberland County, Pennsylvania.
2. An earlier Order approving this settlement was granted on August 18, 2004, a
copy of which is attached as Exhibit A. That petition, at paragraph 3 referenced a
remaining sum from the policy limit oL.$93,500.00 which was being retained by the
expiration of the statute of limitations. The statute has now run and the final ~Hl1QUnt of :
$94,330.82 is available for distribution.
3. The sole heir and beneficiary in this case is Geraldine Miller, the m9tQer
of the decedent.
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4. As with the earlier petition, having been authorized to do so by the
department of revenue, petitioner requests that the settlement fund be allocated as 80%
wrongful death and 20% survival, or $ 75,464.65 on the wrongful death claim and
$18,866.16 on the survival action.
5. Counsel has been retained pursuant to a contingent fee agreement providing
for counsel fees in the amount of 33 1/3 percent plus litigation costs. The remaining costs
are in the amount of $257..00. The inheritance tax department has indicated that counsel
fees and costs are to be deducted consistent with their allocation which would result in
counsel fees and expenses on the wrongful death claim of $25,360.48 and counsel fees
and expenses in the amount of $ 6,340.12 on the survival claim, which Petitioner feels is
fair and reasonable.
WHEREFORE, Petitioner respectfully prays that this Court issue an Order as
follows:
a. approving the terms of the final settlement for $94,330.82;
b. approving the allocation" of the settlement as $ 75,464.65 to the wrongful
death claim and $18,866.16 to the survival claim;
c. approving payment for counsel fees and expenses on the wrongful death
claim in the amount of $25,360.48; and
d. approving payment for counsel fees and expenses on the survival claim in the
amount of $ 6,340.12.
Dated: ,.PIa~ l- ~o~
,
RESPECTFULLY SUBMITTED:
Leslie . Fields, Esquire
I.D. No. 29411
COSTOPOULOS, FOSTER & FIELDS
831 Market Street/P.O. Box 222
Lemoyne, Pennsylvania 17043
Phone: (717) 761-2121
ATTORNEY FOR PLAINTIFFS
VERIFICATION
I, Tammy Fairchild, Adminstratrix of the Estate of Kelly H. Alvarez, do hereby verify
that the statements made in the foregoing document are true and correct. I understand that
any false statements herein are made subject to the penalties of 198 Pa. C. S. Section 4904,
relating to unsworn falsification to authorities.
Date:. V/:l~5'
T1m~i~~~XOf
the Estate of Kelly H. Alvarez
VERIFICATION
I, Geraldine Miller, do hereby verify that the statements made in the foregoing
document are true and correct. I understand that any false statements herein are made
subject to the penalties of 198 Pa. C. S. Section 4904, relating to unsworn falsification to
authoritip<:
Date:, 1!J /:L/o5
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ESTATE OF KELLY H. ALVAREZ,
Deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2003-00198
PA No. 21-03-0198
ORDER
AND NOW, this
I g ftt
day of
A u..6~~T
. 2004, upon
consideration ofthe Petition for Approval of Partial Settlement of Wrongful Death and Survival
Claims, it is ORDERED as follows:
a. The settlement with Republic Western in the amount of$625, 000.000, with
$150,000.00 being in the form ofa uniform qualified assignment is approved;
b. The settlement with State Farm for the policy limits of $200,obo.00 is approved;
c. The allocation of the settlement as $660,000.00 to the wrongful death claim and
r.
$165,000.00 to the survival claim is approved;
d. Payment of counsel fees and expenses on the wrongful death claim in the amount
of $220,901.60 to Costopoulos Foster & Fields is approved; and
e. Payment of counsel fees and expenses on the survival claim in the amount of
$55,225.40 to Costopoulos, Foster & Fields is approved.
BY THE COURT:
A TRUE COpy FROM RECORD
In Testimony wherof. I hereunto
set my hand and the seal
of said Court Carlisle, PAD4
ThiS .25 day of . 20
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; EXHIBIT
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ESTATE OF KELLY H. ALVAREZ,
Deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2003-00198
PA No. 21-03-0198
PETITION FOR APPROVAL OF PARTIALSETTLEMENT Of-
WRONGFUL DEATH AND SURVIVAL CLAIMS
AND NOW comes the Petitioner, Tammy Fairchild, Administratrix of the Estate of
an
Kelly H. Alvarez, by and through her attorney, Leslie M. Fields respec~~y re~sentirj~
~ ' '- '+~.Q
the following: ~..~ 1= ~jr ~
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1. Petitioner is Tammy Fairchild, Administratrix of the Est~~~':t>f KelJx H. "
- 0;) -:;:..
Alvarez, Letters of Administration having been granted on March 5, 2003. Petmoner ~ llle
0'\
adult sister of Kelly H. Alvarez, deceased, who died as a result of a multi-vehicle collision
which occurred on February 18, 2003 in Camp Hill, Cumberland County, Pennsylvania.
2. The collision was caused by the negligence of Alvin l. Boyer, a Michigan truck
driver, and resulted in extensive property damage and personal injuries to approximately
ten (10) individuals in addition to the decedent. Mr. Boyer was insured by Republic
/"
Western Insurance Company with a single limit policy of $1,000,000.00 dollars to cover
all claims for personal injury and property damage.
3. After extensive negotiations, all known personal injury and property damage
claims have been settled with Republic Western Insurance Company, with the instant
Estate to receive $625,000.00 dollars in settlement of the wrongful death and survival
claims, of which $150,000.00 (present value) is to be structured as set forth in paragraph 6
below. The remainder of the $1,000,000.00 policy limit will then be exhausted with the
exception of $93,500.00. This $93,500.00 dollar fund will be retained by Republic
Western Insurance Company for the payment of any as yet undisclosed personal injury or
property damage claims until thirty (30) days after the expiration.of statute of limitations, or
until March 21, 2005. Any amounts remaining of that fund will then be paid to the Estate
pursuant to an additional petition for court approval to be filed at that time. A copy of the
release and settlement agreement with Republic Western is attached hereto as Exhibit "A".
4. In addition to the $625,000.00 dollar payment from Republic Western
Insurance Company, the full policy limits of a stacked under insured motorist policy,
totalling $200,000.00 have been offered by State Farm Insurance Company, which has
also consented to the terms of the settlement with Republic Western described above. A
copy of their offer to settle is attached hereto as Exhibit "B".
5. The Commonwealth of Pennsylvania, Department of Revenue, has approved
an allocation of the proposed settlement in this case with the gross amount of $660,000.00
being allocated to the wrongful death claim and $165,000.00 to the survival claim as set
forth in their letter, a copy of which is attached hereto as Exhibit "C".
6. The sole heir and beneficiary in this case is Geraldine Miller, the mother
of the decedent. As set forth in paragraph 3, Ms. Miller desires to structure part of the
proceeds of the settlement as a uniform qualified assignment with a cost of $150,000.00 to
be placed with Pacific Life and Annuity Company, as set forth in their Uniform Qualified
Assignment and Release, a copy of which is attached hereto as Exhibit "0". This will
provide payments to Geraldine Miller commencing 9/112004 in the amount of $577.00
monthly for 10 years followed by the payment of $150,000.00 on 9/1/2014.
8. Counsel has been retained pursuant to a contingent fee agreement providing
for counsel fees in the amount of 33 1/3 percent plus litigation costs. (osts to date are in
the amount of $1,127.00. The inheritance tax department has indicated that counsel fees
and costs are to be deducted consistent with their allocation which would result in counsel
fees and expenses on the wrongful death claim of $220,901.60 and counsel fees and
expenses in the amount of $55,225.40 on the survival claim, which Petitioner feels is fair
and reasonable.
WHEREFORE, Petitioner respectfully prays that this Court issue an Order as follows:
a. approving the settlement with Republic Western for amount of $625,0000,
with $150,000 being in the form of a uniform qualified assignment as set
forth above;
b. approving the settlement with State Farm for the policy limits of
$200,000.00;
c. approving the allocation ofthe settlement as $660,000.00 to the wrongful
death claim and $165,000.00 to the survival claim; and
d. approving payment for counsel fees and expenses on the wrongful death
claim in the amount of $220,901.60; and
e. approving payment for counsel fees and expenses on the survival claim in the
amount of $55,225.40.
RESPECTFULLY SUBMITTED:
. M..
Leslie . Fields, Es
1.0. No. 29411
COSTOPOULOS, FOSTER & FIELDS
831 Market Street/P.O. Box 222
Lemoyne, Pennsylvania 17043
Phone: (717) 761-2121
ATTORNEY FOR PLAINTIFFS
-\
ESTATE OF KELLY H. ALVAREZ,
Deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2003-00198
PA No. 21-03-0198
AND NOW, this --il ~
ORDER
day of
, 2005, upon
consideration of the Petition for Approval of Final Settlement of Wrongful Death and
Survival Claims, it is ORDERED as follows:
a. The final settlement in tn~ amount of $94,330.82 is approved;
b. The allocation of the settlement as $75,464.65 to the wrongful death claim
and $18,866.16 to the survival claim is approved;
c. Payment of counsel fees and expenses on the wrongful death claim in the
amount of $25,360.48 to Costopoulos Foster & Fields is approved; and
d. Payment of counsel fees and expenses on the survival claim in the amount of
$6,340.12 to Costopoulos, Foster & Fields is approved.
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BY THE COURT:
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WILLIAM C. COSTOPOULOS
DAVID J. FOSTER
LESLIE M. FIELDS
GEORGE H. MAT ANOOS
COSTOPOULOS, FOSTER & FIELDS
A TIORNEYS AND COUNSELORS AT LAW
831 MARKET STREET
P.O. BOX 222
LEMOYNE, PENNSYLVANIA 17043-0222
March 17, 2005
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013-3387
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Re: Estate of Kelly Alvarez
No.: 2003-00198
Dear Register of Wills:
TELEPHONE 761-2121
AREA CODE 717
FAX 761- 4031
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Enclosed please find the Inheritance Tax Retum and a check in the amount of $563.37
regarding the above-referenced matter.
Should you have any questions or need additional information, please do not hesitate to
confact me.
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Verj truly yours,
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Leslie M. Fields
LMF:jme
Enclosure
Carlisle Office: 10 East Louther Street. 1'1 Floor. Carlisle, PA 17013
(717) 243-0407 . Fax (717) 243-0950
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU Of INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 1712B"0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
FIELDS LESLIE M
831 MARKET STREET
LEMOYNE, PA 17043
-----~-- fOld
ESTATE INFORMATION: SSN: 181-60-3204
FILE NUMBER: 2103-0198
DECEDENT NAME: ALVAREZ KELLY
DATE OF PAYMENT: 03/21/2005
POSTMARK DATE: 03/19/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 02/18/2003
NO. CD 005097
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $563.67
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TOTAL AMOUNT PAID:
$563.67
REMARKS:
CHECK# 1252
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
-
Register of Wills of Cumberland County
STATUS REPORT UNDER RULE 6.12
N f D d t Kelly Alvarez
ame 0 ece en :
Date of Death: February 18, 2003
Estate No.: 2003-00198
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:
I. State whether administration of the estate is complete:
Yes I&l No 0
2. Ifthe answer is No, state when the personal 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 final account with the Court?
Yes 0 No I8l
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the parties in
interest? Yes g No 0
c. Copies of receipts, releases, joinders and approval of formal or informal
accounts may be filed with the Clerk ofthe Orphans' Court and may be
attached to this report. df. ' . (':;~.~~ T.-
Date: April 22, 2005 _ ::=1...
Igna re
Leslie M. Fields, Esq.
Name
831 Market Street
Lemoyne, PA 17043
Address
(717) 761-2121
Telephone No.
Capacity: 0 Personal Representative
~ Counsel for personal representative
uA
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:
373
5/23/2005
KELLYHALVAREZ
21-03-0198
LESLIE M, FIELDS, ESQ
831 MARKETST
P.O. BOX 222
LEMOYNE, PA 17043
JA
Qty
1
Fee Description
SUPPLEMENTAL IN
Fee
15.00
Total
$15.00
Total:
$15.00
Olecks should be made payable to the Register of Wills. Tenus: Net 30.
Please return one copy of this invoice with your payment. Thank you.
REV-1500EX(8-00)
.' COMMONWEALTH OF
PENNSYLVANIA
. DEPARTMENT OF REVENUE
OEPT. 280601
HARRISBURG, PA 17128-{)601
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DECEDENrs NAME (lAST, FIRST, AND MIDDLE INITIAL)
Alvarez, Kelly H.
DATE OF DEATH (MM-DD-YEAR)
02/18/2003
- ! DATEClF BIIUH (MM-DIl-YEAR)--
i 12/12/1979
- -~------
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITIAL)
D 1. Original Return
o 4. limited Estate
D 6. Decedent Died Testate (AIlachcopy ofWiU}
~ 9. Litigation Proceeds Received
REV-1500
OFFICiAL
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
JL-O ~ J)~~~ _
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
, 181-60-3204
-I THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAl SECURITY NUMBER
~ 2. Supplemental Return
o 48. Future Interest Compromise (date ofdelth alter 12-12-82)
D 7. Decedent Maintained a living Trust (Attach copyofTMQ
o 10. Spousal Poverty Credit (da" of death belween12-31-91 and 1-1-95)
o 3. Remainder Return (dale ofdoalh pr10r i:l12-1H12)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (A1lacl1 Sch 0)
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inte(~Vivos Transfers & Miscellaneous Non~Probale Property
(Schedule G or L)
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 (Une 8 minus line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
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NAME
Leslie M. Fields, Esq.
- FIRM-NAME (If Applicable) - -
Costopoulos, Foster & fields
TelEPHONE NUMBER
(717) 761-2121
COMPLETE MAILING ADDRESS
831 Market Street
P. O. Box 222
Lemoyne, PA 17043
(1)
(2)
(3)
(4)
(5)
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14. Net Value Subject to Tax (Une 12 minus Line 13)
12,526.04
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
12,526.04
(14)
12,526.04
SEE INSTRUCTIONS ON REVERSE SIDE FDR APPLICABLE RATES
x .0
(15)
(16)
(17)
(18)
(19)
563.67
z
o
!;;:
I-'
;:)
Q.
::l!
o
u
~
15. Amount of Une 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
12,526.04 xO 45
563.67
x.12
x .15
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
20.0
Dece<:lent's Complete Address:
STREd ADdRE~
628_NoIth Front Street
CITY Wormleysburg
------r- . -
I STATEpA
I iIP;~04;-'
-
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
563.67
Total Credits (A> 8 > C I (2)
3. InteresVPenalty if applicable
D.lnterest
E. penaily
----.--
-- TotallnteresVPenally ( D > E ) (3)
4. If Line 2 is greaterthan Line 1 > Line 3, enter the differenca. This is the OVERPAYMENT.
Check box on Page t Line 20 to request a refund (4)
A. Enter the interest on the tax due.
(5)
(5A)
563.67
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
8. Enter the total of Line 5 > 5A. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
563.67
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.:......................................................................................... 0 [KJ
b. retain the nght to designate who shall use the property transferred or its income; ............................................ 0 [KJ
c. retain a reversionary interest or...........................,,,...................................................................",...................... 0 [iJ
d. receive the promise for life of either payments, benerrts or care? ...................................................................... 0 [KJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .................................,..,....,................................................................... 0 IKl
3. Did decedent own an "in trust for" or payable upon death bank account or secunly at his or her death? .............. 0 [KJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................,.................... 0 ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penaRies of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, Ills true, correct
and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
S. IGNATUR OF~.. SON RESPON,. LE!.?~~ING RETURN
.M._ 7":>".d--.
_S5 v
831 Mark t Str"et, Lel11(l}'".e, PAI70~3____
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
_.~/'
.
2--or
DATE
ADDRESS
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 far the use of the surviving spouse is 3%
[72 PS ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)}.
The statute does not exemot 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 o' .""Ft:::J
or a stepparent of the child ~ 0% [72 P.S. ~9116(a)(1.21l. fZtl
The tax rate imposed on the net value of transfers to or far the use of the decedenfs lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~ h)-e. :J3s, ro
The tax rate imposed on the net value of transfers to or for the use of the decedent's sibUngs is 12% [72 P.S. ~9116(a)(1.31]' A sibling i 1C\. ;1.. 65. eJ()
individual who has at least one parent in common with the dececlent, whether by blood or adoption.
[\l. t\.P, D
~~/~/6
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG, PA 17128-08Q<,erc.oneD (',r-FICe I"r NOTICE OF INHERITANCE TAX
I1l_~1 'i '....!L J UI~ :....~RAISEMENT,ALLOWANCEORDISALLOWANCE
f' OF DEDUCTIONS AND ASSESSMENT OF TAX
- DATE
ESTATE OF
DATE OF DEATH
FILE NO.
COUNTY
ACN
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
REV-1541 EX (06-051 PC
2D05 f:UG 30
Pc,' I. 27
r i ,~.
08-29-2005
ALVARE2
02-18-2003
21 03.{)198
Cumberland
501
Appeal Date: 10-28-2005
(See reverse side under Objections)
KELLY
H
LESLIE M FIEL. D. ~i~. '. Q (C
831 MARKETr*TReEt"' c
PO BOX 222';" .' ,
LEMOYNE'PA 17043
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
Register of Wills
Cumberland County Courthouse
Carlisle, PA 17013
. .CUT ALONG THIS LINE c:> RETAIN LOWER PORTION FOR YOUR RECORDS <=>
nREii:1547 EX -(06-Osfpc'" u. -. m - - -Notit-E'C:lF -fN~'-ERiT jiNCi(tAX AP-PRAiSEME-Nt; 'ALLOWANCE' OR - - - - - -. n - - - - - - n - - - - - - - - - n - - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
EST ATE OF ALVAREZ KELLY H FILE NO. 21 03-0198 ACN 501 DATE 08-29-2005
TAX RETURN WAS: (i:8:I ) ACCEPTED AS FILED ( D ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: LITIGATION RETURN
1, Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3, Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule 0)
'il. Cash/Bank Deposits/ Misc. Personal Property (Schedule E)
. 6. Jointly Owned Property (Schedule F)
,
7, Transfers (Schedule G)
8, Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9, Funeral Expenses/Adm, Cosl8lMisc, Expenses (Schedule H) (9) 0,00
10, Debts/Mortgage Liabilities/Liens (Schedule 1) (10) 0,00
11. Total Deductions (11) 0,00
12, Net Value of Tax Return (12) 12.526,04
o' 13, Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) 0.00
". '0"": 14.. Net Value of Estate Subject to Tax (14) 12.526.04
NOTE: If an assessment was issued previously, lines 14,15 and/or 16,17 and 18 will reflect figures
that include the total of ALL returns assessed to date.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
0,00
0,00
0.00
0,00
12.526.04
0,00
0,00
(8)
NOTE: To Insure proper
credit to your account.
submit the upper portion
of this form with your
tax payment.
12.526,04
ASSESSMENT OF TAX:
15, Amount of Line 14 at Spousal rate
16, Amount of Line 14 taxable at Lineal/Class A rate
17, Amount of Line 14 taxable at Sibling rate
18, Amount of Line 14 taxable at Collateral/Class B rate
19, Principal Tax Due
TAX CREDITS:
(15) 0,00 X ,00 0,00
(16) 12.526,04 X ,045 563,67
(17) 0,00 X,12 0,00
(18) 0,00 X,15 0,00
(19) 563,67
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID H
03-19-2005 CD005097 0,00 563,67
TOTAL TAX CREDIT 563.67
BALANCE OF TAX DUE 0.00
INTEREST 0,00
TOTAL DUE 0,00
IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
(IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A CREDIT (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
pJ(