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Home My WebLink About03-0316Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Ba H. Khuu also known as , Deceased Petitioner(s) who is/are 18 years of age or older, apply(les) for:. (COMPLETE "A" or "B" BELOW:) Social Security No. 171-74-8281 A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut Decedent, dated and codicil(s) dated Litiqation Purposes only named in the Last Will of the state relevant drcumstances, e.g. renunciation, death of executor, etc. B. Grant of Letters of Administration (c.t.a., d.b.n.c.t.a.: pendente lite; durante absentla; durante minorltate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: I Relationship Residence Name I Tam H. Khuu son 7774 Gmsne Farm Drive · Ypsilanti, MI 48197 (COMPLy- i u. IN ALL CASES:) Attach additional shee~ if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence at Manor Care, 940 Walnut Bottom Road, Carlisle, Pennsylvania (llst number, s~-~et and municipality) Decedent, then . (Location) Decedent at death owned property with estimated values as follows: ' (If domidled in PA) All personal property ...................................... $ 950.0{I (If not domidled in PA) Personal property In Pennsylvania ........................... $ (If not dOmiciled in PA) Personal property In County ................................ $ Value of real estate in Pennsylvania .................................................. $ N/A Total ................................................................... $ 950,00 Real estate situated as follows: N/A 53 years of age, died February 14 ,200~3, at Manor Care, 940 Walnut Bottom Road, Carlisle Wherefore, Petitioner(s) respectfully request(s) the probate*of the last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: Signature Typed or prl, n~ed naive and residence N,qa Kovc~c=ki 35 W. Lauer Lane Camp Hill, PA 17011 Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above-named swear(s) and affirm(s) that the statements, in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to and affirmed and subscribed before me this 9th day of DECREE OF REGISTER Estate of Ba H. Khuu No. 21-2003-316 also known as Social Security No: 171-74-8281 Date of Death: February 14, 2003 AND NOW, April 10th ,20 03 . in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters D Testamentary [] of Administration Litigation Purpose only (c.t.a.; d.b.n.c.t.; pendente lite; durante absenfla; durante minoritate) are hereby granted to N.qa Koveleski in the above estate and that the instrument(s), if any, dated described in the petition be admitted to probate and filed of record as the last Will of Decedent. FEES Leffers Sho~ Ce~ffica~s Renunci~ion (1) $ 18.00 (1) $ 3.00 $ 5.00 Register Of Wills Donna M. Otto, 1st DePUty ~Z~,- t~' · Affidavit ( ) Extra Pages ( ) $. · Codicil JCP fee Inventory & Tax forms Other ·Total $10.00 $ $ 36. O0 Attorney: June Lee Cullen ID No: 83582 Address: 115 Pine Street Harrisbur,q, PA 17101 Telephone: (717) 232-3770 Date Filed: April 10th, 2003 MAILED LETTERS TO ATrORNEY ON 4/10/03 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION REGISTER OF WILLS IN RE: Estate ofBa H. Khuu, deceased · No. 21-2003-316 RENUNCIATION To the Register of Wills of Cumberland County, Pennsylvania: I, the undersigned, Tam H. Khuu, only child of the above decedent, hereby renounce the right to administer the estate and respectfully ask that Letters of Administration be issued to Nga Koveleski. Date: Date: Yam H. Khdu, ~onl~f Ba H. Khuu 7774 Greene Farm Drive Ypsilanti, MI 48197 ~atureofWi~- Printed Name of Witnesls - Address of Witness - i - 21-2003-316 CERTIFICATION OF NOTICE Name of Decedent: Ba H. Khuu Date of Death: February 14, 2003. Will No.: To the Register: UNDER RULE 5.6(a) Adm. No.: 2003-00316 I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on April 25, 2002: Tam H. Khuu 7774 Greene Farm Drive Ypsilanti, MI 48197 Notice has now been given to all persons entitled thereto under Rule 5.6(a). Date: , Esquire !8L2ucas & Associates 115 Pine Street Harrisburg, PA 17101 717.232.3770 Counsel for Personal Representative REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA INVENTORY of all real and personal estate of Ba H. Khuu, deceased, late of 940 Walnut Bottom Road, Carlisle, Borough of Carlisle, Cumberland County, Pennsylvania, 17013, who died on February 14, 2003. No. 6702-01238 Bank Account (Checking): Commerce Bank, Account No. 0513282376 PERSONAL ESTATE SCHEDULE Value at Date of Death $ 943.33 None. REAL ESTATE SCHEDULE REAL ESTATE SCHEDULE IN PENNSYLVANIA (Description must be adequate to identify the property. Mortgages, judgments or other encumbrances on real estate should be noted.) None. MEMORANDUM OF REAL ESTATE OUTSIDE THE COMMONWEALTH OF PENNSYLVANIA (Do not include value in total of the inventory.) AFFIDAVIT OF EXECUTOR OR ADMINISTRATOR COMMONWEALTH OF PENNSYLVANIA cow vo /f ss: v Personally before me, the undersigned authority, a notary public in and for said County and State, appeared Nga Koveleski, who, being duly sworn according to law, deposes and says that she is the administratrix of the estate of Ba H. Khuu, deceased, that the foregoing schedules constitute a complete inventory and appraisement of the real and personal estate of Ba H. Khuu, deceased, except real estate outside the Commonwealth of Pennsylvania, that the figures opposite each item of real and personal estate in the foregoing schedules are determined and stated by the undersigned to be the fair value of the said items as of the date of the decedent's death. Sworn and subscribed before me ~=xecutor-Administrator COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES F~EPARTMENT .,280601 H~ISBURG, PA'. 17128-0601 March 16,2004 JUNE L. CULLEN Ct;mL ~ 220 CUMBERLAND PARKWAY SUITE #4 MECHANICSBURG, PA. 17055 Telephone 717-787-6670 Dear MS. CULLEN: Re: Estate of BAH. KHUU File Number 2103-0316 The Department has been advised that the above-referenced estate is presently involved in litigation. The Department will suspend further activity on this estate until MARCH 16, 2005. You are required to notify the Department when the status changes or the extension date expires. If you have any questions, please contact me at (717-787-6670). STEVENiJAMES Inheritance Tax Division FAX 717-772-0412 ~;,;:: ~,. ..A. f' N \ ~ ~ -=::t _P- '" __ \ ~~ -r"" '- "" <'" '" ,~~ 0. .. .. ... - .. .. \ ..... r 1Il" 'C) ~ ).... ~ - - ... - - .. , aM \ ~ \ . ,- - .- - '<~ ~ f"'"' r- f""'4 d.. ;0.. <c> \~ ":J CO . '(/) - ~ 'a !'";t. -: .iO.-. .., .. " .. ... .. . . . . -= . \ . \ III ." \0 8 C'l . ~ .... ?~cc~\~~, f"\n.r n.;., , L\J " ... 11..- '- .. :Y -- " r0 0 -.... r() "'0 '~ ... ... .. .. '<- '('--J .-. .. t l!) \? \4.. . , c- ,'-' ~) .~ Q1 ~ c0 <? c0 <" o-g i.1 (f)<" -;-.. W, .c:( ?(\)?(l.. "6~2a) \o,-:O'Cl/i ~ -:S ? ,- (/)...0-;:::: '0, ? 0 ~ &8<,,0 REV- 1 50G EX (5-001 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT I DATE OF BIRTH (MM-DD-YEAR) 07/02/1940 FILE NUMBER 21 03 COUN1Y CODE YEAR SOCIAL SECURITY NUMBER 171-74-8281 00316 NUMBER I THIS RETURN MUST BE FILED IN DUPLICATE WITH THE . REGISTER OF WILLS SOCIAL SECURITY NUMBER (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) D 2. Supplemental Retum D 4a. Future Interest Compromise (dateofde<lth after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach copy ofTrust) D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) D 3. Remainder Return (dale of death prior to 12.13-82) D 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (AltachSch0) 1 Country Club Place East Camp Hill, PA 17011 (1) (2) (3) (4) (5) (6) (7) (9) (10) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES x .0 (15) 3,288.00 x.O~. (16) x .12 _ x .15 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT I- Z W C W U W C DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) Khuu, Sa, H. DATE OF DEATH (MM-DD-YEAR) 02/14/2003 W I- :.::~eIl U~:':: wo..U :x:oo u~'" o..lD 0.. <( ~ 1. Original Return D 4. Limited Estate D 6. Decedent Died Testate (Attach copy of Will) D 9. Litigation Proceeds Received I- :z w o :z o 0.. ell W a:: a:: o U THISSE~T,ION ,.,US1 BE COMPLETEP..ALL CORRESPONDEN.CE AND CONFIDENTIAL TAX tNFORMATleJ!il.{SHOULD'9EjDlmaen;!p.j~ NAME COMPLETE MAILING ADDRESS James D. Pivonka CPA FIRM NAME (If Applicable) James D. Pivonka CPA TELEPHONE NUMBER (717) 975-0185 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) z o ~ -I :::> l- ii: <( u w ~ z o ~ ~ :::> a.. :i o U ~ 15. Amount of Line 14 taxable at the spousal tex rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20.0 -") 943.33 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4 Mortgages & Notes Receivable (Schedu Ie D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities. & Liens (Schedule I) 11. Total Deductions (totai Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 3,288.00 (8) 943.33 (11) (12) (13) (14) (17) (18) (19) ~ C:=3 i.:.:.:.:) c:..n -, .0 ,'n ~") c::) l:) C:J 1:-.'1 . i::-:J , ,::::) . -'1, - " C''5 r"r-l C) /> ;I~ a 4,231.33 ;?:.~ c::: G') f'....) Ul -;j 943.33 3,288.00 3,288.00 147.96 147.96 ~ Decedent's Complete Address: STREET ADDRESS '-14\ lIt R"",rl -~ CITY C I" I STATE I ZIP ar Isle PA 17030 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 147.96 Total Credits (A + 8 + C ) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 31s greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. (5) (5A) 147.96 11.72 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, A GENT 159.68 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred;.......................................................................................... D b. retain the right to designate who shall use the property transferred or its income; """"""""""""'''''''''''''''''''' D c. retain a reversionary mterest; or.......................................................................................................................... D d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 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? .............. 0 4. Did decedent own an Individual Retirement Account, annUity, or other non-probate property which contains a beneficiary designation? ....................................................................................................................... 0 ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. No ~ ~ [KJ [KJ o ~ Under penalties of pe~ury, I declare that I have examined this retum, induding accompanying Schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Oedaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPO~S)Bj-E OR FILING RETUR~\ ~~'<-fi6 . .Uc:3J____.. 35 Lauer Lane, Camp Hill, 17011 SIG_N~~ REO~~Ti~S-ENTATI~~_ __ A J_Q2_____~ly_t?_EI9c::_~E::_?~!'-g?~Pf-1ill,mJ?Q1J ... . .... '__mmm DATE 08/23/05 DATE 08/23/05 For dates of death on or after July 1, 1994 and before January 1, 1995, the lax rate imposed on the net value of transfers to or for the use of the surviVing spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)J. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of tr ~-A P D The statute does not exempt a transfer to a surviving spouse from tax, and the statutory r! 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 yearf or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal t The tax rate imposed on the net value of transfers to or for the use of the decedent's si _ individual who has at least one parent in common with the decedent, whether by blood or adoption. se is 0% [72 PS. ~9116 (a) (1.1) (iill. a tax retum are still applicable even if )f a natural parent, an adoptive parent, - ~ . A-c; .;;- ~-I ~9116(12) [72 P.S. 99116(a)(1)). I is defined, under Section 9102, as an REV-15G8 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMor,WEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Khuu, Sa H FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. Commerce Bank Checking Account VALUE AT DATE OF DEATH 943.33 2. Pending medical malpractice/wrongful death action (remains pending as of 08/23/05) 0.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 943.33 REV-1510EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISe. NON-PROBATE PROPERTY ESTATE OF Khuu, Sa H. This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. FILE NUMBER DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A CDPY OF THE DEED FOR REAl ESTATE VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. Cash Gifts Andrew Khuu, Grandson 6,288.00 O. 3,000.00 3,288.00 Various Dates Between 04/10/2002 - 10/3112002 2. Cash Gifts 520.00 O. 3,000.00 0.00 Andrew Khuu, Grandson 01/0312003 3. Cash Gifts 1,845.00 O. 3,000.00 0.00 NQa Koveleski, ex-wife Various Dates Between 03/20/2002 -10/3112002 4. Cash Gifts 500.00 O. 3,000.00 NQa Koveleski, ex-wife 0.00 01/2412003 TOTAL (Also enter on line 7 Recapitulation) $ 3,28800 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+(12-99)W COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Khuu, Sa H. FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Neill Funeral Home - Total Invoice $2645.00 (Amount paid with remaining estate funds) 723.21 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)IEIN Number of Personal Representative(s) Street Address City ,State Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State .Zip Relationship of Claimant to Decedent 4. Probate Fees 220.12 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 943.33 .' " Law Offices Of CHRISTOPHER S. LUCAS HEALTH LAW AND GOVERNMENT RELATIONS 220 Cumberland Parkway . Suite#4 Mechanicsburg, P A 17055 Christopher S. Lucas AOMmEo Pennsylvania and District of Columbia June L. Cullen AOMmEo Pennsylvania and Georgia facsimile 717.691.3130 telephone 717.691.1203 www.lucasheaIthlaw.com jIcullen@lucashealthlaw.com February 27,2004 f' A Department of Revenue- Bureau of Individual Taxes Inheritance Tax Division Dept. 28060 I Harrisburg, PA 17128-0601 RE: Decedent: Ba H. Khuu SSN: 171-74-8281 Cumberland County Administration No.: 2003-00316 Dear Sir or Madam: Pursuant to 72 P.S. S 9116, we respectfully request an extension to file an Inheritance Tax Return on behalf of the above-referenced resident decedent. It is unlikely that any tax will be due, however, the Administratrix has not filed the Inheritance Tax Return to date due to the uncertainty of a pending medical malpractice/wrongful death action. Should you have any questions, please do not hesitate to contact me. Sincerely, ~~A~ Uune L.~len cc: N ga Koveleski, Administratrix COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND EST A TE TAX OFFICIAL RECEIPT KOVELESKI NGA 35 WEST LAUER LANE CAMP HILL, PA 17011 nn____ fold ESTATE INFORMATION: SSN: 171-74-8281 FILE NUMBER: 2103-0316 DECEDENT NAME: KHUU BA H DA TE OF PAYMENT: 08/25/2005 POSTMARK DATE: 08/24/2005 COUNTY: CUMBERLAND DATE OF DEATH: 02/14/2003 REMARKS: CHECK#1942 SEAL ACN ASSESSMENT CONTROL NUMBER 101 TOTAL AMOUNT PAID: INITIALS: JA RECEIVED BY: REGISTER OF WILLS REV-1162 EX(11-96) NO. CD 005726 AMOUNT $159.68 $159.68 GLENDA FARNER STRASBAUGH REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISInN PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP (06-05) 11-07-2005 KHUU 02-14-2003 21 03-0316 CUMBERLAND 101 APPEAL DATE: 01-06-2006 ( See reverse side under Objections) Amount Remitted I I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 9Y!_~~9~~_!~~~-~~~~------~-__~~!~!~_~9~~~_~9~!!9~_~9~_Y9~~_~~99~~~__~____________________ REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX BA H FILE NO. 21 03-0316 ACN 101 JAMES D PIVONKA 1 COUNTRY CLUB PL EAST CAMP HILL PA 17011 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN BA H ESTATE OF KHUU DATE 11-07-2005 TAX RETURN WAS: (X) ACCEPTED AS FILED 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 Cl) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 943.33 .00 3.288.00 (8) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax 4,231.33 (9) ClO) 943.33 NOTE: .00 (11) Cl2) Cl3) Cl4) 943 33 3,288.00 .00 3,288.00 I~ an assessment was issued previously, lines re~lect ~igures that include the total o~ ~ ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal 16. Amount of Line 14 taxable at 17. Amount of Line 14 at Sibling 18. Amount of Line 14 taxable at 19. Principal Tax Due TAX CREDITS: 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. rate Lineal/Class A rate rate Collateral/Class B rate Cl5) Cl6) Cl7) Cl8) .00 X 00 = 3,288.00 X 045 = .00XI2= .00 X 15 = Cl9)= .00 147.96 .00 .00 147.96 . ~.., KCl.C.L1"I {+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 08-24-2005 '- CD005726 11 .69- 159.68 TOTAL TAX CREDIT 147.99 BALANCE OF TAX DUE .03CR INTEREST AND PEN. .00 TOTAL DUE .03CR · IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. nl' IF TOTAL DUE IS REFLECTED AS A ..CREOIT" (CR), YOU MAY BE OUEI<.I' A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) Cumberland County - Register Of Wills 00e Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 1/04/2006 CULLEN JUNE L ESQUIRE 331 NORTH 17TH STREET CAMP HILL, PA 17011 RE: Estate of KRUU BA H File Number: 2003-00316 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 2/14/2006 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~1~Aji&~ GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Judge Personal Representative(s) ,\Z Law Offices Of CHRISTOPHER S. LUCAS LLC HEALTH CARE LAW AND GOVERNMENT RELATIONS www.lucash.ealthlaw.com ChristopherS. Lucas Admitted in Pennsylvania and the District of Colum Scott A. Lucas of Counsel Admitted in Pennsylvania and New York 220 Cumberland Parkway Suite 4 Mechanicsburg, PA 17055 facsimile 717.691.3130 direct dial 717.691.0203 cs lucas:allucashealthlaw. com January 20,2006 Cumberland County Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Ba H. Khuu File Number: 2003-00316 Dear Sir or Madam: Please find enclosed one original and one copy of a STATUS REPORT UNDER RULE 6.12 for Ba H. Khuu. Please file the original and time-stamp and return the copy in the envelope provided. If you have any questions, please do not hesitate to contact me. Respectfully, C1S:~.~ CSL/lmz Enclosures . ; ~.J Gj r-~-,-) -~ c'.': Register of Wills of Cumberland County r-. ~) STATUS REPORT UNDER RULE 6.12 Name of Decedent: Ba H. Khuu c_,:' Date of Death: 02/14/2003 Admin. No: 2003-00316 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: The sole asset of the estate is a wrongful death claim. Administration will be completed promptly upon claim adiudication. 3. Ifthe answer to No.1 is Yes, 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 representatives account is: N/ A c. Did the personal representative state an account informally to the parties in interest? Yes No X Date: d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and maybe attached t~. ~ I J zo lOb ~ _ _ I J Christopher S. Lucas, Esq. P A I.D. No: 77903 220 Cumberland Parkway, Suite 4 Mechanicsburg, P A 17055 717.691.0203 telephone Capacity: Personal Representative - X Counsel for Personal Representative ~x Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 .--= Date: 1/25/2007 CULLEN JUNE L ESQUIRE 331 NORTH 17TH STREET CAMP HILL, PA 17011 RE: Estate of KHUU BA H File Number: 2003-00316 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: 2/14/2007 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. rl~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court - ...... cc: File Personal Representative(s) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 ......,-:,. '':'::'''~ ...'.. Date: 1/25/2007 KOVELESKI NGA 35 WEST LAUER LANE CAMP HILL, PA 17011 RE: Estate of KHUU BA H File Number: 2003-00316 .- 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: 2/14/2007 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 Pa. O.C. Rule 6.12 STATUS REPORT REGISTER OF WILLS OF rLC~r(Oa,vv:L COUNTY, PENNSYLVANIA Date of Death: PA- o:lllli-\ fL()O~ \4 OA~ G- \< \-\- U U Name of Decedent: File Number: ;((jlJ_oo~\G 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: . . . . . . . . . . . . . . . . . . .. DYes ~No 2. If the answeris No, state when the personal representative reasonably believes that the administration will be complete: A~ ;200<6 3. If the answer to No. 1 is YES, state the following: a. Did the personal representative file a final account with the Court? . . . . . .. DYes DNo b. The separate Orphans' COUli No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? ............................... DYes DNo 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 repOli. Dote o AJ bit 0 1 /~ Capacity: ~ersonal Representative D Counsel q" 'Z" ::~: I Form R W-l 0 rev. 10.13.06 i REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA STATUS REPORT UNDER RULE 6.12 Name of Decedent: Ba H. Khuu Date of Death: 02/14/2003 Will. No: 21-03-0316 File No.: 2003-00316 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: The sole asset of the estate is a wrongful death claim. Administration will be completed promptly upon claim ad1udication. C': C ~ 3. If the answer to No. 1 is Yes, state the following: ~ ~ -) a. Did the personal representative file a final account :with the Court? Yes No X I'.) ) b. The separate Orphans' Court No. (if any) for the person~ representatives account is: N/ A c. Did the personal representative state an account informally to the parties in interest? Yes No X ~~s~p~~~ of receipts, releases, joinders and approvals of ;" \:t9J.mal or informal accounts may be filed wIth the Clerk of the Orphans' Court and may be attached to this report. qj Date: 2-IL~1 01 . ucas Pa I.D. No: 77903 Law Offices of Christopher S. Lucas LLC 220 Cumberland Parkway, Suite 4 Mechanicsburg, P A 17055 Voice: 717.691.0203 Facsimile: 717.691.3130 E-mail: cslucas@lucashealthlaw.com Capacity: _ Personal Representative ~ Counsel for Personal Representative Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 1/15/2008 CAMP HILL, PA 17011 CULLEN JUNE L ESQUIRE 331 NORTH 17TH STREET Q :;.: c.n ~ ..-'; .~ c-' r" RE: Estate of KHUU BA H File Number: 2003-00316 C;"l 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: 2/14/2008 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, &' C" ~ .f' "~.. ,l'J " . .;".. "t% .- j / (,~<~.~1:. 1.1b4!~~.tjk~.t.f~~~vt, Glenda Farner Strasb~ugh Clerk of the Orphans' Court cc: File Personal Representative(s) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (71 7) 240 - 6345 Date: 1/15/2008 KOVELESKI NGA 35 WEST LAUER Lfu~E CAMP HILL, PA 17011 (.n ,-- ...., ::? (,..) .~ eFj RE: Estate of KHUU BA H File Number: 2003-00316 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 lS due by: 2/14/2008 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, ~"4_ ,~u1&~ /1 Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA STATUS REPORT UNDER RULE 6.12 Name of Decedent: Ba H. Khuu Date of Death: 02/14/2003 File No.: 2003-00316 ni i'...~ :. 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 to No.1 is Yes, 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 representatives account is: N/ A c. Did the personal representative state an account informally to the parties in interest? Yes No X 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. A Family Settlement Agreement has been filed with the Clerk of the Orphan's Court in this matter. A COPy of the executed Family Settlement Agreement (without exhibits) is attached to this report. ~ Date: Z } fL.! t> &' I -==.....co~__~ Christopher S. Lucas Pa I.D. No: 77903 Law Offices of Christopher S. Lucas LLC 220 Cumberland Parkway, Suite 4 Mechanicsburg, P A 17055 Voice: 717.691.0203 Facsimile: 717.691.3130 E-mail: cslucas@lucashealthlaw.com Capacity: _ Personal Representative ~ Counsel for Personal Representative IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION IN RE: ESTATE OF BA H. KHUU, No. 2003-00316 FAMILY SETTLEMENT AGREEMENT This Family Settlement Agreement ("Agreement") is made the II day of Rbl\<"lh 2008, by and among Nga Koveleski, as Administratix ofthe Estate of Ba H. uu, and Tam H. Khuu, as beneficiary of the said estate, (referred to as the "Beneficiary") . BACKGROUND 1. Ba H. Khuu, ("Decedent"), died on February 14,2003, a resident of South Middleton Township, Cumberland County, Pennsylvania. 2. Decedent's social security number is 171-74-8281. 3. Decedent died intestate. 4. On April 10, 2003, letters of Administration were granted in the Estate ofBa H. Khuu to Nga Koveleski. 5. Tam H. Khuu is the only child of the Decedent. 1 6. The Beneficiary constitutes all of the surviving heirs, issue, and/or legatees of Decedent. 7. The Administratrix advertised the grant of letters of Administration for the estate. 8. The Administratrix prepared and filed an Inventory for the estate. 9. The Administratrix prepared and filed Pennsylvania Inheritance Tax Returns and federal and state income tax returns, and paid the appropriate taxes thereon. 10. The Administratrix has paid all the general legatees and all the taxes, debts and expenses of the estates known to her, and she has no knowledge of any unpaid claims, absolute or contingent, which may be asserted against the estates, nor does she have any reason to believe there are any such claims. 11. The Pennsylvania Inheritance Tax Return for Decedent, reflecting all estate receipts, disbursements and distributions is annexed hereto as Exhibit "A." 12. The Beneficiary acknowledges that he has been furnished with a complete copy of the Pennsylvania Inheritance Tax Returns, which show all transfers and distributions from the estate. 13. The Beneficiary acknowledges and agrees that this accounting is satisfactory and proper and he accepts distribution in accordance with its provisions. 2 14. The Beneficiary acknowledges receipt from the Administratrix of the property allocated to him on Exhibit "A" in full and complete satisfaction of his rights under the Probate, Estates and Fiduciaries Code of Pennsylvania. 15. The Beneficiary acknowledges receipt of the letter from the Estate's attorney, dated February 5, 2008, advising the Beneficiary to review this Family Settlement Agreement with an attorney of his choice. (See attached 2/5/2008 letter to Beneficiary, Exhibit "B. ") 16. The Administratrix paid funeral and interment expenses. 1 7. The Administratrix paid Grant of Letters and Short Certificate expenses. 18. The Administratrix paid advertisement expenses. 19. The Administratrix paid the Decendent's 2002 income tax to the Internal Revenue Service. 20.The Administratrix paid Highmark, Inc. for Decedent. 21. The Administratrix was reimbursed with the funds in the Estate Checking Account held at Commerce Bank. 22. The Administratrix has completed the administration of the estate. 3 PLAN OF DISTRIBUTION 1. The net of Decedent's estate equals <$4,462.01>. (See Estate Summary of Ba H. Khuu, attached as Exhibit "C. ") 2. The Beneficiary desires that this Family Settlement Agreement make unnecessary the filing of an accounting in the Orphans' Court Division of the Court of Common Pleas of Cumberland County in order to avoid the delay, expense and publicity of a formal court accounting. 3. The Beneficiary has been given the opportunity to review the books and records of the Administratrix, and based upon such opportunity or examination, he has determined that he has sufficient information to make an informed decision to waive his right to an accounting. AGREEMENT In consideration of the willingness of the Administratrix to distribute and terminate the estate in accordance with the terms of this Agreement, without the protection afforded him by a formal adjudication of an Administratrix's account, Tam H. Khuu, the undersigned beneficiary, individually and with respect to his heirs, personal representatives, successors and assigns, do hereby: 1. Acknowledge that I have read this Agreement and represent that the facts set forth above are true and correct to the best of my knowledge, information and belief. 4 2. Waive the filing of formal accounts of the administration of the estate, with respect to the income and principal thereof, in any court which has jurisdiction, in particular, the Orphans' Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania; 3. Declare that I have examined the accounts and statements, which are attached hereto and incorporated herein, and find them to be true and correct in all particulars; understand that the distribution is still subject to the payment of certain administration expenses; accept and approve it with the same force and effect as if it had been prepared and duly filed with, audited, adjudicated and confirmed absolutely by such court which has jurisdiction over this estate, and, as if the balance of principal and income had been awarded by said court in accordance with this Agreement and the account and statement; 4. Warrant that I know of no outstanding and unsatisfied claims against the estate and approve the distribution of the balance of principal and income shown on the attached account and statement as set forth above; 5. Absolutely and irrevocably release and discharge the Administratrix, her attorneys, her personal representatives, heirs, successors and assigns from any and all actions, liabilities, claims and demands, including specifically but not limited to liability arising in connection with any mistake of fact or law or negligent or careless act or omission by the Administratrix, in connection with the administration and distribution of assets shown in the statement, without a formal court accounting and adjudication; 5 6. Agree to refund to the Administratrix such part or all of the distributive share which has been distributed to me which may at any time be determined to have been an erroneous distribution to me regardless of the cause of such error, even if attributable to negligence; 7. Agree that any period of limitation of actions for the collection for any erroneous distribution to any of us shall commence only at such time as the Administratrix obtained actual knowledge of such erroneous distribution and that in no event shall the obligation to collect any erroneous distribution start earlier than the actual discovery thereof by the Administratrix; 8. With respect to any distributions of income or principal, which I have received, or will receive upon execution of this Agreement, agree to indemnify and hold harmless the Administratrix, her attorneys, her personal representatives, heirs, successors and assigns, from any liability, loss or expense (including but not limited to costs and counsel fees), arising from any cause whatsoever, which may be incurred by the Administratrix as a result of the administration of this estate or distribution in accordance with this Agreement including, but not limited to, any liability for any federal and state income taxes, together with any interest and costs incidental thereto, relating in any way to the estates and also including, but not limited to, any assets received or payments or distributions made by reason of any negligence or mistake of fact or law; 9. Understand that this Agreement may be signed in counterpart originals, all of which together shall be deemed to constitute one original, 6 FEB-06-2008 08:52 P.08/14 10. Acknowledge that this Agreement shall be indexed and recorded in the estate proceedings and that the terms hereof shall be binding upon their respective heirs, successors, administrators and assigns, and; II. Agree that this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, we agree to be bound hereby and have signed this Agreement this R+tL-. day of r-e1:Ylu.C~J6' , 2008. Witness: Tam H. Khuu, Beneficiary Witness: ._, ~7 -?' ,< )Jt~.~~~<j y,... '-r/i-x.-/ ! " ~ (1JJ'0-{J!9" rc( Nga oveleski, Adminstratrix 7 10. Acknowledge that this Agreement shall be indexed and recorded in the estate proceedings and that the terms hereof shall be binding upon their respective heirs, successors, administrators and assigns, and; 11. Agree that this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, we agree to be bound hereby and have signed this Agreement this II /it day of februtt(rl , 2008. I - .~ , Beneficiary Witness: N ga Koveleski, Adminstratrix 7 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: ESTATE OF BA H. KHUU, No. 2003-00316 FAMILY SETTLEMENT AGREEMENT This Family Settlement Agreement ("Agreement") is made the II day of ~ 2008, by and among Nga Koveleski, as Administratix of the Estate of Ba H. buu, and Tam H. Khuu, as beneficiary of the said estate, (referred to as the "Beneficiary"). BACKGROUND 1. Ba H. Khuu, ("Decedent"), died on February 14,2003" a resident of South Middleton Township, Cumberland County, Pennsylvania. 2. Decedent's social security number is 171-74-8281. 3. Decedent died intestate. Q r''''",) c,~;-' i..::..;.) = -0 3: - _U --1 w (.n Ul :- I I 5. Tam H. Khuu is the only child of the Decedent. 1 v' 6. The Beneficiary constitutes all of the surviving heirs, issue, and/or legatees of Decedent. 7. The Administratrix advertised the grant of letters of Administration for the estate. 8. The Administratrix prepared and filed an Inventory for the estate. 9. The Administratrix prepared and filed Pennsylvania Inheritance Tax Returns and federal and state income tax returns, and paid the appropriate taxes thereon. 10. The Administratrix has paid all the general legatees and all the taxes, debts and expenses of the estates known to her, and she has no knowledge of any unpaid claims, absolute or contingent, which may be asserted against the estates, nor does she have any reason to believe there are any such claims. 11. The Pennsylvania Inheritance Tax Return for Decedent, reflecting all estate receipts, disbursements and distributions is annexed hereto as Exhibit "A." 12.The Beneficiary acknowledges that he has been furnished with a complete copy of the Pennsylvania Inheritance Tax Returns, which show all transfers and distributions from the estate. 13.The Beneficiary acknowledges and agrees that this accounting is satisfactory and proper and he accepts distribution in accordance with its provisions. 2 14. The Beneficiary acknowledges receipt from the Administratrix of the property allocated to him on Exhibit "A" in full and complete satisfaction of his rights under the Probate, Estates and Fiduciaries Code of Pennsylvania. 15. The Beneficiary acknowledges receipt of the letter from the Estate's attorney, dated February 5,2008, advising the Beneficiary to review this Family Settlement Agreement with an attorney of his choice. (See attached 2/5/2008 letter to Beneficiary, Exhibit liB. ") 16. The Administratrix paid funeral and interment expenses. 17. The Administratrix paid Grant of Letters and Short Certificate expenses. 18. The Administratrix paid advertisement expenses. 19.The Administratrix paid the Decendent's 2002 income tax to the Internal Revenue Service. 20.The Administratrix paid Highmark, Inc. for Decedent. 21. The Administratrix was reimbursed with the funds in the Estate Checking Account held at Commerce Bank. 22. The Administratrix has completed the administration of the estate. 3 PLAN OF DISTRIBUTION I. The net of Decedent's estate equals <$4,462.01>. (See Estate Summary of Ba H. Khuu, attached as Exhibit "C. ") 2. The Beneficiary desires that this Family Settlement Agreement make unnecessary the filing of an accounting in the Orphans' Court Division of the Court of Common Pleas of Cumberland County in order to avoid the delay, expense and publicity of a formal court accounting. 3. The Beneficiary has been given the opportunity to review the books and records of the Administratrix, and based upon such opportunity or examination, he has determined that he has sufficient information to make an informed decision to waive his right to an accounting. AGREEMENT In consideration of the willingness of the Administratrix to distribute and terminate the estate in accordance with the terms of this Agreement, without the protection afforded him by a formal adjudication of an Administratrix's account, Tam H. Khuu, the undersigned beneficiary, individually and with respect to his heirs, personal representatives, successors and assigns, do hereby: I. Acknowledge that I have read this Agreement and represent that the facts set forth above are true and correct to the best of my knowledge, information and belief. 4 2. Waive the filing of formal accounts of the administration of the estate, with respect to the income and principal thereof, in any court which has jurisdiction, in particular, the Orphans' Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania; 3. Declare that I have examined the accounts and statements, which are attached hereto and incorporated herein, and find them to be true and correct in all particulars; understand that the distribution is still subject to the payment of certain administration expenses; accept and approve it with the same force and effect as if it had been prepared and duly filed with, audited, adjudicated and confirmed absolutely by such court which has jurisdiction over this estate, and, as if the balance of principal and income had been awarded by said court in accordance with this Agreement and the account and statement; 4. Warrant that I know of no outstanding and unsatisfied claims against the estate and approve the distribution of the balance of principal and income shown on the attached account and statement as set forth above; 5. Absolutely and irrevocably release and discharge the Administratrix, her attorneys, her personal representatives, heirs, successors and assigns from any and all actions, liabilities, claims and demands, including specifically but not limited to liability arising in connection with any mistake of fact or law or negligent or careless act or omission by the Administratrix, in connection with the administration and distribution of assets shown in the statement, without a formal court accounting and adjudication; 5 6. Agree to refund to the Administratrix such part or all of the distributive share which has been distributed to me which may at any time be determined to have been an erroneous distribution to me regardless of the cause of such error, even if attributable to negligence; 7. Agree that any period of limitation of actions for the collection for any erroneous distribution to any of us shall commence only at such time as the Administratrix obtained actual knowledge of such erroneous distribution and that in no event shall the obligation to collect any erroneous distribution start earlier than the actual discovery thereof by the Administratrix; 8. With respect to any distributions of income or principal, which I have received, or will receive upon execution of this Agreement, agree to indemnify and hold harmless the Administratrix, her attorneys, her personal representatives, heirs, successors and assigns, from any liability, loss or expense (including but not limited to costs and counsel fees), arising from any cause whatsoever, which may be incurred by the Administratrix as a result of the administration of this estate or distribution in accordance with this Agreement including, but not limited to, any liability for any federal and state income taxes, together with any interest and costs incidental thereto, relating in any way to the estates and also including, but not limited to, any assets received or payments or distributions made by reason of any negligence or mistake of fact or law; 9. Understand that this Agreement may be signed in counterpart originals, all of which together shall be deemed to constitute one original, 6 FEB-06-2008 08:52 P.08/14 10. Acknowledge that this Agreement shall be indexed and recorded in the estate proceedings and that the terms hereof shall be binding upon their respective . . heirs, successors, administrators and assigns, and; 11. Agree that this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, we agree to be bound hereby and have signed this Agreement this x-+L. daYOCf~ ,2008. Witness: Tam H. Khuu, Beneficiary Witness: ~ CZ--f~ I . ~1l( ~eleski. Adminstratrix 7 10. Acknowledge that this Agreement shall be indexed and recorded in the estate proceedings and that the terms hereof shall be binding upon their respective heirs, successors, administrators and assigns, and; 11. Agree that this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, we agree to be bound hereby and have signed this Agreement this II /It day of februfi'l ' 2008. Witness: Witness: N ga Koveleski, Adminstratrix 7 RI:;V,,)~:;l ;5"1)1 C e :. (, 2COS 8:45AV! PUC ADMIN SVCS COMMONWEAlTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128.0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENrs NAME (LAST, FIRST. AND MIDDLE INITIAL) ~ Khuu, Sa, H. ~ DATE OF DEATH (MM.DD.YEAR) DATE OF BIRTH (MM.DD.YEAR) W 02/14/2003 07/02/1940 U W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (\.AST, FIRST, AND MIDDLE INITIAL) C ~ :.:~~ tlG.u ::z::~o ull.al ~ [i] t Origl~al Re~urn o 4. Limited Estate o S. Decedent Diad Testa!e (AnaUlCllPl<IWIn) o 9. Litigation Proceeds Received o 2. Supplemental Return o 41. Future Int8rest CompromISe (~DIC o'dcalh l~crl2-l2-llZl o 7. Decedent Maintained a L:vlng Trust (Al1~cn COll'/ onrv>!) o 10. SpouSal Poverty Credit (IlalO oIcIll"'" bClWe<:n lZ41,t1"and ,.,.oS! iT.. 11~. " COMPLETE MAILING ADDRESS ,~o. 0068 P. ~ ..[Q,.COPV ............'~ ..--..... .._.....,..."',~~~_., ,.'...~.. '...'-""~ .....-."......-...,. FILE NUMBI!R 21 03 00316 COUNTVCooe YCAR - NUMeeR - - SOCIAL SECURITY NUMBER 171~74-8281 THIS ReTURN MUST BE FILED IN DUPLICATE WITH THE; REGISTER OF WIl.LS SOCIAL SECURITY NUMBER o 3. Remainder Retum (d... .rdesl, oriorlO 1..13..12) o 5. Federal EstlIte ~ Return Required 8. Total Number of Safe Dapo$it Boxes o 11. ElecUor, to tax under Sec. 9113(A) lJ.mh Sell O} t- Z LlI Q ;It o ~ ~ It 8 CPA CPA 1 Country Club Place East Camp HilI, PA 17011 (1) (~ (3) (4) (5) z o ~ ...I ::J .... ii: < u w 0:: I. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3 Closely Held Corporation. Partnership or SOle.Proprietorship 4 Mortgages & Notes Receivable (Schedule D) S. C1l3h. Benk D$poslls & Misoellaneous F'Gfsonal Property (Schedule E) 6. Joi~tly Owned Property (Schedule F) o Separate BIlling Requested 7. inter-Vivos Transfel'$ & Mlseallaneous No~.Probate Properly (Schedule G or ~) S, Total Gross Asse1s (Iotal Lines 1.7) 9. Fursrel ElIpenses & Administrative Cosli (Schedule H) 10. Oebts of Decedent. Mortgage LlablUlIes. & Liens (Schedule I) 11, Tolel Deduc1ions (tolal Lines 9 & 10) 12. Net Value of Estate (~ine a minus ~ine 11) 13, Charitable and Govemmental BequeslS!Sec 9113 Trusts for which an election to tax hes not been made (Schedule J) 14 N8\ Value Subject to Tax (Line 12 minus Line 13) (6) (7) (9) (10) z o ~ ~ ;:) a. :iE o U g SEE INSTRUCTIONS ON REVeRSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14laxable at Ill. spousal lax rate, or transfers under Sec. 9116 (a)(1.2) ;(.0_ (15) ~6. Amount of Line 14 taxable at lineal rate 3,288.00 x.o~. (16) 17 Amoun! of Line 14 taxable at Sibling rate _'._.._.._.._.....___.~........___..__.. x .12 18. Amount of Line 14 taxable at collateral r1le _........._._......._.__..____._..........,____.. x .15 19. Tax Cue 20.0 CHECK HERE IF YOU Ar~E REOUESTlNG A REfUND OF AN OVt:f~F'AYMENT I!.. '"'~I"'V.(yr'(~.; ~~l:':'/,j' -. ':~:.:~: y:...,.{)'t:'i l~~~"'. .... "-.; 943.33 i 3,288.00 (6) 943,33 4,231.33 (11) (12) (13) 943.33 . 3.288.00 .--... (14) 3,288.00 147.96 (17) (18) _.._ (19) 147.96 : ':'f:~~;t:;:/-~7.~'-":.;1~-.j:~~-':.~}~~;;~:r\iifr~-~,~5j"*~:,~:~~~. .:.,'..... ..,. ~eo, 6, 2C08 8:46AV! PUC ADMIN SVCS - No, 0068 Decedent's Complete Address: STREET ADDRESS CINe I' I ar IS e STATEpA Tax Payments and Credits: 1 Tax Due (Page 1 Line 19) 2 Credits/Payments A Spousal Poverty Credit B, Prior Payments C, Discount (1) 147,96 Totai Credits ( A + B + C) (2) 0,00 3, InteresVPenally if applicab[e D, Interest E, Penalty Total Interest/Penalty ( 0 t E ) (3) 4, [f Line 2 is greeter than Line 1 -+ Line 3, enter the difference. ThiS is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) P. 4 ZIP 17030 5. If Line 1 t Line 3 IS greater than Line 2, enter the difference. This IS the TAX DUE, A. Enter the interest on the tax due. (5) (5A) B. Enter the lotal of Line 5 + SA, This is lhe BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 147.96 11.72 159.68 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "XlIIN THE APPROPRIATE BLOCKS ,. Did decedent make a transfer and; Yes a. re~in the use or income of the property transferred;.""""'".""."."".""."""""...."".""""".""""".",,.""."";.,, 0 b. relain the right to designate who shall use the property transferred or ita Incomej """"".""."".."."",,.....,,"'... 0 C. retain a reversionary interest; 01"""."."."..."""....".."..""".."..".""."...""."""".".......""""""""""'''''''''''''''''' 0 d. receive the promise lor life of either payments, beoeilts or care? ""..".....""""""........""""""""".""".""."". 0 2., If death occurred after December 12, 1982, did deeedentlransfer property within one year of death without receiving adequate consideration? "".""""""".""".,...""..."..;.""""........"""..."..."".".",,,...,,.......".."'.". [!l 3. Did decedent own an "In trust for" or payable upon death bank account or seCUrtty at his or her death? ....""".". 0 4. Did deoedent own an [ndividual Rebre-mentAcoount, annuity, or other non-probate properly which contains a beneficiary designation? .".".."."...""."....".""."...."""".".".""."".""""."......".."","'''''''''...""...""... 0 No [iJ [iJ [iJ lil D ~ ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Uncler pe~alties of p9rjVry, I declal'9 that I have eXllllined this relllm, inc:lud'ng ea:o/l1PWlying achedllies and stalements. and to tile best of my knD\\ledge and beiisf, it ie rue. ;orreC1 end IXlmplelD, Declaration of prapS1$r other than the pel1on,1 reprBlsnlativs ie bawd on all infomatan ~f whi~ prvflarer has any knllWledge SIG.I,JATURE OF PERSON RESPON LE OR FILING RETURN DATE A~ . -------.-----..---.-..-...-.--.-.-----------.--.----.---"_.__..~~!~~05 . ~~~~~~~-\;%~ec~~m~ ~.i!h..1IQ:k-~ ---------------DATE 08/23/05 -- ~D~~:;::!~:~:II 17011 - ---------.--- _.._._.[Y_,._......._...__,..._,......._".~_....,..,_..,e..._.,~......_.____..___.......___.._...__.._......._._.__.._.__..__,.__..... ....-_..._-..._...__......._"...............~. .",,"......,,-... .-........ ...... ..-......_....,......,..._._.. For dales of death on or after July 1, 1994 and before January " 1995, the tax rale imposed on the net value of lransfers 10 or for Ihe use of the surviVing spouse is 3% [72 I:>.S. 99116 (a) (1.1) (i)l, . For dales of death on or after January 1, 1995, the tax rate imposed on lhe net value of transfers to or for the use of the surViving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)). The statute does nol ex~mole transfer to 8 sUlviving spouse from tax, and the slatutory requlrem~nt9 for disclosure of assets and fifing a tax relum are still applicable even if the sUNlvlng spouse is the only beneficiary. For dates of death on or ilfter July 1, 2000; The tex rate imposed on the net value of transiers from a deceased child twenly.one years of age or younger at dealh to or for the use of a natural parent, an adoptive parent, or a stepparent of Ihe child:s 0% [72 P,S. ~91'6(a}(1.2)1. The tax rate imposed on the net value oftransfers to or for the use of Ihe dECedent's lineal beneficiaries is 4.5%, excepl as noted in 72 P.S, ~9'16(1.2) [72 P,S, ~9"6(a)(')]. The lax rate Imposed on [he nel value of transfers to or for the use of Ihe decedent's siblings is 12% [72 P,S, 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an Individual who has at ieast one parent In common with the decedent, whether by blood or adoption, Fec, 6, 2COS 8:46AVi PUC ADM!N SVCS No, 0068 P. 5 REV.1S0a EX. (6-S6) . COMMONWEAI.TH OF ?ENNSYI.VANIA INHERITANCE TAX RETURN RESloeNT OECEOENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Khuu, Sa H, FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by tile estate. All property Jolntly.owned with right of survivorship must be di&closR on Schedule F, ITEM NUMBER 1. Commerce Bank Checking Account oeSCRIPTION VAI.UE AT OATE OF DEATH 943.33 2. Pending medical malpractcelwrongful death action (remains pending as of 08123/05) 0.00 TOTAL (Also enter on line S, Recapitulation) $ (If more spaoe Is noeded, inser1 additional sheets of the same Size) 943.33 ; eD, 0, 2 CO 8 8 : 46 AM pue ADMIN SVCS No.0068 P. E REV.1510 EX" (6'$e. CCMMONWEALTI-l OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Khuu, Sa H This schedule must be completed and filed il the answer to any of quesbons 1 through 4 on the ,reverse side ollhe REV.1500 COVER SHEET is yes. SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY DESCRIPTION OF PROPERTY OATE OF OEATH ITEM INCLUDE ~e NAME O~ 'lI'E TIl/INSFEREE. 'lllelll RSlATlONSKIP TO DiCEOENT .l."lO % OF OECO'S EXOLUSION TAXABLE NUMBER ~E DATi Of TIWISFEP. ATTAOK o\COPY OF '!loll: OEeo.eoR MiAl. EST""; VALUe OF ASSET INTEREST II~ APPLICAIILEI VALUE 1. Cash Gifts 6,288.00 O. 3,000 DO Andrew Khuu, Grandson 3,288.00 Various Dates Between 04/10/2002 . 10/31 f2002 2. Cash Gifts 520.00 O. 3,000.00 0.00 Andrew Khuu, Grandson 01/0312003 3. Cash Gifts 1,845.00 O. 3,000.00 0,00 N~a Koveleski. ex-wile Various Dates Between 03120/2002 -10/31f2002 4. Cash Gifts 500.00 O. 3,000.00 0.00 N~a Koveleski, ex.wife ' . 01/2412003 I , , .. , TOTA\. (AlSO enter on line 7 Recapitulation) $ 3,288,00 (If more space is needed, Inserl additional sheets of the same size) reb. 6. 2COS 8:47A~ PUC ADM1N SVCS N~. 0068 p RE\!.1S1' EX+(12-99lW COMMONWEALTH OF !lENNSYLVANIA INHERITANCE TAX FlETUFlN RESIDENT DECEDENT SCHEDULE ,N .FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Khuu, Sa H, FILE NUMBER . Deb" 01 decedenl mU1l1 bo roport.d on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Neill Funeral Home. Total Invoice $2645.00 (Amount paid with remaining estate funds) 723.21 B. ADMINISTRATIVE COSTS: 1. Plmnal Ropresentatlve's Commissions Name 01 Personal RepresentatlVe(s) Social Security Number(sllEIN Number 01 Personal Representative(s) street Address City Year(s) Commission !laid: . Slate Zip 2. Attorney Fees 3. Family El(emptlon: (11 decedanfs address Is no! the same as cla/manl's, attach explena.tion) Claimant Strea! Address City Role!ionship 01 Claimant fo Decedent State .Zip 4. Probete Fees 220.12 5. Aooountant's Feas 6. Tax Return Prsparer's Fees 7. TOTAL (Aleo enler on line 9, Recapitulation) $ (If more space Is nteded, ins!!n additional sheels ot the same size) 943.33 No. 0068 P. 8 PUC ADMIN SVCS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, A~LOMANCE OR DISALLOWANCE DF DEDUCTIONS AND ASSESSMENT OF TAX '~e6. 6. 2COS 8:47AYi BUREAU OF INDIVIDUAL TAKES INHERITANCE TAX DI~ISIDN PO lOl( 2&0601 ~AR~ISBURG PA 17128-0601 REU-lS47 EX AfP CO&-DS) DATE 11-07-2005 ESTATE OF KHUU BA H DATE OF DEATH 02-14-2003 FXLE NUMBER 21 03-0316 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 01-06-2006 ( S., NlVlrse sitl~ under Ohjections) AmOunt Remitted I I MAKE CHECK PAYA'~E AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS 4-- REv:is4;-ix-AFP-coi:053-NDTicE.op-iNHERiTANci-TAx-APPRAisEMENT;-ALLOWANCi-OR-----.--------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTArE OF KHUU JlA H FILE NO. 21 03-0316 ACN 10] DATE 11-07-2005 JAMES D PIVONKA 1 COUNTRY CLUB PL EAST CAMP HILL PA 17011 APPROVED DEDUCTIONS AND EXEMPTIONS: 943.33 9. Funeral Expansas/AdR. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .00 11. Total Deductions (11) 943.33 12, Net Value of Tax Return 112) 3,288.00 13. Charitab1e/;overn..ntal Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 lff. Het Value of Esiate Subjeot to TaK (Iii) 3,288 . 00 NOTE: If an assessment. was issued preViDuslY, lines 14, lS and,or 16, 17, 18 and 19 will re~lect figures that include the total Df !bh returns assessed to date. ASSESSMENT OF TAX; 15. Amount of Line 14 at Spousal rete (1S) 16. A~ount of ~ine 14 taxable at Lineal/Class A rate (16) 17. Amount of LinG 1ft at Sibling rate (17) 18. Amount of ~!n. lff taxable at Collateral/Class B rate (1&> 19. Prinojpal Tax Due TS: TAX RETURN WAS: (X) ACCEPTED AS filLED R'SERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON; ORIGINAL RETURN 1. Real Est.t. (Schedule A) 2. Stocks and Bonds (Schedule B) 3. CloselY Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) s. Cash/lank Deposits/Misc. Per$on.l Property (Sehedule E) 6. Jointly Dwned Property (Schedule F) 7. Transfers (Schedule 0) 8. Totel Assab INTEREST/PEN PAID (a) 1.69- DATE 08-Z4-Z0D5 NU"BER CD0057Z6 .- -....... ( ) CHANGED (1) (2) (5) (ft) (5) 11'0) (7) .00 .QJl ,DO .00 943.33 .00 3121iS8.00 (I) NOlEl To insure proper ~redlt to your account1 submit the upper portio 01 this form with your iax paynBnt. 4.231.33 .00 X 3, 288 . 00 X .00 X .00 X 00 = 045 = 12 = 15 = (19)= .00 147.96 .00 .00 147.96 A"DUNT PAID 59. 8 TOTAL TAX CREDn BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 147.99 .03CR .00 .03CR ftlle ~~ I~e~ ~YAU~'. un P~VM~NT IS REQUIRED. Christopher S. Lucas Admitted in Pennsylvania and the District of Colum Law Offices Of CHRISTOPHER S. LUCAS LLC HEALTH CARE LAw AND GoVERNMENT RELATIONS www.lucashilalthlaw.com 220 Cumberland Parkway Suite 4 Mechanicsburg, PA 17055 Scott A. Lucas of Counsel Admitted in Pennsylvania and New York facsimile 717.691.3130 direct dial 717.691.0203 cs lucas@lucashealthfaw.com February 5, 2008 VIA FEDERAL EXPRESS 858248168441 Tam H. Khuu 7774 Greene Farm Drive Ypsilanti, MI 48197 Re: Estate of Ba H. Khuu Dear Tam: I wish to close the estate of Ba H. Khuu by filing a Family Settlement Agreement (Agreement). I have enclosed two copies of the Agreement for your reVIew. Upon your review, please sign one copy and return it in the enclosed Federal Express envelope by Friday, February 8, 2008. The second copy is for your file. I will forward a complete and fully executed Agreement to you for your file. If you have any questions, please contact me as soon as possible at 717.691.0203. Thank you. Estate of Ba H. Khuu 2008.02.05. Ltr. Tam H. Khuu Page 2 Respectfully, C~ Christopher S. Lucas CSL/cak Enclosures Estate Summary of Ba H. Khuu Claims: 1. Pa. Dept. of Public Welfare 2. Hal S. Fineburg, MD (nursing facility care) 3. Carlisle Regional Medical Center 4. Cumberland-Goodwill Fire Rescue 5. Highmark, Inc. for Decedent Administrative Expenses: 1. Funeral and interment related expenses 2. Grant of letters, short certificates 3. Advertisements 4. IRS 2002 income tax for Decedent Total Claims and Expenses: Assets: Commerce Bank Account Net Estate: $361.85 $130.00 $56.80 $357.00 $350.13 $3,745.00 $39.00 $181.12 $265.00 $5,485.90 $1,023.89 <$4,462.01>