The URL can be used to link to this page

Home My WebLink About03-0468 PETITION FOR GRANT OF LETTERS OF ADMiNISTRATiON also known as ~/4~5To ,1;)~f,. ,5'C~.-f-ff To: /~_u f~6~'--$~7 Register of Wills for the Deceased. County of (-~n,-~m~'__n~,/r~ in the Social Security No. ~' ~ ~ ~ Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appll ~_ ~ for letters of administration (d.b.n.; pendente lite; durante absentia; durante minorilate) on the estate of the above decedent. Decendent was domiciled at death in ~ ~~ ~ COunty, Pennsylvania, with h,~ lastfamilyorprincipalresiden~eat ~j~ R~u~l~ ~D .~~. (list sireet, number and municipality) Decendent, then / ~ years of age, died ~ ~ 19~, at Oe~**Zy ~T ~/ ~'/~/~ ~_ ~ ' Decendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property $ ~; ODO · ~ (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: Petitioner . after a proper search ha ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: ~]~ame _ Relationship Residence THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. ~£ -. _ / .~. ~ .A(/_,~x~ ) OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND 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 belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this 6th day of JUNE 2o0.~ ~x ~/~ - No. &l-03- q ff Estate of C~R ~ g':VO P~v'R~' ~ '~i ~ v ~:~ ~:. ~ ~C ~&~'0~i~ ge. c~;~rDeceased · :~: ',: ':.'.~BURGESS GRANT OF LETTERS OF ADMINISTRATION AND NOW JIINF q: ?OO."A 1~ , in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that KFRMTT flFNF BIIR0, F~ A/I<?A I<_ 0~FNF BIIRGF~S AND VIVIAN S ABURGESS is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to KFRMTT GFNF RIIRGF~S A/K/A K. GFNF RIIRGFSS AND V~VIAN S BURGESS in the estate of CHRISTOPHER!:!-~ BURGESS A.K.A. CHRISTOPHER SCOTT BURGESS ~,~Register of Wills (~ 0 ~ FEES Letters of Administration ..... $ _~.,%./90 Short Certificates( ) .......... $~_EX)__ ATXORNE¥ (Sup. Ct. I.D. No.) Renunciation ................ $-- ~J0.d~ $ lO. O(-~ ADDRESS TOTAL ~ $_.,_~_~O Filed ~1>. z .GJ 7.0..~. ........... A.D. 19_ ~ PHONE WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES BUREAU FOR PUBLIC HEALTH - VITAL REGISTRATION PHYSICIANS / MEDICAL EXAMINER'S CERTIFICATE OF DEATH ROOM 165, 350 CAPITOL STREET. CHARLESTON. WV 25301 TYPE/~tNT STATE FILE NUMSER Christopher Scott Burgess 4SOC~LSECUn'TYNUMeE" I~E'La""~'~ J I J X ~May 24'2003~ 467 - 65 -0783 ~ ] 9 ~,~ u~n, ~ ~ u.~., DAY e %~T~, ~.)~,.T. ~, ~ B,.Th~C~ C~.~C"~ '~ ~ '~ .... Dec. I0~I983 orpis Cristi, TX I~ CITY~ T~' OR L~AT~ OF OEATH I~ COUNTY O~ ~ATH ~ ~T~ ~TUS-~rr~. [~ S~ ~ I ~2a ~CE~NT'S USUAL ~U~n~ ~2b KIND OF BUSINESS/INDUSTRY Single None Material Handler ~,: ," ....... Warehousing ~ I PA Cumberland Mechanicsburg 414 Resovoir Rd. ~ ~ ~ ~es I 17055 I ~'~' ~ I .- ._ IE'"~"'~";~%~'~: ~ ) Igi~tl~l~i . ' J 18 MOTHER'S NAME (F,Gt. M~dle Ma~n S~) ' ~ Kermit Gene Bur~e~ ~4]4 Resovoir Rd, , Mechanicsburg, PA 17055 ~.al ~ Cremal~n ~ ~al ,r~ Slate I ~ J ,,m,u,.m,,, ~.,~Zo.~~:;'[,c~.~{,..~pl[vet Cemetery I Moorefield, West Virginia 217 Winchester Ave ~oorefield I ~alh ~ TO~ ~ ~~e o~ I d I I ~ztlk~ll]l ~mll ~n~anlc~rl~sc~tri~ti~lo~ath~t~tm~tl~int~tN~in~rlI J2~ ~S AN AUTOPSY J2Sb ~RE AUTOPSY FINDINGS Form VS-002 (Rev. 6/92) STATE COPY I hereby certify that the above is a true photographic copy of a record filed with the Vital Registration Office, Bureau for Public Health, Charleston, West Virginia. Witness my hand and seal this thirtieth day of May, 2003. Gary~~ First North American National Bank ~' c5 9960 Mayland Drive ---' !- Richmond, VA 23233 ~:: ~_~ CLAIM FORM FOR COMPANY OR ORGANIZATION STATE OF OHIO COUNTY OF CUMBERLAND CASE NO. 21-03-468 The undersigned, First North American National Bank, herein referred to as a claimant, herewith presents and filed their claim against the Estate of deceased Chris Burgess on account of the following described indebtedness owing by said Estate of Claimant, via: Credit Card #: 4104137501427618 Balance: $900.46 Before me, the undersigned authority in and for said County in said State, personally appeared Stephanie Spencer, who being first duly sworn, says that she is The Recovery Supervisor of First North American National Bank, the claimant, and that she has full complete knowledge of the correctness of the above claim against the estate of Chris Burgess, deceased, and the amount claimed is justly due(or to become due ), and after allowing all proper credits. '-'gnat/are for Authori~e~dr Person~el-~or Claimant Subscribe and sworn to before me this I~, day o1~~ Notary P~-b lic My Commission Expiros 4/30/05 FIRST NORTH AMERICAN NATIONAL BANK~ Recovery Department P.O. Box 42395 Richmond, VA 23242 .rul.., 15, 2003 Ge::e Burgess -- 1,- Reservoir Road Mechanicsburg, PA 17055-6146 [{e: Estate of Chris Burgess ~Xccount Number: 4104137501427618 Cas,~: 21-03-468 Dez~r Mr. Burgess: iinciosed you will find a copy of the claim filed for the above referenced estate. The ~Mginal claim was mailed to Cumberland County Probate Court. If you have any q ae:~tions reg_arding this matter, please do not hesitate to contact me. :; int ~rely, ~ · yn: cia Green iCpecmlty Legal Department , S0OI 677-4339 Ext. 8132 · ~88~ 357-9196 (FAX) · CITY PL ' US VISA CREDIT CARD APPLICATION ,,~u~t !Tit[,,P, lus ",'ISA cre. dit card account with Fir~Ba~ ~ ~ (NB,~ ) 225 Chasuun Meadows Court, Kennesaw GA 30 44 the "Bank" ;**i.'.::i::;i:i:.~i~5i ~i.:.::s. ll apphcant fmamed ma a I forase arateac ' . ( .The ..... ::"-:::::::::-'::::::::::::::::::::: ~_ . ., : Y. PP Y p . count. Aftercred~ta royal __ ' ..................... account, each applicant may oe m[om mr amounts extenoed under the plan to any jtohi~t Store: 3720 Amount of Purchase: $ appiicant. Account # Date: 05/05/03 Saved App#: 000BURGES9 Last Name First Name Initial I Suffix Date of Birth GESS CHRIS Apt.g: City State }IR ROAD PA 7055 ~0-83 I0 1 Mos 0783 years at current) Al: City EDGE LANE MECHANICSBURG PA 17055 [ Employer's Name [ Job Title 2000 i R~red ~ GOVERNMENT I S~['-Employed [Work Phone[ PACKER Mos you) BOBBY I Relative's Phone VISA· Checkim Savin~s Last Name First Name Initial ISuffix iDate of Birth Ap~ City State I Employer's Name i Job Title : i Social Security~ P~rsonal Monthly Salary I Relationship to Applicant CREDIT CARD AGREEMENT; SIGNATURES OPTIONAL TOTAL PROTECTION'" PLAN have read and kept a copy of the FNANB Circuit City Plus VISA Agreement (the "Agreement") and agree By electing the optional F'NANB Total Protection its terms, including the provisions granting a security interest in durable goods purchased by use of the cancellation program, I acknowledge I have read and Depending on the type of Circuit City Plus VISA account for which I qualify, I understand that understand the PROGRAM SUMMARY, in the Credit aiifferent interest rates and fees may apply. The information I have provided above for FNANB's decision is Card Agreement, and agree to the program terms. I gning below, I grant FNANB permission to check my credit and employment history and obtain acknowledge TOTAL PROTECTION provides benefits copy of my credit report. I understand that the Agreement provides for arbitration. These provisions are for: loss of life, disability, involuntary unemployment, the Agreement. I agree to pay all amounts due on this account in accordance with the provisions and leave of absence as outlined in the PROGRAM in the Agreement, which is made a part of this application by reference. SUMMARY. Monthly fees charged are calculated at $0.79 per $100 of the account's average daily balance as of the account's monthly closing date. I may cancel at any time. Yes, Please enroll me, the primary applicant, in the Total Protection debt cancellation program. A CHRIS BURGESS B C .Accept Total Protection Plan Circui[ City ores, Inc, Store 3720 MECHANICSBURG, PA 17050 (717) 795-1038 13:14:00 05/05/03 ST0[~]~ (~0~)¥ Trans#: 372002264174 Merchant #: Register #: 05 Cashier: 420063 Mdse Desc: Consumer Electronics/Major Appliance/Home Office CCP-M 007552 Sale $ 1,000.00 FNANB 4104137501427618 The cardholder agrees to the credit card amount shown hereon and agrees to perform the obligations set forth in the cardholder's agreement with the issuer. For purchases made using a Circuit City credit card, or other credit card issued by First North American National Bank, a security interest in the merchandise listed below is hereby retained by the credit card issuer under the credit card agreement. Qty Model Description 1 HITDZMV350A CAMCORDER 1 ESPService CAMCORDER Signature: 051303 Statement 41041375014276180000040000001000004 FNANB P.O. BOX 100044 ACCOUNT # 4104 1375 0142 7618 KENNESAW, GA 30156-9244 NEW BALANCE $1,000.00 PAYMENT DUE DATE 06/07/03 I,,1,1,,,11,,I,I1,,I,,,11,11,,,11,,,11,,,I,,,111,,,I,,,111,,,I MINIMUM PAYMENT DUE $40.00 FIRST NORTH ANER. ICAN NATIONAL BANK P 0 BOX 8,50007 ~ BALTINORE, ND 21285-0007 .~ E~ MAKECHECKS PAYABLETO FNANB h"llh,,llh,,,l,l,,hl,.ll,.,,,ll,h,hll,,,,.Ihl,,llh. I 0000000 CHRIS BURGESS AMOUNT ENCLOSED 414 RESERVOIR ROAD HECHANICSBURG PA 17055-6146 PLEASE INDICATE ANY CHANGE TO ADDRESS OR TELEPHONE BELOW Street Address . Home Telephone ( ) City-State-Zip Business Telephone I ) IE Detach Here ACCOUNT # . 4104137501427618 Previous Balance S0.00 Statement Closing Date 05/13/03 Payments and Credits S0.00 Days in Billing Cycle 30 Payment Due Date 06/07/03 + Cash Advances SO.00 New Balance $1,000.00 MINIMUM PAYMENT DUE 540.00 + Purchases/Adjustments $1,000.00 Credit Line $1,000.oo + FINANCE CHARGES S0.00 Available Credit S0.00 = New Balance $1,000.00 Available Cash Advance- SO.00 CALL 1-866-522-7587 TO MAKE YOUR PAYMENT OVER THE PHONEI Posting Transaction Reference Transactions Date Date Number Charges & Credits · Promotional Pumhaaes 179 CAMCORDER 05/06 05/05 412003674000 CIRCUIT CITY PURCHASE 1,000.00 Order 6 - 6 oz. Omaha Steaks Top Sirloins al the sale price of $29.99. Call 1-800-288-9055. Ask for ilem 628GBX. Slsndard shipping will be added. Limi! of 2. Offer expires 06/30/03. For one enchanted evening, you could rule the Kingdom! Use your FNANB Visa card, or any Visa card, this May and June, end you could win a Walt Disney World vecatlon for you and seven guests, featuring an exclusive after-hours party at the Magic Kingdom Park for all Ihe winners and their guests all from Visal To find out more, see Ihe Official Rules in the enclosed Insed or go to vlsa.com/Mngdom or fa-mb.com. ACCUMULATED DEFERRED FINANCE CHARGES WILL BE WAIVED IF YOUR PROMOTIONAL PAYOFF BALANCE IS PAID IN FULL BY THE PROMOTIONAL ENDING DATE SHOWN IN THE PROMOTIONAL SUMMARY SECTION BELOW. ,, PROMOTIONAL SUMMARY Deferred Monthly Corresponding Accumulated Promotional Promotional Outstanding Average Daily Periodic Annual Deferred Payoff Ending .... Promotions Balance Rate *** Percentage Rate Finance Char,qes Balance Date CCP PROMO 1:)MOS NO INT W &300.00 1.9583% 23.50% ~5.87 $1,000.00 05/11/2004 m · SEE EXPLANATION OF CODES ON REVERSE ** AVAILABLE CASH ADVANCE IS INCLUDED IN AVAILABLE CREDIT LIMIT MAIL BILLING AND OTHER INQUIRIES TO: · ABBREVIATIONS: 'py. = Payment, 'cr' = Credit First North American National Bank For 24 hour automated fnformation can 1-866-522-7587 P.O. BOX 100045 FNANB Customer Service Representatives are available Monday. Friday 10am - 9pm ET Kennesaw, GA 30155-924,5 To report your credit card lost or stolen 24 hours a day call (888) 898-4142 See form on reverse side. For T.D.D. ~eiephone Device for the Hearing Impaired), calJ (g00) 925-1794 /H 4104137501427618 061303 Statement 41041375014276180000080000001029004 FNANB P.C). BOX 1000~ ACCOUNT # 410~ 1375 0142 ?$10 KENNESAW, GA 30156-9244 NEW BALANCE $1,029.00 PAYMENT DUE DATE 07/08/03 h,hh,,Ih,hlh,l,,,ll,lh,,Ih,,Ih,,I,,,llh,,h,,llh,,I MINIMUM PAYMENT DUE $80.00 F]'RST NORTH AMEI{ICAN NATIONAL BANK P O BOX 8,50007 _MAIL ,, ,~(~ECK MAKE CHECKS PAYABLE TO FNANB BALTIMORE, MD 21285'0007 : h',lll,,,lll,,,,hl,,hl,,ll,,,,,Ihh,hll,,,,,Ihh,llh,,I 0000000 CHRIS BURGESS AMOUNT ENCLOSED ~+].~, RESERVOIR RD MECHANICSBURG PA 17055-6146 PLEASE INDICATE ANY CHANGE TO ADDRESS OR TELEPHONE BELOW Street Address Home Telephone ( ) City-State-Zip __ Business Telephone I ) I~ Detach Here Previous Balance $1,000.00 Statement Closing Date 06/13/03 [ ACCOUNT # m~ 4104137501427618 - Payments and Credits SO.00 Days in Billing Cycle 31 Payment Due Date 07/08/03 + Cash Advances S0.00 New Balance $1,029.00 MINIMUM PAYMENT DUE S80.00 + Purchases/Adjustments S29.00 Credit Line $1,000.00 + FINANCE CHARGES ~0.00 Available Credit S0.00 = New Balance $1,029.00 Available Cash Advance** $0.00 CALL 1-866-522-7587 TO MAKE YOUR PAYMENT OVER THE PHONEI Posting Transaction Reference Transactions Date Date Number Charges & Credits,e' Miscellaneous 06/13 06/13 LATE PAYMENT CHARGE 29.00 i IMPORTANT INFORMATiON..I YOUR MINIMUM PAYMENT INCLUDES ANY OVERLIMIT AND PAST DUE AMOUNTS. PLEASE REMIT IMMEDIATELY. DON'T JEOPARDIZE YOUR INTEREST FREE TERMS. ACCUMULATED DEFERRED FINANCE CHARGES WILL BE ASSESSED ON YOUR PROMOTIONAL PURCHASES IF THE REQUIRED MINIMUM PAYMENT IS NOT RECEIVED BY THE DUE DATE ON THIS STATEMENT. Deferred Monthly Corresponding Accumulated Promotional Promotional Outstanding Average Dally Periodic Annual Deferred Payoff Ending .., Promotions Balance Rate *** Percentage Rafe Finance Char~es Balance Date CCP PROMO 12MOS NO INT W $1,000.00 1.9583% 23.50% ~25.45 81,000.00 05/11/2004 ,,FINANCE CHARGE SUMMARY Average Monthly Corresponding Periodic I ANNUAL i ViSlTOUR Dally Periodic Annual FINANCE PERCENTAGE ~.. WEBBITE AT 3~ Balance Rate '** Percentage Rate CHARGE WWW.FNANB.COM Purchases A SO. 00 1.9583% 23.50% S0.00 RATE Purchases B S0.00 1.9583% 23.50% SO. 00 SEE REVERSE SIDE FOR Cash Advances C S0.00 1.9583% 23.50% S0.00 IMPORTANT INFORMATION Purchases D Cash Advances E *°* PERIODIC RATE MAY VARY FROM MONTH TO MONTH SEE EXPLANATION OF CODES ON REVERSE ** AVAILABLE CASH ADVANCE IS INCLUDED IN AVAILABLE CREDIT LIMIT MAIL BILLING AND OTHER INQUIRIES TO: ABBREVIATIONS: .py. = Payment, 'cr' = Credit First No~h American National Bank For 24 hour automated information call 1-056-522-7587 P,O. BOX 100045 FNANB Customer Service Representatives are available Monday - Friday 10am . gpm ET Kennesaw. GA 30150-924,5 To report your credit card lost or stolen 24 hours a day call (888) 898-4142 See form on reverse side. For T.D.D. (Telephone Device for the Hearing impaired), call (800) g25-1794 HI 4104137501427618 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Date of Death:, a ! .~,~ ~)tO ~'RO Will No. ~-] - 0"~ - ~g Admin. No. ~]-2~O~'-~d~ To the Register: I certify ~at notice of ~enefici~ inter, t) ~te administration required by Rule 5.6(a) of ~e O~hans' Coua Rules was served on or mailed to the following benefici~ies of the above-captioned estate on : Name Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Signature Telephone (7/~ . ~ ~ Capacity: _ ~Personal Representative ~.Counsel for personal representative JRD/June 30, 1992/17858 OgT 1 In Re: Estate of CHRISTOPHER S BURGESS · ORPHANS' COURT DIVISION Late of UPPER ALLEN TOWNSHIP · COURT OF COMMON PLEAS OF · CUMBERLAND COUNTY Estate No.' 21-03-468 ' PENNSYLVANIA NO. 21-2003-468 NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT ORPHANS' COURT RULE Personal Representative: K. GENE BURGESS Counsel for Personal Representative: Date of Grant of Original Letters: 06-09-2003 Date of Delinquency Notice: 09-19-2003 The undersigned, Mary C. Lewis, Register of Wills, in accordance with Rule 5.6, 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 certification required by Rule 5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e), Supreme Court Orphans' Court Rules, was given by the Register of Wills on SEPTEMBER 19, 2003, and that the ten (10) day notice to file the certification has expired. Accordingly, in accordance with Rule 5.6(e) 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: 10-15-2003 Distribution: Personal Representative Counsel for Personal Representative Estate File A heating is scheduled for 3 . ~.5 at ~:30,~,~. In Courtroom No. 3. If the Certification of Notice is filed prior to the hearing date, the~y be cancelled· George ]~4-I~)fffer, l~.J. I JRD/June 30, 1992/17858 OCT 1 5 20O3 In Re: Estate of CHRISTOPHER S BURGESS · ORPHANS' COURT DIVISION Late of UPPER ALLEN TOWNSHIP · COURT OF COMMON PLEAS OF · CUMBERLAND COUNTY Estate No.: 21-03-468 ' PENNSYLVANIA NO. 21-2003-468 NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT ORPHANS' COURT RULE Personal Representative: VIVIAN S BURGESS Counsel for Personal Representative: Date of Grant of Original Letters: 06-09-2003 Date of Delinquency Notice: 09-19-2003 The undersigned, Mary C. Lewis, Register of Wills, in accordance with Rule 5.6, 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 certification required by Rule 5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e), Supreme Court Orphans' Court Rules, was given by the Register of Wills on SEPTEMBER 19, 2003, and that the ten (10) day notice to file the certification has expired. Accordingly, in accordance with Rule 5.6(e) 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: 10-15-2003 ~'~'~r-~ Distribution: Personal Representative ~ll~l~Register Counsel for Personal Representative Estate File A heating is scheduled for ~~ ,,2r~r~ at ~:~,o~.~,/, In Courtroom No. 3. If the Certification of Notice is filed prior to the hearing date, the ~~b,e cancelled. George'E. l~fferfP.J~ ~ REV'-~500 EX , (600) OFFICIAL USE ONLY PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN ,,LE.U.BER DEPT. 280601 RESlDENT DECEDENT 2 1-0 3 0 4 6 6 HARRISBURG, PA 17128-0601 COUNTY CODE YEAR '~UMBER-- DECEDENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL SOCIAL SECURITY NUMBER z Burgess, ChristopherS. 4 6 7- 6 5- 0 7 8 3 U,,I DATE OF DEATH (MM-DD-Year) I DATE OF BIRTH (MM-DD-Year) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ REGISTER OF WILLS I O 05/24/2003 12/10/1983 III (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER "' [] 1. Original Return BI 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) a::,,, E~ 4. Limited Estate E~ 4a. FuturelnterestCompromise(dateof0eathafter12-12-82) ~] 5. Federal Estate Tax Return Required -J [] 6. Decedent Died Testate (A~tach copy of Will) ~1 I 7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes E~ 9, Litigation Proceeds Received LJ 10. Spousal Poverty Credit (~ate of death between 12-31-91 and 1-1-95) Election to tax under Sec. 91 13(A) (At[ach Sch O) ~_ THIS SECTION MUST BE coMPlETED ALLCORRESPONDENCE ~ z NAME COMPLETE MAILING ADDRESS z R. Mark Thomas, Esq. 101 S. Market Street o a. FIRM NAME (If Applicable) O TELEPHONE NUMBER o 717-796-2100 Mechanicsburg PA 17055 OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) ' ~ 7 '. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 6,950.11 (Schedule E) 6. Jointly Owned Property (Schedule F) (6) r-'] Separate Billing Requested !:-i :--~, :2~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) I-" (Schedule G or L) a. 6,950.11 <:~ 8. Total Gross Assets (total Lines 1-7) (8) O 15,593.33 LU 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 2,129.88 11. Total Deductions (total Lines 9 & 10) (11) 17,723.21 12. Net Value of Estate (Line 8 minus Line 11) (12) -10,773.10 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) -10,773.10 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z 15. Amount of Line 14 taxable at the spousal tax ~0 rate, or transfers under Sec. 9116 (a)(1.2) X ~ (15) <~ 0.00 X __ (16) 0.00 I-- 16. Amount of Line 14 taxable at lineal rate I:1. 17. Amount of Line 14 taxable at sibling rate X .12 (17) 0 18. Amount of Line 14 taxable at collateral rate X .15 (18) 19. Tax Due (19) 0.00 20. > > BE SURE TO ANSWER ALL QUESTIONS ON REVE~E SiDE;AND ECH:E :. Decedent's Complete Address: STREET ADDRESS 414 Reservoir Rd. CITY Mechanicsburg ISTATE PA IzIP 17055 Tax Payments and Credits: 0.0 0 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits ( A + B + C ) (2) 3 Interest/Penalty if applicable D, Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4, If Line 2 is greater than Line 1 + Line 3, enter the difference, This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 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 decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ........................................................................... [] [] b. retain the right to designate who shall use the property transferred or its income; ........................................ [] [] c. retain a reversionary interest; or ...................................................................................................... [] [] d. receive the promise for life of either payments, benefits or care? ............................................................. [] [] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................................................... [] [] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of ~preparer other than the personal representative is based on all information of which preparer has any knowledge. SlGNATIJRI~OF PERS(2~I~ RESPONSIBLE FOR FILING RETURN , ~ .,/,,~ DATE ADDRESS - 414 ~sevo{r Road - Mechanicsburg PA 17055 SIGNATLJR. E ¢/ ADDRESS 101 S. Market Street Mechanicsbur§ PA 17055 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling Js defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (1 97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF :ILE NUMBER Burgess. Christopher S Pl 03 0468 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Personal belongings 135.00 2. PNC Bank Checking Acct. #5004054439 5,530.83 3. PNC Bank - Savings Acct. #5004057744 201,28 4. Federal Income Tax Refund (2003) 1,083.00 TOTAL (AIsc enter on line 5, Recapitulation) $ 6,950.11 (If more space is needed, insert additional sheets of the same size) REV ~511EX * (1-97) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVECOSTS RESIDENT DECEDENT ESTATE OF :ILE NUMBER Burgess. Christopher S 21 03 0468 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Elmore Funeral Home 6,506.83 2. Olivette Cemetery - Burial Plot 300.00 3. Elmore Ltd. - Headstone 4,674.00 4. Moorefield Examiner - Obituaries 47.50 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees R. Mark Thomas 500.00 3 Family Exemption: (if decedent's address is not the same as claimant's, attach explanation) 3,500.00 Claimant K. Gene Burgess and Vivian S. Burgess Street Address 414 Resevoir Rd. city Mechanicsburg State PA Zip 17055 Relationship of Claimant to Decedent Parents 4. Probate Fees Open Estate - $38.00; Additional Short Certificates - $12.00; File Inheritance 65.00 Tax Return - $15.00 5, Accountant's Fees 6. Tax Return Preparer's Fees TOTAL (Also enter on line 9, Recapitulation) $ 15,593.33 (If more space is needed, insert additional sheets of the same size) .~v,~E×~,~9,, ~ SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RE~URN MORTGAGE LIABILITIES~ & LIENS RESIDENT DECEDENT ESTATE OF :ILE NUMBER Burgess. Christopher S. 21 03 0468 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. Bigglemans Towing & Storage 220.00 2. Verizon Wireless 97.48 3. Internal Revenue Service - 2002 Income Taxes 203.83 4. First North American National Bank 1,029.00 5. Capital One 579.57 TOTAL (Also enter on line 10, Recapitulation) $ 2,129.88 (If more space is needed, insert additional sheets of the same size) , REV: S,3E ×+,9 SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF 21 03 0468 Burgess. Christopher S RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE |. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a)(1.2)] 1. K. Gene Burgess :ather 50% 414 Resevoir Rd. Mechanicsburg, PA 17055 2. Vivian S. Burgess Mother ;0% 414 Resevoir Rd. Mechanicsburg, PA 17055 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 HROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET ||. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART I! - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) CONNONNEALTH OF PENNSYLVANIA ~,_ DEPARTNENT OF REVENUE BUREAU OF INDIVIDUAL TAXES ZNHERZTANCE TAX DZVZSXON NOT/CE OF INHERZTANCE TAX PO BOX Z80601 APPRAZSEHENT, ALLOHANCE OR DZSALLO#ANCE HARRISBURG, PA 171Z8-0601 OF DEDUCTIONS AND ASSESSHENT OF TAX XEV-Z;47 EX AFP (09-04) DATE 11-Z9-200~ ESTATE OF BURGESS CHRZSTOPH S DATE OF DEATH 05-Z~-Z00$ FILE NUNBER 21 05-0R68 ....... ~ .... '~ COUNTY CUHBERLAND R HARK THOHAS ESQ ACN 101 101 S HARKET ST .ECHANICSBUR$ P~,::~055, ] Aaoun~ Rem1~ad HAKE CHECK PAYABLE AND RENZT PAYNENT TO: REGISTER OF HILLS CUNBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THIS LINE ~ RETAZN LONER PORTION FOR YOUR RECORDS ~ DZSALLONANCE OF DEDUCTIONS AND ASSESSNENT OF TAX ESTATE OF BURGESS CHRISTOPH S FILE NO. 21 05-0~68 ACN 101 DATE 11-29-200~ TAX RETURN NAS: (X) ACCEPTED AS F/LED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Es~a~e (Schedule A) (1) .00 NOTE: To insure proper 2. S~ocks and Bonds (Schedule B) (2) .00 credi~ ~o your account, 3. Closely Held S~ock/Par~nership Zn~ares~ (Schedule C) ($) .00 submi~ ~ha upper portion ~. Hor~gages/No~as Receivable (Schedule D) (~) .00 of ~his form wi~h your 5. Cash/Bank Daposi~s/Hisc. Personal Propar~y (Schedule E) ($) 6~950.11 ~ax payment. 6. Jointly Ownad Propar~y (Schedule F} (6) .00 7. Transfers (Schedule G) (7) .00 8. To,aX Asse~s (8) 6,950.11 APPROVED DEDUCTIONS AND EXENPTZONS: 15,595.$$ 9. Funeral Expansas/Adm. Cos~s/Nisc. Expanses (Schedule H) (9) 10. Dab~s/Nor*gaga LAabili~ias/Lians (Schedule I) (10) Z,129.88 11. To,al Deductions (11) 17.72~.21 12. No~ VaZua of Tax Re~urn (12) 10,775.10- 15. Charitable/Governmental Bequests; Non-alac~ed 9115 Trusts (Schedule J) (13) .00 1~. Na~ Value of Es~a~a Sub~ac~ ~o Tax (1~) 10,775.10- NOTE: Z~ an assess;ant ~as issued previously, lines 1~, 15 and/or 16, 17, 18 and 19 ~ill reflect figures that lnclude the total of ALL returns assessed to date. ASSESSNENT OF TAX: 15. A;oun* of L/ne 1~ a~ Spouse1 ra~a (15) .00 X O0 = .00 16. Aaoun* of Line lq *axable a* Lineal/Class A ra~a (16) .00 X 0~5 = .00 17. Amoun~ of Line 1~ a~ Sibling re~e (17) .00 X 1Z = .00 18. Aaoun~ of Line lq ~axabla a~ Collateral/Class B ra*e (18) .00 X 15 = .00 19. Principal Tax Due (19)= .00 TAX CREDITS: PAYH~NT REC[ZPT DISCOUNT (+} ANOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUEI .00 INTEREST AND PEN. .00 TOTAL DUE .00 IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS RE~UIRED. ~-~A FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) RESERVATION: Estates of decedents dying on or before December 1Z, 198Z -- if any future interest in the estate is transferred in possession or enjoyment to Class B [collateral] beneficiaries of the decedent after the expiration of any estate for life or for years, the CommonHealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the laHful Class B (collateral] rate on any such futura interest. PURPOSE OF NOTICE: To fulfill the requirements cf Section ZllO of the Inheritance and Estate Tax Act, Act Z3 of ZOO0. (7Z P.S. Section 91q0). PAYNENT: Detach the top portion of this Notice and submit Hith your payment to the Register of Nills printed on the reverse side. --Make check or money order payable to: REGISTER OF HILLS, AGENT REFUND (CR): A refund of a tax credit, Hhich Has not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications ara available online at Hw~.revanua.state.ca.us, any Register of Nills or Revenue District Office, or free the Department's Iq-hour answering service for forms orders: 1-800-36Z-ZOSO; services for taxpayers Hith special hearing and/or speaking needs: 1-800-~?-30ZO (TT only]. OBJECTIONS: Any party in interest not satisfied ~ith the appraisment, alloHance or disallowance of deductions or assessment of tax (including discount or interest) as sho~n on this Notice amy object ~ithin 60 days of the date of receipt of this notice by filing one of the following: A) Protest to the PA Department of Revenue, Board of Appeals. You may object by filing a protest online at H~.boardofappeals.state.pa.us on or before the expiration of the sixty-day appeal period. In order for an ale:tronic protest to be valid, you must receive a confirmation number and processed date from the Board of Appeals Hebsite. You amy also send a Hritten protest to PA Department of Revenue, Board of Appeals P.O. Box ZBIOZ1, Harrisburg, PA 171Z8-10Z1. Petitions may not be faxed. B)Election to have the matter determined at the audit of the account of the personal representative. ADNIN- C) Appeal to the Orphans' Court. ISTRATIVE CORRECTIONS: Factual errors discovered on this assessment should be addressed in Nriting to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment RevieH Unit, P.O. Box 280601, Harrisburg, PA 171ZB-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return far a Resident Decedent" (REV-IS01) for an explanation of administratively correctable errors. DISCOUNT: If any tax due is paid ~ithin three (3) calendar months after the decedent's death, a five percent (Si) discount of the tax paid is allo~ed. PENALTY: The leg tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you ~ould appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning Hith first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes Hhich became delinquent before January l, 1982 bear interest at the rate of six (BI) percent per annum calculated at a daily rate of .00016q. All taxes ~hich became delinquent on and after January l, 198Z Hill beer interest at a rate Hhich Nill vary from calendar year to calendar year .ith that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOOq are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor ~ lOX .0005q8 19BS-1991 llZ .00030l ~ 9X .O00Zq7 19B~ 162 .000~38 1992 9Z .O00Zq7 200Z 62 .O0016q 19B~ llZ .000301 1993-199q 7Z .O00lez 2003 SZ .000137 1985 13Z .000356 1995-1998 9Z .0002q7 200q ~Z .000110 1986 lOZ .O00ZTq 1999 72 .000192 1987 lOX .O00Z7~ logo 7Z .O0019Z --Interest is calculated as follo~s: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent NiIZ reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date sheen on the Notice, additional interest must be calculated. STATUS REPORT UNDER RULE 6.12 BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND , PENNSYLVANIA Name of Decedent: CHRISTOPHER SCOTT BURGESS Date of Death: 5/24/2003 File No. 2003-00468 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to the 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 Orphan's 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. Signature ~- R. Mark Thomas, Esq. · ~ Name (Please type or print) 101 S. Market St. ~-_-., Address :_~ Mechanicsburg PA 17055 ;..~':Z . 717-796-2100 , ..-r. Tel. No. Capacity: Personal Representative X Counsel for personal representative