Loading...
HomeMy WebLinkAbout10-17-11 DECEDENT'S ESTATE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF JAMES R. JACOBS ,DECEASED No. 21-10-0175 PETITION FOR ADJUDICATION / STATEMENT OF PROPOSED DISTRIBUTION PURSUANT TO Pa. O.C. Rule 6.9 7 - -; -,_ -, .~ . -- . - ,:: ~ . . ~~ ~ _:_, . -_ ~ --~ ; This form may be used in all cases involving the Audit of the Account of a Decedent's Estate. If space is insu~cient, riders may be attached. Attach the spouse's election, if any; the papers required under items 8-19 inclusive; and any instrument pertinent to the adjudication. INCL UDE ATTACHMENTS AT THE BACK OF THIS FORM. Name of Counsel: Charles E. Shields, III Supreme Court I.D. No.: 38513 Name of Law Firm: Address: 6 Clouser Road, Mechanicsburg, PA17055 Telephone: (717) 766-0209 Fax: (717)795-7473 Form OG01 rev. 10.13.06 Page 1 Of 10 r Estate of JAMES R. JACOBS ,Deceased 1. Name(s) and address(es) of Petitioner(s): Name: JOAN M. JACOBS Address: 333 W. Simpson Street Mechanicsburg, PA 17055 Identify any executors or administrators who have not joined in the Petition for Adjudication and Statement of Proposed Distribution and state reason: None Is this the first accounting by this fiduciary? ..................... ~ Yes ~ No If not, identify prior accountings, the accounting periods covered, and the date of adjudication of the prior accounting. 2 Decedent died on February 6, 2010 Letters Testamentary or ~ Letters of Administration were granted to Petitioner(s) on Februarv 23.2010 Date of Will (f applicable): N/A Date(s) of Codicil(s) (if applicable): N/A Date of probate (different from date Letters granted): Same Was a bond required? ~ Yes ~ No If yes, state amount: Are proofs of advertising of the grant of Letters attached? ......... ~ Yes ®No Dates of advertising of the grant of Letters: C'arl;cle Rer,t;r,et• 4/2R 5/5/ 5/t ~/ant n Cumberland Law Journal: 4/30, 5/7, 5/14/2010 Form OG01 rev. 10.13.06 Page 2 Of 10 Estate of JAMES R. JACOBS ,Deceased 3. Was decedent survived by a spouse? ............................. Yes /® No If yes, name of the surviving spouse: 4. Has the surviving spouse filed to take an elective share? ............. Yes ~ No (See Section 2201 et sic. of the Probate, Estates and Fiduciaries Code) If yes, date of election: 5. In the case of an intestacy, state the names of the decedent's surviving children or surviving issue of deceased children (rf none, so state): 6. Did decedent marry after execution of Will or Codicil(s)? ........... ^ Yes ~ No Were any children born to decedent after execution of Will or Codicil(s)? ........................................... ~ Yes ~ No If yes, give names and dates of birth: Name: Date of Birth: 7. If required by the Medical Assistance Estate Recovery Act, 62 P.S. § 1412, was a request for a statement of claim sent to the Department of Public Welfare? .............................. ~/ Yes ~ No D.P.W. provided a Clearance Letter as of 4/29/2010. Form OC-01 rev. 10.13.06 Page 3 of 10 Estate of JAMES R. JACOBS Deceased Written notice of the Audit as required by Pa. O.C. Rules 6.3, 6.7 and 6.8 has been or will be given to all parties in interest listed in item 9 below, all unpaid creditors and all claimants listed in item 10 below. In addition, notice of any questions requiring Adjudication as discussed in item 14 below has been or will be given to all persons affected thereby. A. If Notice has been given, attach a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice. B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice shall be submitted at the Audit together with a statement executed by a Petitioner or counsel certifying that such notice has been given. C. If any person entitled to Notice is not sui juris (e.g., minors or incapacitated persons), Notice of the Audit has been or will be given to the appropriate representative on such party's behalf as required by Pa. O.C. Rule 5.2. D. If any charitable interest is involved, Notice of the Audit has been or will also be given to the Attorney General as required under Pa. O.C. Rule 5.5. In addition, the Attorney General's clearance certificate (or proof of service of Notice and a copy of such Notice) must be submitted herewith or at the Audit. 9. List all parties (charitable and non-charitable) of whom Petitioner(s) has/have notice or knowledge, having or claiming any interest in the estate as beneficiaries under the Will or Codicil(s) or as intestate heirs if there is a complete or partial intestacy: A. State each party's relationship to the decedent and the nature of each party's interest(s): Address of Each Party in Interest Joan M. Jacobs 333 West Simpson St. Mechanicsburg, PA 17055 Mother and Petitioner Interest 100%- Intestate Share Form OC-01 rev. 10.13.06 Page 4 of 10 Estate of JAMES R. JACOBS _ ,Deceased B. Identify each party who is not sui juris (e.g., minors or incapacitated persons). For each such party, give date of birth, the name of each Guardian and how each Guardian was appointed. If no Guardian has been appointed, identify the next of kin of such party, giving the name, address and relationship of each. None C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for this Audit (see Pa. O. C. Rule 12.4). N/A D. If distribution is to be made to the personal representative of a deceased party, state date of death, date and place of grant of Letters and type of Letters granted. N/A Fo,r, oc-o~ rev. ~o.t3.o6 Page 5 of 10 Estate of JAMES R. JACOBS ,Deceased 10. Other than the claim for the family exemption, list the names of all known claimants and the amount of their claims and state whether each claim is admitted. Name and Address of Each Claimant Amount of Claim Claim Will Claim Admitted? Be Paid In Full? Chase Visa Card $14,707.72 --Yes ~ Y s o c/o West Asset Management, Inc. No v i PO Box 6183 Omaha, NE 68106-0183 Citibank MasterCard $5,341.52 es ~No ~ Yes [~'~o c/o AscensionPoint Recovery Services 200 Coon Rapids Blvd., Suite 200 Coon Rapids, MN 55433-5876 Chase MasterCard $7,737.77 es ~ YY s c/o West Asset Management, Inc. ~NO `=' "O PO Box 6183 Omaha, NE 68106-0183 AAA Visa Card (Bank of America) $5,216.38 Yes ^~ s No c/o FIA Card Services ^No Q PO Box 15409 Wilmington, DE 19885-5409 If the estate is insolvent, attach a schedule setting forth the order of preference under 20 Pa.C.S. § 3392 and the proposed payments. 11. Was family exemption claimed? ................................ ®/ Yes ~No Was family exemption allowed? ................................ /©Yes No Family exemption claimant's name and relationship: Name: Joan M. Jacobs Relationship: Mother Form OC-0/ rev. 10.13.06 Page 6 of 10 Estate of JAMES R. JACOBS ,Deceased 10. Other than the claim for the family exemption, list the names of all known claimants and the amount of their claims and state whether each claim is admitted. Name and Address of Each Claimant Amount of Claim Claim Will Claim Admitted? Be Paidln Full? Pinnacle Health Medical Services $40.00 D Yes ^ Yes c/o Bureau of Account Management ~No o 3607 Rosemont Avenue, Suite 502 PO Box 8875, Camp Hill, PA 17001 Pinnacle Health Medical Services $80.50 es ~ Yes ^No ~o c/o Bureau of Account Management 3607 Rosemont Avenue, Suite 502 PO Box 8875, Camp Hill, PA 17001 Holy Spirit Hospital $75.00 Wes ~ YY s PO Box 822183 ONO "~' "O Philadelphia, PA 19182-2183 Yes ^ Yes No ~ No If the estate is insolvent, attach a schedule setting forth the order of preference under 20 Pa.C.S. § 3392 and the proposed payments. 11. Was family exemption claimed? ................................ ®/ Yes ONo Was family exemption allowed? ................................ /®Yes ~No Family exemption claimant's name and relationship: Name. Joan M. Jacobs Form OC-01 rev. 10.13.06 Relationship: Mother Page 6 of 10 A Estate of JAMES R. JACOBS Deceased 12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate Tax paid, the date(s) of payment(s), and the interest(s) upon which paid, are as follows: Date Payment Interest 13. On the date of death, was the decedent a fiduciary (personal representative, trustee, guardian, agent under power of attorney) or surety on the bond of a fiduciary? ................... ~ Yes /^ No If yes, provide the name of the estate, indicate whether an account has been filed and confirmed absolutely and all awards performed, or, in the alternative, how the decedent's estate will be discharged for the decedent's fiduciary administration of the estate. 14. A. Describe in detail any questions requiring adjudication and state the position of the Petitioner(s) as to each question: None B. Has notice of the question requiring adjudication been given to the parties identified in Paragraph 9 above? .................. ~ Yes ~ No 15. If Petitioner(s) has/have knowledge that a share has been assigned, renounced, disclaimed or attached, provide a copy of the assignment, renunciation, disclaimer or attachment, together with any relevant supporting documentation. Form oc-ot rev. to.t3.o6 Page 7 of 10 Estate of JAMES R. JACOBS Deceased 16. Had the decedent been adjudicated an incapacitated person? .......... ~ Yes ®/ No If yes, attach a copy of the Order if available; otherwise state the Court, term, number, date, and name of Hearing Judge. 17. A. List or attach a separate list of additional receipts and disbursements since the closing date of the Account. B. Has notice of the additional receipts and disbursements been given to the parties identified in Paragraph 9 above? ............. Yes ~ No 18. If a reserve is requested, state amount and purpose. Amount: Purpose: If a reserve is requested for counsel fees, has notice of the amount of fees to be paid from the reserve been given to the parties in interest? ........................................ Dyes /®No If so, attach a copy of the notice. 19. Is the Court being asked to direct the filing of a Schedule of Distribution? .......................... DYes ~No As to real estate only? ........................................ QYes /~ No Farm oc-o/ rev. 10.13.06 Page 8 of 10 Estate of JAMES R. JACOBS ,Deceased Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties entitled and suggest(s) that the distributive shares of income and principal (residuary shares being stated in proportions, not amounts) are as follows: A. Income: Proposed Distributee(s) Amount/Proportion Joan M. Jacobs 0 B. Principal: Proposed Distributee(s) Amount/Proportion Joan M. Jacobs 0 Submitted By: (All petitioners must sign. Add additional lines if necessary): ,~, ~~-~ me of Petition JOAN M. JACOBS Name of Petitioner: Form oc-ol rev. 10.13.06 Page 9 of 10 Estate of JAMES R. JACOBS ,Deceased Verification of Petitioner (Verification must be by at least one petitioner.) The undersigned hereby verifies * [that heisne she is nrre Administratrix of the above-named name of corporation Estate and] that the facts set forth in the foregoing Petition for Adjudication /Statement of Proposed Distribution which are within the personal knowledge of the Petitioner are true, and as to facts based on the information of others, the Petitioner, after diligent inquiry, believes them to be true; and that any false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities). Signature of Peti oner * Corporate petitioners must complete bracketed information. Certification of Counsel The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/ Statement of Proposed Distribution is a true and accurate reproduction of the form Petition authorized by the Supreme Court, and that no changes to the form have been made beyond the responses herein. ~ 1 tgnature of Counsel for Petitioner Form oc-or rev. ro. rs.o6 Page 10 of 10 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA. ORPHANS' COURT DIVISION FILE NO. 21-10-0175 FIRST AND FINAL ACCOUNT OF JOAN M. JACOBS, Administratrix For ESTATE OF JAMES R. JACOBS Date of Death: Date of Incapacity, if any: Date of Administrator's Appointment: Date of First Complete Advertisement: Accounting for the period: 2/6/2010 None 2/23/2010 5/14/2010 2/23/2010 9/30/2011 __p ,--, _ ' !~ -, _. ~._; PURPOSE OF ACCOUNT: The Administratrix offers this Account to acquaint interested parties with the transactions that have occurred during the Administration. It is important that the Account be carefully examined. Requests for additional information, questions or objections can be discussed with: Charles E. Shields III 6 Clouser Road Mechanicsburg, Pennsylvania 17055 Phone Number: (717) 766-0209 Supreme Court I.D. No. 38513 1 SUMMARY OF ACCOUNT PRINCIPAL RECEIPTS PAGES Real Estate 3 $ 0.00 Common Stocks 3 0.00 Miscellaneous Personalty 3 10,774.99 Shortfall Payment by Administratrix 3 271.88 $11,046.87 Less Disbursements: Administration Expenses 4 $ 645.94 Fees and Commissions 4 4,022.37 Family Exemption 4 3,500.00 Funeral Expenses 4 2,411.18 Grave Marker 4 80.81 Governmental Taxing Authorities 4 467.38 Sub-Total Disbursements 5 $11,046.87 INCOME Receipts 5 $ -0- Less Disbursements 5 $ -0- Balance before Distributions 5 $ -p- Distributions to Beneficiaries 5 $ _0_ Income Balance on Hand 5 $ _0_ COMBINED BALANCE ON HAND 6 Debts of Decedent /Proposed Distribution 7 BALANCE AFTER PAYMENT OF APPORTIONED NON-PRIORITY DEBTS $11,046.87 $33,198.89 $ -0- $ -0- 2 PRINCIPAL RECEIPTS Real Estate None $ 0.00 Common Stocks None $ 0.00 Miscellaneous Personalty PNC Bank Acct No. 507 003 14 11-checking account, $ 63.53 non-interest bearing Members 1St Fed. Credit Union A. Savings Account NO. 133 830-00 $ 857.41 B. Interest Accrued on Savings Acct as of DOD .04 C. Checking Account No. 1330830-11 non-interest bearing $ 1,278.17 Sale of Assorted Drums and related items to Dale's Drum $ 1,000.00 Shop of Harrisburg, PA Paycheck of Jan. 31 through Feb. 13, 2010, Dale's Drum Shop $ 695.09 1998 FORD SW VIN 2FMZA147WBD38713* $ 585.00 Geisinger Quality Options, Inc., Reimbursement on Ins. Claim $ 1,526.00 Kemper Ins., Refund on Car Insurance $ 56.00 Assorted Baseball and Football Cards, estim. value per $ 42.50 discussion with Card Stadium, 3715 Walnut St. Harrisburg, PA IRS Refund 2009 Personal Inc Tax $ 1,006.00 Miscellaneous Personalty (as was detailed more fully at large $ 68.25 at Item 10 of Schedule E of the Inheritance Tax Return) Per Capita Distribution of Share of Casino Proceeds from $ 2,705.00 Eastern Band of Cherokee Indians IRS Refund on Close-out 1040 for calendar year 2010 $ 892.00 $10,774.99 TOTAL PRINCIPAL RECEIPTS $10,774.99 SHORTFALL PROVIDED BY ADMINISTRATRIX $ 271.88 TOTAL ADJUSTED PRINCIPAL RECIEPTS $11,046.87 * INFO NOTE: Actual consideration shown on Motor Vehicle Title Paper shows a higher price which included Auto Sales Commission. Figure shown here is actual net figure received by Estate. 3 DISBURSEMENTS OF PRINCIPAL INFORMATIONAL NOTE: ESTATE IS INSOLVENT. FOR CONVENIENCE OF YOUR HONORABLE COURT AND CREDITORS, DISBURSEMENTS ARE SET FORTH HEREINBELOW ACCORDING TO LEGAL PRIORITIES OF PAYMENT, AS FOLLOWS: COSTS OF ADMINISTRATION GENERAL: Probate fees and original issue of short certificates $ 83.50 Additional probate fees $ 30.00 Filing Fee to Register of Wills for Inheritance Tax Return $ 15.00 Filing Fee for Accounting with Orphans' Court $ 130.00 Photocopies, certified mailings to creditors, etc. (estim.) $ 155.00 Advertising in Cumberland Law Journal $ 75.00 Advertising in Carlisle Sentinel $ 134.44 Additional Short Certificates $ 12.00 Service Charge on Checking Account 11.00 $ 645.94 FEES AND COMMISSIONS Joan M. Jacobs, Administratrix(waived) $ 750.00 Charles E. Shields III, attorney's fees $ 2,621.37 Janet Brackbill, H& R Block, Accountant for 2009 $ 126.00 Personal Income Tax Return Reserved to pay estimated fee to Janet Brackbill for preparation of 2010 Fed 1040 and PA 40 closeouts, Fed 1040 and PA 41 Estate Income Tax Returns. 525.00 $ 4,022.37 FAMILY EXEMPTION Family Exemption: JOAN M. JACOBS 3 500.00 $ 3,500.00 FUNERAL EXPENSES AND MEDICAL SERVICE EXPENSES WITHIN SIX (6) MONTHS OF DEATH Hollinger Funeral Home of Mt. Holly Springs $ 2,330.37 Grave Marker: W.N.C. Marble & Granite Works 80.81 $ 2,411.18 GOVERNMENTAL TAXING AUTHORITIES West Shore Tax Bureau, 2009 Personal Income Tax $ 100.56 PA 40 2009 Personal Income Tax $ 250.00 Penna. Dept. of Revenue for 2010 Personal Income Tax $ 83.00 West Shore Tax Bureau for 2010 Personal Income Tax 33.82 $ 467.38 4 SUBTOTAL OF ALL PRIORITY AND PRE-DEATH PAYMENTS $11,046.87 TOTAL RECIEPTS OF INCOME $ -0_ DISBURSEMENTS OF INCOME $ -0- RECAPITULATION PRINCIPAL BALANCE DISBURSEMENTS FROM PRINCIPAL BALANCE OF PRINCIPAL ON HAND INCOME BALANCE ON HAND COMBINED BALANCE ON HAND $11,046.87 $11,046.87 $ -0- $ -0- $ -0- 6 CLAIMS OF PRIVATE NON-GOVERNMENTAL AND NON-SECURED CRREDITORS FOR DEBTS OF DECEDENT [These are to be paid at the rate of $0.0 on the dollar. This is based on the percentage of funds left versus face amount of these debts which follow. The face amounts are given in the first column and the proposed payment amounts are given in the second column in brackets.] Chase Visa Card No. 4417 1222 2210 2445 $14,707.72 [$ -0-] Citibank MasterCard No. 5418 8702 6002 3826 $ 5,341.52 [$ -0-] Chase Master Card No. 5422 4320 5109 9376 $ 7,737.77 [$ -0-] AAA Visa Card (Bank of America) No. 4264 2960 2401 6732 $ 5,216.38 [$ -0-] Pinnacle Health med services for office visit of 1/27/10, etc $ 40.00 [$ -0-] Acct. No. 272338 balance due by patient Pinnacle Health for services rendered on 1/21/10, etc. $ 80.50 [$ -0-] Acct. No. 100189893 balance due by patient Holy Spirit Hospital for assorted services provided on 2/6/10 $ 75.00 [$ -0-] Acct. No. 36465482 TOTAL CLAIMS /PROPOSED DISTRIBUTION $33,198.89 [$ -0-] ,~,.zz~L . ~ ~, (SEAL) JOAN M. JACO , Administratrix of the Will of James R. Jacobs, Deceased 7 VERIFICATION JOAN M. JACOBS, Administratrix of the Will of James R. Jacobs, deceased, hereby declares under oath that she has fully and faithfully discharged the duties of his office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; that, to his knowledge, there are no claims outstanding against the Estate; that all taxes presently due from the Estate have been paid; and that the grant of Letters Testamentary and the first complete advertisement thereof occurred more than four months before the filing of the foregoing First and Final Account. This statement is made subject to penalties of 18 Pa. C.S.A. Section 4904 relating to unsworn falsification to authorities. (Seal) JOAN M. JA OBS Dated: 6~~~~~ /3, ~//