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03-0755
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of. Se\ e. also known as Social Security No. Deceased. \9'l-6~-35~O No. ;:].1-0 :j-7.5b" To: Register of Wills fCjlr the I ~~I County of CUmber u...LQ in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: for letters of administration on the estate of ,t9 Decendent at death owned property with estimated values as folIlows: (If domiciled in Pa.) AIl 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 situated as follows: $ 0/50.00 $ $ $ Petitioner_ after a proper search h~ ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: NiV) I[ O~ 6 THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. -- '" '-' 0.> U C 0.> "0 __ Of;; ,e 0.> ... ~o.> C "00 c=o.::: ttSo.::: 3~ 0.>'- :; 0 ca c OJ) en J~/IC. ,~ ';:1< 1t1.J('';/zs /.-{ ffJ(:)(;~1C J..O FF /?-/~~-g :0 c" ~, (<J :"'~~ ~::.J OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF ~umber )CLf7d } 55 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. affirmed and 29th ~~ hL. 4lJjJ- !-NAAJUS 1.-1, !tAJ6J2J.o PF .-.. '" '-' (l) .... =' ..... tIS =: Cll) ii5 1'":'.0 ~-'.:: C., ...)\ "-l No. 21-2003-755 L~-:J [ '~l Estate of Selena M.Angeloff , Deceased ,"r"'\ 1=3 GRANT OF LETTERS OF ADMINISTRATION AND NOW September 15th :lHJ. 2003, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that Frances M. Anqeloff is/" entitled to Letters of Administration, and in accord with such finding, Letters of Administration Frances M. Anqeloff are hereby granted to in the estate of Selena M.Angeloff FEES Letters of Administration $ 18.00 Short Certificates(2 ) . . . . . . . . .. $ 6 . 00 Renunciation...( 1.).......... $ 5.00 JCP $ 10.00 TOTAL _ $ lQ_OO Filed Septauber. .15th,.200;'\~ Administrix will pick up letters. Register of Wills Donna M. Otto, 1st Deputy ATTORNEY (Sup. Ct. l.D. No.) ADDRESS PHONE RENUNCIATION 21-2003-755 In Re Estate of .sa. J t-{l ().... fY) afle.. a. LUr1 bHJ an tL 1:. n ail. j" ff deceased. To the Register of Wills of The undersignCL1 nfl. /)0 V ^~ j I ,{n (1 1)..1 u j f l.:k. .o.v.~ >' the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters County, Pennsylvania. /' be issued to -f rfLA-.t!..1:J. ~~ ~ doff WITNES~/if o.JJ... e. kre 1../ fhand this 1/ day of _9 ,19~. ~~~~}t ~:?A?~:: 110/6 t#\ddrcss) ,. (Signature) {''Y'', ':~~,' (Address) (Signature) i',-.., r~ ~ ,'. '" ,...' '00-_.... (Address) m. ~a. 9-/I-tJ,3 21-2003-755 WELTMAN, WEINBERG & REIS Co., L.P.A. ATTORNEYS AT LAW 323 W. Lakeside Avenue, Suite 200 Cleveland, Ohio 44113-1099 216.685.1000 www.weltman.com COLUMBUS 614.228.7272 CINCINNATI 513.723.2200 PITI'SBURGH 412.434.7955 DETROIT 248.362.6100 November 26, 2003 Cumberland, Register Of Wills One Courthouse Square Carlisle, PA 017013 Re: Estate of Selena M Angeloff Case No. 2~-03-755 Our Client: Bank of America, N.A. Accotmt No. 4024116008270199 Balance Due: $1,239.22 Our File No. 3289247 Dear Clerk of Courts: This law fn-m represents Bank of America, N.A. in connection with its claim which we wish to file on our client's behalf into the estate of Selena M Angeloff, deceased. Our client's claim is based upon its account number 4024116008270199 in the amount of $1,239.22. As of the date of this letter, this is the amount due. Included with this letter is the claim form which we wish to present to this court and which we are forwarding to the attorney and/or fiduciary of this estate. It would be appreciated if all correspondence and disbursements with respect to this matter be forwarded to our office and to the attention of the undersigned. Additionally, it would be appreciated if any notices of any hearings also be forwarded to the undersigned. Thank you for your cooperation in this matter. Sincerely Yours, Veda Flowers Legal Assistant 216-685-1171 VLF:iar Enclosure cc: Frances M Angeloff WELTMAN, WEINBERG & REIS Co., LP.A. ATTORNEYS AT LAW 323 W. Lakeside Avenue, Suite 200 Cleveland, Ohio 44113-1099 216.685.1000 www.weltman.com COLUMBUS 614.228.7272 CINCINNATI 513.723.2200 PITTSBURGH 412.434.7955 DETROIT 248.362.6100 November 26, 2003 Frances M Angeloff 401 Boyer St Pob 293 Summerdale, PA 17093 CERTIFIED MAIL ge~ Estate of Selena M Angeloff Case No. 2~-03-755 Our Client: Bank of America, N.A. Account No. 4024116008270199 Balance Due: $1,239.22 Our File No. 3289247 Dear Sir or Madam: This law firm represents with Bank of America, N.A.respect to the claim which we wish to file in the estate of Selena M Angeloff. It is our understanding that you are the Fiduciary of the estate. We are asking that you please accept our client's claim which is based upon its account number 4024116008270199 in the amount of $1,239.22. As of the date of this letter, this is the amount due. Please direct all correspondence and disbursements with respect to this estate directly to our office. It would also be appreciated if you contact us to advise us when you anticipate making disbursements in this matter so that we may mark our file for follow-up at that time. Thanking you in advance for your cooperation in this matter. This law firm is attempting to collect this debt for our client and any information obtained will be used for that purpose. Lastly, do not hesitate to contact us to further discuss this matter. VLF:iar Enclosure cc: Frances M Angeloff Sincerely Yours, Veda Flowers Legal Assistant 216-685-1171 WWR#3289247 FORM 93-O.C. DIVISION IN THE COURT OF COMMON PLEAS of CUMBERLAND, REGISTER OF WILLS, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE:ESTATE OF No.-z~0-03-755 Selena M Angeloff Deceased For a credit card with Bank of America, N.A., Account No. 4024116008270199 CLAIM To the Clerk of Orphans' Court Division: Index and make proper entry in your official records of the claim of Bank of America, N.A. c/o Weltman, Weinberg & Reis Co., L.P.A., 323 West Lakeside Avenue, Suite #200, Cleveland, Ohio 44113-1099 (Claimant) in the amount of $1,239.22 against the estate of the above named decedent. This claim is filed under Section 3532 (b) (2) of the Probate, Estates and Fiduciaries Code. The said decedent, who resided at PO Box 312Summerdale PA 17093 (Address) Written notice of this claim was given to Frances M Angeloff (Personal representative, if any, or counsel) , died on 08/14/03 on 401 Boyer St Pob 293 Summerdale, PA 17093 & Address or Personal Representative, if any, or counsel (Claimant) Veda Flowers, Agent for the Claimant c/o Wel~nan, Weinberg, & Reis Co., L.P.A. 323 W. Lakeside Ave., Suite200 Cleveland, Ohio 44113 (Claimant's Address) WELTMAN, WEINBERG &REIS LAKESIDE PLACE 323 W LAKESIDE AVE STE 200 CLEVELAND OH 44113-1099 CUMBERL,adN-D, REGISTER OF WILLS ONE COURTHOUSE SQUARE CARLISLE, PA 017013 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone September 20, 2005 717-787-6677 Frances M. Angeloff 401 Boyer St. P.O. Box 293 Summerdale, Pa. 17093 Re: Estate of Selena M. Angeloff File Number 2103-0755 Dear Ms. Angeloff: 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 September 20, 2006. 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 (717-787-6677). Sincerely, ~-? ..-::,.~;::.::"~.,,, 7- ...----- ". ,- --/ .---~ /' ~~-'- --_._~ i '. Emerson Luciano Inheritance Tax Division E-Maileluciano@state.pa.us FAX 717-772-0412 RJ. Name of Decedent: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Date of Death: Will No. 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: Signature Name Address Telephone ( ) Capacity: ~ Personal Representative Counsel for personal representative Cumberland County - Register Of wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/13/2005 ANGELOFF FRANCES M 401 BOYER STREET PO BOX 293 SUMMERDALE, PA 17093 RE: Estate of ANGELOFF SELENA M File Number: 2003-00755 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. I, for decedents dying on or after July I, 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: 8/14/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~!~A.J~ GLENDA FARNER-~~~S~G; REGISTER OF WILLS cc: File Counsel Judge rP STATUS REPORT UNDER RULE 6.12 Name of Decedent: SFLF1Jft- I-A ftO&fZ'LO FF Date of Death: ~ 11 bU S I J4 J.iY)3 t;\~. } Wrll No.: 3,00.3-0() IS'S Admin. Nu.:- Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the fonowing with respect to completion of the administration of the above-captioned estate: 1. State whether a~is~on of the estate is complete: Yes 0 No Ed" 2. lithe answer is No, state when the personal representative reasonably believes that the administration will be complete: ~1i Ll', JJ L ;+i 5 M-i m - ~< b I~ a.JlotheR Ve.aR. 3. lithe answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No 0 b. The separate Orphans' 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 0 No 0 Date: ~os- c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court md may b, attachod to thh r.~!f ~~p~ IX 441- Signature ..:1" C"J :ffJH ~E; ).). A;v~kkFF- Name U: C CL (' .' ;-.- ' 1)D. "13nx d1:1) ~f1m/)')jt))4J..;;))/i 171fi3 Address C~' I, { (-- ( c CD I ( ,- LF;) c--/ (,-,;.::. C'-,I c) '71'7 - ~ 3;)..- R-fd7 Telephone No. Capacity: ~onal Renresentative o Counsel for .personal representative " .) ~ - ~ Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/05/2006 ANGELOFF FRANCES M 401 BOYER STREET PO BOX 293 SUMMERDALE, PA 17093 RE: Estate of ANGELOFF SELENA M File Number: 2003-00755 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: 8/14/2006 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 ~ \ Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 NameOfDecedent:J!~<u hZLuU.../ O~~ Date of Death: Q{Jvt'td /4 Olo().;) o I Estate No.: ',.;)OD3--Ctf7.::Li) Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the adnThJ.istration of the above-captioned estate: 1. State whether ad~istr~n of the estate is complete: Yes 0 No ~ 2. If the ansy;er is No, stqte ',xrhen the nersonal representative reasonably believes that the administration will be complete": ~'fu.j 11LJ ;+hl n ~ht ()ex}- Y (}llR., 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a fmal account with the Court? Yes 0 No 0 b. The separate Orphans' 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 0 No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. '- iJ-a 1!UJ) JiL 4d1/r SIgnature ~< H')('L,-<-; J) l+JJ&EJ.JJFF . Name Date: I jd5J()(/ '7. () ff6u~ cQl~ ~Ll JA 1-1 EQ''0ltLf) '~'l 17m3 Address ') } 1-- '13;)- ~g- ;~Y7 Telephone No. Capacity: ~onal Representative o Counsel for personal representative r \ Cumberland County - Register Of wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/27/2007 (") ~=O <-::0 -.0 sP .2:;~;~ ~"l~.'-) ;::.-~ ~J~.~ ~::U --1 I"--.) = <-= .....! <- C I N -.J -0 '-:i' N N ANGELOFF FRANCES M 401 BOYER STREET PO BOX 293 SUMMERDALE, PA 17093 RE: Estate of ANGELOFF SELENA M File Number: 2003-00755 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: 8/14/2007 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 P:,." 0, " C: p-T.l'n or 17 c:'T.'.... I' 'D, S DVPAn't""' a, ::)' o..t..\...ul\""- 'c:..i::;: 0.1'......'"';;...' .L..~.t. VI\....L REGISTER OF "\VILLS OF COuNTY, PEN"NSYL VANIA Name ofDecedent ~J. 11/1111 j )17.oJ 1R / O;nflJ1f Date of Death: {JfP,J:; } ~ ;JOO.3 File Number iJJ ()1J3 - ()() 1.# Pursuant to Pa. O.c. Rule 6.12, I report the follO\ving with respect to completion of the administrati0l1 of the above-captioned estate: 1. State whether administration of the estate is complete: . . . . . . . . . . . . . . . . . . .. D Y e~ ~ 2. If the answel~is No, state when the peIsonal repl'esentative reasonably believes that the adriiinistration will be complete: )J 0-1- ..s (,Le.e.. I h bpe.Aid 1'1 h 4 /J (', t:t ~ eff ~ 3. If the answer to No.1 is YES, state the following: a. Did the personal representative file a fmar' account with the Court? . . . . ' . DYes 0 No b. The separate Orphans' 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? .............,:,...............' 0 Yes d. Copies of receipts, releases, joinders and approvals of formal or'informal accounts may be filed with the Clerk oftbe Orphans' Court and may be attached to this repOlt. l!t!;/!d:1/i,~fj,J!l. Jo,JA-ff Capacity: ~al Representa:tive DCoul1sel FR/hl)('t-RS J), IJAJ&plrJPF Name of Person Filing this F0I"171 1), D. 6 (J,y' ~ti3 s'~ m In JTR ~ lJi/Z. ])f), J 1C/i3 " '7),'1- ;3;)- !f;JI TelephCJI,e D",C1~Id: J, /)ofJ7 V(j , ,j,) , , .', _.Jill')" l' '("'( ,,_'_k,1 1 0 tJ i )8 S,NVH&JO :In \11)11" v /IU.J 0 o fJ : II WV L - ~nv LDOl ,=-:J:"Jii Rj.V-.'Cr ;'(?v. /Oi3.0r5 ~ Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone:(717) 240-6345 Date: 7f 11/2008 ANGELOFF FRANCES M 401 BOYER STREET PO BOX 293 SLiMMERDALE , PA 17 0 9 3 RE.: Estate of ANGELOFF SELENA M File Number: 2003-00755 Dear Sir/Madam: r~a n r--; . ~ ~ r-, .. " *J j te t' ("' ~5 ;-~ r ..- f m --- ; ~ ~ J3 C ; i i_~ c.? ~:~ f r, _~ 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: 8/14/2008 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, J I v~cit~..tR.f ~ ~" Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel ~a. ®.C.//Rine 6.1~ S'T~T'IJS ~P~RT REGISTER OF WILLS OF I.GINvi~CQ)..Q,n~c~. COUNTY, PENNSYLV:~NIA Name of Decedent: SE' ~n~ M ~ I ~. ~~ ly Date of Death: ~~~,5-f - 1 ~, t~t703 File Number: 0703 `(,7 (7 7 ~~ 'D..,-,,.,~,..++„ D., !l l' D„lo ~ 17 T ,•cr,nrt t}1n f~ll~~x~ina ixnth ,-ec»ert to nmm~letinn of the administration of .~ u~~uuau w i u. v.~~. a~ua~. v. a., a a~.r v...aa~ •'b Y__' r- the above-captioned estate: l . State whether administration of the estate is complete :.................... [D Yes No 2. If the answeris 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 b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account infornlally to the parties in interest? .............................. . ~ QYes C] No d. Copies of receipts, releases, joinders and approvals of foi~nal or informal accounts maybe filed with the Cleric of the Orphans' Court and maybe attached to this report. Dnte ~ O L iii ~ ~~- ~ ~' 7~"Q ~,- ,' r Signature of Person Filing this Forni Capacity: ersonai Representative Q Counsel ~~ ~ ~~ 1 Nnme of Person Filing this Forn: 1`x.0. ~©x o2~i,~ Address ~ j ~U/YYl n1 ~ ~~ti~l ~ I-C . J ~G~~ Telepha~e Form RN'-10 re~~. l0 13.0/ CERTIFICATION OF NOTICE UNDER RULE 5.6(A) Name of Decedent: Selena M. An~eloff Date of Death: August 14, 2003 Will No. To the Register of Wills: Admin. No. 21-03-00755 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 March 31, 2009 Name: Address: Dallas M. Eyler 401 Boyer Street P. O. Box 293 Summerdale PA 17093 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Notice of Exception. Date: April 1, 2009 ~~ Signature Elizabeth H. Feather, Esquire, Esquire Name 3631 North Front Street Harrisburg, PA 17110 Address (717)232-7661 Telephone Capacity: Personal Representative n ~ X Counsel for Personal Representativ~0 ° `- 7a. ; r n 146835 -~ ~~ " ' ~ i ~ ~ ~ , ~r ~ t t ~0~,~ -p ~3 - O ' a IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE. Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of Selena M. Angeloff, deceased, No. 21-03-00755 TO: Dallas M. Eyler c/o Frances Angeloff 401 Boyer Street P. O. Box 293 Summerdale, PA 17093 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent, Selena M. Angeloff, died on August 14, 2003, in Cumberland County, Pennsylvania. ^ The Decedent died testate (with a Will) ®The Decedent died intestate (without a Will). Name(s), address(es) and telephone number(s) of all personal representatives appointed: Name Address Telephone Frances M Angeloff 401 Boyer Street P.O. Box 293, Summerdale, PA 17093 717-732-8827 If the Decedent died testate, the Will has been filed with the Office of the Register of Wills of Cumberland County Pennsylvania If the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the Register of Wills of: Cumberland County Pennsylvania A copy of the Petition can be obtained from the Cumberland County Register of Wills. Date: March ~~ 2009 Signature ~ ~ti. 't, Name Eliz eth H. Feather, Esquire Address 3631 North Front Street Capacity: ^ Personal Representative ® Counsel for Personal Representative Harrisburg, PA 17110 Telephone (717) 232-7661 146834 COMMONWEALTH OF PENNSYLVANIA DEPARTM F REVENUE BU OF INDIVIDUAL TA%ES DEPT. 280801 HARRISBURG, PA 17128-0801 RECEIVED FROM: CALDWELL & KEARNS 3631 NORTH FRONT STREET HARRISBURG, PA 17110 -------- bIE PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX111-981 N0. CD 01 1355 ACN ASSESSMENT AMOUNT CONTROL NUMBER ESTATE INFORMATION: SSN: i97-58-3580 FILE NUMBER: 2103-0755 DECEDENT NAME: ANGELOFF SELENA M DATE OF PAYMENT: 06/15/2009 POSTMARK DATE: 06/12/2009 COUNTY: CUMBERLAND DATE OF DEATH: 08/14/2003 1.01 ~ 5920.23 TOTAL AMOUNT PAID: REMARKS: RECEIPT TO ATTORNEY CHECK#71910 SEAL INITIALS: WZ RECEIVED BY: 5920.23 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS JAMES R. CLIPPINGER CHARLES J. DEHART. III JAME9 L. GOLD SMITH P. DANIEL ALTLAND JEFFREY T. Mc GUIRE• STANLEY J. A. LABKOWSKI DOUGLAS K. MAR SILO BRETT M. WOODBURN MICHAEL D. REED PAULA J. LEICHT ELIZABETH H. FEATHER KAREN W. MILLER DOUGLAS M. OBERHOLSER •BOARD CERTIFIED CIVIL TRIAL ADVOCATE CALDWELL &KEARNS A PROFESSIONAL CORPORATION ATTORNEYS AT LAW 3631 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 1 7110-1 5 3 3 June ] 2, 2009 OF COUNSEL CARL G. WARS JAMES D. CAMPBELL, JR. THOMAS D. CALDWELL, JR. 119 2 8-2 0011 RICHARD L. KEARNS RETIRED >IJ-232-J661 FA%: >I>-232-2J66 thefirmOceldwellkeams.com Glenda F. Famer-Strausbaug, Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 c-~ o ~~ ~~~ a 12E: Estate of Selena Angeloff }~~ ~ File No. 21-03-007.55 I,~n o'O~" z Dear Ms. Famer-Strausbaug: ~~ to cn Enclosed please find the original and two copies of the Pennsylvania Inheritance 'Ta~ Return in regard to the above-referenced Fstate. Please file the same and return ope time- stamped copy to me ~n the enclosed self-addressed, stamped envelope I I hay a also enclosed a check in the amofmt of $920.23, as payment of the inheritance, tax. Thank you for your assistance in this matter. If you have any questions, please contact me Very truly yours, a~. a.~, Elizabeth H. Feather CALDWELL &KEARNS, P.C. Ic~rthcr(ncaldwt III<canls.~ptn EHF: SE Encs. cc: Frances Angeloff (w{enc.) 09131-001/149697 .} ;_1. s,~ ~> 4 . ri ., t T . i-1 J 1` K, .` C..i -, -Y, ;. .~ I m 0 m o I 3 ~ o IOO~Nh W~NO lid~~~ ~a ~ ° ~ ~ ~i mo N ~6 ~ '~A ~ LL a ~-o .- a W O J _~n N O Q O O ~ s F m w '~ [S] w ~n r o '~V]' ~ ~"'~ ~ _ ~t- r z o a ~ a u. x ~ ~ ~ ~ ~ 0 Z cn m ~ ~ a m = ~~-,-,~~,,,.r.r.~ o~F~Acc ~;- ., ,,,:,Ynnr 1~~A~. 1 ?~09 .~tJi:. 5 Phi i2~ 5T ~:.~ ~~ N w O ~ N N 7 m L ~ QO ~ j 7 M O ~ viU~~ ~~ No N ~ o ~ o r Q ~U ~~ cn C p dj ~ ~U N ~ ~ C ~ li ~~U V_ U m c N C~ J 15056051058 REV-1500 EX (06-05) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 03 00755 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 197-58-3580 08/14/2003 04/14/1978 Decedent's Last Name Suffix Decedent's First Name ANGELOFF MI SELENA M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW • 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death 4. Limited Estate prior to 12-13-82) 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Re uired d q eath after 12-12-82) 6. Decedent Died Testate (Attach Copy of Will) 7. Decedent Maintained a Livin Trust 0 9 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) • 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec 9113(A) b t . e ween 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORM Name ATION SHOULD BE DIRECTED T0: Daytime Telephone Number ELIZABETH FEATHER, ESQ. (717) 232-7661 Firm Name (If Applicable) r`•~ C~ c:r:a CALDWELL & KEARNS REGISTER OF:VWLiL~ USE ONLY , -_ . ~~' First line of address T ~<~ ~ ~ r, "'~ 3631 N. FRONT STREET ,_ --~ 7 ~ ~ ~ : Second line of address ~_%c~} ,.. < "? ,--4 ... , ......_ . "r~' J. _. a. -i .. City or Post Office - :ate ` ~ ..,. - . State ZIP Code DATE FILED fV ~ ~ , ;, , ~r1 HARRISBURG v PA 17110 Correspondent's a-mail address: efeather@caldwellkearns.com 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. SIG AT ~ E OF PERSON RESPONSIBIjE FOR FILING RETURN ADDRESS 401 Boyer Street, PO Box 293, Summerdale, PA 17093 SKaNATI~RE OF ~RFj~P~RF~ OTHE~ THAN REPRESENTATIVE ~.. A r DATE e ADDRE~ (~/~ r ~ ~~ 3631 N. Front Street, Harrisburg, PA 17109 + PLEASE USE ORIGINAL FORM ONLY 1 505605 1 058 Side 1 L 15056051058 J 15056052059 REV-1500 EX Decedent's Name: SELENA M ANGELOFF RECAPITULATION 1 Real estate (Schedule A). ...... . ........... 2. Stocks and Bonds (Schedule B 1 3. Closel Held Cor oration, Partnershi or Sole-Pro rietorshi 2 p P P (Schedule C) .. , . 3 4. Mortgages & Notes Receivable (Schedule D) , ... . P 5 Cash, Bank De osits & Miscellaneous Personal Pro ert 4 P y (Schedule E) .... . 6. Jointly Owned Pro e ~ • ~ 5' P rty (Schedule F) Separate Billin 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properh, Requested .... . (Schedule G) ~ • 6• Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7).. . ............................... 9. Funeral Expenses & Administrative Costs (Schedule H), , .......... 8 10. Debts of Decedent, Mort a 9. 9 ge Liabilities, & Liens (Schedule I) .. , 11. Total Deductions (total Lines 9 & 10).. , , 10 .... ..... 12. Net Value of Estate (Line 8 minus Line 11) „ , 11 .......... 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .. , , • ................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . , TAX COMPUTATION • SEE INSTRUCTIONS FOR APPLICABLE RATES ~ 14 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable 15. at lineal rate X .0 45 17. Amount of Line 14 taxable 20,449.50 16. at sibling rate X .12 18. Amount of Line 14 taxable 17. at collateral rate X .15 19. TAX DUE .... . .................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Social Security Number 197-58-3580 0.00 0.00 0.00 0.00 33, 780.67 0.00 0.00 33,780.67 13,331.17 0.00 13,331.17 20,449.50 0.00 20,449.50 920.23 920.23 ~~~ J S\a@ Z 15056052059 5~56p5 .~ REV-1500 EX Page 3 Decedent's Complete Address: SELENA M ANGELOFF STREET ADDRESS 407 FOURTH STREET PO BOX 312 CITY SUMMERDALE Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit _ B. Prior Payments C. Discount - 3. InteresUPenalty if applicable D. Interest E. Penalty File Number 21 03 00755 DECEDENT'S SOCIAL SECURITY NUMBER 197-58-3580 PA I zIP ---- 17093 (1) 920.23 Total Credits (A + B + C) (2) 4. if Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENTotal InteresUPenalty (D + E) (3) Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (4) A. Enter the interest on the tax due. (5) 6. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (56) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIAT 1. Did decedent make a transfer and: E BLOCKS a. retain the use or income of the property transferred :.......................................... Yes No 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? ..... 0.00 0.00 0.00 920.23 0.00 920.23 ................ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RET URN. 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 survivin sous is three (3) percent [72 P.S. §9116 (a) (1.i) (i)]. g p e 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 zero 0 ercent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does no_ t exgmot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets an filing a tax return are still applicable even if the surviving spouse is the only beneficiary. () p d 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 arent adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)J, p , an The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, exce t as note 72 P.S. §9116(1.2) [72 P,S. §9116(a)(1)]. p dm The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S, §9116(a)(1.3)]. Asibling isdefined un Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. der REV-1508 EX+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, $c M~$C. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF SELENA M. ANGELOFF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. 21 03 0755 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE 1. Belco Credit Union account #7766090 checking OF DEATH 2. Belco Credit Union account #7766090 savings 41.40 3. YMCA payroll 6.90 4. IRS 2003 federal income tax refund 558.31 5. Miscellaneous ersonal roe 3,037.00 P p p rtY (clothes, furniture, household goods) 6. Personal injury litigation survival action proceeds received by the Estate on April 20, 2009 100.00 30, 037.06 TOTAL (Also enter on line 5 Recapitulation) E I 33 780 67 ~~f Na~~ ~~ ~~eeaea insert additional sheets of the same size) EV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF SELENA M. ANGELOFF FILE NUMBER 21 03 0755 Debts of decedent must be reported on Schedule I. ITEM NUMBER A• FUNERAL EXPENSES: DESCRIPTION ~' James R. Gingrich Memorials- headstone 3, 080.00 t3. ADMINISTRATIVE COSTS: t • Personal Representative's Commissions Name of Personal Representative(s) Frances M. Angeloff, Administratrix 3,000.00 Social Security Number(s)/EIN Number of Personal Representative(s) 219-62-0898 Street Address 401 Boyer Street, PO Box 293 city Summerdale .State PA Zip .17093 Year(s) Commission Paid: 2009 z Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 1,845.00 Claimant Dallas M. Eyler 3,500.00 street Address 401 Boyer Street, PO Box 293 city Summerdale State PA ,Zip 17093 Relationship of Claimant to Decedent minor son 4• Probate Fees 5• Accountant's Fees 141.00 6• Tax Return Preparer's Fees ~• Legal advertising in the Cumberland Law Journal and The Sentinel a. Rent to Rich Stambach for decedent's house from September 2003 throu h Nov b 241.30 g em er 2003 (time took for the Administratrix to move decedent's and her minor son's belon in s o t f h 1,500.00 g g u o t e house) s. Decedent's 2003 local earned in come tax paid to West Shore Tax Bureau 23.87 (Ii more space is needed, insert additional sheets of the same size) TOTAL (Also enter on line 9, Recapitulation) I $ 13,331.17 SCHEDULE H -Family Exemption- explanation of address The decedent's minor son, Dallas M. Eyler, resided with the decedent, Selena M. Angeloff, at 407 Fourth Street, Summerdale, PA 17093. After decedent's passing he moved in with his grandmother and guardian, Frances M. Angeloff, at 401 Boyer Street, Summerdale, PA 17093. F v'-lst3 ~x+I;-o~j Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF SELENA M. ANGELOFF FILE NUMBER NUMBER 21-03-0755 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE I TAXABLE DISTRIBUTIONS (Include outright spousal distributions and transfers under Do Not List Trustee(s) OF ESTATE Sec, 9116 (a) (1.2).] 1 ~ Dallas M. Eyler minor son 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 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, insert additional sheets of the same size. $ BELCO COMMUNITY CREDIT UNION DECEDENT ESTATE INFORMATION 1. Name(s) in which the account was held: SELENA ANGELOFF 2. Account number: 7766090 3. Balance as of date of death: $58.42 Balance Accrued Dividends YTD Dividends For Regular Savings: $ $6.90 $ Christmas Club: $ $ $2.05 Whatever Cfub: $ $ $ Checking: $ $51.52 $ 00 $ $0 $ Money Market: $ . $ $0.00 $ $ Certificates: Balance $ $ $ $ $ 4. Date the account was initiated: 5. Name(s) in which Safe Deposit Box was held 6. Date the box was initially rented: 7. Branch address at which the box is located: 8. Loan Information: LINE OF CREDIT Unsecured Loans: VISA B. C Miscellaneous: Accrued Dividends YTD Dividends Certificate Number For $ $ $ $ $ $ $ $ $ $ S1 SAV 2/12/01 S4 CHECKING 6/20/03 N/A Balance Accrued Interest Per Diem Int Secured Loans: $ $ $ $ $ Mortgage Loans: $ $ $ $ $ $ October 1, 2003 the balance in the S4 checkin account of $599.71 was transferred to account of Frances M An eloff. And on November 5, 2003 the S1 Savin s was closed in the amount of $6.90 check # 003533na ~..., _ , ~EI.+~~ ~~~~ t:~1Yl~ 4lIU~ W WI, SELENA M. ANGELOFF *** FO SOX 312 51R~RDALE PA 1?093 B1JY A NEfl OR USED AUTO WITH BELCO LOAN OF $10000 OR MORE FROM 9J1_1pf31/03 AND YOU WILL BE ENTERED TO WIN $1500 CASH FOR GAS JOINT OWNERS ~~~~ 19?-5 1 TRgN ffFeG.mrE 08010308310 tsar[ a+rE DESCRIPTION AMMOtJNT rINANC[ r[[sr CHARGE FINE5 8AI-J1fVCE 0801 PREVIOUS BALANCE 51-SATifIHGS 0801 WITHDRAWAL CASH 3 9 0831 NEW BALANCE -25 0 9i 91 08011 PREVIOUS BALANCE S4-CHECKING 0805 ~ • DRAFT PAID 4E 0808 * DIRECT DEPOSIT 0144 -? o 4E ---~ Yf+1CA PAYROLL 2313?0514 523 4 52 5: 0808 WITHDRAWAL CASH 0811 * ACH PA3IMENT 0149 -150 0 37 52 PREMIER CR CARD CHECKFAYMT- -?D 0 30 5 0812 ~ DRAFT PAID 0$12 ~ DRAFT PAID 0145 -65 0 23 5 0813 DRAFT FAID 0147 -60 0 17 5 0814 ~ DRAFT FAID 0148 -?5 0 10 5 0814 I DRAFT PAID o1D1 -28 0 7 5 0818 DRAFT PAID 0146 -25 0 5 5 D821 * DIRECT DEPOSIT 0150 -10 2 4 4 ---~' Yf~TCA PAYROLL 231370514 558 1 59 7 0831 NEST BALANCE I 59 ? ~ ------------------------ CLEARED D 0101 **** 0144 0145 0146 014? 0148 * *S~~ __ __ • ' ------------------ ------------------ --0150- - - - - - -- reaauaiwu® asErriw~aiwi~®~••~•~ ` I 0 YIO Et d8 BHCAI , IF ~ 10 O R OYE0., RILL 1 E 2• D 5 wore ¢•rve ie ~ c iew ce n ~w a ewi+ee ewa Y61iR 0.00 ~~ ~~~-!~~ .:.r.,,,.,~ ae..~r ww+ PlAk~~l l l CAR SHOPPING? IF YOU BUY A CAR WITH A BELCO LOAN OF $10,000 OR MORE, YOU WILL GET A $20 G~1S CARD & MAY WIH $1,500! HOW-1pf31 i BELCH ~~~~ ~Nrwr~aj 4er/~ WMr SELENA M. ANGELOFF *** PO SOX 312 S~'~~~.E PA 17093 TRAM ff'FEGTNE DATC o+t TE DE5CRIPTION 1001 PREifIOUS BAI„ANCE S1-SAVINGS 1031 NEST BALANCE 1001 FRESIIOUS BALANCE S4_CHECKIHG 10011 TRAHSFERfOTHER FRIME ACCT 172540 1031 ~ NEF7 BALANCE 0410 E~OB 6NCAR, IF ~700FCyER, A1LLRE I 2.05 ¢Fre ¢~e ~e ~ c iew ~e ¢ ~x a eai we ew¢ Y6i1R NEED TO GO SHOPPING? CHOOSE FROM 1 OF OUR LOy,T RATE HOLIDAY LOAN OFFERS! 12 MONTHS FOR 8.gg~ ApR ~ 24 MONTHS FOR 9.99 APR JOINT OWNERS (~!'041T1 1 197-58 '10010310310 AMMOLJNT ~INAnIC~ r~~sr CHARGE FINES BALANCE 0.00 0 ~~~~ ~~ 41~ W W ~,,t~~ ~i ~~ f 111 BELCO'S LOW RATE HDLIDAY LOAN OFFERS A GREAT WAY TO BORROW MONEY AND MAKE THE HOLIDAYS MORE MEMORABLE. ~: ti o a ai in 0 h CU ~~ O n 0 rn I~ 0 ~tl~ . f f; YWCA of Greater Harrisburg John Crain Kunkel Center 11 Ol Market Street Harrisburg, PA 17103 PH 717.234.7931 FAX 717.234.1779 Childhood Programs Residence Programs Emergency Shelter Violence Intervention & Prevention Programs Hotline: 1-800-654-1211 Legal and Visitation Services ~~~~~~ YWGq Greater Harrisburg affiliated with the United Way August 20, 2003 Ms. Fran Angeloff 401 Boyer Street Summerdale, PA 17093 Dear Ms. Angeloff, I have enclosed Selena's last paycheck stub that will be directly deposited into her checking account on August 21, 2003. The amount deposited includes the vacation time she had earned. Please accept my sincerest condolences for your loss and if I can be of additional help or if any questions arise please feel free to call me at 724-2242. Sincerely, Sarah G. Longway, CPA Director of Finance YWCA OF GREATER HARRISBURG :MP. NO. NAME EARNINGS ' DEPT. CD AMOUNT DEDUCTIONS CD CHECK NO. Regular 75.50 593.43 AMOUNT .Vacation 13.65 107.29 Federal Tax 40.49 0 3 9 9 2 0 Sta e Tax 19.62 FICA/Medicare 53.60 UNEMPLOYMENT COMP 0.14 CHECK DATE MED-E/E 6..22 DENTAL-SINGLE. 11.13 LOCAL - WS 1.6°s 11.21 08/21/03 CHECK AMDUNl TOTAL EARNINGS - TOTAL DEDUCTIONS - GROSS YTD EIC YTD FED W/H YTp FICA WJH YTD STATE WiH YTD LOCAL W/H YTD OTHER DEDUCTIONS l' • ~ 1 YWCA OF GREATER HARRISBURG ~~ ~ ~~ CITIZENS BANK 3-7615 1101 MARKET STREET PEnINSYLVArTIA O ~. 9 9 ~ 0 HARRISBURG, PA 17103 360 ~A~, i Y V C~1 PH. 717-234-7931 EMPLOYEE N0. ANGELSO-0O1 PAY Five Hundred Fifty Eight dollars and 31 cents DATE AMOUNT TO THE ANGELOFF, SELENA M 08/2.1/03 $558.31 ORDER OF 407 FOURTH ST ~_____~_.,~___-_T PO BOX 3.12. ~~j~~T 1~T~ ~ n _i~.~...~~T,.., TlT 1~-1~ 4~~.1~T.~A1 ~ ~1 TA/nC~!_n~n~ri ~nr- n~v ~,F ~P COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF .INDIVIDUAL TAXES ~a '' PO BOX 280601 HARRISBURG, PA 17128-0601 February 24, 2009 Nichole Matteo, Esq. Viltari, Brandes & Kline, P.C. 161 WasFiington Street, Suite 400 Conshohocken, PA 19842 Re: Estate of Selena M. Angeloff File Number 2103-0755 _.. Court of Common Pleas Cumberland County Dear Ms. Matteo: The Department of Revenue has received the Petition for Approval of Settlement Claim ~~ to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival .:.action.. It has been forwarded to this Bureau for the Commonwealth's approval. of the allocation • ' of the proceeds~paid to settle the actions.' . •• . :Pursuant to the Petition, the 25 year old decedent diecJ~`as a result of: riieclical negligence. `. Decedent is survived by her minor child. . ` Please be advised That, based upon these fads and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the net proceeds of this action, $270,333.54 to the wrongful death claim and $ 30,037.06 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 fla.C.S.A. §8302; 72 P.S. §9106, 9107. Costs and fees must be deducted in the same percentages as the~proceeds are allocated. In re Estate of Menvman, 669 A.2d 1059 (Pa. Cmwlth. 1995). trust that this letter is a sufficient representation of the Department's position on this matter: As the Department has no objections to the Petition, an attorney from the Department :of Revenue will not be attending any hearing regarding it. Please contact me if.you or the Court :has any questions or requires anything additional. from this Bureau. . • . Sinc rely, :.. - . '' ~ ....... ..:..: , , _ anon °E. Baker „ . ,. ,:, ,Trust y L,'....,'.-.'.,, ..: - :::,~ ~: ~ ~ ... , .,,, aluatlon Specialist ~- ~ ~ ?~ `,fitiheritariee'Ta~l~ivisiir~ ~'~ ~~„~. - ::~~ ... ~: - " ; ' - - - ... :::~ .. Bureau of Individual Taxes PHOrtE: 717-783-5824 Fax: 717-783-3467 enat~.: shabaker~state ea us ~ .~ r r ~i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COC.INTY, PENNSYLVANIA FRANCES M. ANGELOFF, individually . and as Administratrix of the Estate of SELENA M. ANGELOFF, deceased , Plaintif, f, . vs. JACK L. ARMSTRONG, M.D., et. al. Defendants. ; DOCKET NO.: 04-4743 CIVIL AC"PION -LAW MEDICAL MALPRACTICE ORDER FOR ALLOCATION AND DISTRIBUTION OF SETTLEMENT PROCEEDS eNn Ti'(1T? A DDD/ltT A T !1T [vmr.frrrr.: t~...~. ..,._-~_ _. And now, dais l day of ~ G%"'uti- , 2009, upon consideration of the outstanding Petition for Leave to Compromise. or Settle a YYrongful Death Action Pursuant to Pa.R.C.P. 2206 and for Approval of Structured Settlement, the proposed settlement with all defendants having a gross value of $525,000.00 is hereby approved, to be allocated and distributed as follows: (a) To: Villari, Brandes & Kline, P.C. $ ~~-1.~., Reimbursement for Costs (b) To: Villari, Brandes & Kline, P.C. $ 1SU,185.30 Counsel Fee (c) The balance, the sum of $3 ,370.60, hereby allocated 90% to the Wrongful Death Action and 10% to the S rvival Action, and shall be distributed as follows: i. Wrongful Death Action 1. $27333.54 to the Estate of Dallas Eyler, a minor, Beneficiary of the Estate of Selena Angeloff ii. Survival Action I . $30,.037.06 to Frances Angeloff, Administrator of the F.,state of Selena Angeloff; who shall not be required to post additional security prior to receiving said proceeds. It is further ORDERED Ghat the Dallas M. Eyler Structured Settlement delineated in the Assignment Agreement,. attached. to Plaintiff's Petition as Exhibit. "G" is approved, and that Frances Angeloff, as Grandmother and Natural Guardian of Dallas M. Elyer, shall execute said document. J. Distribution: Peter M. Villari, Esq. Nicole T. Matteo, Esq. VILLARI, BRA.NDES & K~1NE, P.C. 161 "Washington Street, Suite 400 Conshohocken, PA 19842 Attorneys for Plaintiff Leigh A.J. Ellis, Esquire' Cindy Ellis, Esquire FOULKROD ELLIS, P.C. 2010 Market Street Camp Hill, PA 17901 Attorneys for Defendants, Jack L. Armstrong, M.D., Joan M. Montello, M.D., Amy Reisinger, L.P.N., and Medical Arts Allergy, P. C. Francis E. Marshall, Esquire Aaron S. Jayman, Esquire DICKIE, MCCAMEY & CHILCOTE, P.C. 1200 Camp Hill Bypass, Suite 205 Camp Hill, PA 17011 Attorneys foJ° Defendant, Jodi Johnson, C.R.N.P. 2 ORDER FORM • ~~ James R. ~~~~ MEMORIALS "A Trl6ute to UJe" 5243 Simpson Ferry Road, Mechanicsburg, PA 17055. (717) 766-5622 Order 2~~~~ Supplier Ack. # Date Recd t,. ~~• ~ I I .... Found. ordered ;~ Si ;, -, Complete SOLD TO: ~ A _~ ~~; Position verified r~~~ ~c lu 401 ~~ j~~ y Date of Order ,. ? ~ r' C" ~~~" I ~rr6rT Cemetery , `_,.,~, y,. ~ ,7 ~•x `''~~ Location I rt` ~ Center Over Phone (H) '1^_, , _~ _ ~~~~ (~) -----~-.__ Graves ~_ Lot # Approx. Date of Completion ~n~, ~, {,,,, r hY ~ 1, n~'1' Lettering ~ Wh'It~ Oval ~hlgt rL Type of Memorial ~ r q c~'~A rA o ~ , n r ~ ~~ Material t~ n ~ n r , „ 1 rk',. Size ~1 ~ n,,l, t~,r r,~ 2 a - ~' X -~_ X a~ Finish Base. X ~_ X n~~ Finish n~_ -, , {, ~ _~ (~~ ~An Misc. 3- 9 Design Location: Vase~~~laF,nq ~1V'ntnils l~L)cv t ~ ~ ~ ^ Corner Posts ------ Agreement: A 50% deposit is required prior to commencement of work. ~ ~ II Agree to pay stated balance upon erection regardless of laborlroubles or shipments or enyohe g~a~ ~~ I~is or~~ro act ~n~be c~nc pad by customer unless agreed by both ponies. The article herein mentioned shall remain the property of Jemss R. Gingrlch Msmorl.ls until paid in lull and they reserve the right to remove the same is not paid as stated. I agree to carefully proofread all names and tlates foraecuracy and accept full responsibility foranyemors or omissions. THERE W ILL BE AN ADDITIONAL CHARGE FOR ANY LETTERING ADDED TO THIS MEMORIAL AFTER ERECTED ON THE CEMETERY. I further agree to pay the balance staled for the work pertormed under this contract within thirty (30) days of receipt of the final invoice end further agree wRh,n thirty (30) IdayS of the invoce datenen adtlition thereeo I agree i~t becomes necessary fort ames R. Gingdch to^insliu te'legal preceeding to collect any luntls tlue Irom me for my account being past tlue Ihlny (30) days, to pay all court coals and altomeys tees incurretl by James R G' pa,d to collect me same. Price $ ~ ;_ ~ _ Foundation $ ~1 _ I ''J i ~.~ $ -~ TOTAL $ DEPOSIT c H S H $ mgnch Memonals Balance Due 2 3~ . Dealer ~d_~ ~ Upon Completion $ ~ p ~n _ ~` Customs ` C. \` - -~"''-= Salesman (I further agree that the above names, spelling, and dafes'~'e correct) • Type of Sale Date Entered WHITE/Office YELLOW/Protluction PINK/Customer GOLDENROD/Branch James R. Gingrich Memorials 5243 Simuson Ferrv Road Mechanicsburg, PA 17055 (717) 766-5622 Frances Angefoff ,Jta Cement 401 Boyer Street Statement Date: 5/17/2004 P. O. Box 293 Summerdale, PA 17093 Invoice Date: 12/23/2003 Contract FamilyName FirstNames 28239 Angeloff Contract$ Paid Interest Balance Selena 3,080.00 $2,617.50 $0.00 $462.50 Payment Date Payment Amount Interest Charge Check# 9/25/2003 $230.00 $0 00 Notes 10/23/2003 $237.50 . $0 00 cash 12/2/2003 $237.50 . $0 00 1015 1/5/2004 $237.50 . $0 00 3645 2/4/2004 $237.50 . $0 00 cash 2/27/2004 $237.50 . $0 00 cash 3/31/2004 $1,200.00 . $0 00 cash . 3708 Balance X462.50 ate. A finance charge of 11/2% per month (18% annually) will he added after 30 days a ~ ~~ ~ Q d ~, ! ~ o ~ ~ °' o o ~ -o ~ c m ~ m ~ ~ ~ ~ a m (~ ~ C ,may ~\] ° `D o a ~~ ~ O ~~ (~ c t " s ~. ~ ~~ ~"',, /~ `~i ~ L~\ sr.~ Q _a a. V ~ r'1, ~ n 3 J ~ ~°. ~~ ~ ~ ~ ~~~ ,. twS\ ~(+(\~ ~ _ A ~\` . N `~ \`,l~~l^ \S\i~ p~~ ~., Y! ``~ ^r~ ', ~ ~ ~ch p ~. Q •. ~ m m o ~ ~ ~ ~ a C 3 ~ ~. ~~ ~~ z 0 l~~~"' ~ 1 TAX PAYERS COPY THE WEST SHORE TAX BUREAU 3607 ROSEMONT AVENUE P• O. BOX 656 CAMP Nlll, PENNSYLVANIA 17011 CASH RECEIPT `~ ~ NAME . ,.~ / ~ ~ , ~'~ ~-d- ADDRESS ~~U~~~ t ~ ~-..~__ ~. .....~ ...: 1 clry , ' ~'' 7~~~, ~,~ (• 1 ~ zIP / ~' ~• ,"• SOCIAL SECURITY # j '.~~ i ~ -' ,~ 1.- '" ..3 ~. RESIDENT MUNICIPALITY ~ +., /? AMOUNT pglp ~'` :.? f~J ~'.~• ~' QUARTER i 2 3 4 (CIRCLE ONE) F ~ ~O ~ J RECEIVED By ~,:~- DATE ~~I~I~~ 6 ~ ~ ~ CAPITOL BY91M[!e fORMD INC NEW CUM![R UND. PA 1)O)O ZOY!)O•2 West Shore Tax Bureau 3607 Rosemont Avenue P.O. BOX 656 Phone: (717) 761-4900 To: SELENA ANGELOFF 407 4TH ST SUNIlrlERDALE PA 17093 Camp Hill, PA 17001-0656 26-JUL-2004 SS#: 197-58-3580 Tax Year: 2003 Auditor: PAULA Your 2003 Local Earned Income tax filing was audited and resulted in a balance due payable to West Shore Tax Bureau (w'Ea1°Aisj , Please remit $~'~ 87 within 30 days of the date of this letter. EXPLANATION: Used incorrect tax rate - resident of an Act24 School District where the rate is greater than one percent(1~). Used incorrect gross wage amount. Used State instead of Local Tax. Used incorrect Quarterly Payment or Tax Credit. W2 not enclosed. Filing was prorated incorrectly. Taxpayer mathematical error. OPT TAX (OCCUPATION PRIVILEGE TAX) included with EIT (EARNED INCOME TAX) XX Your check was not enclosed with Final Return. Missing Supporting Documents. Enclosed is a payment card to be returned with remittance. You do not need to complete the Reason for Reporting Quarterly section of the payment card. Document#: O1 04-05-20 PAUL You are entitled to receive a written explanation of your rights with regard to the audit, appeal, refund and collection of the earned income tax by calling the West Shore Tax Bureau at 761-4900 during the hours of 8:30am to 5:00 pm, During July and August the Bureau is open on Friday from 8:OOam to 1:OOpm. m a v C7 ~ c~ ~O~v -mom ~DO~~n C ~' •--~ D ~ O C ~ ~ ~_ ~ O(D`~ ~ (;') ~ O ~ C pWp ~ ? (Q v ~ ~ (n CD (D ~ O n r d D ~ ~_ ~ ~ N Z W O C ~ ~ .~ _ ~ ~ D ~ 0 z J ~ ~ M---~ o -~ ~1 ~~` Jj ~ m w m w ~ r~, r., c ,-. ~; . ~. _ ~ ` 1 - ° ~ ~ - , ~ - ~ ,, ~; , ..~., . , .:., V a~ :~ :m ~1 :. ~ ,~rj ~ o o UNIT SON S~ ~ ~ ~ T ~ N ~,~ N ° ~ ~~ -0 L I oZ~~ o~~Z-. Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone:(717) 240-6345 Date: 7/20/2009 FEATHER ELIZABETH ^} 3631 N FRONT STREET ~ '~ ` ~'i i HARRISBURG, PA 17110 j C'> ,-__ r r G? e,_:a ~J; ,~~ n ~ Cn N r silo ~ Q~ O ~ C7 C1~- O ~ , ~. i-~ .: SI ~.. _ r. , i:.rt RE: Estate of ANGELOFF SELENA M - '~' File Number: 2003-00755 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: 8/14/2009 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, ~~l~cvwtat/~y 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: 7/20/2009 ANGELOFF FRANCES M N ~ ,:_~ ~ ~ ~ ~~ `a 401 BOYER STREET PO BOX 293 ~ ') C r C,i ti:J r~ SUMMERDALE, PA 17093 ~ ~' m N ,a~ ;;;~ ~~.X C i7,.7 s >-~ roro RE: Estate of ANGELOFF SELENA M File Number: 2003-00755 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: 8/14/2009 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, /~z~L~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel STATUS REPORT UNDER RULE 6.12 Name of Decedent: Selena M. Angeloff Date of Death: August 14, 2003 Estate No. 2003-0755 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. State whether administration of the estate is complete: Yes ^ No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: March 31, 2010. 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 ^ B. The separate Orphans' Court No. (if any) for the personal representative's account is: Separate Orphan's Court No. C. Did the personal representative state an account informally to the parties in interest? Yes ^ No ^ D. Copies of receipts, releases, joinders and approvals of formal or informal accounts maybe filed with the Clerk of the Orphans' Court and may be attached to this report. Date: July 23. 2009 ~~'~ .iG'1 4 f (? ~~.:" YI ,ti ~~ r/ 1 ., , ~ r f`iv~ ~S ~Z1 !~~ +;~ 7r?f ~~~ ~~~- ~ ~~ Sign re Elizabeth H. Feather, Es uire Name (Please type or print) 3631 North Front Street Address Harrisburg, PA 17110 X717) 232-7661 _ Telephone Capacity: ^ Personal Representative ® Counsel for Personal Representative COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 012219 FEATHER ELIZABETH 3631 N FRONT STREET HARRISBURG, PA 17110 fold ESTATE INFORMATION: SSN: ~ 97-58-3580 FILE NUMBER: 2103-0755 DECEDENT NAME: ANGELOFF SELENA M DATE OF PAYMENT: 01 / 1 1 / 2010 POSTMARK DATE: 01 /08/2010 COUNTY: CUMBERLAND DATE OF DEATH: 08/14/2003 AMOUNT ACN ASSESSMENT CONTROL NUMBER 101 ~ 5292.66 TOTAL AMOUNT PAID: REMARKS: CHECK#53952 5292.66 INITIALS: SAP SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS JAMES R. CLIPPIN GER CHARLES J. DEHART. III JAMES L. GOLDSMITH P. DANIEL ALT LAND JEFFREY T. MCGUIRE• STANLEY J. A. LASKOWSKI DOUGLAS K. MARSICO BRETT M. WOODBURN MICHAEL D. REED PAULA J. LEICHT ELIZABETH H. FEATHER KAREN W. MILLER DOUGLAS M. OBERHOLSER •BOARD CERTIFIED CIVIL TRIAL ADVOCATE CALDWELL &KEARNS A PROFESSIONAL CORPORATION ATTORNEYS AT LAW 3631 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 1 7110-1 5 3 3 January 8, 2010 Glenda F. Farner-Strausbaugh, Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 RE: Estate of Selena Angeloff File No. 2403-00755 Dear Ms. Farner-Strausbaugh: OF COUNSEL CARL G. WA55 JAMES D. CAMPBELL. JR. THOMAS D. CALDWELL. JR. 119 2 8-2 0011 RICHARD L. KEARNS RETIRED 717-232-7661 FAX: 717-232-2766 thefirm®caldwellkeams.com Pursuant to the Notice we received from the Pennsylvania Department of Revenue, enclosed please find a check in the amount of $292.66 representing the additional amount owed per the Notice. Aself-addressed, stamped envelope is enclosed for the return of a receipt for this payment. Thank you for your assistance with this matter. Please contact me with any questions you may have. Very truly yours, `~, Elizabeth H. Feather CALDWELL &KEARNS, P.C. efeather(a,caldwellkearns. com EHF: SE Encs. cc: Frances Angeloff (w/enc.) 09131-001/157825 tV O ~O ° -,- ~z_~ ~~ ' ~ ~ n ~ i~ Z c -- ~_<_ ; z - c ;.~ -;-, v ~ " " '~ ',,:fir =:_~ .: ~ ' ++ ' W _ 44 C. ~~. ~~1 ' [~ ~S ~ ~ '~~ c.-~ r ~ l PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF THE ESTATE IS NOT COMPLETED, FILE A 6.12 FORM YEARLY UNTIL COMPLETION. STATUS REPORT UNDER RULE 6.12 Name of Decedent: Selena Aneeloff Date of Death: August 14 2003 Estate No. 2003-0755 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 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 B• The separate Orphans' Court No. (if any) for the personal representative's account is: (Not Applicable in Dauphin County). C• Did the personal representative state an account informally to the parties in interest? Yes ® 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. Date: January 22, 2010 r.n ~~-001/.8299 ~ c i= ~ - N r- ~ ~~_ =` ~ T .- iy' i N ~ cn - ~ Z 1 Cam' `' ~4 ~ u 7 U `~' ~..; ' .~ ~y ~ 1 ~ ~~. °s 4 `~' o o ~ o cv U S1 1 tore g Elizabeth H. Feather Name (Please type or print) 3631 North Front Street Harrisbur>;, PA 17110 (717)232-7661 Telephone Capacity: ~ Personal Representative ®Counsel for Personal Representative 11V 1~.G: ESTATE OF: ~ ~ THE COURT OF COMMON PLEAS SELENA ANGELOFF ~ CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS COURT DIVISION Estate No. 2003-0755 RECEIPT AND RELEASE KNOW ALL MEN BY THESE PRESENTS, that the undersigned does hereby acknowledge receipt from Frances M. Angeloff, Administratrix, of the Estate of the above-named Decedent, of the following: Nineteen Thousand Twenty-One Dollars and 96/100 Dollars ($19,021.96) cash, representing the net proceeds of the Estate. IN CONSIDERATION of said payment and transfer, the undersigned does hereby release, remise, quitclaim and forever discharge the said personal representative of and from all action, suits, payments, accounts, reckonings, claims and demands whatsoever for or by reason thereof, or any other account, matter, cause or thing whatsoever relating to the Estate of the said Decedent. AND the undersigned does hereby release all real estate of the decedent and of the said personal representative from all liens, claims, actions, suits, payments, accounts and demands whatsoever for or by reason thereof or of any other account, matter, cause or thing whatsoever. IN WITNESS WHEREOF, the undersigned has caused this instrument to be executed this ~c~2 day of January, 2010. WITNESS: i7 By: Frances M. A.ngeloff, As and and Natural Guardian of Decedent's minor son, Dallas Eyler 09131-OO1-158298 A,r,. HERITANCE TAX pennsylvania ~ BUREAU OF INDIVIDUAL TAXES AP~~1-~~ ~ ~'ANCE OR DISALLOWANCE r z ~rpt •. - . ,t~ DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION O~i,.~ leF1~i~...^-~D ASSESSMENT OF TA)a REV-1547 EX AFP C10-09) PO EOX 280601 HARRISBURG PA 17128-0601 1~9 DEC -4 PM I% ~O DATE 11-30-2009 ESTATE OF ANGELOFF SELENA M DATE OF DEATH OS-14-2003 (~'~ ~ ~' FILE NUMBER 21 03-0755 ~~1~~CI~RI,AND~., ~ COUNTY CUMBERLAND ELIZABETH FEATER ESQ ACN 101 CALDWELL 8 KEARNS APPEAL DATE: 01-29-2010 3631 N FRONT ST (See reverse side under Objections) HBG PA 17110 Amount Remitted ~- MAKE CHECK PAYABLE AND R MIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG-THIS-LINE- -~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ _ ---- ---------------------------------------------------- ----------------- REV-1547 EX AFP (10-091 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWAMC~ OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: ANGELOFF SELENA MFILE N0.:21 03-0755 ACN: 101 DATE: 11-30-2009 TAX RETURN MAS: (X) ACCEPTED AS FILED ( ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) •00 NOTE: To ensure proper 2. Stocks and Bonds (ScMduls B) (2) ,00 ' credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .0~ subait the upper portion of this forty r-ith your 4. Mortgages/Notes Receivable (Schedule D) (4) •0~ tax peyaent. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 33, 780 .67 6. Jointly OMned Property (Schedule F) (6) .00 7. Transfers (Schedule 6) (7) .00 8. Total Assets (g) 33, 780.67 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 13,331.17 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .00 11. Total Deductions (11) 13,331.17 12. Nst Value of Tax Return (12) _ 20,449.50 13. Charitable/Governmental Begwsts; Non-elected 9113 Trusts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 20.449.5n NOTE: if an assessment was issued previously, lines 14, 15 and/or 16, 1~, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Awount of Lins 14 at Spousal rate 16. Aaount of Line 14 taxable at Lineal/Class A rate 17. Amount of Lins 14 at Sibling rats 18. Aaount of Lins 14 taxable at Collateral/Class B rate 19. Principal Tax Dus TAX CREDITS: DATE NUMBER INTEREST/PEN PAID (-) 06-12-2009 CD011355 .00 (15) . 00 X (16) 2 n ~ 449 ~n X (ln nn x (18) . 00 x AMOUNT PAID 00 045= 920.23 12 .00 15 = .00 (19)= 920.23 920.23 BALANCE OF UNPAID INTEREST/PENALTY AS OF 06-13-2009 TOTAL TAX PAYMENt 920.23 BALANCE OF TAX DU!E .00 INTEREST AND PEN. 292.66 TOTAL DUE 292.66 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A ''CREDIT!' (CR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORA FOR INSTRUCTIONS. r,~;'~, F ~ ` ~-~N~N~I+~~TANCE TAX BUREAU OF INDIVIDUAL TAXES rf T OF ACCOUNT INHERITANCE TAX DIVISION ~ ,h~ I ~Q-~ ~'~~~ PD BOX 280601 HARRISBURG PA 17128-0601 za~~ Fps ~ ~ ~~ i= s ~ ~il.~l-it, C~ ORPN~~.i`~'S ui~llRT' ELIZABETH FEATER E5~' " '- ` ' "`' ''"'' CALDWELL 8~ KEARNS 3631 N FRONT ST HBG PA 17110 Pennsylvania DEPARTMENT OF REVENUE REV-1607 EX AFP (12-09) DATE 02-08-2010 ESTATE OF ANGELOFF SELENA M DATE OF DEATH 08-14-2003 FILE NUMBER 21 03-0755 COUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE _~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ _ _ _ _ REV 1607 EX AFP C12 09) ~ ~~~ *** INHERITANCE TAX STATEMENT OF~ACCOUNT~~***~ ~~ ~~~~~ ~~~~~~~ ~~ ESTATE OF:ANGELOFF SELENA M FILE NO.: 21 03-0755 ACN: 101 DATE: 02-08-2010 THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELDW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 11-23-2009 920.23 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-) .00 920.23 06-12-2009 CD011355 292,66 01-08-2010 CD012219 292.66- TOTAL TAX PAYMENT 920.23 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. i,\ IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YDU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM ,~ FOR INSTRUCTIONS. BUREAU OF INDIVIDUAL TAXES ~ ~= `~~1~~~~TANCE TAX INHERITANCE TAX DIVISION A T O F AC C O U N T PO BOX 286601 ~~~""t ~~°"~~'~~ - HARRISBURG PA 17128-0661 2QI~J FMS 16 P~ ~ = S 1 CLER~~ ~ QRP~~.i'~ ~ Ul)~~T ~~ ear ~ , ' };~ t`!~ ~~. ELIZABETH FEATER E ~''' `''~' "-`~ CALDWELL 8~ KEARNS 3631 N FRONT ST HBG PA 17110 Pennsylvania ~ DEPARTMENT OF REVENUE REV-1607 EX AFP (12-09) DATE 02-08-2010 ESTATE OF ANGELOFF SELENA M DATE OF DEATH 08-14-2003 FILE NUMBER 21 03-0755 COUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG_ THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS -~ _ _ _ _ REV X1607 EX AFP~ (12~ 09~ ~~~~~ *~* INHERITANCE TAX STATEMENT~OF~ACCOUNT ~~***~~~~~~~~~~~ ~~ ~~ ESTATE OF:ANGELOFF SELENA M FILE NO.: 21 03-0755 ACN: 101 DATE: 02-08-2010 THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 11-23-2009 PRINCIPAL TAX DUE: 920.23 PAYMENTS CTAX CREDITS): PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-) 06-12-2009 CD011355 .00 920.23 01-08-2010 CD012219 292.66- 292.66 TOTAL TAX PAYMENT I 920.23 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ~ IF PAID AFTER THIS DATE, SEE REVERSE SIDE FDR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YDU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM '~ ~. ;. FOR INSTRUCTIONS. J