HomeMy WebLinkAbout04-0693PETITION FOR PROBATE and GRANT OF LETTERS
also known as c~c_ 3~x? ~s~;~c~' ~
Social Security No. /'~c/ ~- qg~Deceased.
To:
Register of Wills for the
County of ~ in the
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the executrix _~.f~2~ ~fq..~('~ named
andin thecodicil(s)last will Ofdatedthe above decedent, dated d £ ~v_ ,~ : ~ ~ ,~9e~,~C
(state relevant circnmstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in ~%~-ffo..~ ~( __. Cgunty, Pennsy~a,~ia, with
~% last family or principal residence at c>.~3~ ce]r~o-~_ ~C',~c~& ~
(list street, number and muncipality)
Decendent. then ~/~ years of age, died , I q ~ ,~ C c~
at ~'. 6~ ~ c~4 "~
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after exeaution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters q-< ~ ~c4~-~ .~c~ ~_~
theron. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
OATH OF' PERSONAL REPRESENTATIVE
COMMONWEALT. H OF PENNSYLVANIA
",COUNTY OF (,.~-'~v'c~k:~,~.~v~:~, ~ ~8
The petitioner(s) above-n~ed swe~(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and be~ef of petitioner(s) and that as person~ repr~en-
tative(s) of the above decedent p~itioner(s) will well ~d truly administer t~estate ~ccording to law.
Sworn 'o or ,ffir~d ~d subscribed ~ :~~ ''~9
before m~s ~,~ / day of [ ~v ~
t
No.
Estate 0~~ -~ ~c ~ ,~ , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW~-x'~x'~c A_~ c~/'51.34
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated ~0- o) - O~r
described therein be admitted to probate and filed of recold as t,he last will of
and L et t er s-'~, i::S*'~owoTx--~ _. _._- - ,
are hereby granted to ~ ~/-~e-'...~O~ ~0.~/9
, in consideration of the petitiOn on
FEES
Probate, Letters, Etc .......... $ i (~ 'GO
Short Certificates( ) .......... $ 2. oO
$ I~ · (~-o
TOTAL ~ $ '----~---~
Filed . ..~...'.~. 3. Y.a.9.~.~ ............
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
his is to certify that the information here given is correctly copied from an original certificate of dcalh duly lilcd ~ ill m. ~
l.ocal Regislrar. The original certificate will be forwarded to [he Stale Vital Records Office tier permancm ['ilino
WARNING: It is illegal to duplicate this copy bi/photostat or photograph.
Fee for this certificate. $2.00
P 1042g277
No.
Local Registrar
Date
Enola
·
CERTIFICATE OF DEATH !:! ,-~ ~-,~
Hale 174-- 54 -- 4822 ],.June 23,
North Enola Road ~ ~ite
~'~2 ~'~+' ~rried Subrts
239 North inola Road
PA 17025
2004
012982-1'.
Enola
LAST WILL AND TESTAMENT OF DOUGLAS FRANCIS
-
I, Douglas Francis, a resident of Enola, Cumberland County Pennsylvania, being
of sound mind and memory and being over the age of eighteen (1'8) years and lawfully
married to my loving wife Frieda Francis, and not being affected by any duress, menace,
fraud, mistake, or undue influence, do make, publish, and declare this to be my last Will
and Testament hereby expressly revoking any and all Wills and Codicils previously made
by me.
I. MARRIAGE AND CHILDREN
I am married to Elfriede Frances, and all references in this Will to wife or spouse, are to
her, my beloved wife and the mother of our children.
II. ADMINISTRATRIX
I hereby appoint my wife Elfriede Francis as Administratrix of this, my Last Will and
Testament, to handle all details, make all decisions, and manage all affairs appertaining to
my death and the events subsequent thereto to include sole and total authority to
administer my estate. My wife is also authorized to carry out all the provisions of this
Will, conduct the affairs of my estate, pay my just debts, incur obligations, and make
funeral arrangements as she may deem necessary. It is my wish that, my wife Elfriede,
the Administratrix of this, my Last Will and Testament, serve without obligation or bond.
III. BENEFICIARY:
I hereby identify and select Elfriede Francis, my wife, as the sole and total beneficiary
and recipient of the proceeds of my estate without limitation of any kind, meaning any
and all !terns of personalty and realty and any and all types or forms of property or
possessions.
Subscribed, sworn, and acknowledged before me,
Commonwealth of Pennsylvania
County of _t~_//l'W~! [/'~l'zg~_
IV. ALL REMAINING PROPERTY, RESIDUARY CLAUSE:
I give, devise, and bequeath all of the rest, residue, and remainder of my estate, of
whatever kind and character, and wherever located, to my beloved wife El,friede Francis.
The testator and the witnesses respectively, whose names are signed to the attached
instrument in those capacities, personally appearing before the undersigned authority and
first being duly sworn, do hereby declare to the undersigned authority under penalty of
perjury that the testator declared, signed, and executed the instrument as his last will
signed it willingly directed another to sign for him, he executed it as his free and
voluntary act for the purposes therein expressed, and each of the wimesses, at the request
of the testator, in his hearing and presence, and in the presence of each other, signed the
will as witness and that to the best of his knowledge the testator was at that time eighteen
(18) years of age or older, of sound mind and under no constraint or undue influence.
~ .~/~ ~--~0 Signature of Testator
d/,~o t.~/,~ $ ~"~'.~a,/o'.~ DOUGLAS FRANCIS
.. Address
Witness # 1
Address
Witness #2
Address
day of June 2004.
NOTORIAL SEAL
Notary Public's Signatur~
My Commission Expires:~ff~?
, a notary public, by
, the testator, and by
, and
, the witnesses, this
2
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 11/01/2004
FR3~NCIS ELFRIEDE
239 ENOLA ROAD
ENOLA, PA 17025
RE: Estate of FP3~NCIS DOUGLAS S
File Number: 2004-00693
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPH~_NS, 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 ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of Wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 11/02/2004
Your prompt attention to this matter will be appreciated.
Thank You.
cc:
File
Counsel
Judge
GLENDA FARNER STP~ASBAUGH
Clerk of the Orphans' Court
Name of Decedent:
Date
of
Death:
Will No.
To the Register:
CERTIFICATION OF NOTICE UNDER RULE 5.6(ai
I
Admin. No.
I certify that notice of (benefidal haterest) ~ required by Rule 5.6(a) of the Oxphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on :
Name Address
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
Signat~J - - ~'
Name
Address
[- T~fi ?0.
Telephone (
Capacity: __
)
Personal Representative
Counsel for personal representative
cumberland County - Register Ot Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 4/25/2006
FRANCIS ELFRIEDE
239 ENOLA ROAD
ENOLA, PA 17025
RE: Estate of FRANCIS DOUGLAS S
File Number: 2004-00693
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
wills a Status Report of completed or uncompleted administration.
This filing is due by:
6/23/2006
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Si~~~
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
Register of Wi Us of Cumberland County
STATIJS REPORT UNDER RULE 6.12
~
Name ofDecedent: ;;:j)/Jzvylr. S c-5. r (lt11<!js
Date of Death: (p/513 I aaYf
Estate No.: 0:) C() If- GO&;? 3
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 adm~tion of the estate is complete:
Yes 0 No ~
2. If the answer is No, state when the personal r~ir sentative reasonably believes that
the administration will be complete: Cf...'_ m &7
J. If the answer to No. 1 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 infonnally to the parties in
interest? Yes 0 No 0
c. Copies of receipts, releases, joinders and approval offonnal or informal
accounts may be filed with the Clerk of the Orphans' Court and may be
Date: 7/114.ltf1;tlachedtotbiSreport . ~~~
Slgna
l U~;e J G I-- ,a tlcJ) <;
-
Name
'j
dJ39
Address
~YlO(~ i
C/lok ~d
() It 17GJ ~s-
1117- 5'7h - 9t19 $/
Z i : J !\' d 7-1 I
',,- F' ",
::UJi
Telephone No.
Capacity: fQPersonal Representative
o Counsel for personal representative
v
Cumberland County - Register or Wl~~S
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
o
::r"J
, - [)
, -,
, -'
Date: 6/08/2007
e,
. '
FRANCIS ELFRIEDE
239 ENOLA ROAD
ENOLA, PA 17025
,~::'~,
RE: Estate of FRANCIS DOUGLAS S
File Number: 2004-00693
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by:
6/23/2007
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
~~~
,/
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
In Re: Estate of
FRANCIS DOUGLAS S
ORPHANS' COlJRT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 2004-00693
NOTICE OF FAILURE TO FILE STATUS REPORT
Personal Representative: FRANCIS ELFRIEDE
Counsel for Personal Representative:
Date of Decedent's Death: 6/23/2004
The Orphans' Court record indicates that neither the above named personal representative
nor the above named counsel for the personal representative have filed with the Register of Wills
or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme
Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court
Orphans' Court Rules, is hereby given by that the you have ten (1 O) day to file the Status Report.
If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of
such delinquency and the undersigned will requests that a Court conduct a hearing to determine
whether sanctions should be imposed upon the delinquent personal representative or counsel for
the delinquent personal representative.
Date:
7/312007
~~~
/ ,
/'
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
; ,~':~',j/-Jr')J
'\/HdtJO
,I' '. ,. '-~"
;:JU lid Iv
I 0 : i lid 8 - lnr WilZ
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j, ,Ii .!~, . i ,"1' '_I i 1'~.l.J
-'.J'~......v' \".,i..j\J'..jv"~~u
JUN 27 2007
IN RE: ESTATE OF
FRANCIS DOUGLAS S
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 2004-00693
NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 6.12, SUPREME COURT ORPHANS' COURT RULE
Personal Representative: FRANCIS ELFRlEDE
Counsel for Personal Representative:
Date of Decedent's Death: 6/23/2004
Date of Delinquency Notice:
The undersigned, Glenda Farner-Strasbaugh, Clerk of Orphans' Court, in accordance
with Rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court
Division, Court of Cornmon Pleas of Cumberland County, that neither the above named personal
representative nor the above named counsel for the personal representative have filed with the
Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule
6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12,
Supreme Court Orphans' Court Rules was given on the above date and that the ten (10) day
notice to file the Status Report has expired. Accordingly, in accordance with Rule 6.12 the Court
is hereby notified of such delinquency and the undersigned requests that a Court conduct a
hearing to determine whether sanctions should be imposed upon the delinquent personal
representative or counsel for the delinquent personal representative.
Date:
6/26/2007
.tt~h-~~2
Glenda Farner Strasbaugh - ~! :}; ~ ~
Clerk of the Orphans' Court _,_'0_/"-
-'~3S:~ ~
'---
_ ::0
~ ---l
j~
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
A hearing is scheduled October 1. 2007 at HAM ~
in Courtroom NO.2. If the Status Report is filed prior to the _ ng dateJ~__ . ill
automatIcally be cancelled. \ '--v/~ ,~.. ~/ \
'-----ct'~v ~ \(0.'1 ~\
Edgar B. Bayley, J. '
C)
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Pa. O.t. Rule 6.12 STATUS REPORT
REGISTER OF WILLS OF C,/JJfJ.iwtJbr1 d COUNTY, PENNSYLVANIA
Name ofDecedent: VOlJ11 as <;). F ra.lf\/!.-,' ~
Date of Death:--d V r1 e _ f?. 3 / ~o1 File Number:
d... t)v'1- \)\Pq~
Pursuant to Pa. O.C. Rule 6.12, 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: . . . . . . . . . . . . . . . . . . .. ~ D No
2. If the answel.is No, state when the personal representative
reasonably believes that the adlilinistration will be complete:
3. lfthe answer to No.1 is YES, state the following:'
a. Did the personal representative file a finaI'account with the Court? . . . .., DYes EB'N'0
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
~Olf - 06foq3
c. Did the personal representative state an account
infom1ally to the parties in interest? ..............,................' ~y es D No
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be
filed with the Clerk of the Orphans' Court and may be attached to this report.
Dale
/()II~ I ~1f
','i-..i
Capacity: DPersona] Representative o Counsel
E/?,'edoL. FI/'dI1CI S
Name of Pason Filing this F01'nl
c;l8~ t~k-
Address (~C I a... ' Fn
11'7- SI'Jt,- 9099/
/?o d- J
/'7tJd.-S-
"'''' !.d.7-'"
V::: : ! (, <:: J..!L
Telephone
1"0"/71 flN'.ID reti Jtj,j3.06
~
FH
FR-EEBUR-N
HAMILTON
RICHARD I!:. FREEBURN
STEPHEN A. SCHNI!:IDE~
LAWRENCE F. BARONE
ROBERT D. HAMILTON (1967-2005)
Your Personal Injury and Workers' Compensation Attorneys
Stephen A. Schneider
Writer's Extension: 5
steve@pa-injurylawyer.com
June 15, 2006
Robert Giles, Secretary
Workers' Compensation Appeal Board
Capitol Associates Building
901 N. 7th Street, Third Floor South
Harrisburg, Pa 17102-1412
RE: Do"!!Jas Francis v. Barrish"r!! Ciw School
S.S. No.: 174-54-4822
WCAB Appeal No.: A05-0328
Dear Secretary Giles:
I write to inform you the Parties have successfully negotiated a resolution of the above-
noted appeal.
Therefore, on behalf of the Claimant! Appellant, Douglas Francis, I hereby respectfully
request that the appeal docketed A05-0328 be marked withdrawn and dismissed.
By copy of this letter and attached Certificate of Service, I am providing opposing
counsel with a copy of said submission.
Thank you for your attention to this matter.
/!
Very)jIY yO,"
/ / /'/
i f.' /
h/ f~\ (/
/ Stephen A. Schneider
4415 North Front Street, Harrisburg PA 17110
www.pa-injurylawyer.com
(717) 671-1955
.
Fax: (717) 671-1960
.
(800) 303-8005
~
15056051047
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN ii jj r
Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ 1 U ~ ~ l9 '`
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 7y 5~ '~8~2 0(~,~3~ooy o~~~ Iy~o
Decedent's Last Name Suffix Decedent's First Name MI
~-rtanCl s ~au51 us S
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
~rc,nc is ~L~rf ~ do ~-
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
~ (~ ~ ~ o ~ ~ ~ y REGISTER OF WILLS
FILL INAPPROPRIATE OVALS BELOW
~ 1. Original Return O
O 4. Limited Estate O
O 6. Decedent Died Testate O
(Attach Copy of Will)
O 9. Litigation Proceeds Received O
2. Supplemental Return
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
O 3. Remainder Return (date of death
prior to 12-13-82)
O 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
O 11. Election to
(Attach Sc
Sec.91~A)
ca
..o
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION ~~ BE DI
Name Daytime Telephon~
RI~Ot L Frr~r,cis 711 5 ~
~L~ ~
Firm Name (If Applicable) REGISTER 'USI
LJC~
"tD --1
First line of address ~
~3`i N ~n%o ~ u Read
Second line of address
State ZIP Code DATE FILED
City or Post Office
E Nv i ~ PA 1 ~c~~5
EC~ TO ~ -~
Q7 ~ ~-J 1-
~ .:~
-.~-
~~-~..-„
__ -
+l~ l
Correspondent's a-mail address:
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 preparer other than the personal representative is based on all information of which preparer has any knowledge.
-~--~--._e~_ _...-._...,,,.. ~...,...,..,.,, PTO ru in ---iioni DATE
SIGNATU OF PREPARER HER T AN REPRESENTATIVE DATE
A fi~ ZS ~~~ SC7Y1Lt; .~~4 3~ ~ SC-~:O~~l S~" N ~ U' l.~/bq(~rL Cti~ ~~ ~ 7~ l~
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051047 15056051047
15056052048
REV-1500 EX
De
cedent's Social Security N
u
mber
' ii
r
~
.7 ~ J ~ ~'~ ~
Decedent
s Name: 1
S
RECAPITULATION
1. Real estate (Schedule A) . ......................................... ... 1. ~. ~ ()
2. Stocks and Bonds (Schedule B) .................................... ... 2. Q • ® d
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. O. (~ U
4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. ~ • ~ (/
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. O. (~ 0
6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. ~ . (~ [~
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested..... ... 7. ('} . (~
8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~. Q !)
9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10.
11. Total Deductions (total Lines 9 & 10) ................................ ... 11. O . (7
12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. ~. (~ p
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ..................... ... 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. ~ . n [~
TAX COMPUTATION -SEE INSTRUCTIONS 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. Q. o n
16. Amount of Line 14 taxable //~~
d d
at lineal rate X .0 . 16. V •
17. Amount of Line 14 taxable
17 h
U Q
at sibling rate X .12 • . V •
18. Amount of Line 14 taxable
15 •
X
18
Q •
.
at collateral rate .
19. TAX DUE ...................................................... ...19. ~ • b U
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
15056052048 15056052048
REV-1500 EX Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
--___
STREET ADDRESS _
N, ~N~I~' G --
_ - ~ 3 _' -----~ _
CITY ~ ~{ ~, ~ ~ STATE ~~ ZIP ~ ~ ~ ~ s,
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
D. Interest
(1)
Total Credits (A + B + C) (2) (~ ,
__ __
E. Penalty
Total InterestlPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, 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 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 ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 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 zero (O) percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [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 four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
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321 SECOND STREET, NEW CUMBERLAND, PENNSYLVANIA 17070
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
BUREAU OF INDIVIDUAL TAXES ~ `"'.t"'", ~pp;[tAl~S~1~NT, ALLOWANCE OR DISALLOWANCE
INHERITANCE TAX DIVISION °~~ `^ OF ItEITUCTIDN$ AND ASSESSMENT OF TAX
PO BOX 280601 ~ ~` t F- ,
HARRISBURG PA 17128-0601 , ~~kLIJ ~;;' ~, ,_., REV-1547 EX AFP (01-09)
~}p A DATE 06-29-2009
~~U3 ~UL _6 Fitt ~~' i~~ ESTATE OF FRANCIS DOUGLAS S
DATE OF DEATH 06-23-2004
~~~ ~ FILE NUMBER 21 04-0693
COUNTY CUMBERLAND
ELFRIEDE L FRANC~~~ya~R ~ ACN 101
239 N ENOLA RD APPEAL DATE: 08-28-2009
ENOLA PA 17025 (See reverse side under Objections)
Amount Remitted-
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ -- --------------
------------------------------------------------------------------------- --
REV-1547 EX AFP CO1-09) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF FRANCIS DOUGLAS S FILE N0. 21 04-0693 ACN 101 DATE 06-29-2009
TAX RETURN WAS: C X) ACCEPTED AS FILED C ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1) .00 NOTE: To insure proper
(2) .00 credit to your account,
C3) .0 0 submit the upper portion
of this form with your
C4) .00 tax payment.
C5) .00
c6) .00
cn .00
cs) .00
APPROVED DEDUCTIONS AND EXEMPTIONS:
•00
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .00
11. Total Deductions C11) -~~
12. Net Value of Tax Return C12) •0 0
13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) C13) •00
14. Net Value of Estate Subject to Tax (14) •00
NOTE: If an assessment was issued previously, l ines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15) • 00 X 00 _ . 00
16. Amount of Line 14 taxable at Lineal/Class A rate C16) • 00 X 045 = . 00
17. Amount of Line 14 at Sibling rate (17) •0 0 X 12 = .00
18. Amount of Line 14 taxable at Collateral/Class B rate (18) •0 0 X 15 _ .0 0
19. Principal Tax Due C19)= .00
TAX CQFTITTS e
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-)
AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED.
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE
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