HomeMy WebLinkAbout04-0824 PETITION FOR PROBATE and GRANT OF LETTERS
s,u,e oX
also known as To:
Register of Wills for the
Social Security No. /~t9-.5'0- ~2~$'Deceased'
County
of
in
the
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the executr;x named
in the last will of the above decedent, dated ,,'~bwu ~ ~. ~ /?//5 ,1971
and codicil(s) dated
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in C°/tm~t.,e/~q/ .County, Pennsylvania, with
last family or p~rincipa], resi?nce at ~ ~d~ ~t~/~
Decend~nt~hen ~. years of age, died ~.~ ZZ ,~O~,
Except as follows, decedent did not marry, was not divorced anti did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) ' All personal property $ /, ~o. ~o
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
V~ue of real estate in Pennsylvania $
situated as follows:
WHEREFORE, petitioner(s) respectfully reouest(s] the probate of the last will and codicil(s)
presented herewith and the grant of letters
theron. (testam~tary; administration c.t.a.; administration d.b.n.c.t.a.)
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA 3
COUNTY OF (~k'/P/DE;~-2.,q~ f 8s
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing p~ition are
true and correct to the best of the knowledge and belie~of petitioner(s) and that as person~ represen-
tative(s) of the above decedent petitioner(s) will well ~ truly administer the estate according to law.
Sworn ,o or affirms,_ and subscribed : ~--~ ~~ ~
bef~ m~ this ~'~ day of [ ~t~t~ ~. ~ ~ ~'
Estate Of Q~~-~--~ ~' '~o~ , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW~O---'O~'k~-~'~- ~ r-Q~)04 )~ _, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated c~ ~ Jcl - 1~ I
described therein be admired to probate ~d filed of record as the last will of
~d Letters ~~ a~ ~
~e hereby granted ~ o_t~ ~ ~Q ~ ~- 0
Probate, Letters, ~c ..........
Short Certificates( ) .. · ....... $
Filed ..
REGISTER OF WILLS OF ~'~/~;~y_~ COUNTY
OATH OF SUBSCRIBING WITNESS
~ a subscribing witness to the will presented herewith, (each) being duly qualified according to
law, depose(s) and say(s) that //~" ~'~J present and saw
the testat.r4.~ , sign the same and that /'/'~" signed as a witness at the
request of testat~-t'~ in h ~r- presence and (in the presence of each other) (in the presence of the
other subscribing witness(es)).
me this o ,J~-/~t~ day of /~'el~'~7' '~/'/~'g~Y(Name) '~q$- ~' Still
(^ddress)
Registe% (Name)
(Address)
REGISTER OF WILLS {Y~OUNTY
OF NON-I G WITN
(each) a subscriber hereto, duly qualified to law, depose(s) and say(s~that
at~ iar with the signature of
test of (one of the to) the herewith and
that ~ the signature on the will the handwriting of
'tq~best of X'~.knowledge~ and belief.
Sworn'l~r affirmed and subsc~ before
me this ~,. N~.y of (Name)
Register
(Name)~
(Address)
REGISTER OF WILLS OF COUNTY
OATH OF/SUBSCRIBING WITNESS
/
/ codici, berewitb, qualified according to
(each) a subscribing witne~to the will presented
law, depose(s) and ~ t~at ?/'j// ~/ present and saw
the testat ~ sign the same and that ~ ,~/~ ~ signed as a witness at the~
request o~at in ~ _ p~and (in t~ence of each other, (in the presence of the/
o~scribing witness(es)). ~ ~ ~
~ ~'~" (Addres~
~ / ~e~
~ (Addressj
REGISTER OF WILLS OF C~/5~vz.~ COUNTY
OATH OF NON-SU~BS_.CRIBING WITNESS
~a subscriber hereto, (~ being duly qualified according to law, depose(s) and say(s) that
~ /~ familiar with the signature of ~~ ~ ~ ,
testatP{~ of (9~ ~v ...... *~ .................... ~.~,,~,.~ ......~ to) the will presented herewith and
that ~ . believes the s~gnature on the will m ~'the h~dwriting ~
tO the best of P~ knowledge and belief. ~ ~ 4
Sworn to or aff~e~nd subscribed before ~ ~ .
~ ~ ,~ Re~i~ter
(Address)
RENUNCIATION
In Re Estate of C~7-~:~//I/~C' ~ ~O~C deceased.
To the Register of Wills of C/ff N/~ K/-/Tt~/D County, Pennsylvania.
Thc und~signed ~0~ ~, L~, ~T~ ~ ~C~T~/~ of
the above d~ent, hereby renounces) the fi~t to ad~st~ the estate ~d r~fu~y ~k(s) ~at Letters
WITNESS /7~V/ handthis ~ dayof ~t~/~ ~1/9/~/
(Address)
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00 ,~ ~ ~o ~.~j~~
~ ~ ~ Local Registrar
P 10589910 AU ; 25 200 ,
No. ~ Date
~ ~v~ ...... .~...~.~-: CERTIFICATE OF DEATH
~ Pa~{a ~ ~tem
26~ 2~ e ~. ~rk ~lle PA
N. ~rlisle PA 17013
LAST WILL AND TESTAMENT OF
CATHERINE I. BOWERS
I, CATHERINE I- BOWERS, widow, of 43S "B" Street in the Borough of
Carlisle, Cumberland County, Pennsylvania, being of sound and disposing
mind, memory and understanding, do hereby make, publish and declare this as
and for my last Wilt and Testament, hereby revoking and making void any and
all Wills by me at any time heretofore made. ~? ~ <~ ~
2. I give and bequeath the sum of $200.00 to each o~y gr~dchild~n
daughter, Patricia E. Fry, as Executrix of this my last Will and Testament and
I further direct that neither one shall be required to post any bond to secur~
the faithful performance of her duties in the Commonwealth of Pennsylvania or
in any other jurisdiction.
IN W/TNESS ~VHEREOF, I have hereunto set my hand and seal to this my
last Will and Testament written on two (2) pages this / ~ day of February,
1971.
Catherine I.
Signed, sealed, published and declared by Cat]~erine ~. Bowers, the
Testatrix above named, as and for her last Will and Testament, in our presence
who, in her presence, at her requesta and in the presence of each ether, have
hereunto subscribed our names as attesting witnesses.
CERTIFICATION OF NOTICE UNDER RULE 5.6{a)
Name of Decedent: Catherine J. Bnwers
Date of Death: August 22, 2004
Will No. Admin. No. 21-04 0824
TO THE REGISTER:
I certify that notice of beneficial interest required by Rule 5.61a) of the Orphans' Court was
served on or mailed to the following beneficiaries of the above-captioned estate on October 28,
2004
Name Address - -
John A, Stover, Jr. 6126 Wallingford Way, Mechanicsburg, PA
Catherine J. Scheft 6228 Bluebird Avenue, Han'isburg. PA 17112
Loretta M. Lane George Street, P.O. Box 216, Dalmatia, PA 17017
Michael H. Smith c/o Lorctta M. Lane, P.O. Box 216, Dalmatia, PA 17017
Scott A. Smith c/o Loretta M. Lane, P.O. Box 216, Dahnatia, PA 17017
Wmifred L. Evans c/o Loretta M. Lane, P.O. Box 216, Dalmatia, PA 17017
Evelyn L. Durnin 1910 Douglas Drive, Carlisle, PA 17013
Douglas 54. Durnin c/o Evelyn L. Dumin 1910 Douglas Drive Carlisle. PA 17013
Laurie A. Gleim c/o Evelyn L. Durnin 1910 Douglas Drive Carlisle, PA 17013
Chris Durnin c/o Evelyn L. Durnin, 1910 Douglas Drive, Carlisle, PA 17013
Karan Hammakcr cio Iris F, Bowers, 361 E Street, Carlisle, PA 17013
Linda Devor c/o h'is F. Bowers, 361 E Street, Carlisle, PA 17013
Stcven A. Bowers c/o Iris F. Bowers, 361 E Street, Carlisle, PA 17013
Marlin E. Bowers c/o Iris F. Bowers, 361 E Strcct, Carlisle PA 17013
Patricia E. Fry 18 Lantern Lane, Shippensburg, PA 17257
Keith A. Fry c/o Patricia E. Fry, 18 Lantern Lane, Shippensburg, PA 17257
Brian D. Fry c/o Patricia E. Fry, 18 Lantern Lane, Shippensburg, PA 17257
'x,~ Timothy W. Ft'> c/o Patricia E. Fry, 18 Lantern Lane, Shtppensbur~z. PA 17257
Notice has now been given to all persons entitled thereto under RuNe 5.61a) except
· SHIELDS, III
6 Clouser Road
Mechanicsburg, PA 17055
Telephone: 1717) 766-0209
Counsel for Personal Representative
~EV,'SOOEX 16.Qnl
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
OFFICIAL USE ONLY
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FILE NUMBER
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
NUMBER
COUNTY CODE
YEAR
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
/J? - 22- 20D'f /2 - 2-D -196'/
{IF APPLICABLE} SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
#/,.1
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
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B-zos
1ZJ1, Original Return
D 4. Limited Estate
IZI 6, Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after 12.12-82)
D 7. Decedent Maintained a Living Trust (Attach copy 01 Trust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
D 3, Remainder Return (dateofdealtl prior to 12.13.82)
D 5. Federal Estate Tax Return Required
o 8, Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach SchO)
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NAME ClIl/-l<LcS
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COMPLETE MAILING ADDRESS
FIRM NAME (If Applicable)
tP CLOU.s~ R.l>.
/'YJE'f!Ii/f./V1CSBl.tr?6, PA
/70S.>
TELEPHONE NUMBER
717- 76~ - ,p.$.o'1
1. Real Estale (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
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OFFICIAL USE ONLY
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3. Closely Held Corporation, Partnership or Sole.Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
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(,;,)
(6)
~$SS; 7~
(7)
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/) (--)
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8, Total Gross Assets (Iotal Lines 1-7)
9, Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
I.J:)
(9)
(10)
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/,~3'.'J9
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(8)
11.7r.'f.i'
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(11) ~/,O'.,"
(12) " /;3;1..87
(13) 0
(14) 1/3Z.n
x.O~ 1151 tl
x,D I/S (16) fS,9!
x .12 (17) 0
x .15 0
(18)
(19) , 5.91'
13. Charitable and Governmental BequestsfSec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15, Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
t?
1 /32. n
16. Amount of line 14 taxable at lineal rate
17. Amount of line 14 taxable at sibling rate
o
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18. Amount of line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUNO OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS S,f/fAN /DDb Afc/HPif/Al HtNllc
/ (){) P Iv. SPv7/1 ST.
CITY C,It<LlSJ.E I STATE /l,4 I ZIP /701,5
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
~ 9./
5:
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Total Credits (A + B + C ) (2)
3
InteresUPenalty if applicable
D.lnterest
E. Penalty
o
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4.
TotallnteresUPenalty ( 0 + E )
If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
(3)
(4)
(5)
(5A)
(5B)
5.
If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Une 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred; ....................... ..................... ...... 0
b. retain the right to designate who shall use the property transferred or its income; ..................... ......... 0
c. retain a reversionary interest; or........... ....................... ................ ......................... ............. ............... D
d. receive the promise for life of either payments, benefits or care? .......... ................... .................. .................... D
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
.1(1
No
~
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[XI
II
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IF THE ANSWER TO ANY OF THE ABOVE QUESTiONS is YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
Under penalUes 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.
Declara~o f preparer other than the personal representative is based on all information of which preparer has any knowledge
X D~P~RSO~E~18LEFORFILlNGRETURN DATE '/t-3/o~
ADDRESS 'A-77UC/~ t:. Y
/8 L"'N~R'( LNG SHIPPEN'.5/JIIRG, fJ,f /7:/S7
,
SiGNATUR 0 PREP ER OTHER TH ~P N~ DATE
X F .:LB-
ADDRESS HAlllES IF. SII/~$ E:Sf'. I ,/
II CLP".5~ A!A, /IfE()H.#/v/CSdilRG" fJ4 /;7DSS' \ 13/ oS-
UI .. II. _
For dates of death on or .fter July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. !l9116 (a) (1.1) (ill.
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. !l9116(a)(I.2)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineai beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. !l9116(.)(1)].
The tax rate Imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. !l9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
~EV-1500EX(fi.0fJ)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
OFFICIAL USE ONLY
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FILE NUMBER
INHERITANCE TAX RETURN
RESIDENT DECEDENT
YEAR
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NUMBER
COUNTY CODE
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
13()/UEJI?S, (!.II T#l?~/""E 3-
DATE OF DEATH IMM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
t>? - 22- 20DFf /2 - U -/96'/
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
N/~
SOCIAL SECURITY NUMBER
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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COMPLETE MAILING ADDRESS
NAME CIII/-I<L.cS
E. S/{/ € L.J>.5 :PL
fs. CLOUSER I€l>.
MEC/i/f./I//CSBul?6-, PA /70S$'"
!Zl1. Original Return
D 4. limited Estate
~ 6. Decedent Died Testate (AltachcopyofWiII)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after 12-12-82)
D 7. Decedent Maintained a living Trust (Attach copy of Trust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
D 3. Remainder Return (date of death prior to 12-13.82)
D 5. Federal Estate Tax Return Required
o 8, Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach SchO)
FIRM NAME (If Applicable)
TELEPHONE NUMBER
7/7-76(;,-19.$.09
OFFICIAL USE ONLY
1. Real Estate (Schedule A)
2. Slocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
(1)
(2)
(3)
(4)
(5)
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4. Mortgages & Notes Receivable (Schedule Dj
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
(9)
(10)
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(6)
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(7)
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(8) 11.7r..'f.efo
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(11) ~ I, '3'.1'1
(12) ~ 1;3;l..87
(13) 0
(14) ! /3Z.f7
\D
12. Net Value of Estate (Line 8 minus line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to lax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal lax f) , _0 fl...- (15) tJ
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate 1 /32.11 ,0 liS (16) f S, 98'
0 x .12 (17) 0
17, Amount of Line 14 taxable at sibling rate
() 0
18. Amount of Line 14 taxabie at collateral rate x .15 (18)
19. Tax Due (19) 'S.9f'
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
/IGHMARI(
P.O. 80:11: 890089
Camp Hill, P A 17089-0089
IlIGHMARK RESlo;ItVI.<::S THE RIGHT TO RKI"AIN
THE REMITTANCE COpy 010' INVOICli:S € .. y
PLEASE CASH OR DEDOSIT Y
INVOICE NO. P.O. NUMBER DATE VOUCHER GROSS AMOUNT DISCOUNT N AMOUN
EFUND 2004-11-17 00589888 409.05 0.00 409 . O~
HNDLI PAY DATE I VENDOR NO I VENDOR NAME TOTAL AMOUNT
CHECK NO 409.0'
I 304871 n 2004-11-23 I CATBOW0004 I CATBOWOO04-001
0000065
WARNING -
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Camp 1I1II, PA 11089-0089
C>>ECKIiO 30487]" 72
FOVR HuNDRED NJNE DOLLARS 'IND OJ CENTS
ESTATE OF CATHERINE J BOWERS
18 LANTERN LANE
SHIPPENSBURG, PA 17257
DATE OF CHECK
MO DA.Y YR
11/23/2004
DOLLARS
CENTS
**********409.05
V""j il nolC."$h.d WIthin 1 Yaaf
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AtjTHOKlZMj SIGNATtJRIo: Higl1markl Inc.
II' ~01,B7lo7 2u' I:ol, ~:1O lob 271:
0002.5 . 20811'
REV.t~EX+(j.gl)~..
, '~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY.OWNED PROPERTY
ESTATE OF
f.3ow E!'1?5J elf lJofE=/CII'I E J:
FILE NUMBER
:21- IJlf-J z. t(
H 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
A, EiV""YN j. ,801tJ19PS
q/(IJ EVel YIf L. ])uRAlIN
1'110 b()UGt.I/S
(!A/UloS' 1!0 "II
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171>13
L>.4UGII"h:lI'
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JOINTLY-OWNED PROPERTY:
LETIER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of~nancial institution and bank account number or similar identifying number, Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deedforjoinlly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1, A, "lit If,1 M~T I3AAI~, r!HEWN6 ","C(!T. f/' 'kJ4~3o ' I, SO 31. <:7 50.& ~7"'I. ,~
(su hf/r &lft kf!v tTlhtthtl f,. SeJ.",I.,G)
TOTAL (Also enter on line 6, Recapitulation) $ 7'1. ,1/
-
(If more space is neede<!, insert additional sheets of the same size)
,R""""""','".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
/3oWfflS, C~7#eRIIfIE J:
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBATE PROPERTY
FILE NUMBER
:2/. ol/- 8'z1
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1S00 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AN DTHE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
ATTACHACOPVOFTHEDEEDFQRREAlESTATE. VALUE OF ASSET INTEREST IF APPLICABLEl
NUMBER
1. I'JIIT dAHK S/l-Y1N6S A(!Cr /$Ult/~ l/lItJ7~
/leer: ,p 02/ 06 DC'I> 'lrZ"1o/3 , ,r
SSS. 7'1 I~"'" -0- sS's; 7'/
(fit<: I~~ ,,{' /,f1fT J/!J"AK A/I'aclud}
TOTAL (Also enter on line 7, Recapitulation) $ Ss- 5",7'1
(If more space is needed, Insert additional sheets of the same size)
Nov 09 04 10:558
~ M&fBank
499 Mircheil R,wC to...1J11sboro, DE 19466 \'1nii Code: j)E,\']H.l.~
Phone (888\ 502-4:'49
Fax ,.302i9::.4.-2955
',\jC1v:;:mh~r9 21JD4
Fax: 717-795-7473
Charles E. Shields, III
Attorney At Law
6 Clouser Road
Mechanicsburg, PA 17055
fie' ES{(Jt~[Ji'_i;'{llhr;t;nec~ 11()J1'e/:,
SocioI.Se~;lIritL_16 ():2!)~\ 2QJ.
DWt'..2I Dgglt,~,dJL.>::'!0Ln ,2004
Dear Sir or Madam:
Per your inquiry dated November L 2004. please he advised that at the time of death, the above.named decedent had on
deposit wnh this bank the foI1owin,:
J\pe ofAccollnt
('hecking ACCOWH
Account .,,,"umber
.JU4330
Ownership (;Vnmes i~t)
Catherine J Bow2rs
E\'dFil .J BOWt'!'s
Opl'ning Dmt'
9,1}:"67 Closed 9..24ilJ4
Balance on Dale qrDearh
Sl.53i27
1r:~'rue[i Imeres!
s
Uuu
T'O({d
31.539.2"7
"
7,'1i'}(! or~(,collnr
Savings AccounJ / Sunai Account
.--tC(\'1,'ou.\'umber
0210000009/:,')9";3
()ll'nershw (7'/ames il!j
CarheJ'ine.J BO\H?rs. clnmtoJ'
F,"I.m/fr': n'NSI (. !. ,/hi.',f,'!<3
(~rlen"f7g Duff!
3//77 Closed 8'3U'{).i
f~ajonCi! on Di),e ~ (De..'!/;
355.5 ;'.:
..J('.'.)(I.') It/l,.:'resi
OJ
.r,.)!,)
.,,'55~:'. 9/
P'e:i.~<:> he advised. there WIi.S no s;lte den()~it nox lound tor the above decedent, For further ~lccount information,
r(>{!arding ()wnershjp~ closures and/or reimbursement of funds. etc.. please call t.he High Street Carlisle Of11ce '# 717-
2...W~-45Jh.
.liK".':',:!'.
.........,
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p.l
REV-151'1 EX+ (12-99) ~.
~~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
BOII/E/? S, C.II T~€tff/AI€ J:
FILE NUMBER /1
;2/-0'1- ?27
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
l;oF~AfJ4.N f( t)"1H FtlAlEJeAi. HomE; /Ale. oj" eAtf!USL€
a) Pref"'-id amou.nts as sh.wn o. b;1I "tt-ad..J h. ,.,jD
b.) (V/i.r ea...t M MlOwn .sd,~d.e. I-Iv>> / ruuJ h,"//,'nj' ~
Q.5 "'1 555.93
C.) 1>>.bMte due PD.,J cl.ira.Hy t;....., esttl.t.. fwnds ~
2'1..57
:2. 18~&I/es F/"tve,.s ~;;Z,.SO
~. I€"f G,.-Ji. /Vt>,.ks ".
/Ileal, k GnlGe lln,lu;/ f'11e tADeI, sf Chureh 01 C'lJrJ:.s/e '/0. 00
1. run.,.al , :t 100.00
B. ADMINISTRATIVE COSTS:
,. Personal Representative's Commissions
Name of Personal Representative(s) p,f-r,e/CIA E: F,(,)' Lull/VEl)
Social Security Number{s)/EIN Number of Personal Representative(s) 1
Street Address I~ LM'rERN bfA'€
City SH II'I'F/YSJ/I.(RCr State /lJ9 Zip 1725'7
--
Year(s) Commission Paid:
(!f/,4f(LES F.. S#IGZPS :or ~
2. Attorney Fees '375. 00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant A/PAlE: NP/f/I!;
Street Address
City State _Zip
Relationship of Claimant to Decedent
4. Probate Fees ...J Dr; ;;"a! ;~Sll' tI sh#l'f el!J'fif.,""kS ~
I.Js.IJ/J
5. Accountant's Fees
6. Tax Return Preparer's Fees
"
IUvertisi1 ill CumJ.u-I....J t..w JDll.rJIAI 7S.o0
7.
,I'
8'. ,4J1l"ert;s '':1 ;h Car/,'sle Sehf,ite/ /07. '/'1
'f. 1=/(,,,*/ hll. T A.x' Ife Iu /'11 r",e f 16. D(>
TOTAL (Also enter on line 9, Recapitulation) $ / '3'. <1'1
,
Debts of decedent must be reported on Schedule I.
(If more space is needed, insert additional sheets of the same size)
Hoffman-Roth Funeral Home, Inc.
219 North Hanover Street
Carlisle, P A 17013
(717)243-4511
September 3, 2004
Patricia B. Fry
18 Lantern Lane
Shippensburg, PA 17257-
The Funeral Service for Catherine J. Bowers
14352-162
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
OUR SERVICE:
Traditional FLlneral Service Package . . . . . .
FUNERAL HOME SERVICE CHARGES
$3590.00
$3590.00
SELECTED MERCHANDISE:
Ventura Casket, . . . . .
Monarch Intennent Receptacle. .
Ethel Maid C833 Pink . . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THATVOUHAVESELECTED . . . . . . . . . . . . .
$1170.00
$930.00
$120.00
$5810.00
Cash Advances
Opening Grave, . . . . . . .
Certified Copies of Death Certificates.
Flowers
HaIrdresser
Organist. .
$500.00
$20.00
$ I 32.50
$30.00
$50.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES.
$732.50
Total
Total Cost
. . . . . . . . . . . . . . . . . . . .
$6542.50
TOTAL AMOUNT DUE
$246.57
/n"\
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History
08/25/20U4 CREDIT Organist.
0813012004 Homesteaders Life Company.
08/3012004 Discount Received.
1)910312004 M&T Bank
$-50.00
$-5634.04
$-55.96
$.555.93
This statement is net and payable in full within 30 days of receipt.
.......... - - - - - - - - - - - ~ -.............................. ---.... - - -.. - - - - - - - - - - - - - - - - - - - - - - --
Hoffman-Roth Funeral Home, Inc.
219 North Hanover Street
Carlisle, P A 17013
(717)243-4511
September 3,2004
Patricia B. Fry
18 Lantern Lane
Shippensburg, PA 17257-
The Funeral Service for Catherine J. Bowers
14352-162
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
OUR SERVICE:
Traditional Funeral Service Package . . . . . .
FUNERAL HOME SERVICE CHARGES
$3590.00
$3590.00
SELECTED MERCHANDISE:
Ventura Casket . . . . .
Monarch Interment Receptacle.
Ethel Maid C833 Pink . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THATYOUHAVESELECTED . . . . . . . . . . . . .
$1170.00
$930.00
$I20.00
$5810.00
Cash Advances
Opening Grave, . . . . . . .
Certified Copies of Death Certificates.
Flowers. .
Hairdresser.
Organist. .
$500.00
$20.00
$ I 32.50
$30.00
$50.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES.
$732.50
Total
Total Cost
$6542.50
History
08/25/2004 CREDIT Organist.
08130/2004 Homesteaders Life Company.
08/30/2004 Discount Received.
09111312004 M&T Bank. . .
$-50.00
$-5634.04
$-55.96
$-555.93
TOTAL AMOUNT DUE
$246.57
This statement is net and payable in fUll within 30 days of receipt.
................................................................... ---................................... -..........................
Please return this portion with your Remittance
$
Amount Enclosed
Service to # 14352-162
Cathenne J. Bowers
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FEDERATED
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~~~. CJq ~ cW~~~"<
o OTHER
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ORIGINAL
2861
ACCT. NO.
PJb;,,.,J,P-. In if (]I Bo.o L/L ). ^~
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~. ~(..,~i-)-~ "&~_()./f"/€-//--"
. Name of Deceased
",7 .- . O<t,C;~ 0
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CARD ~RAL HOME, Inc.
D OTHER
~.
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~!l?~. -.-,"--/' L. .A_' -~ r~.---i'L 'Na;~-;;;oec;~sed
QCHECK. Ie,J'(/
,
ORIGINAL
2861
ACCT. NO.
:J CREDIT
CARD
cW~~~~~".
C OTHER
Pw.L_
" _'JC ; ( f
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--_..._~-~--~ .\....._--- ------.---
'~l(/Jll /0.'((/
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LAST BALANCE
D INTEREST
O L.ATE PAYMENT
QlABll.O
SUB TOTAL
CREDITS
$ ;)Lf(,.'J? _
----------
------.-..-
'---------..- -~-
LESS PAYMENT d. LJ I:, .,51
----__L____
NEW BALANCE $- 0 -
09895
LAST BALANCE
n INTEREST
O LATE PAYMENT
~
SUB TOTAL
CREDITS
LESS PAYMENT
~---------------,-
'--'----"--.-
!.t!5. '5C
---....~-
---~,--_._-
~-C'1
t.. C',:;<
,,;,yJ.5'-J ,~
NEW BALANCE ~_~Z
09846
LAST BALANCE uS KS-1l-.fZ'
!-' INTEREST
'L-J I,.ATE PAY.~
CHARGg
SUB TOTAL
CREDITS u fi I,XC; C:
LESS PAYMENT . ':::-l t:3'1 t ~
NEW BALANCE
09836
'~7!1 ..-; i:'n
.'S ':: f/.:;,X __ (...
~ HOMESTEADERS LIFE COMPANY
2141 GRAND AVENUE. P.O. BOX 1756
DES MOINES, IOWA 50306
515-288-7481
ASSIGNMENT
OF OWNERSHIP
(IRREVOCABLE)
1. IRREVOCABLE ASSIGNMENT TO FUNERAL HOME/MORTUARY. The undersigned hereby irrevocably assigns,
(Note: This form does not assign death benefits to the funeral, home.)
, /. ,
L i . , . / II
. ~ l ( ,r-i j.' ..' - /. ..~.-
transfers, and delivers to i r.. , .J "J" h ' f' , . ... the
" I ~ ~ . "
7' JFuneral Home/Mortuary) ., ./
/ I ;'(I,ULlU-I'i. i {~~',~ It k &'-f':;"'~ '"i'Y]
ownership rights under the policy/certificate insuring the life of -
(Insured Name)
Said assignment shall be contingent upon the Funeral Home/Mortuary assigning ownership rights to the Trustees
of the Funeral Assurance Trust in accordance with paragraph 2 below. I understand that, as original owner of
the policy/certificate, I retain the right to change the beneficiary/assignee of the policy/certificate death benefits.
Notwithstanding the foregoing, the undersigned shall retain physical custody of the policy/certificate of insurance.
I UNDERSTAND THAT, BY ASSIGNING MY OWNERSHIP RIGHTS TO THE FUNERAL
HOME/MORTUARY, I CAN NOT SURRENDER MY POLICY/CERTIFICATE FOR THE
CASH VALUE OR RECEIVE ANY REFUND FOR ANY PREMIUMS PAID AFTER THE
30 DAY RIGHT-TO-CANCEL PROVISION DESCRIBED IN THE POLICY/CERTIFICATE.
- I I
x. s!>r /1 ?
Si,grlature of Policy/Certificate Owner , Djlie
l
BOTH SECTIONS MUST BE COMPLETED
2. IRREVOCABLE ASSIGNMENT TO TRUSTEES OF FUNERAL ASSURANCE TRUST. In accordance with
paragraph 1 above and as a representative of the Funeral Home/Mortuary listed above, the undersigned hereby
irrevocably assigns, transfers, and delivers to the Trustees of the Funeral Assurance Trust, as Nominee,
under the Trust Agreement dated April 1 , 1995, (conformed copy of which appears on the reverse side hereof),
the ownership rights under the policy/certificate insuring the life of the insured as specified above. This Assignment
shall be irrevocable and will not be altered, amended, revoked, or terminated, in whole or in part, by the
undersigned. The undersigned hereby renounces for himself any interest, either vested or contingent, including
any reversionary right or possibility of reverter in and to the policy/certificate assigned to Trustees, and any
power to determine or control, by alteration, amendment, revocation, or termination, or otherwise, the
beneficial ownership or control of the policy/certificate.
,,;' -!--i ,,' "._,1 ,-,-,,; /~ ....0(..., - ',;
Signature 'Of Funeral Home/Mortuary Represen,~dve
(' /
"" l
,;
/'-(
,-"
l21ate
Policy/Certificate Number (to be filled in by Homesteaders Life Company)
ACCEPTANCE. The Trustees of the funeral A,surance Trust have agreed pursuant to the terms of said Trust to accept
ownership of the policy/certificate assigned herein. The Trustee shall be deemed to have accepted this assignment upon
receipt by said Trustees of a properly executed assignment in the Home Office of Homesteaders Life Company and upon
issuance of the policy/certificate assigned hereunder.
Blue/Homesteaders life Company
White/Homesteaders Life Comp.my
Pink/Funeral Establishment
Canary/Owner
H245.FlEX Rev 2/96
@HlC, 1995, All rights reserved. No use or reproduction without express permission.
\
FUNERAL ASSURANCE TRUST
THIS AGREEMENT dated April 1, 1995, by and between Homesteaders Life Company as Trustor, and Robert D. Wortman and
Kathryn A. Richer as Trustees.
WITNESSETH:
WHEREAS, Homesteaders Life Company is an Iowa Company, authorized to conduct the business of insurance under the laws
of the various states where it is authorized to do business; and
WHEREAS, Homesteaders Life Company sells and issues annuity contracts and life policies/certificates insuring the lives of
individuals in which the owner designates a beneficiary; and
WHEREAS, from time to time certain annuitants or policy/certificate holders may wish to irrevocably assign their ownership
rights under policies/certificates issued by Homesteaders Life Company to Trustees to hold such rights in a Trust as their Nominee
until the Trustees are notified of the death of the Insured at which time the Trustees authorize Homesteaders Life Company to
make payment of the proceeds of the policy/certificate in accordance with the terms of said policy/certificate; and
WHEREAS, the Trustees and Homesteaders Life Company desire to create a plan whereby annuitants or policy/certificate holders
may irrevocably assign their ownership rights in said policieslcertificates to Trustees for the purpose set forth herein;
NOW, THEREFORE, in consideration of the premises and the terms and conditions herein contained, the parties agree as follows:
1. TRUST. Homesteaders Life Company has authorized and the Trustees hereby agree to accept ownership rights under said
policieslcertificates of the Insured designated in the Irrevocable Assignment herein which are assigned to the Trustees by
the Irrevocable Assignment executed by the owner appearing on the reverse side hereof. Separate evidence of acceptance by
the Trustees of the assignment of the policytcertificate assigned shall not be required to complete said assignment and third parties
shall be entitled to rely upon the terms of this document as valid evidence of acceptance.
2. DISPOSITION OF TRUST PROPERTY. The Trustees authonze disposition of the proceeds payable under said policies/cer-
tificates as follows: The Trustees shall retain the ownership rights until notified of the death of the Insured. Upon such
notification, accompanied by proof of death, the Trustees authorize Homesteaders Life Company without further direction
to pay the proceeds of the policy/certificate in accordance with its terms.
If the policy be a single premium annuity, the Trustees shall not initiate any request for payment of an arlnuity unless
reqUired to do so by a court appOinted fiduciary.
If no legal claim to the proceeds is made within sixty (60) days after the death of the Insured, the Trustees may direct
the Company to pay the proceeds to the executor or administrator of the Insured or to any person who had incurred liability
for or paid or provided for the maintenance, illness, or burial of the Insured.
3. PREMIUM PAYING POLICIES/CERTIFICATES. The Trustees shall have no responsibility to effect payment of premiums due
on policies/certificates on a premium paying basis. All transactions relating to notification of premiums due and payment
of premiums shall be conducted between Homesteaders Life Company and the Insured or Owner. Upon lapsation, if the
minimum requirements of Homesteaders Life Company are not met, the policy/certificate and the Trust will terminate.
4. DISCHARGE. The Trustees shall be discharged of all duties and responsibilities to and authorizes Homesteaders Life
Company to pay the policy/certificate proceeds. The Trustees shall not be responsible for failure or the refusal of Homesteaders
Life Company to pay any or all of the proceeds of the policy/certificate, nor shall the Trustees be liable to Homesteaders
Life Company for any wrongful payment of policy/certificate proceeds, and Homesteaders Life Company shall hold harmless
and indemnify the Trustees from any and all claims, liability, or damage with respect to wrongful payment of proceeds.
5. SUCCESSORS. The remaining Trustee may appoint any person or concern to fill any vacancy created by death, resignation,
or inability to act of a Trustee. In the event that any remaining Trustee fails to or is unable to exercise his/her power
hereunder then the officers of Homesteaders Life Company shall appoint a Trustee to fill the vacancy. Legal title to the
policies/certificates held in Trust shall be vested in the Trustees by virtue of their office. No assignment or conveyance shall
be necessary to transfer title from a Trustee ceasing to act to a successor Trustee.
6. AMENDMENT. Homesteaders Life Company and Trustees reserve the right to modify or amend this agreement but no such
modification shall adversely affect the rights of any beneficiary becoming such prior to the effective date of any such
amendment or modification.
7. TERMINATION. The Trustees or Homesteaders Life Company may terminate this Agreement for the future giving written
notice thereof thirty (30) days in advance of the termination date. This Trust as to existing policies/certificates will nevertheless
continue until the death of all Insureds named in the policies/certificates; and provided further in any event should there
be in existence any outstanding policies/certificates which are in the hands of the Trustees at the time of twenty-one (21)
years after the termination hereunder, such policies/certificates shall be surrendered to Homesteaders Life Company.
8. NOTICES. Either Homesteaders Life Company or the Trustees may give notices to the other by hand delivering the same
or depositing the same in the mail addressed to the other at 2141 Grand Avenue, Des Moines, Iowa, 50312. Any notice
given by mail shall be deemed given when deposited in the United States mail, postage prepaid.
9. BOND. Trustees are to serve without bond.
10. CHOICE OF LAWS. This Trust Agreement shall be governed by the laws of the state of residence of the Insured.
IN WITNESS WHEREOF, the within named parties have executed this Agreement 011 the date first above written.
TRUSTOR:
TRUSTEES:
HOMESTEADERS LIFE COMPANY
/s/
Robert D. Wortman
By
/s/
Craham I. Cook
I'rpsident
/s/
Kathrvn A. Richer
H245-FLEX Rev ::./%
PRENEED FUNERAL AGREEMENT AND ASSIGNMENT
EXHIBIT 1 - STATEMENT OF FUNERAL MERCHANDISE AND FUNERAL SERVICES
NOTE: THIS A~~MENT IS TS ~E FUNDED BY THE _~SSIGNMEj ~,~ IN~URANC~BENEFITS
FOR THE BENEFIT OF {;;I~ J I~ ~t...O '-11,:> /3 y- c~ Ii;.
I-k dr~. //
GUARANTEED PROFESSIONAL SERVICES
Services of Funeral Director and Staff $
Embalming (See Agreement and Below') $
Other Preparation $
Visitation _ Days at $ /Day $
Funeral Ceremony/Memorial Service $
Other Use of Facilities and Staff (Specify)
$
Transfer of Remains to Funeral Home $
If beyond a mile radius, which is our service
area, there will be a charge of $_ per mile one way,
Family Car(s) at $ each $
Limousine Hearse $
Cremation $
Forwarding/ Receiving Remains $
Other Services/Facilities/Equipment (Specify)
$
TOTAL GUARANTEED SERVICES I $ 2~ ~S- -I
NON.GUARANTEED CASH ADVANCES
$ Escort
$ Grave Opening and Closing
$ Memorial Cards/Book
$ Clothing (Specify)
$ Monument/Marker
$ Engraving
$ Other (Specify)
$
$
(Funeral Recipient/Insured)
IN AGREEMENT WITH AND ASSIGNMENT TO
Death Certificates
Flowers
Music
Honorariums
Obituaries
Hairdresser
Shipping Container
Other (Specify)
at$
: 1119816
(Phone)
GUARANTEED MERCHANDISE
Casket ul c:-
Manufacturer 10(IL 7'fi....M?
Model Name V/<:N, v,<..fi
Model Number I
Exterior Description U i ~
Interior Description
Outer Burial Contain~)l A, ' .(
Model Name ;'YI Qyt ,-",:.
Model Number I
Manufacturer (,v. I tJ.I'v-{>
Constructed of eel"'" c..-.t-re
Other Guaranteed Merchandise (Specify)
$ )0')0-
$ 7{" 'S
TOTAL GUARANTEED MERCHANDISE
$
$
1$ IB3S -I
$
$
$
$
$
$
$
$
$
We charge you for our services in obtaining:
TOTAL NON-GUARANTEED CASH ADVANCES 1$
TOTAL GUARANTEED AND NON-GUARANTEED FUNERAL PRICE
I
1$ Lf'+-Clr) ,
I
'REQUIRED PURCHASES-<:::harges are only for those items that you selected or that are required. If we are required by
law or by a cemetery or crematory to use any items, we will explain the reasons in writing below.
EXHIBIT 1 ABOVE AND THE PRENEED FUNERAL AGREEMENT AND ASSIGNMENT ON THE REVERSE SIDE
SHALL CONSTITUTE THE TERMS AND CONDITIONS OF THIS AGREEMENT.
A;:JEMENT ~:!.D ASSIGNMENT BY:,! AGR7MJNrr~C'~E '{f-
~<_. _<' __, ,.,' ~.gnatur:~ n~Jlnr9haser) (Date)
J_ ,-: ~l
-"'-- '......-" - ,'--"
,--o! 1_ "C .....
" II', /..
''-'/.1 ) I'
" (Date)
(Addres'>}' .-' ..1 J~n,nne J.." / . ;/1 (['none) '-;:'
)' ( ',' '-d /(J/ J / :()/ '.
. -- ----f >':;.:' .... -'
(City, State) (Zip) (Zip)
HOME SALES ONLY, You, (he Buyer, may cancel (his transaction at any time prior to the third business day after the date
of this transaction. See the attached ~otice of Cancellation lorm (or an explanation of this right
,'001
;'2)HLC, 19112, All rights fPserved. No use Ilf reproduction without express permis,:;ion.
Cl)pies: Orip;inal. Homesteaders Life Company; Pink - Prnvider; Canary - Purchaser
Rev, 03/10/95
X"G.
PRENEED FUNERAL AGREEMENT AND ASSIGNMENT
AGREEMENT -The provider agrees to provide the funeral service as specified on Exhibit 1 in consideration of an
assignment of death benefits of life insurance or annuity coverage with an initial face amount at least equal to the
now-current total retail price for the items selected.
PRICE GUARANTEE-The prices shown on Exhibit 1 are the now-current retail prices and are illustrated for the sole purpose of
establishing the amount of insurance required to fully fund thi.s agreement. At the time the goods and services are provided. the
then-current retail prices will be charged. If the retail prices then exceed the death benefits assigned and the guarantee is not limited
as described below, the provider will supply and perform as specified and accept the available assigned death benefits as payment
in full.
EXCESS BENEFITS-If the actual death benefits exceed the then-current retail prices, the excess will be paid to the beneficiaries. TIle
beneficiaries may authorize payment of excess proceeds for additional items which are desired but not specified on Exhibit 1.
FREEDOM OF CHOICE-This agreement may be canceled at any time prior to the performance by the provider. Charges
are only for those items that are used. If required by law to use any items, the provider will explain the reasons in writing. The
purchaser, during his/her lifetime and thereafter, the purchaser's next of kin or legal representative retains the right to select the
provider that will supply the services and merchandise; however, if an alternate provider is so selected, this agreement shall become
null and void and the original provider agrees to then relinquish all claims to the life insurance or annuity proceeds.
CANCELLATION-The cancellation of this agreement does NOT cancel the life insurance or annuity, which may only be canceled
according to the terms of the life insurance or annuity. Unless the life insurance is canceled within 30 days of issue, only the
surrender value, if any, will be refunded. In the early years of coverage, this may be considerably less than the premiums paid.
If the life insurance or annuity is canceled, penalties may be assessed.
LIMITATION OF GUARANTEE-If the purchaser funds this agreement with limited benefit life insurance coverage and the funeral
recipient dies during the limited benefit period or with life insurance or an annuity with an initial face amount less. than the
now-current retail prices for the items selected, the party responsible for the funeral must pay any difference between the available
death benefits and the then-current prices.
OBLIGATIONS-This agreement shall be void unless the purchaser applies for and has issued the life insurance coverage, pays all
premiums due, fully maintains the cash values intact, and the death benefits thereof are assigned to the provider.
NON-GUARANTEED CASH ADVANCE5---Cash advances are amounts established to pay for items which are not guaranteed.
At the time these items are provided, those responsible for payment for funeral expenses must pay any difference between
the current retail price and the advanced amount. The provider may not allocate any portion of the cash advances to pay for guaranteed
items.
EMBALMING-If you selected a funeral that may require embalming, such as a funeral with viewing, you may not have to pay for
embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct cremation or
immediate burial. If we charged for embalming, we will explain why below (or on the reverse side).
SUBSTITUTION-If the provider is unable to perform due to the unavailability of merchandise or other factors beyond its control,
it may substitute merchandise of like quality in lieu of the merchandise selected. If the provider is unable to perform or another
provider is chosen, the life insurance or annuity proceeds may be available for use with that provider; however, prices and guarantees
would be at the discretion of that alternate provider.
PURCHASER ACKNOWLEDGMENTS-By his/her signature on this agreement, the purchaser acknowledges receipt of a
completed copy of this agreement and acknowledges that a current General Price List, a current Casket Price List, a current Outer
Burial Container Price List, and each of said documents, were made available to him/her prior to his/her selection of services and
merchandise.
ASSIGNMENT-In fulfillment of the consideration required under this agreement, the purchaser assigns to the provider the right to
receive death benefits contingent upon the performance by the provider as specified on Exhibit 1. This assignment remains in effect
until revoked in writing, with a copy of said writing having been received by Homesteaders Life Company prior to such time as
services or merchandise are provided by the assignee provider. This assignment shall exist even though an insurance beneficiary
is named. It notifies Homesteaders Life Company and directs them to pay benefits to the assigned provider up to its legitimate
interests as described above. The assignment shall not be effective until it has been filed at the home office of Homesteaders Life
Company and it shall be subject to any payments made or actions taken by them prior to its filing.
INSURER RESPONSIBILITY-Homesteaders Life Company is not a party to this agreement and is not responsible for the
fulfillment of its terms. The sole responsibility of Homesteaders Life Company shall be to pay the proceeds of the life insurance
or annuity.
SEE THE OTHER SIDE FOR ADDITIONAL TERMS AND PROVISIONS
@HLC, 1992, All rights reserved. No use or reproduction without express permission.
Copies: Original- Homesteaders Ufe Company; Pink - Provider; Canary. Purchaser; Green. Other
Rev. 12/02/94
E-FLEX.
.ENROLLMENT FOR
GROUP INSURANCE TO
. HOMESTEADERS LIFE COMPANY
2141 GRANO AVENUE/P.O. BOX 1756/DES MOINES, f(MIA 50306/515-288-7481
GROUP
ENROLLMENT
FORM
PROPOSED INSURED (Please Print)
Last
i,i '~l;"" .' ;'/(
. (, I
First
Jnitial
s"
. " , 2 , '.") ..
.. I " ....
Birthdale Age Social
Mo./OaylYr. ], ";-Security No.
" ~ ,': ) " (/
Slate Zip Phone No.
J '\I ~>>I'/ <,;
U:;j;
~_,4.....__..t..,
" ..l.;"
Residence - No. and Street
City or Town
OWNER OF THE CERTIFICATE (Complete only if OWner is other than Proposed Insured)
Last
First
Initial
Address
City
Slate Zip 58 No.
J ! .~'.~' ~'-. C. \ (,."-'- t
A ~tL,~r &4. f /~
(After payment under anf assignments, remaining proceeds are to be paid
to the estate of the insured unless a beneficiary is specified above.)
Relationship to Insured
BENEFICIARY
'. j. ".
.' ..,~t,U,' ,_/l.....-,
, ." .~~. \ .~
Relationship to Insured
REQUESTED BENEFITS IF yOU CHOOSE THE LIMITED DEATH BENEFIT PLAN, DEATH
BENEFITS ARE LIMITED AS FOLLOWS:
rn Years Premium Payable
Single Premium Initial 4i..Ut. ') <I Less Ulan 5 years 15t Year Death Bene1it = 50% 01 Face Amt.
Face Amt. $ Add'l Benefit if Death by Accident = 50% of Face Amt.
~ Certificate 5 years or greater 1st Vear Death Benefit = 35'% of Face Amt.
'-1'1 'hi . Add'l Benefit if Death by Accident = 65% of Face Amt.
D Rider Premium $ 2nd Year Death Benefit = 70% of Face Amt.
Add'l Benefit If Death by Accident = 30% of Face Amt.
D Limited Death Benefit Plan Payments Method Dividends
D Monthly D Check-Q-Matic (Complete D Purchase Add'] Ins.
Years Initial D C-Q-M form and submit D ACCUffi. at Interest
Premium Face Amt. $ Annually voided check) D
Payable D Paid I n Cash
D Semiannual Direct Billing D
Premium $ Reduce Premium
D Quarterly D Multiple BiUing - (List other policies for C-Q-M or MB)
REPLACEMENT-Will lhe proposed certificate replace any existing life insurance or annuity contracts?
o Yes [a(~o (If "Yes," complete replacement papers)
DECLARATIONS-I authorize Homesteaders Life Company to release information concerning this enrollment form
and my certificate to those persons who perform or are designated to perform services on my behalf. I represent
on behalf of myself that all statements and answers contained in this enrollment form are full, complete and true
as written, to the best of my knowledge and belief. It is agreed that (1) No agent of Homesteaders Life Company
has any power or authority to change or modify any of the provisions of this enrollment form; (2) No insurance shall
take effect until the premium has been paid and a certificate has been issued while the insured is living;
(3) All premium checks must be made payable to Homestead.;rs Life Company. Do not make checks payable to
the agent or leave the payee's name blank. I have paid $ ';' 'I 'It) with this enrollment form. I understand a
copy of this enrollment form will serve as receipt for the premium paid.
Signed at ',./11,,:,. !~j -";.rto
City
i_".,
1" "
State
Date
;'
,
19_.
Signature of Owner (If other than Proposed Insured)
Signature of Proposed Insured
Agent's Statement: By my signature I certify that, to the best of my knowledge, all information contained in this
enrollment form is correct, was recorded accurately, and confirm this enrollment form was signed in my presence.
Agent
No.~~___ _
o Security Option
o Advantage Option
Agent's Signature
Owner
GP.195.TD
Notice of Information Practices
This description of the information practices of Homesteaders Life Company and your Homesteaders Life Company
agent is being provided in accordance with the requirements of insurance information and privacy laws.
Collection
To issue and administer your certificate, we need to obtain information about you. Most of this information will be
obtained from your enrollment form for group insurance.
Disclosure
The information about you which we obtain will not be disclosed to others without your authorization except to the
extent necessary for the conduct of our business, and as authorized by the laws of your state. For example, necessary
items of information may be disclosed to:
. our agents to enable them to adequately service your certificate; and
. persons or organizations which perform a business, professional, or insurance function for us; and
. other insurers, agents, or insurance support organizations to enable them to perform a business function
concerning an insurance transaction with you; and
. a State Insurance Department or other governmental authority; and
. a funeral home if you have purchased a prearranged funeral contract.
Access to Information
You have a right of access to information we maintain in our files about you.
Within 30 business days of our receipt of your written request you may have access to recorded information
about you which is locatable and retrievable. We will inform you of the identity of any institutional source which gave
us the information. If you wish, we can arrange for you to see this information or obtain a copy by mail. You
may be asked to pay a charge for the cost of providing copies.
We will advise you of those persons to whom the information has been disclosed within two years prior to the request
if we have the information, or if not we will give you the names of the persons to whom such information is normally
disclosed.
Disputed Information
You may request correction, amendment, or deletion of any information in our files pertaining to you. We will respond
within 30 business days concerning your request.
We will tell you what action we have taken. If we do not agree with you, we will notify you of our refusal, give you
our reasons, and give you the opportunity to file a concise statement stating why you dispute our action.
We will notify any person who furnished us the information, within the preceding two years, at the dispute regarding
I the Information. Your statement of dispute will be sent to every person to whom disclosure has been made.
I Additional Information
I Please direct all requests to the Poiicyowner Service Department, Homesteaders Life Company, P.O. Box 1756,
I Des Moines, Iowa, 50306.
,
'1
i
i GP-195~TD
!<EV-1513EX+(',!97)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DE EDENT
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)
1. SEE A'lTACHMENT Each of the grand-
children will recei
a pro-rated arrount
the residue. There
will not be any f
left over to distri
bute to the natural
children.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, 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 $
catherine J. Bowers
FILE NUMBER
21-04-824
ESTATE OF
ve,
of
unds
(If more space is needed, insert additional sheets of the same size)
Attachment for Catherine Bowers Estate
Name
John A. Stover, Jr.,grandson
Catherine J. SCh01T, granddaughter
Loretta M. Lane, daughter
Michael H. Smith, grandson
Scott A. Smith, grandson
Winifred L. Evans, granddaughter
Evelyn L. Durnin, daughter
Douglas M. Durnin, grandson
Laurie A. Gleim, granddaughter
Chris Durnin, grandson
Karan Hammaker, granddaughter
Linda Devor, granddaughter
Steven A. Bowers, grandson
Marlin E. Bowers, grandson
Patricia E. Fr, daughter
Keith A. Fry, grandson
Brian D. Fry, grandson
Timothy W. Fry, grandson
Address
6126 Wallingford Way, Mechanicsburg, PA
6228 Bluebird Avenue, Harrisburg, PA 17112
George Street, P.O. Box 216, Da]matia, PA 77017
c/o Loretta M. Lane, P.O. Box 216, Dalmatia, PA 17017
c/o Loretta M. Lane, P.O. Box 216, Dalmatia, PA 17017
c/o Loretta M. Lane, P.O. Box 216, Dalmatia, PA 17017
1910 Douglas Drive, Carlisle, PA 17013
c/o Evelyn L. Durnin. 1910 Douglas Drive, Carlisle, PA \70\3
c/o Evelyn L. Durnin, 1910 Douglas Drive, Carlisle, PA 17013
c/o Evelyn L. Durnin, 1910 Douglas Drive, Carlisle, PA 170] 3
c/o Iris F. Bowers, 361 E Street, Carlisle, PA 17013
c/o Iris F. Bowers, 361 E Street, Carlisle. PA 17013
c/o Iris F. Bowers, 361 E Street, Carlisle, PA 17013
c/o Iris F. Bowers, 361 E Street, Carlis]e. PA 17013
18 Lantern Lane. Shippensburg, PA 17257
c/o Patricia E. Fry, 18 Lantern Lane. Shippensburg, PA 17257
c/o Patricia E. Fry, 18 Lantern Lane, Shippensburg. P A ] 7257
c/o Patricia E. Fry, 18 Lantern Lane, Shippensburg, PA 17257
)
,
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, ')
LAST WILL AND TESTAMENT OF
CATHERINE J. BOWERS
I t CATHERINE J. BOWERS, widow, of 435 "B" Street in the Borough of
Carlisle, Cumberland County, Pennsylvania, being of sound and disposing
mind, memory and understanding, do hereby make, publish and declare this as
and for my last Will and Testament, hereby revoking and making void any and
all Wills by me at any time heretofore made.
1. I direct my hereinafter named Executrix to pay all of my just debts and
funeral expenses as soon after my death as may be found convenient to do so.
2. I give and bequeath the sum of $200.00 to each of my grandchildren
and should any grandchild be less than 21 years of age I direct said sum shall
be paid to his or her parents as Guardian of the Estate of such minor grandchild.
At the present time I have the following Fifteen (15) grandchildren: John A.
Stover, Jr., Mrs, Catherine J. Schorr, Michael Smith, Scott Smith, Winifred
Smith, Douglas Durnin, Laurie Ann Durnin, Chris A, Durnin, Karan Bowers,
Linda Bowers, Steven Bowers, Marlin Eugene Bowers, Keith A. Fry, Brian Fry,
and Timothy Fry.
3. All the rest, residue and remainder of my estate, real, personal and
mixed, and wheresoever the same may be situate, I give, devise and bequeath
in equal shares to my Five (5) children, their heirs and assigns, they being:
Betty Jane Stover, of 80 I-D South Market Street, Mechanicsburg, Pennsylvania;
Loretta M. Lane, of Box 4, New Kingston, Pennsylvania; Evelyn L, Durnin, of
136 South Bedford Street, Carlisle, Pennsylvania; Marlin E, Bowers, of R. D,
# 1, Carlisle, Pennsylvania; and Patricia E. Fry, of R. D. # 3, Newville,
Pennsylvania.
4. I hereby nominate, constitute and appoint my said daughter, Loretta M,
Lane, as Executrix of this my last Will and Testament, but should she pre-
decease me or faU to qualify, then I nominate, constitute and appoint my said
daughter, Patricia E. Fry, as Executrix of this my last Will and Testament and
1 further direct that neither one shall be required to post any bond to secure
the faithful performance of her duties in the Commonwealth of Pennsylvania or
in any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my
last Will and Testament written on two (2) pages this I 'j..u- day of February,
1971.
".~Cf . ") ,j
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Catherine J. Bg'wers
(SEAL)
Signed, sealed, published and declared by Catherine J. Bowers, the
Testatrix above named, as and for her last Will and Testament, in our presence,
who, in her presence, at her request, and in the presence of each other, have
hereunto subscribed our names as attesting witnesses.
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C~UJ-S1,(J. f " Mc~ 0 .
CHARLES E. SHIELDS, III
ATTORNEY-AT-LA W
6 CLOUSER ROAD
Corner ofTrindle and Clouser Roads
MECHANICSBURG, PA 17055
GEORGE M. HOUCK
(1912-1991)
TELEPHONE (717) 766-0209
FAX (717) 795-7473
January 14, 2005
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
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Register of Wills
Cumberland County Court House
I Courthouse Square
Carlisle, P A 17013
Re: Estate of Catherine J. Bowers
21-04-00824
Dear Register of Wills:
Please find enclosed two copies of the Inheritance Tax Return to be filed for the above
estate as well as the following checks:
Check No. 996 in the amount of 15.00 for filing costs
Check No. 997 in the amount of$5.98 for tax.
Thank you for your kind attention to this matter.
V~~CR)
Charles E. Shields, III
CES:slk
Enclosures
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COMMONWEAl. TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU DF INDIVIDUAL TAXES
DEPT. 280601
HARRIS8URG, PA 17128,0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
SHIELDS CHARLES E III
6 CLOUSER ROAD
MECHANICSBURG, PA 17055
__,__n_ fold
ESTATE INFORMATION: SSN: 160~50~8205
FILE NUMBER: 2104-0824
DECEDENT NAME: BOWERS CATHERINE J
DATE OF PAYMENT: 01/18/2005
POSTMARK DATE: 01/15/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 08/22/2004
NO. CD 004855
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $5.98
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TOTAL AMOUNT PAID:
$5.98
REMARKS:
CHECK# 997
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WillS
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STATUS REPORT UNDER RULE 6.12
Name of Decedent: C/f7#E7Z/A/E J7 ~a/~s-
Date of Death: f';Z2.oLj
Will No.
Admin. No. 2./-1;l/-,f'21/
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. I f 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.
account with the
Did the personal representative
Court? Yes No )<.
f 11e a final
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c.
account informally
Did the personal representative state
to the parties in interest? Yes ><
,
an
No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
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Signature
Date:
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Charles E. Shields, III, Esquire
Name (Please type or print)
6 Clouser Road, Mechanicsburg, PA 17055
Address
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(717 ) 766-0209
Te 1. No.
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Capacity:
Personal Representative
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Counsel for personal
representative
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(MAH:rmf/AM3)
STATUS REPORT UNDER RULE 6.12
Name of Decedent:
RICHARD J. PASCO SR.
Date of Death:
August 30. 2004
No. 21-04-0822
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 X 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? X Yes No
Date:
d. Copies of receipts, releases, joinders and approvals of formal or informal
accounts may be filed with the Clerk of Orphan's Court and may be
3/9/06 attached to this rep~-, ~ ~
fure &- V
SALZMANN HUGHES PC
E. Ralph Godfrey. Esquire
Name (please type or print)
354 Alexander Spring Road. Suite 1
Address
Carlisle. PAl 7013
City, State, Zip
(717) 249-6333
Telephone Number
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Personal Representative
Counsel for Personal Representative
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