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HomeMy WebLinkAbout05-02-11G' Cumberland DECEDENT'S ESTATE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF Evelyn F. Shearer No. 21-10-0162 DECEASED PETITION FOR ADJUDICATION / STATEMENT OF PROPOSED DISTRIBUTION PURSUANT TO Pa. O.C. Rule 6.9 { .,„~ r'„^,~ ',,,~ ._. " //''''~~ ~7 1 ~ .~ . }_ , -Y-Z +"~ ~ ~~~ ti This form may be used in all cases involving the Audit of t1~e Account of cr Decedent',s Estate. If space is insufficient, riders may be attached. Attach. the spouse 's election, i f any, the papers required under items b'-19 inclresive; and any instricment pertinent to the adjudication. INCL UDE ATTACHMENTS AT THE BACK OF THIS FORM. Name of Counsel: Keith O. Brenneman Supreme Court I.D. No.: 47077 Name of Law Firm: Snelbaker & Brenneman, P. C. Address: 44 West Main Street, Mechanicsburg, PA 17055 Telephone: 717-697-8528 Fax: 717-697-7681 Form OC-Ol rev. ] 0.13.06 :Page 1 of 10 I~ ~~ Estate of Evelyn F. Shearer ,Deceased 1. Name(s) and address(es) of Petitioner(s): Name: Geoffrey A. Shearer Address: 1111 Tunbridge Lane Mechanicsburg, PA 17050 Identify any executors or administrators who have not joined in the Petition for Adjudication and Statement of Proposed Distribution and state reason: None Is this the first accounting by this ~ duciary? ..................... D Yes No If not, identify prior accountings, the accounting periods covered, and the date of adjudication of the prior accounting. 2. Decedent died on January 11, 2010 Letters Testamentary or Letters of Administration were granted to Petitioner(s) on February 19.2010 Date of Will (if applicable): September 12, 2002 Date(s) of Codicil(s) (if applicable): N/A Date of probate (if different ft~om date Letters granted): same as above Was a bond required? I'es No If yes, state amount: _ Are proofs of advertising of the grant of Letters attached`? ......... i0 Yes No Dates of advertising of the grant of Letters: Cumberland Law Journal_ March 5. 12_ 19, 2010 and The Sentinel, March 5, 12, 19, 2010 Form OC-01 rev. 10.13.06 Page 2 of 10 Estate of Evelyn F. Shearer Deceased 3. Was decedent survived by a spouse? ............................. Yes No If yes, name of the surviving spouse: 4. Has the surviving spouse filed to take an elective share? ....... . ..... Yes No (See Section 2201 et sue. of the Probate, Estates and Fiduciaries Code) If yes, date of election: 5. In the case of an intestacy, state the names of the decedent's surviving children or surviving issue of deceased children (if none, sv state): N/A 6. Did decedent marry after execution of Will or Codicil(s)? ........... Yes No Were any children born to decedent after execution of Will or Codicil(s)'? ..................................... . ..... Yes No If yes, give names and dates of birth: Name: Date of Bil•th: 7. If required by the Medical Assistance Estate Recovery Act, 62 P.S. § 1412, was a request for a statement of claim sent to the Department of Public Welfare? .............................. Yes No Form OC-Ol rev. 10.13.06 Page 3 of 10 Estate of Evelyn F. Shearer Deceased 8. Written notice of the Audit as required by Pa. O.C. Rules 6.3, 6.7 and 6.8 has been or will be given to all parties in interest listed in item 9 below, all unpaid creditors and all claimants listed in item 10 below. In addition, notice of any questions requiring Adjudication as discussed in item 14 below has been or will be given to all person~> affected thereby. A. If Notice has been given, attach a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice. B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice shall be submitted at the Audit together with a statement executed by a Petitioner or counsel certifying that such notice has been given. C. If any person entitled to Notice is not sui juris (e.g., minors or incapacitated persons), Notice of the Audit has been or will be given to t'~he appropriate representative on such party's behalf as required by Pa. O. t~. Rule 5.2. D. If any charitable interest is involved, Notice of the Audit has been or will also be given to the Attorney General as required under Pa. O.C. Rule 5.5. In addition, the Attorney General's clearance certificate (or proof of service of Notice and a copy of such Notice) must be submitted herewith or at the Audit. 9. List all parties (charitable and non-charitable) of whom Petitioner(s) has/have notice or knowledge, having or claiming any interest in the estate as beneficiaries under the Will or Codicil(s) or as intestate heirs if there is a complete or partial intestacy: A. State each party's relationship to the decedent and the nature of each party's interest(s): Form OC-01 rev. 10.13.06 Page 4 of 10 Estate of Evelyn F. Shearer Deceased B. Identify each party who is not sui juris (e. g., minors or incapacitated persons). For each such party, give date of birth, the name of each Guardian and how each Guardian was appointed. If no Guardian has been appointed, identify the nest of kin of such party, giving the name, address and relationship of each. N/A C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for this Audit (see Pa. O.C. Rule 12.4. N/A D. If distribution is to be made to the personal representative c-f a deceased party, state date of death, date and place of grant of Letters and type of Letters granted. N/A Form OC-O1 rev. 10.13.06 Page 5 of 10 Estate of Evelyn F. Shearer Deceased 10. Other than the claim for the family exemption, list the names of all known claimants and the amount of their claims and state whether each claim is admitted. Name andAddress of Each Claimant Amount of Claim Claim Will Claim Admitted Be Paid In Full? None ,... ~__ 'I Yes Yes No ~ No Yes Yes No No Yes Yes ~No No ]Yes ~ Yes No { No If the estate is insolvent, attach a schedule setting forth the order of preference under 20 Pa.C.S. § 3392 and the proposed payments. 11. Was family exemption claimed? ................................ Yes No Was family exemption allowed? ................................ Yes No Family exemption claimant's name and relationship: Name: Relationship: Form OC-DI rev. 10.13.06 Page 6 of 10 Estate of Evelyn F. Shearer Deceased 12. The amount of Pennsylvania Transfer Inheritance TaY and additional Pennsylvania Estate Tax paid, the date(s) of payment(s), and the interest(s) upon which. paid, are as follows: Date Payment Interest 04/08/2010 12/30/10 588.00 31.59 .27 13. On the date of death, was the decedent a Educiary (personal representative, trustee, guardian, agent under power of attome or sure ~ on the bond of a fiducia `1 ....... y) ~ ry . ...... , ..... Yes ®/' No If yes, provide the name of the estate, indicate whether an accc~unt has been filed and confirmed absolutely and all awards performed, or, in the alter.~native, how the decedent's estate will be discharged for the decedent's fiduciary administration of the estate. 14. A. Describe in detail any questions requiring adjudication and stake the position of the Petitioner(s) as to each question: N/A B. Has notice of the question requiring adjudication been given to the parties identified in Paragraph 9 above? .................. Yes No 15. If Petitioner(s) has/have knowledge that a share has been assigned;, renounced, disclaimed or attached, provide a copy of the assignment, renunciation, disclawimer or attachment, together with any relevant supporting documentation. Forns OC-01 rev. 10.13.06 Page 7 of 10 Estate of Evelyn F. Shearer Deceased 16. Had the decedent been adjudicated an incapacitated person? .......... Yes No If yes, attach a copy of the Order if available; otherwise state t:he Court, term, number, date, and name of Hearing Judge. 17. A. List or attach a separate list of additional receipts and disbursements since the closing date of the Account. None B. Has notice of the additional receipts and disbursements been given to the parties identified in Paragraph 9 above? ........... ~ Yes No 18. If a reserve is requested, state amount and purpose. .Amount: 1'U~~' UD Pu''~'OSe~ Filing fees, accountant fees and other miscellaneous co:~ts associated with the administration of the decedent's estate. If a reserve is requested for counsel fees, has notice of the amount of fees to be paid from the reserve been given to the _Y N parties in interest? .................................. ..... © es © o If so, attach a copy of the notice. 19. Is the Court being asked to direct the filing of a Schedule of Distribution? ..... ~/' Yes ~No As to real estate only? ...................... . . ..... . . . .. . . . . . . Yes '] No Form UC-Ol rev. 10.13.06 Page 8 of 10 Estate of Evelyn F. Shearer Deceased Wherefore, your Petitioner(s) ask(s) that distribution be awarded t~~ the parties entitled and suggest(s) that the distributive shares of income and principal (residu~~ry shares being stated in proportions, not amounts) are as follows: A. Income: Proposed Distributee(s) Amount/F'ropvrtion See Accounting B. Principal: Proposed Distributee(s) Amvunt,/F'roportivn See Accounting Submitted By: (All petitioners »zicst sign. Add additional lines if necessary): Name etitioner: Geoffrey A. Shearer Name of Petitioner: Form OC-Ol rev. 10.13.06 Page 9 of 10 Estate of Evelyn F. Shearer Verification of Petitioner (Verification must be by at least one petitioner.) The undersigned hereby verifies ~` [that he/she he 1S title Executor Deceased of the above-named name of corporation Estate of Evelyn F. Shearer and] that the facts set forth in the foregoing Petition for Adjudication /Statement of Proposed Distribution which are within the personal knowledge of the Petitioner are true, and as to facts based on the information of others, the Petitioner, after diligent inquiry, believes them to be true; ar,~d that any false statements herein are made subject to the penalties of 18 Pa. C.S. ~ 4904 (relating to unswom falsification to authorities). Signature of rtroner * Corporate petitioners naicst co~nplete bracketed information. Certification of Counsel The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/ Statement of Proposed Distribution is a true and accurate reproduction of the form Petition authorized by the Supreme Court, and that no changes to the form have been made beyond the responses herein. Signature of Counsel for Petitioner Form OC-01 rev. 10.13.06 Page 10 of 10 PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1~784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Joul-nal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued. weelcly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, VIZ: March 5 March 12 and March 19 2010 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. ~~4., ~~ '~ `~•,~ ~ ~ `e~'' `S G, ~lsa Marie Coy11e, Edit ~`~..,~ SWORN TO AND SUESCIZIBED before me this 19 day of March, 2010 Notary Shearer, Evelya F., deed. Late of the Borough of Camp Hill. Executor: Geoffrey A. Shearer, 1111 'hznbridge Lane, Mechanics- burg, PA 17050. Attorneys: Keith O. Brenneman, Esquire, Snelbaker & Brenneman, P.C., 44 W. Main Street, P.O. Box 318, Mechanicsburg, PA 17055. IaC~T~~i~I6,L SC/~L C)E~:C~ri/i.i-# Fi Cr~?I.LIf~S P~i~JiOfy F~ll~:flG ca,~~ss~~: aouv, r«~~a~~±..~r~to coura~ My Carnmis~lar~ Exr~lr~~s Abe 2~, 2010 PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tames IQeinklaus, Director of Sales and Marketing, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13,1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): March 5,12 and 19, 2010 COPY OF NOTICE OF PUBLICATION ...~. EXECUTOR'S NOTICE Letters Testamentary on the°:Estate of`EVELY:N F. SHEARER, late of the Borough of Camp Hill, Cumberland County., .Pennsylvania, have been granted to the undersigned. All persons knowing themselves to be indebted to said Estate?will make payment immediately, .and those having claims will`preseni them`for settlement to; Affiant further deposes drat he/she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication Geoffrey A'. Shearer, Executor are true. ~~ 1111 Tunbridge Lane _ sr'~ Mechanicsburg, PA 17050 ~,, ..Keith O: Brenneman,.Esquire "' .~".~ ----~,,,,,..---~ T Sneibaker & Brenneman, P: C. ~ 44 West'Main Street P. O. Box 318 Mechanicsburg PA 1?055 Attorneys "for Executor Sworn to and subscribed before me this ~~ i ~..~~ Notary Public My commission expires: NOTARiAI BEAt BAMQI ANN HECKEND4RN Not~tty Pwblic CARLISLE BOROUGH, CUMBERLAND CNTY My Cofrimission Expires Jan ~!7, 2014 K COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 March 25, 2010 SNELBAKER & BRENNEMAN PC KEITH O BRENNEMAN 44 W MAIN ST MECHANICSBURG PA 17055 Re: Evelyn Shearer SSN: ###-##-1919 Dear Attorney Brenneman: Pursuant to your letter dated February 22, 2010, the DE~partment of Public Welfare (DPW), Estate Recovery Program, has reviewed the information you provided regarding the above-referenced individual. It has been determined that this individual did not receive any type of assistance during the questioned period. Therefore, according to the information you provided, t:he Department's Estate Recovery Program will not seek any recovery from thi:~ estate. If your client applied for Medical Assistance and had an application and/or hearing pending at the time of death, please advise us and provide ~~ny additional information that may affect a recovery by our Department. If you have any questions, please feel free to contact me. Sincerely, ~, ~ ~ Vince A. Porter Recovery Section Manager (717)772-6604 l~_ rI` '/' ~ . /!~ ~ / n s~-~s 7 F l /_~ ~ . _ .wS':~ ~ ~ Kr. J ~ ~L ` ~-' --~ c: ~ _t~ ~ ~_. ' 1 _...t ti `~?° ... ~~ 4___..> - ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, `Y~ -, ~~= ORPHANS' COURT DIVISION -~ ---~ r= ~ ~-~- ~' FILE NO: 21-10-0162 ~' ~-~~ `'~ ~~~ FIRST AND FINAL ACCOUNT OF Geoffrey A. Shearer, Executor For ESTATE OF EVELYN F. SHEARER Social Security #: Tax I D #: Date of Death: Date of Incapacity, if any: Date of Executor Appointment: Date of First Complete Advertisement: Accounting for the period: 184-09-1919 80-6153562 January 11, 2010 None February 19, 2010 March 5, 2010 January 11, 2010 to February 1 '1, 2011 Purpose of Account: Geoffrey A. Shearer, Executor, offers this Account to acquaint interested parties with the transactions that have occurred during his Administration. It is important that the Account be carefully examined. Requests for additional information, questions or objections can be discussed with: Keith O. Brenneman Snelbaker & Brenneman, F'.C. 44 West Main Street Mechanicsburg, PA 17055 Phone #: 717-697-8528 Supreme Court I.D. No: 4 7 077 LAW OFFICES SNELBAKER 8C BRENNEMAN, P.C. Page 1 LAw o~cEs SNELBAKER SC BRENNEMAN, P.C. SUMMARY OF ACCOUNT PRINCIPAL Receipts Net Gain on Sales or Disposition Less Disbursements: Debts of Decedent Funeral Expenses Administration Expenses Family Exemption Federal, State & Local Taxes Fees and Commissions Balance before Distributions Distributions to Beneficiaries Principal Balance on Hand For Information: Investments Made Changes in Holdings INCOME Receipts Less Disbursements Balance before Distributions Distributions to Beneficiaries Income Balance on Hand COMBINED BALANCE ON HAND Listing of unpaid creditors: Persons interest in the Distribution of Estate Proposed Statement of Distribution Affidavit/Verification PAG E Page 2 3 $ 22,830.92 3 0.00 $ 22,830.92 3 $ 2,611.29 3 509.04 3 1,467.20 4 0.00 4 1,218.80 4 3,750.00 9,556.33 $ 13,274.59 4 n nn 4 4 4 $0.00 5 $O.OQ $0.00 5 $0.00 $0.00 $ 13,274.59 6 6 7 8 PRINCIPAL RECEIPTS Assets Listed on Inventory per copy of attached: $22,489.81 (Valued as of Date of Death) ADJUSTMENTS TO INVENTORY 0.00 SUBSEQUENT RECEIPTS 7/12/2010 Highmark, premium refund 335.24 8/9/2010 Internal Revenue Service, additional refund amount 5,87 TOTAL PRINCIPAL RECEIPTS $22,830.92 PRINCIPAL GAINS OR LOSSES ON SALES OR OTHER DISPOSITIONS GAIN LOSS NONE TOTAL GAINS AND LOSSES NET GAIN/LOSS TRANSFERRED TO SUMMARY DISBURSEMENTS OF PRINCIPAL LAW OFFICES SNELBAKER SC BRENNEMAN, P.C. DEBTS OF DECEDENT 1/14/2010 Brown Optical & Hearing Aid Service, medical expense 1/14/2010 Continuing Care RX, medical expense 1 /14/2010 West Shore EMS Carlisle, ambulance service 2/12/2010 Church of God Home, Inc., nursing home expense 2/12/2010 Continuing Care RX, medical expense 2/22/2010 Darryl K. Guistwhite, medical expense 4/19/2010 Church of God Home, Inc., nursing home expense 7/12/2010 Darryl K. Guistwhite, medical expense FUNERAL EXPENSES 1/29/2010 Jesse H. Geigle Funeral Home, funeral expense 2/19/2010 Jesse H. Geigle Funeral Home, funeral expense 4/19/2010 Gingrich Memorials, inscription on marker ADMINISTRATION EXPENSES 4/30/2010 Citizens Bank, service charge 8/13/2010 Snelbaker & Brenneman, P.C., costs advanced a. Cumberland Law Journal, advertise Executor Notice b. Register of Wills, probate fee c. The Sentinel, advertise Executor Notice d. Register of Wills, filing fee for Inventory, Inheritance Tax return & additional probate fee e. Certified Mail costs 12/31/2010 Citizens Bank, service charge *** Reserve for filing fees, accountant fees and other miscellaneous costs associated with the administration of the estate $0.00 $0.00 $0.00 $0.00 $0.00 90.00 440.27 119.97 661.27 81.78 122.42 1,063.00 32.58 $ 2,611.29 $ 237.77 136.27 135.00 $ 509.04 $ 26.76 438.44 75.00 83.50 219.40 55.00 5.54 2.00 1,000.00 $ 1,467.20 Page 3 DISBURSEMENTS OF PRINCIPAL -CONTINUED FAMILY EXEMPTION NONE $0.00 $0.00 LAW OFFICES SNELBAKER 8C BRENNEMAN, F.C. FEDERAL, STATE & LOCAL TAXES 4/8/2010 Register of Wills, Agent, Estimated Inheritance Tax $ 588.00 4/13/2010 Pennsylvania Department of Revenue 583.00 7/12/2010 Pennsylvania Department of Revenue 15.94 12/30/2010 Register of Wills, Agent, Inheritance Tax 31.86 $ 1,218.80 FEES AND COMMISSIONS 8/13/2010 Snelbaker & Brenneman, P.C., attorney services $ 1,605.50 *** Snelbaker & Brenneman, P.C., attorney services 2,144.50 to be paid upon confirmation of the Accounting TOTAL DISBURSEMENTS OF PRINCIPAL $ 3,750.00 DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES NONE $0.00 TOTAL DISTRIBUTIONS OF PRINCIPAL TO BENEFICf ARIE_S $0.00 PRINCIPAL BALANCE ON HAND FIDUCIARY VALUE AT ACQUISITION x:/11 /2011 VALU E Cash $ 16,419.09 $ 7,155.42 Annuity 0.00 15,334.39 *** Less items to be paid at Distribution upon -3,144.50 confirmation of Accounting TOTAL PRINCIPAL BALANCE ON HAND $ 13,274.59 $ 22,489.81 INFORMATION SCHEDULES PRINCIPAL INVESTMENTS MADE NONE $0.00 TOTAL PRINCIPAL INVESTMENTS MADE $0.00 CHANGES IN PRINCIPAL HOLDINGS NONE RECEIPTS OF INCOME NONE $0.00 TOTAL RECEIPTS OF INCOME $0.00 Page 4 DISBURSEMENTS OF INCOME NONE TOTAL DISBURSEMENTS OF INCOME DISBURSEMENTS OF INCOME TO BENEFICIARIES LAw o~icEs SNELBAKER SC BRENNEMAN, P.C. NONE TOTAL DISBURSEMENTS OF INCOME TO BENEFICIARIES $0.00 $0.00 $0.00 $0.00 Page 5 * UNPAID CREDITORS: NONE ** PERSONS INTERESTED IN DISTRIBUTION OF ESTATE: Abigail Best 5 Ascot Lane Carlisle, PA 17013 2. Geoffrey A. Shearer 1111 Tunbridge Lane Mechanicsburg, PA 17050 Trindle Spring Lutheran Church 15 State Road Mechanicsburg, PA 17050 LAW OFFICES SNELBAKER SC BRENNEMAN, P.C. Page 6 PROPOSED DISTRIBUTION TO BENEFICIARIES I, Geoffrey A. Shearer, Executor and Accountant herein, proposes to distribute the balance of the Estate of Evelyn F. Shearer, Deceased, to wit: $13,274.59 in accordance with the Last Will and Testament of said Decedent as follows: 1. Trindle Spring Lutheran Church 3% of my net estate per Item Second of Will 2. Abigail Best 1 /2 of residue as per Item Third of Will 3. Geoffrey A. Shearer 1 /2 of residue as per Item Third of Will TOTAL DISTRIBUTION: LAW OFFICES SNELBAKER SC BRENNEMAN, P.C. $ 398.24 $ 6,438.18 $ 6,438.17 Page 7 AFFIDAVIT /VERIFICATION GEOFFREY A. SHEARER, Executor under the Last Will and Testament of EVELYN F. SHEARER, Deceased hereby declares under oath that he has fully and faithfully discharged the duties of his office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; to his knowledge, there are no claims outstanding against the Estate; that all taxes presently due from the Estate have been paid; and that the grant of Letters Testamentary and the first complete advertisement thereof occurred more than four months before the filing of the foregoing First and Final Account. This statement is made subject to penalties of 18 pa. C.S.A. ;section 4904 relating to unsworn falsification to authorities. eoffrey A. Shearer, Executor Dated: ~ ZQ ~/ Subscribed and sworn to by GEOFFREY A. S EAR R before me this o ~ day of i , 2011 ~~ Notary Public COAAlA4PiW~ALTH OF PEi~VSYLVMNA IVc~ial Seal Sari K ~p Nolary PubBc M9fl'161i1k,8bs;~ RNV~ Qlld Q01/1ly My Comn~ssion E~h+es Nav. 22.20'11 ME'nr~b~er ~Pnnsyhrania Association of Notaries LAw o~icEs SNELBAKER SC BRENNEMAN, P.C. Page 8 INVENTORY REGISTER OF ~NILLS OF CUMBERLAND COUNTY, :PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA 1 COUNTY OF CUMBERLAND ` SS 2I-IO-OlE~2 File Number Geoffrey A. Shearer, Executor Personal Representative(s) of the Estate of EVELYN F. SHEARER deceased, depose(s) and say{s) that the items appearing in the following inventory include all oi~the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- ~~_ ~,,,, tort' are true and correct. I understand that false state- ments herein are made subject to the penalties of rey A. shearer, Executor 18 Pa.C.S. § 4904 relating to unsworn falsification to 1111 Turnbridge Lane authorities. Mechanicsbur;~, PA 17050 Attorney -- (Name) Keith O. Brenneman 47077 (Supreme Court L D. No.~ (.4cldi°ess) Snelbaker & Brenneman, P.C., 44 West Main Street, Mechanicsburg, PA 17055 (Telepl~one) 717-697-8528 DATE OF DEATH LAST RESIDEIVCE DECEDENT'S SOC. SEC. NO. 0/11/2010 2001 Market Street, Camp Hill Borough, Camp Hill, PA 17011 184-09-191 9 FIGURES MUST BE TOTALED I . Citizens Bank, checking account #6100610357 4,935.26 2. Federated, money market account #9880535 1,676.16 3. Internal Revenue Service, refund due the Decedent on 2009 (Form 1040) income tax return 544.00 4. Jol:n Hancock, annuity #BK2048032 15,334.39 r-.a -7 0 l ..r ~ ~ ~ ~:,~ r17 F ~ - rte" ~ ~ ~ i i ~ ~ ::7 1 ~ ~ ...,.r~ .:! ~ ~ ~~~ t'+J w r t~ i t7 • , -•ri • t (Attach additional sheets as needed) 'COTAL: ~ 22,489.81 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 2Q Pa, C.S. ~ 3301(b)) Form RW-09 re~~. 10.13.06