The URL can be used to link to this page

Home My WebLink About01-1080 PETITION FOR PROBATE and GRANT OF LETTERS Estate ofS~\..\'\.eu.. f'l, C \e ~~Q ~- No. c:L/'" 0 f - I ~ 8"C also known as ---.J To: Register of Wills for the 't Dec~sed. County of (l OmL3f'/21 AtJ () in the Social Security No. :lnL\ -;... :<,{) --6'( '~'1--- Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or 9lder an the execut in the last will of the above decedent, dated ~ <..J (\ Q.. L\ and codicil(s) dated Rrx: named , W;":~ro\ (state relevant circnmstances, e.g. renunciation, death of executor, etc.) Decendent, th ,#,;2(x) l , at Except as follows, dec nt did not marry, was not divorced did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never 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: $ ~;;L( (,n 0 $ ( $ $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters ~ s-ra. me /7 f-~ r-y r (testamentary; administration c.I.a.; administration d.b.n.c.La.) theron. ~ '" 'Q)' u c:: ., :.2~ "'~ .,... ~., c:: -00 c': cU ";:: 3~ ., '- ;0 Ol c:: Oll i:ii ,~~~-~~ _. -,"-Ie ,,:0-- E' ~i~ Rl OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA I S8 COUNTY OF (! U /YJ/8EI?( /M.. )V J The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belie of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will wild tr dminister the estate according to law. ~ ()Q' ::s l::l ..... l::: ~ ~ Sworn to or affirmed and subscribed before me this . . d2j~ ex.. day of ~~L0~~~ \ ~~ I YY)a. I, i. .' l >1 (ill. 'U.c:,Jz~ ~.P fl.;;iJ / 7 - d- 3 - q Reglste No. 21-01-1080 Estate of SHIRLEY M. CLEPPER , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW NOVEMBER 28, _ ~__~001, in c,,::siaeralion , f_',(":1f>',! "Ii the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated JUNE 4th. 2001 described therein be admitted to probate and filed of record as the last will of SHIRLEY M. CLEPPER and Letters TESTAMENTARY are hereby granted to LINDA S. FREEBURN LrYJao t. ~.tu~ fU' (i',u. .1Af:~A..O; C\"pu:t'i--' Register of Wills J FEES Probate, Letters, Etc. ......... $ 60.00 Short Certificates( 1) . . . . . . . . .. $ 3.00 ~ EXTRA .PGS... .2.. $ 6.00 JCP $ 5.00 TOTAL _ $ 74.00 Filed .~OYE~ER .28" 2.Q01.............. ATTORNEY (Sup. C. I.D. :-10,) ADDRESS PHONE ,..... '+- 17) t:: 'At:. 0 .) 1....._ (q N ':1 " Cl... 1.0 N ~.,:-'~ "'. .# :> 'j",I "i.i ;~.:;, .:!~:j 0 ~,,,. Z I;:) (Jl ':CJ () ill , .0 ...,:;; OJ a: p .... s:: a: Q) - [j U CALLED EXECUTRIX 11-29-2001 ORDERS ATTACHED TO LETTERS H105.805 REV 9/86 This is to certifY that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 p 7651136 XJ~R ('wl~ Loc RegIstrar No. 9- J6'OL_ Date H 1 05. 43 ReI'. 2.'87 COMMONWEALTH OF PENNSYLVANIA. OEPARTMBH OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH TYPf./PRrNT IN PERMANENT BLACK JNK --..--------..~-.-.""----,-,..,~.'-...-....---....._~'_'_.~=_=""_'_......_o........__.__="_="_,.~~==''';'~'_.''-""''_~'__-~-' -=~._"",--,--.,- ~__:..f~E..:.~~~~_,.___~ _______.___._.~_~_,__ NAME Of DECEDfNT (f-"51 _ M,.j()lc., ...:>1) _ JSEX ].'VUALSECURnV"U'''lfA.. "f"" , L'F C.EAlH'.'""" D... ....H' ! I. S hi~ ~1. C 1 e.) ) c r .-..-1..-..-.-----.[;-----..--------- =-__E__~.___. -'-2.ll.L=--J.Q_=8L8.2.___t:__S.e.11L.2'.f.+__2.DllL__ AGE (i.....SI ~,'i[",C;>y) UNOER 1 YEAH UNDER 1 DAY !JATE OF 8!RTli BlAfHPLACE :C.!'idl~iJ PlACE OF ~fAYHjO~'(.~ W"l' '~"'<:' --.('e "'~~r,,';f'L"-; ,'" '}!"t<l "(j"i Montt:;;-~ 1icv<:!I- ;M;"~~ Ml."'If1 ()jy I..U') ..>\,llllJ<futJ.gf1LOllU!!';) 1-<<5~Plr":... --~--- ----- ---- - ~ - Ul-rtfn- _ ~_ _ _ _~_ ___ ~ ___ ___ 6 2 Y"! j 8 - 2 6 - 1 9 3 9 Tow c r C i t v 'OPd"'''' rJ ffVOu".' on< 1-; DOA l ; ~~:;:::" :::J "..""'", ; J :"';; 'v' XJ 5. , '6 1 - !laI COUNTY OF DEATH crrv, OORO, TWPOF DEATH- FACILITY NAME 11t nOIIf1'.,r'lUltun, {.Jl"'" ';l~::;;fI(;-;:-u~~- . ['AS OECEO[NT OF "'SPANIC OR,e'N" l:V:C~~~~~ No [-Xl ~, lJ 11 Y6"S, sPtKrty Cubun. (' i-'t'<..: 1)0) Ilb. lluph.in Co. k. H.::rrr isburg 7334 Sleepy Hollow Road Illig. P1\. 17112 .~o,~.o. Pu"'O "m. ~, DECEDENT'S USUAL OCCUPATION KINO Of aUS~~SSlfNOUS~_ WAS DECEDENT EvER IN DeCEDENT'S EDUCATION M-AAI1AL STATUS _ MdHltld tO~~~~~POU$E l~;~~l~~h~~~al~tl~~;~t;'j'f-- US, ARMED fORCES? EI~mlt{~~;;;~':~~;a~r 'lralleC{~~:l;~~U] ~1I"~~"~r~:~~:~~ll{j. ',II .."Ie, J'~lna'U~1l n<\;II1,) 11.. ProducU.on MJrker 110. CIS Reeves Co. 12. Yo,O Nota: 13. ,0"1 11 ,,,~,., Divorced " DECEDENT'S MAiliNG ADDRESS {Slleef. C'(yITOwlI. SWte.l'VC<xlt!1 DECEDENT'S ACTUAL RESIDENCE ($ee'flSln.lCh/.I11S (JIlOlner !;ldej 7053 Carlisle Pike I.. Carlisle, FA. 17013 17&. SI.3Ie--P..ennsylva:n.ia.--___ Did d6ce<le/11 17c.O Y"",d6ceduntliVedln~____~.___._________twP FAfHER'S NAME (FIISI, Ml(ldle. LJSI] 17b. COUo,y-~.curnberland. llVil In a IQwIlsn,p7 17d.rxJ ~h~~~~I:~~ol~CarJisla_.--==:--=:::=--_,~~C'!y;boro rave MOftiER'S NAME (f"~l M,L111Itt. M~,(Jen ~uH'.J.r""J "Thelrm \v,wner INFOHMAN j'S MAIUNG ADOHESS I$lfo..>cl, C,lyl1..Jwn, SWle 2,r.. l\XJe) 'Ob. 7 c..Sleeuv Hn 11 ow RD HhQ PA DATE OF DISPOSITJON ~LACE OF QISPOSmoU'. Name otCt!rTllltelY, CrllmiITory (Monl", Day, 'l'ear) Of OU'lG/ Place 21b. 9-28-D1 ,'uoover FH & CrerrBto . ~~%M:;/WSL To lhO;! besl o! my knOwlllt~l}6. dealt' uccurrtld at tnu ('mt'!, dalO and plal;O:! 5rat~d (S.y(\illu1e<lll(! !~l~e) (1_ ' /) ,;tJ ,,.. ---,. )1,:"....'--"_ A-Ltf-...iL h :~ME;J~O:;~ ~I (~,c:~_ NOu;):D:;~~;:~:;:;'~ ;---- ,. 27, PART J: Enltt/ rrut d'~da5a5, Inlurl~5 or l;omphcUlollS wnlCh c.aust'd Ihtl' dt.'alfl au /Ict tlnl6/ Ihe mode 01 ay' g. s.:ch as cald'ac 01 ",\p,riltory ,HfllSI. ~hock or 11";]1l !;"lwllI LISl only ona cauStl (,In eaCll ~nu C,t)fTown, SliIttl, I'D COde 21d. Harri shurg. PA. 17112 Cr.omtor:vtllilLing~,., llJ:[tm..l'A l' LICENSE NUMB. ER' .. DATE SI.ICCN EO. /) C- -- (Monlt1 Day, "-~al) 2,[i /l/ / .L~92 ",,-j L __.'.~l.fr <~ "l,e::! o~ 'IiA.S CASE flt:FEHlll:D ro MEDiCAl. E:(AMINERlCcnON[j,? Yus [] Nag- 15 ~ ~ . ApprOlhm.ai9 ;imef\la/OOIWI!'<jr! =-=~~ ===-----=1 d DUE TO Ion ASACONo(QUENCE'OII--------...-.------------ ----.-- -;- ...-.-.::-- ---~--..--.-~.-------.1 WEn!: AUTOPSY FINDINGS T~A~~;; Dt3.01 ~=- -~--==-~-----=- - ~A~ ;F-~~UI~;- ~- ~- r~~ ut- I~~==--I-. 1~}b-NOHK1-rE;"'ZHIUE H':wNJUfW OCCUHREO-~--l A\lAIUOLE PRIOR TO \MlJ(1!!l Da., Yt>,u) COMPLETION Of CAUSE I~-' ~ _ OF DEATH? Nalur31 LM Ham cod. [J 'I [ 1 ACCldlt"l l_J PendIng IO<lasll<JOIlIo'l r] Y;)5 '--- j No '1 NoL. fJ No [] ""~,d. [] Cuu"J~'''''d''''mm'd [J ~~<;:"o:.;",~~~:::'hu"';;-;;;'~."::,;;"~,.;;y..;,;;;;;-M- Jl>c-l"OCArlON-'S";';:c"y'i~';;,S"";'- -. ----.--- "_I 25.-. 28b 2'3. JOe 1301. CE~1"IFIEAICr'OC~Unli"Dl\t!l , - ---~----~fC'1 NArURE,~DTLJ?;.:TL-EQFt7[RrIFS::' - '" ') CERTIFYING. PHYSICIA.N 1i-'f1YSI/,;I.anC";lIly,n'jca u~,c,-,' lJt',Wl ""tlt'fO oJ 1'011'.""- phv~,al\hds PfC""JI.,nct'(]. ,1~d:tl..n(J cOmpll'!ed !:"I!l 1;J) . -.<~. . ...... ) I . '.. I' ....)j) To th. be.1 01 my knoWU:dg., death OCCurre.;J CllH to the CdiJ~e($J .lnd ffi.1nne, alii staIN. .. ,.. .. ~_!!?:..__~_j ________~_-==--___________.~' -_1L":_t.~~=-___~:_____.._____ lICE~~SE NUMB(H .''- ______ _ AH_ ~NEl)~u';IT'. O;,y "'CJ'\ .~:~~~~~,N.:::k~~~~~~~::~:.::::~;~~:',::~;;';: 'S;':;:,~;~~;~~;g ~~~'~~:'~O':~~~'~~:~'~;~~d':~;e~.:;',.. "".d . ..l<J J!,!'1~!:2() /.9.:1.. iI...?i:!____ J"d".':.!..~.~___2.=-2.!~_______.. NAME AND ADOIU:SS or PEHSON WHO COMPLETfD CAU$ OF D(A1H .,..,.EDICAl EXAMJNER/COAOt~ER (llt="12,') fype Of P/lnt ,f[ ..-r -1-/ 0 VV1~'S ,/ j YtrV ;C~;l"\......1... /''''0 On the baSIS of eltamlnation and/or lnvesllgallon, In my OpinIOn, death OCcurred at the lime. dale, alld place, i1nd due to the c/lu$e(sl and '''7) r_! " '---- j" ,(?~l ^/ I) L,/;-;--;(D ~!/'"} /: Jlamannef as ,tated,.., ,. ,...,. ..... ". .,.. .,..... . 32. C'/r--v;/", /.. ... _j) L-L__ ; .:i:-- -: II; } I I1(G1SlRAR "SIt,NA'VRE ~'~:UM"'"3ijC;;;(p -~;;;- --" ~~~~~~E~ -~. r:AnF"WMc q ~~ ~ ~ ~ o-;.-=-t-- -------J PAfHU: Other 5lgt1llicalll c\Jn<.lltiQr.5 COntllbullng 10 death. bUT nol 19su)lIng 1J11he unoerty'lr19 cau5e yivlIn in PAHT 1 . ___li '-1,'=} ~f1~ C'.e.ll:::.C"...:.' .'-/J'(!...!:..~!:~.__.::Yi~~...______.__._. DUE ID(Qn ASACONStOUENCE OF) b-LYi'.rV ~S (n/,}-z...<- '~'~A.. "-.(:..!!:.!L__(:.._{i!,~c._'''rl"...__________. QUE TO (011 AS A CONSE QuE NeE OF) LAST WILL AND TESTAMENT 21-01-1080 I, SHIRLEY M. CLEPPER, of Carlisle, Cumberland County, Pennsylvania, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. I direct that all inheritance taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shall be paid by my personal representative out of my estate. 2. I authorize and empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate to my children, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living. 4. I nominate and appoint Linda S. Freeburn to be the personal representative of my estate, to serve without bond. If she cannot or does not serve, then I appoint Mervin L. Moyer, Jr., to be the substitute personal representative, also without bond. 5. I suggest that my personal representative retain the services of Harold S. Irwin, III, Carlisle, Pennsylvania in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 4th day of June, 2001. SHIRLE~LEPPER (SEAL) Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. gm/vL~ ~~i--a:J- j3~ f~~ ACKNOWLEDGMENT AND AFFIDA VIT WE, SHIRLEY M. CLEPPER, RHONDA S. IRWIN and HEATHER A. BARBOUR, and NATHAN C. WOLF, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her last will and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. ,~ SHIRLEY . CLEPPER ~'0/1 r;zfJ b~/v~ HEATHER A. BARBOUR bilJJdu J ~j$i) RHONDA S. IRWIN COMMONWEALTH OF PENNSYLVANIA :55: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by SHIRLEY M. CLEPPER the testatrix herein, and subscribed and sworn to before me by RHONDA S. IRWIN, HEATHER A. BARBOUR, and NATHAN . W F, witnesses, this 4TH day of June, 2001. Notarial Seal Harold S. Irwin III, Notary Public Carlisle Bora, Cumberland County My Commission Expires Sept. 23, 2002 Member, Pennsvlvanla /\ os,>,;I,ltlor: ot Notaries 21-01-1080 REGISTER OF WILLS OF0 ii 1Y\I~F t2( A-0i)COUNTY OATH OF WITNESS TO WILL F~XECUTED BY MARK '~h\f' Ie-)I \y\.L..Lt' t?~e..\(' NPi\ \-\~\.j C ~6L~ p.", ~ \<. \-\ O~""D F'I ~. -.L ~ u)T \0 , (each) eodicil a subscribing witness to the will presented herewith, (cadl) being duly qualified according to law, depose(s) and say(s) that: testatCU'_ was unable to sign hC:~m_ name thereto; lestal.,t-".___..s name was subscribed thereto In testat~_'s presence; testatq~_ made h(::..I':'.__ mark thereon; testat~ and deponent(s) was (were) present when ltstat<<___'s name was subscribed and c~ when testat'-!::-__ made hlf_ mark; and testaL9-~.:"__._ was present when the undersigned signed the will as witness(es). before me this r-2'?, U day of /II /WD Sworn to or affirmed and subscribed Y76VVrn 6-v l:Jl &cxJ { '-n-)QIl(j ('. ~ ~"-'. c. ro . ~L'~ D u f'iI~ I ') .... Register >+- o <o::t '7) o E:' .... <:::( ~j 0.: ";J ,) r- N :::- ~ "S~: ~i~ I",'K . "' (]) . .0 .~ s:::: .9:!5 00 ij,l ~1~ o . i:j) ow ~a: p 21-01-1080 REGISTER OF WILLS OF (!(JtnAfRifJAJ)) COUNTY OATH OF WITNESS TO WILL EXECUTED BY MARK Sh\-rley \Yj. c.\€pper HE1J-1E/2 It r3ARBr>uR . (each) ~ a subscribing witness to the will presented herewith. (each) being duly qualified according to law, depose(s) and say(s) that: testat~_ was unable to sign IL"::-__-=___ name thereto; testat~~____'s name was subscribed thereto in testat~'s presence; testa[e~_. made h!:'._r:::__ mark thereon; testat~ and deponent(s) was (weN) present when lestatp'=-___.s name was subscribed and ~ when testat~__ made h~_ mark; and testat" '"'_____ was present when the undersigned signed the will as witness(es). Sworn to or affirmed and subscribed -dad d J:.,?<- before me this OZ, to -cA., (Name) day of 5s- ~ /-/f611 $;- ~~/UISL<e.. jl,?/7t113 (Address) Y!OQ-C/rn h-LV 'W d.<XJ1 '-t~/~ e. a<:U.LX~ ~.I. (I. d . ~~\.i) ,\J~~ I ,f r ~ . Register (Name) (Addres,) CUP/,;') , . ,,,~,qUlltJ Hf/er~ ztr. Z d 9Z ADN LO. SliM/, JO . ":'c.;.lGlt5e~ peDjooa~ 't CERTIFCATION OF NOTICE UNDER RULE 5.6(A) NameofDecedent: Sh"\(j \C\, C\t'\2I?<2' Date of Death: q~ Will No.: c2(\O\~ ()~()~ Admin No.: ~ A. (\In ;L\-O\- 10'6"0 To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6( a) was served on or mailed to the following beneficiaries of the above-captioned estate on Name Address \Y\e\'u~" L- \Y\C:f.2' ~,. 550 S~e.~~ Ch.ucCh R~ Qf\n,.h\\e.- ~rA ( \ '):)O..s.. "l Cl C\9...b-\ow" (<cl . (\ (er- \ L, \'\0 ::1-e\ l 0 K"-l (\A ~\. i!-. . \. _ ~~ ~ I c1. ~ C'~J l\\..e r'c.. \ l 0;}.(5 C 0)0<""'\ ~"\r.. ~l("\~ e r ~~ l ~ \ 0 ~ ~~~ In''.(v~ k. -b >_\ t, ~ Ct l'( II ~~ ~('~Df"'. C'<lo~-ec- d~~ --S. ~l~~ RA .C~u.\\e ~ Qc.. \.iw2 \ C\.C'<'e...D CY\ 0,-\ -e-r "0 e::,c)(... ~8" ~ -S~~ \. C"\.c;. \J a.. d9-O\b 1 '1-.iotIce has now beert given to all persons entitled thereto under Rul~.6(a) except rr, ~:. ~-~ - ignahrr~ ~\_rd~3 .. ~\"-Q€-b~ c r-J Name Dat. '".." ':L' ," C1: '0. p ,,'.41 .>..:: ,.j "= . ...- ....,,... ---' '-i ~32,4 S\<?p~_~~,L\\I)"~ Rd- ~ ~, II lll-y~q-o~. Telephone fV") ~€ .:c Capacity: ~ Personal Representative D Counsel for personal representative ru ..JJ ~ U') f;, 5' fi" H';, ...JJ Return Ilec8rp fee ! CJ (Endorsemellt nequ,red) i CJ Restricted [Jel,very fee 1.-"-'" CJ (Endorsemer'.t ReqH,'d) -_. ~~-'---"--~- ::;: Total Postage & Fees L~__..___. : 'm... .. ..i... .~~--.xJ-.(~~i.1 .-. Street, Apt. N"'h'l-::J "'7 /j~. ,.. I '--' or PO Box No, <Q,'-' 7__. .. . .... .~:.I~ ~ -Ci1y,'s"--':zIP;,'-r:'~ ~Ue:;, I t tf:.7 / '/ liiiI_IIH~111 Er~) H Cl' MPLETE THI'; SECT!': (\ '.'C9mplete ~ 1, 2, and 3. A1socOnllpllte itefn','!4if R"tricted Delivery is desirect · Pri1t.~ur name and address on the llilVotrse ' so.t/ijat we can return the card to y~. !' i · At1iaQh this <lard to the back of th~ W~~~e, or 0., the front if space permits. ' '! ' .' :. 1. ArtIcI&Addrassed to: , .: . ." I ~#d~'."'.' I .-,..... :. :",:,,,. .' . ! .......... ........ '. .. '" .LI . i. '. J ' ..... I.,.:. 11,;, 1.a:ai . N~r(tI. 11 (' I fJtL1711~ , 6lJ....(J /- /tJ?CJ . . ]., .'~!IIu.mber .. " (11wJSfflr~ ~ It#i) , ," ~. 3811 ,August 2P01 LL,;; . i 7 0 0 1 2 E<1IJ ! !~eSlic FlE":urn R!)(}'!ipt I'i 1~~J - __.........~r~,J ~ll T~-:--~.;~e Type - 1 ~~ertifled Mail . :J Hegisterecl [] Il1sured Maiil _H' ~~ ~~ .~tncled Dehveryf' 'I r ,.:.JiJ ''r ., [LJ1J6 ............ En_ , JRD/June 30, 1992/17858 . OCT 0 6 Z003 \y Estate No.: 21-2001-1080 ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA In Re: Estate of Shirley M. Clepper Late of Silver Springs Township NO. 21-2001-1080 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: Linda S. Freeburn Counsel for Personal Representative: , AJl. /llJ fit,/'- / l 'rJ'~!1fYo l,,,t Date of Decedent's Death: 09-24-2001 Date of Delinquency Notice: 08-01-2003 The undersigned, Donna M. Otto, Register of Wills, in accordance with Rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of Common Pleas of Cumberland County, that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status 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 by the Register of Wills on 10-06, 2003 , 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. Distribution: Personal Representative Counsel for Personal Representative Estate File Date: 10-06-2003 /2 -S"~ 3 9: 30 '*'~ J A hearing is scheduled for at in Courtroom No.3. If the Status Report is filed prior to the hearing date, the hearing will automatically be cancelle ~~~., ~ , \ . n" \\ \\~\ ~~ G/J 0'" . Register of Wills of Cumberland County STATUS REPORT BY PERSONAL REPRESENTATroE UNDER RULE 6.12 Name of Decedent: SHIRLEY M. CLEPPER Social Security Number: 204-30-8789 Date of Death: September 24, 2001 Estate No. 2001-01080 Administration No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above- captioned estate: 1. State whether administration of the estate is complete: Yes No X 2. If the answer is "No", state when the personal representative reasonably believes that the administration will be complete: Within the next six months. 3. If the answer in No.1 is "Yes", state the following: A. Did the personal representative file a final account with the Court? Yes No 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 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. I~'" ,J " ~ ,. "..." j , " , i _c~ ';f> - r==,,___.-J N6ralF:- Blair, E~e ~- Counsel for Personal Representative Supreme Court ID 45513 5440 Jonestown Road Post Office Box 6216 Harrisburg, PA 17112-0216 (717) 541-1428 Date: November 14, 2003 b \,\JP ' n. \\\\i\O ~ On Cumberland County - Register of Wills Hanover and High Streets Carlisle, PA 17013 Phone: (717) 240-6345 Date: 8/04/2004 LINDA S FREEBURN RE: Estate of CLEPPER SHIRLEY M File Number: 2001-01080 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 AMMENDMENTS 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: 09/24/2004 Your prompt attention to this matter will be appreciated. Thank you. Sincerely, GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative (s) Counsel Judge JRD/June 30, 1992/17858 In Re: Estate of Shirley M. Clepper · ORPHANS' COURT DIVISION Late of Silver Spring Township · COURT OF COMMON PLEAS OF · CUMBERLAND COUNTY Estate No.: 21-01-1080 ' PENNSYLVANIA 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: Linda S. Freeburn Counsel for Personal Representative: None Date of Decedent's Death: 09/24/2001 Date of Delinquency Notice: 10/08/2004 The undersigned, Glenda Famer-Strasbaugh, Clerk of Orphans' Court, in accordance with Rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of Common Pleas of Cumberland County, that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status 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 by the Clerk of the Orphans' Court on April 30, 2004, 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: 10/08/2004 Glenda Famer Strasbaugh Clerk of the Orphans' Court Distribution: Personal Representative Estate File .[i2laoo - q:3o A hearing is scheduled for at in Courtroom No. 3. If the Status Report is filed prior to the hearing date, the hearing will automatically be cancelled· Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of Clepper, Shirley M. No. 21 - 01 - 01080 also known as Date of Death 9/24/2001 , Deceased Social Security No. 204-30-8789 Linda S. Freeburn The Pemonal Representative(s) of the above Estate, deceased, verif7 that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the mai estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appeam in a memorandum at the end of this Inventory. I/We ve~fy that the statements made in this Inventory are true and correct. I/We undemtand that false statements heroin are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unswom falsification to authorities. Personal Representative Attorney: Nora F. Blair Signature: I.D. No.: 45513 Signatur~ Signature: Address: 5440 Jonestown Road Address: 7334 Sleepy Hollow Road PO Box 6216 Hurrisburg, PA 17112 Harrisburg, PA 17112 Telephone: 717/541-1428 Telephone: Dated: Pemonal Property M&T Bank checking account 668.39 Mobile Home (sold to Leiby's Mobile Home Park) 21,999.00 2001 federal tax refund 447.52 200~ state taJt~efund ..... 106.37 ~ Total Personal Property $23,221.28 (Attach additional sheets if necessary) Total Personal Property and Real Estate $23,221.28 REV- 1500 INHERITANCE TAX RETURN .,~..,o~ RESIDENT DECEDENT ol o~o~o DECE~NTS ~ME (~ST, FIRST, AND MIDDLE ~L) SOC~L SECUR~ NUMBER Clepper, Shirley M. 20 4 - 30 - 8789 DA~ ~ O~ (MM-D~R) DA~ ~ BIR~ ~M-D~Y~R) 09/~4/~001 08/~6/]939 REG~TER OF ~LLS D 9. ~P~sR~i~ D 10.~c~ff(~e~n ~ 11.EI~U~.911~A)(A~O) lAME C~PLE~ ~lLING ADDRESS Nora F. Blair ~M mM~ 1~ ~e) 5440 Jonestom Road BI~ Law Office PO Box 6216 ~LEPHONt NUMBE~ H~sb~g, PA 17112 717/541-t428 ~, '. - ~ 1. R~ E~e (~u~A) (1) NO~' : ~ 2. St~ ~ ~ (Sc~u~ B) (2) N on~ 3. C~ ~ ~, P~h~ ~ S~hip (3) N one I 4. ~ & ~ R~ (S~u~ D) (4) None 5. ~h, ~k ~ & M~I~ P~ ~ (5) ~3 ~ ] (~ E) -. Cfi 6. J~ ~ ~ (~u~ ~ (6) N one ~ ~ B]li~ R~ 7. I~-~ T~ & M~ N~-P~ P~ (~ None (~u~ G ~ L) 8. T~I G~ ~ (~ ~ 1-~ (8) 23,221.28 9. Fu~ ~ & ~is~ ~ (~u~ H) (9) 8,219.71 10. ~ ~ ~, ~ ~, & ~ (8~u~ I) (10) 1g,130.79 11. T~I ~o~ (~ ~ 9 & 10) (11) 26,350.~0 12. ~ V~ ~ ~ (U~ 8 ~n~ U~ 11) (12) insolvent 13. C~ ~ ~ 9113 T~ f~ ~ ~ ~ ~ n~ ~ (13) ~ (S~ J) 14. ~ V~ Sub~ ffi T~ (~ 12 min~ ~ 13) (14} 15.~ U~ 14~~, x .00 (15) ~ ~ U~ ~. 911 ~a)(1.2) 16.~ ~ U~ 14 ~ ~ li~ ~ x .045 (16) 17.~ ~ U~ 14~ ~ s~ ~ x .~2 (17) 18.~U~ 14~~ ~ x .16 08) 19. Tax D~ (19) ~. ~ ~ ~ on~ T~ ~ ~p, In~ Fo~ ~-1~ Decedent's Complete Address: I STREET ADDRESS 7073 Carlisle Pike CITY Carlisle [STATE PA Izl~ 17013 Tax Payments and Credits: 1. T~xDue(PEgel Une19) (1) 2. Credit~Payments A. Spcms~ Poven*y Credit C. Discount Tctal Credits (^ +B+C) (2) 0.00 3. Intemst~:'ene#y ~f applk~e D. Inter'es! E Penelty TcXal Interest/Pener~y (D + E) (3) 0.00 4. IfUne2isgrea~rthmtLinel+Une3, e~(arfllediffere~ne. This is the OVERPAYMENT. (4) Check box on Page I Une 20 to request a refund 5. IfLJnel+Une3isgreeterlJ~anUne2, enter the diffemnc~ This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the to~ ~f Line 5 + SA. This is the BALANCE DUE. (SB) 0,0 0 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did deceda~ m~_e a transfer and: Yes No b. retain th~ ~ht to ~ign~ ~no ~h~ll u~ th~ pn:~ tram~:t o~ ~ incom,; ......................................... d. r~:~ th~ ~mm~ ~or li~ ~ ~,' p~tne~, I~m~'it~ ~ D~? .................................................................. 3. D~d~to~'~'intn~tfo~ ~'p~t~l~upondesth~nk~unt~oudtysthiso'h~'d~lth? ............... [] 4. Did decadent ow~ an Individual R~rernent Accent, annuity, or ~her finn-probate pmpe~y which ~3~t~n~ a ba~aci~ ~? ........................................................................................................................ [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS I~ YES, YOU MU~T COMPLETE SCHEDULE O AND FILE rr AE PART OF THE RETURN. SIGNA1URE <~F PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE rtarrisourg, PA 17112 SIGNATURE OF PREPARER O"~HER THAN REPRESENTATIVE ADDRESS DATE Nora F. ~l~lr 5440 Jonestown Road PO Box 6216 Harrisburg, PA 17112 ! F~',~== ~de~h on ~'after July 1, 1994 axJ before Janua~ 1, 1995, the tax mte imposed on the net valueof transfers toot for the use of the sun~ing srx~e is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates ~ deslh on or after Januar~ 1, 1995, the tax rate irnpoesd on tile ne~ value of transfers to or for the use of the suwivi~ s~e is 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute dDes net e~am~ a transfer to a sun/n4ng spoues from tex, and the stetut~/requirements for disck3sure ~ assa~s and ~ing a tax return am still q~icsble even if tile sunning spouse is the only beneltDiar/. The tax rate imp~ed on the ne~ value of transfers from a deceased child twenty.one years of age ~x you~ ~ ~ to ~ f~ ~e ~ ~ a n~u~ parent, an adop~e pemnt, o~ a stepflamnt of the c~ikJ is 0% [72 p.S. §9116 (a) (1.2)]. The ta~ rate imposed on the n~ value of transfers to or for the use ~f the decedent's linesl ~ is 4.5%, ~ ~ ~ in 72 P.S. §9116 1.2) F2 P.S. ~ll6 (a) The tm< rate imposed =n fl~e net value of transfers to (:t for the ues Df the ~s sil31ings is 12% [Z2 p.s. ~9116 (a) (1.3)]. A sibling is defined, under Section 9102, as an individual who hes at least ~ne pare~ in c~rnm~n with the _r~.,-ec-~nt,_ wha~ar by blood ~- ad(3p~n. SCHEDULE E CASH, BANK DEPOSITS, & MISC. =.~.~,. o, =:_-,,v~.A PERSONAL PROPERTY ESTATE OF FILE NUMBER Clepper, Shirley M. 21 - 01 - 01080 Include the. proceeds of I~.~,=igation agd the date t.he_oroceeds were received by the estate. All pmperbJ jointly-owned with the fight of survivomnlp must be dlicluseu on schedule ~-. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH I M&T Bank checking account 668.39 2 Mobile Home (sold to Leiby's Mobile Home Park) 21,999.00 3 2001 federal tax refund 447.52 4 2001 state tax refund 106.37 TOTAL (Also enter on Line 5, Recapitulation) 23,221.28 LEIBY'S MOBILE HOME PARK 7073 CARLISLE PIKE CARLISLE, PA 17013 Phone: (717) 697-1321 E~TATE OF FILE NUMBER Clcpper, Shlrl~ M. 21 - 01 - 01080 Debts of decedent must be reported on Scheduls I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: 1 Hoover Funeral Home 4,718.00 B. ADMINISTRATIVE COSTS: 1. Persalal Rep's Social Secu~y Number(s) / EIN Nufri0er of Personal Represent~ive(s): Stm~ Adclress Year(s) Commission paid 2. Attom~s Fees Nora F. Blair, Esquire 400.00 3. Family F_~: (If ~s address is nc~ the sarne as claimant's, attsch ex~) Claimant Street Address C~ State ~ ~ Relationship ~ Claimant to Decedent 4. Probate Fees Cumberland County Register of Wills 95.00 5. Accountant's Fees 6. Ta~ Re~um Preparers Fees 7. Other Administrative Costs I Vital records (copies of death certificate) 22.00 2 Lot rent for October and November plus late fees 614.00 Total of Continuation Schedule(u) 2,370.71 TOTAL (Also enter on line 9, Recapitulation) 8,219.71 8dm u H ESTATE OF FiLE NUMBER Clepper, Shirley M. 21 - O l - 01080 3 Sales commission on mobile home 2,199.00 4 School real estate tax on mobile home 171.71 Page 2 of Schedule H SCHEDULE I DEBTS OF DECEDENT, MORTGAGE ,=o,,,,o,,,,~,~,~,,~,~v,~, LIABILITIES, & LIENS r ESTATE OF FILE NUMBER Clepper, Shirley M. 21 - O1 - 01080 Include unreimbumed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 Lot rent for June, July, August and September plus late fees 1,468.00 2 First Union Bank (loan on mobile home) 16,662.79 TOTAL (Also enter on Line 10, Recapitulation) 18,130.79 COMMO.WE*~ O~ ~ENNS~.V^.,~ BENEFICIARIES ESTATE ~ FILE NUMBER Clepper, Shiley M. 21 - O1 - 01080 RE~T~NSHIP TO ~U~ OR S~E NU~R ~ ~D ~SS ~ ~R~(S) RECEMNG ~R~ DECE~ OF ESTA~ I. T~ DIS~IBUT~S (i~ ~M s~ dis~) I Lin~ Freeb~ Daughmr 3n~S~ of Resid~ 7334 Sleepy Hollow R~d ~satc ~ H~bb~g, PA 17112 2 Mc~ Moy~, Jr. Son 3ne-Si~ of Rcs[d~ 80 Sher~ Church Ro~ ]sam ~ville, PA 17003 * 3 C=I Moycr Son )ne-Si~h of Resid~ 10220 Allento~ Boule~d [s~ G~IIc, PA 17028 4 Gwendol~ N~ger D~mr 3ne-Six~ of Resid~ 823 Laude~ilch R~ [s~ H~mctsto~, PA 17036 See Continuation Schedule(s) attached Ente~ de#ar amounts for distributions show~ above on lines 15 through 18, as ap~, on R~v 1500 co,er s~ NON-TAXA~J r: DISTRIBUTIONS: A. SPOUSe. DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE1 ~ SCHEDULE J ~OuMO,W~. ~ ~..~v^.~. BENEFICIARIES continued FILE NUMBER ESTA~ OF Clcpper, Shirley M. 21 - 01 - 01080 RELATIONSHIP TO NUMI~R NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY DECEDENT AMOUNT OR SHARE I)o N~ LI~ Tm~s) OF ESTATE I'. tAXABLE DISTRIBUTIONS Sec. 9116(a)(1.2)] 5 Bryan M. Moyer Son Dne-Sixth of Residuary 292 South Faith Road Estate Grantville, PA 17028 6 James Moyer Son One-Sixth of Residuary 7334 Sleepy Hollow Road Estate Harrisburg, PA 17112 Page 2 of Schedule J LAST WILL AND TESTAMENT I, SHIRLEY M. CLEPPER, of Carlisle, Cumberland County, Pennsylvania, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. I direct that all inheritance taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shall be paid by my personal representative out of my estate. 2. I authorize and empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate to my children, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living. 4. I nominate and appoint Linda S. Freeburn to be the personal representative of my estate, to serve without bond. If she cannot or does not serve, then I appoint Mervin L. Moyer, Jr., to be the substitute personal representative, also without bond. 5. I suggest that my personal representative retain the services of Harold S. Irwin, III, Carlisle, Pennsylvania in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 4t~ day of June, 2001. SHIRLE~ ~. LEPPER (SEAL) Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. ~~~,~ ACKNOWLEDGMENT AND AFFIDAVIT WE, SHIRLEY M. CLEPPER, RHONDA S. iRWIN and HEATHER A. BARBOUR, and NATHAN C. WOLF, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her last will and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and headng of the testatrix, signed the will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. SHIRLE~I~. CLEPPER HEA'~HER A. BARB~)UR RHOI~DA-~. IRWIN '~ NAT~IAN C. WOLF ~/~ COMMONWEALTH OF PENNSYLVANIA : .'SS: COUNTY OF CUMBERLAND : Subscribed, sworn to and acknowledged before me by SHIRLEY M. CLEPPER the testatrix herein, and subscribed and sworn to. before me by RHO,N2A S. IRWIN, HEATHER A. BARBOUR, and NATHAN . W F, witnesses, this 4 day of June. Register of Wills of Cumberland County STATUS REPORT BY PERSONAL REPRESENTATIVE UNDER RULE 6.12 Name of Decedent: SHIRI~g M. CLEPPER Social Security Number: 204-30-8789 Date of Death: September 24, 2001 Estate No. Administration No. 2001-01080 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 X No 2. If the answer is "No", state when the personal representative reasonably believes that the administration will be complete: 3. If the answer in No. 1 is '~ges", state the following: A. Did the personal representative file a final account with the Court? Yes No X B. The separate Orphans' Court No. (If any) for the personal representative's account is · C. Did the personal representative state an account informally to the parties in interest? Yes X 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. Date: Octp..ber 27~ 2004 3- Counsel for Personal Representative ~ Supreme Court ID 45513 :~: 5440 Jonestown Road · ~ !:- Post Office Box 6216 ..... Harrisburg, PA 17112-0216 (717) 541-1428 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAl TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-06~1 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 01-31-2005 CLEPPER 09-24-2001 21 01-1080 CUMBERLAND 101 NORA FrBLAIR BLAIR LAW OFFICE PO BOX 6216 HBG PA 17112 '* G- REV-1547 E~ lFP U2-U4l SHIRLEY M Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ...... HitV' :r!1,"f'Ej{'.AFi>..rll1":m..N6i"icl.'b'j!.i:Nj:lERYi'~ilcE.YAx.A"PPHAisE'f.iEil't:."ALliililAN'cE.o'R.............. ..- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF CLEPPER SHIRLEV M FILE NO. 21 01-1080 ACN 101 DATE 01-31-2005 TAX RETURN WAS: (X I ACCEPTED AS FILED I CHAHGED If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Anount of Line 14 at Sibling rat. (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal rax Due RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule Al 2. Stocks and Bonds (Schedule B) 3. Closely Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable {Schedule DJ 5. C.sh/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule fJ 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. funeral Expenses/Adm. Costs/Misc. Expenses (Schedule HJ 10. Debts/Mortgage Liabilities/liens (Schedule IJ 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/GovernMental Bequests; Non~elected 9113 Trusts 14. Net Value of Estate Subject to Tax NOTE: III 12J 131 (41 (51 (61 (71 .00 .00 .00 .00 23.221. 28 .00 .00 ISI NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 23,221.28 "76 31;0 1;0 3,129.78- .00 3,129.78- 00 = 045 = 12 = 15 = .00 .00 .00 .00 .00 191 llOI 8,219.71 18.130.79 1111 ll21 (131 (141 ll91= TAX CR ITS: p ,+1 AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-I TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 (Schedule J) .00 X .00 X .00 X .00 X . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU HAY BE DUEOK A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. I '5 v(