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Home My WebLink About03-0487 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION also known as (f To: Register of Wills for the Deceased. County of .CUI~ERLAND in the Social Security No. 7;kOq,- ~ q, - "'l~:~ c~ Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl ) ~cTf for letters of administration (d.b.n.; pendente lite; durante absentia; durante minoritate) on the estate of the above decedent. 2~e~ende~atsT;aS2;?~Crll~r~:ctiadae~th ~.n' ~ ~,,~v~ ~.~, v--/~t~ ~ . County, Pe0nsylvania, with h Y p p reslaence at ~"~ O~st streelff3Jnumber and municipality) Decendent, then Decendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property $ (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ ~.! 0, o o situated as follows: D.~- Petitioner after a proper search ha~ ascertained that decedent left no will and was survived by the following spouse (if any) and heirs Name Relationship Residence THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. 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 .~nd subscribed before/a)e this /~' day of_~ ......... ' / I - Regis[e;'a[ No. 21-03-487 Estate of BEVERLY JANE BECKER , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW ,IIINE 16.. ?003 Xtt~XX , in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that JOHN So BECKER is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to JOHN S. BECKER in the estate of BEVERLY 3ANE BECKER ~ -l~egistert ott~ill~s - FEES Letters of Administration ..... $ 50.00 Short Certificates(3) .......... $ 9 · 00 ATTORNEY (Sup. Ct. I.D. No.) Renunciation ................ $ 5 o 00 INS. INH TAX RETinAL a 84.00 ~'~ Filed ...~U~qti .15 .......... A.D. 21g_Z0J~ PHONE .; MAILED LETTERS JUNE 16, 2003 TO ADMINISTRATOR RENUNCIATION To the Register of Wills of C c.~ w~ ~a c- ] o,_ w cJ County, Pennsylvania. The undersigned ~RVI~ t&4- ~-C/<'t'/~ / ~.~/~ ~. of the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters be issued to 'x~-~o ~\, ~, ~e_ C. <o._ WITNES~/~,/¢/¢~ /~ ~i~ h.d this ~ Notarial Seal Suzanne M. Wilk, Nota~ Publ~ Evere~ Boro, Bediord Coun~ M~ Commission Expires Mar. 18, 2~6 p4r: :~-~): ' ',.., :t,, ~' ~r,h as.sc*:iat~on Of Notades (Signature) (Address) (Signature) (Address) (Signature) (Address) s to certify that the information here given is correctly copied from an original certificate of death dui),, filed with me as Registrar. The original certificate will be forwarded to the State Vital Records Office fbr permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. ~ ~)cal Registrar P 9 0 5 3 2 7 4 ~~ No. ~ --- Date CO~MONW~LTN OF PENNSYLVANIA · DEPARTMEN~ OF HEALTN · V~AL RECORDS CERTIFICATE OF DEATH ~arch 2, 2003 ......................................................... ~ [086 ~a~k[~ SO.eec OFFICIAL USE ONLY . ~ ~,~,.o~ REV-1500 '~ ~ ~N~VAN~ ~ ~~ INHERITANCE TAX RETURN ~~~, ~ m~ RESIDENT DECEDENT ' I"' ['" ] '~ Ih., ~ ~' ' ., '. "1" ~ ' I ' , , '~,~ ," ', ' ', , ,,~ ~ , ~ , ,,, . , (11) (19) Dec_-ede_ nt's Complete Address: . ~ . Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) (1) 2.~.~ s. Prior Payments C. Discount Total Credits (^ + B * C ) (2) . ., . 3. Interest/Penalty if applicable D. Interest E. Penalty .. Total interes~onaity ( D + E ) (3) 4. If Une 2 is {]mater than Line 1 * Line,3, enter the difference. This is theOVERPAYMENT. Check t~ on Page ! Une 20 t~ mqa~t a refu.d (4) A. Enter the interest o~ the tax due. B. Enter the total of Line 5 + SA, Th~s .is the BALANCE OUE, (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS aY PLACING AN "X" IN THE APPROPRIATE 8LOCKS 1. Did decedent make a lransfer and: Yes No a..~a. ~ use ~x income of ~ pmpe~ tm.(~r~; ........................................................................................ [] [] c. r~ai~arevemon~tr~rest:or ........................................................................................................... : ....... : ...... [] [] 2, If deah occurred ~r ~r 12, 19~ did deced~t ~ ~ ~n ~ ~ of ~ 3. Did decedem own an "in trna fr~' ~ payable upon deah ba~k acnount o~ secu~ at his °r h~ death ............... L_J [] con, ins a beneficiary de~gnation? ....................................................................................................................... · IF THE ANb~ER TO ANY OF THE ABOVE QUESTIONS i~ YES, YOU MUST COMPLETE SCHEDULE G AND RLE IT AS PART OF' THE RETU~: SlC.d~TURE OF PERS~I RESPONSIBLE FOR FLUNG RETURN ,, , ~, ,, - .~.~T~ - ' ' ' '" DATE' ' SIGNATURE OF PREPARER OTHER TitAN REPRESE IVE ADD~'S$ For dates of death on or after July I, 1994 and before January 1, 1995,the lax rate imlx)sed on Ihe na value of tnmsfem to ~ f~r lhe use °f the sawiving sp°use ~ 3% F2 P.S. §~6 (a) (~.~) (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 ofthe sun~4ng Sfx~se is0% [72 P.S. ~116 (a) (1.1) (ii) The statute does not exen~t a ~*ander to a suwiving spouse from tax, and the statut~y requirements for disclosure of assets and fl'r~j a tax return are sail applicable ev~ For dates of death on or alter July 1, 2000: The lax rate imposed on ~e net value of lransf~ from a deceased child twenty-one years of age or younger at death ~ or for the use of a natural parent, an adoptive paten or a aeppam.t of tt~ia is O% F2 P.S. §9~16(aX!2)], The tax rate imposed on ~ n~ ~ue of tr, msfers to or for the, use,.ef thedeced~s a~ea~ ~.is 4,O%, except. .as noted in ~2. P,S...~9't16(1., ..'2) F2.: The ~ rate ~ o~.~ net value of ~ to or.for.~ use of:~ decede~s a'~m~s is 12%*172 P,S. ~S(aX1.3)l- ^ ab~ is' dee~ed,'under Sec~ 9102, REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ~s~ o~ ~ ~ ¢., ~-~ ,'~_~, ~ ~ ~ ~ ~ ~ .,~ ~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a)(1.2)] ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 16 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET ][I 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 1. TOTAL OF PART Il- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ O , o-~ (If more space is needed, insert additional sheets of the same size) '"" SCHEDULE E Es'rA~ PERSONAL PROPERTY ~ _I~.~_'_..RIPTION VALUE AT DATE (ff more space is r, eeded, in~ert add;~o~ s;-.~eL~ of the same size) REV-1509 EX + (1-97) SCHEDULE F COMMON"VEA,TH OF PENNSYLVANIA JOINTLY'OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF /C~ FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifTing number. Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTERES TOTAL (Also enter on line 6, Recapitulation) $ t../ oo O · o O (if mnr¢ ~p~r.~, i .... "'1~'1, ~ .... additional sheets of the same size) SCHEDULE H COUMC~T, O~ n~'YLV~ FUNERAL EXPENSES & A. ~ E~8: B. ADMINISTRATIVE COSTS: 1. PellonaJ ~~ Colmliimns " C~ S~s. 3. F~~(ff~s~b~~s,~~) c~ ~o~ ~., ,,~g%e~ ....... 5. ~s F~ ~ ]~ TOTAL iAIso enler on line g, Recapilulalion) $ ,~'/ SCHEDULE I cc.~.~.t, o~ ~..s~v^.,^ DEBTS OF DECEDENT. ,.~r^~ t~ Rvr~ MORTGAGE L~IL~IES, & LIENS ~ ~ ~~ ............... , ..... ~cl~e u~~ ~I ~. iTEM NUMBER DESC~PTION A~U~ 3 REV-1513 EX+ (9-O0~j~ ' ' SCHEDULE J 'COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT 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)] ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II 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 1. TOTAL OF PART II- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ C) · o-~ (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) ~ SCHEDULE J · COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ~s~ o~ --~.~._ ~.~, ~- ~ ~ ~ ~ ~ ~ ~ ~,~ ~ RE~TIONSHIP 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)] ~;~s~3 ~ P~ I~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II 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 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If more space is needed, insed additional sheets of the same size) May, 6. 2003 11:53AM The Sentinel N0.4396 P. 1 ................. The Sentinel aDmw sx x - advertising T~en~ F~ 717~310 C~fl~d Co~, P~nsylva~ d~c~d, have ~n ~tcd to ~e ~de~cd. 219 ~ ~ ~rso~ ~ow~g ~c~lv~ to ~ indebmd to s~d ~mte ~ m~e pa~ent m- u~~, direly, ~d &ose ha~ag el~ w~ p~t ~ tot s~nt. ~ n~.~z~ . ~ ~, Attorney PLEASE PRI~ A~ INFOR~A~ Runs ~nee a w~k for ~ wee~ Na~: ~K~ ~~" c~:. %W, 9~ ~, $6.~ for notorJ~ proof of publi~aon.. Proof? Y~ ~ No ~ate: ¢ ~ ~p: t 3 25- 7 (Must ~ve all ~o~ in~rm~ion) ~~ TO: ~e SenSei, A~:, [o~J SaTJo~, ~.O. Box ~30, ~]is]e, PA [?013, ~boae: 243-26~t, e~ 20Z o~ ~8 - f~: 243-37~ DAILY SUNOAY WEEKLY INTERNET Reaching ~ore than 1~2,000 r~aders each week In Cumberland, Perry, and Franklin Counties www.cumb~rllnk..com May, $. 2003 fI:34AM C C B A No,1158 P. I TO: CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 NOTICE EXECUT on tho Estate of ~ t/~'~ ~n~ lato of~o ~mm~y, md ~o~ ~ c~ ~1 ~t ~ for s~mt to A~m~ Advertising cost is $7$.00 payable h~ advance. Make checks payable to: Cumberland Law Journal JOHN S. BECKER 25 SME 1 574 SHIPPENSBURG, PA 17257 PH, 717-532-6276 60-8111/2313 PA EL 23248454 '-~ ' ?' O ..~ DATE HARRISBURG, PA 17110-2990 COMMONWEALTH OF PENNSYLVANZA "~ BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 2B0601 HARRISBURG, PA ZT~ZS-060! NOTICE OF ZNHERTTANCE TAX APPRATSEMENT, ALLOHANCE OR DTSALLO#ANCE OF DEDUCTTONS AND ASSESSMENT OF TAX REV-lSd7 EX AFP (01-OS) ~,~. i DATE 07-28-2003 ESTATE OF BECKER BEVERLY J DATE OF DEATH 03-OZ-ZO03 FILE NUMDER 21 03-0q87 '03 JUL 28 /i? :~2 COUNTY CUMBERLAND JOHN S BECKER 25 SME ACN 101 SHZPPENSBURG PA 17957 I A.oun* R..it*.d MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LZNE ~ RETAIN LOWER PORTION FOR YOUR RECORDS REV-15~7 EX AFP (01-03) NOTZCE OF ZNHERZTANCE TAX APPRAZSENENT, ALLOWANCE OR DZSALLOWANCE OF DEDUCTZONS AND ASSESSHENT OF TAX ESTATE OF BECKER BEVERLY J FZLE NO. 21 03-0~87 ACN 101 DATE 07-28-2003 TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION COHCERNZNG FUTURE ZNTEREST- SEE REVERSF APPRAZSED VALUE OF RETURN BASED ON: ORZGZNAL RETURN 1. ReaZ Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account, $. Closely Held Stock/Partnership Tnterest (Schedule C) ($) .00 submit the upper portion q. Mortgages/Notes Receivable (Schedule D) (q) .00 of this form wi~h your 5. Cash/Bank Deposits/Misc. Personal Property (Schedu/a E) (5) 15;662.96 tax payment. 6. Jointly Owned Property (Schedule F) (6). ~80.00 7. Transfers (Schedule G) (7) .00 8. To,al Assets (a) 16,1q2.96 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 5,95q.00 10. Debts/Mortgage Liabilities/Liens (Schedule T) (10) lq,535.61 11. Total Deductions (11) _ ~.q8~-61 12. Net Value of Tax Return (12) q,3q6.65- 15. Charitable/governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) .00 Iq. Net VaZue of Estate Sub~ect to Tax (Iq) q,3q6.65- NOTE: Zf an assessment was issued previously, lines 1~, 15 and/or 16, 17, 18 and 19 ~ill reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amoun~ of Line 1¢ at Spousal rate (15) .00 X O0 = .00 16. Amount of Line lfi taxable at Lineal/Class A ra~e (16) .00 X Oq5 = .00 17. Amount of Line lq et Sibling rate (17) .00 X 12 = .00 18. Amount of Line lq taxable et Collateral/Class B rata (18) .00 X 15 = .00 19. Principal Tax Due TAX CREDITS: (1~)= .00 PAYMENT RECEIPI DZSCOUNT DATE NUHBER TNTEREST/PEN PATD (-) AMOUNT PATD BALANCE OF TAX DUEI . O0 INTEREST AND PEN. I .00 TOTAL DUE I . O0 IF PATD AFTER DATE ZNDTCATED, SEE REVERSE ( ZF TOTAL DUE TS LESS THAN $1, NO PAYMENT TS RE~UTRED. FOR CALCULATION OF ADDTTZONAL INTEREST. TF TOTAL DUE TS REFLECTED AS A "CREDTT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE STDE OF THTS FORM FOR TNSTRUCTTONS.) RESERVATION: Estates of decadents dying on or be~ore December 1Z, 198Z -- if any future interest [n the estate Ks 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 Collonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class S (cottateral) rate on any such future interest. PURPOSE OF NOTICE: To fulfill the requirements of Section Z140 of the Inheritance end Estate Tax Act, Act Z5 of ZOO0. (72 P.S. Sect[on 9140). PAYNENT: Detach the top portion of this Not[ce and submit m[th your payment to the Register of #ills printed on tho reverse side. --Hake check or money order payable to: RESISTER OF HILLS, AGENT REFUND (CR): A refund of a tax credit, ehJch was not requested on the Tax Return, may ba requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (RE¥-1513). Applications ara available at the Office of the Register of Nills, any of the Z3 Revenue District Offices, or by calling the special Z4-hour aris#er[ns service for fores ordering: 1-800-36Z-ZO50~ services for taxpayers with special hearing and ! or speaking needs: 1-800-447-50Z0 (TT only). OBJECTIONS: Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown an this Notice must object within sixty (60) days of receipt of this Not[ce by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. ZBIOZ1, Harrisburg, PA 171ZB-lOZ1, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADHIN- ISTRATIVE CORRECTIONS: Factual errors discovered on this assessment should be addressed in writing to: PA Department cf Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 171Z8-0601 Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for lnhar[tmnce Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. DISCOUNT: If any tax due is paid within three (5) calendar months after the decedent's death, a the tax paid is allowed. PENALTY: The 15Z tax amnesty non-participation penalty is computed on the total cf the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty per[od. This non-participation penalty Ks appealable in the same manner and in the the same t[ma per[od as you would appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January I, 198Z bear interest at the rate of slx (BI) percent per annum calculated at a dally rate of .000164. All taxes which became delinquent on and after January 1, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1962 through ZOO3 ara: Interest Daily Interest Daily Interest Daily Year Rate Factor Yaa__r Rate Factor Yea__r Rate Factor 1982 ZOZ .000548 1987 9Z .000247 1999 7Z .O0019Z 1983 IBZ .00043B 1988-1991 llZ .000301 2000 BZ .000219 19&4 112 .000501 1992 9~ .000247 1985 1SZ .000356 1993-1994 72 .O0019Z ZOOZ 62 .OOO164 1986 IOZ .000274 1995-1998 9Z .000Z47 2003 5~ .000137 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent w[l! reflect mn interest calculation to fifteen (15} days beyond the date of the assesseant. If payment is made after the interest computation data shown on the Notice, add[tionaX interest must be calculated. CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: ~F'~q V~ ¢ {~x XC~ Date of Death: 0 2~ o ~- - 0 ~ Will No. ~,o0g--OOcl~''] Admin. No. To the Register: I certify that notice of (beneficial interest) 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 : Name Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: Signa~re Name ~oh,,,, %. ~o~O(~r- Address ~ ,%~ l Telephone (~/'~) Capacity: ~ Personal Representative Counsel for personal representative OSI PORTFOLIO SERVICES, INC PROBATE DEPARTMENT P. O. BOX 105460 ATLANTA, GA. 30348 IN THE CIRCUIT: CUMBERLAND COUNTY PROBATE COURT DECEASED: BEVERLY BECKER STATE OF: PENNSYVANIA CASE # 21-03-00487 STATEMENT OF CLAIM: HEILIG MEYERS MASTER TRUST HEILIG MEYERS MASTER TRUST, ACCT # 3910474097 PREVIOUS OWNER: HEILIG MEYERS FURNITURE PREVIOUS ACCOUNT # 004121 The undersigned hereby presents for filing against the above estate this statement of claim and alleges: The basic for the claim is GOODS SOLD The social security or tax identification number of the claimant is ID# 51-036904 the name and address of the claimant are HEILIG MEYERS MASTER TRUST~ PROBATE DEPT 2425 COMMERCE AVE~ BUILDING 2100~ SUITE 100~ DULUTH~ GA. 30096 and the name and address of the claimant's attorney, if any, are as set forth below. 1. The/~o~unJgof the claim is $1,539.46 which is now due or, if not due, will become due on (X"'lfJ~ ,20~..~. 2. The claim (is) ( is not)contingent or unliquidated. If contingent or unliquidated, the nature of the uncertainty is: UNLIQUIDATED ............ . 3. The claim (is) (is not) secured... If secured, the security consists of Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are Tree, to the best of my knowledge and belief. ) :,. cO ---- ~ 4~)/~?~./{ ~ ,~i~ Copy mailed to attorney for the Personal ' ' .... /' ' '"~ '-' "--- .~ Representative on ,2003 NOTARY K. ., ~}<b~.~-0'l~An",,'~,-(:; CLERK OF THE CIRCUIT COURT ~ ~ GEORGIA ~ ~ By: ~ ~ FEB. 6, 2004 -,,, ~d'r"r cO..,, vanderbilt MORTGAGE AND FINANCE, INC. Mailing Address: P,O, Box 9800 · Maryville, TN 37802 Street Address: 500 Alcoa Trail · Maryville, TN 37804 Phone: (865)380-3000 · Fax: (865)380-3772 · Toll Free: 1~800-970~7250 Probate Claim: i Docket No. Vanderbilt Account No.~.~._~ Dear Sirs: The above referenced individual passed away in')la~., OF 2003. The estate is indebted to Vanderbilt Mortgage and Finance, Inc. in the amount ors ?, ! gg, ~_ (Current Principal Balance ), see attached security agreement. This amount reflects all re~nds, credits, and set-offs due the customer. The current payoff amount is $ Please enter the above referenced amount as a debt owed by the estate of . Th~k you for your cooperation in tbs matter. Cordially, JU la JUlian ~ : , Recove~ Department Ph~865.380.3000 ext 2759 Ph~800.970.7250 ext 2759 Fax~ 865.380.3772 Cc:File ~ Vanderbilt MORTGAGE AND FINANCE, INC. Mailing Address: P.O. Box 9800 - Maryville, TN 37802 Street Address: 500 Alcoa Trail · Maryville, TN 37804 Phone: (865)380-3000 · Fax: (865)380-3772 · Toll Free: 1-800-970-7250 Chapter 175, Public Acts 1939 Creditor CLAIM AGAINST ESTATE OF Vanderbilt Mortgage and Deceased ~ Finance,Inc. STATE OF TENNESSEE COUNTY OF BLOUNT Address: POB 9800 Maryville,Tn 37802 DATE CLAIM DUE I I--0 1 -~ ~E Quantity items and nature of claim amount of claim credits. Unpaid Balance $ ~; ! ~[r~ :~...-~- (Principal Balance Only). STATE OF TENNESSEE COUNTY OF BLOUNT Comes Julia Julian and who being duly sworn, makes oath that the attached claim is correct, just and valid obligation of the estate of ~.~,~2.~ ~ ~.~. and that neither the claimant nor any other person on his behalf has re~eived~yment thereof, in~vhole or in part, except such as is credited thereof and that no security thereof has been received except as therein stated. Julia Juli~ ~ Sworn to and subscribed before me This the 3~7"~ day of~l,a.~,2004 .., Notary Public _ _ _ t., .. My Commission Expires ,fi--//- O~ Vanderbilt Accc~unt# DateofDeath: o~j o~.o.g`~ ~7~ / J ~3 -- Will No.: N;ao_ Admin. No.: ~0J327¢ Pursuit to Rule 6.12 office Supreme Cou~ Ochans' Corn1 Rules, I repo~ the follow~g with respect to completion 0f the a~stration of the above-captioned estate: 1. State whether a~s~ation of the estate is complete: Yes7 No~ 2. ~e ~swer is No, state when the personal representative re~onably believes that the adm~s~afion MH be complete: 3. ~ the ~swer to No. 1 is Yes, state the follow,g: a. Did ~e person~ representative ~e a ~al accost with ~e Co~? No b. Tile s~ate O~h~' Co~ No. (if ~y) for ~e personM representative's accost is: c. Did ~e'personM representative state ~ accost ~o~aHy to the p~ies ~ ~terest? Yes ~/ No ~' c. Copies of receipts, rele~es, jo~ders and approvM offo~ or ~o~al accosts may be filed wi~ ~e Clerk of~e ~h~s' Co~ ~d may be a~ached to t~s repo~. Date: ~,k-V-oq ~~ ~ Si~e Ad.ess Telephone No. Personal Representative Counsel for~ersonal representative