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Home My WebLink About04-0869PETITION FOR PROBATE and GRANT OF LETTERS Estate of PAUL 1~ SYVERSON, III also known as Paul Roland Syverson, Deceased. Social Security No.: 348- 74-9252 No. 21 - 04 - ~ To: Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner who is 18 years of age or older and the Executrix named in the last will of the above decedent, dated October 17, 2001, and codicil(s) dated (NONE). Decedent was domiciled at death in Cumberland County, Pennsylvania, with his last family or principal residence at 56 Fairview Street, Carlisle, Pennsylvania. Decedent, then 32 years of age, died June 16, 2004, at Balad, Iraq. Except as follows, decedent did not marry, was not divorced and 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: daughter was born April 27, 2004, decedent was Killed in Action. Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (If not domiciled in PA) Personal property in Pennsylvania (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania situated as follows: WHEREFORE, petitioner respectfully requests the probate of the last will and codicil(s) presented herewith and the grant of letters Testamentary thereon. ( \ J~luelyr~ E. Syvarson, ~aleutri~ ~} 56 Fairview S~eet Carlisle, PA 17013 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ) ) SS COUNTY OF CUMBERLAND ) The petitioner above-named swears or affirms that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of p~titioner and that as personal representative of the above decedent petitioner will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this r~~ dayof~t~fla~._ 0 L/ Jac~uelynE. Syv~son 2O 4 ~Jc~ ~ff ~ Regi4~r NO. 21- 04- _~J Estate of PAUL R. SYVERSON, III, Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW~r~_o~_ e~"'] .2004, in consideration of the petition on the reverse side hereof, sa{isfactory proof having been presented before me, IT IS DECREED that the instnnnent(s) dated October 17, 2001, described therein be admitted to probate and filed of record as the last will of Paul R. Syverson, m and Letters Testamentary are hereby granted to Jaequeline E. Syverson. FEES Probate, Letters, Etc ......... $ Short Certificates ( ) ......... $ ~ ~.. OlD -~mmc. im~,~.~,...~o.~ $ ~ .c,~ ~o~ Filed ~.5 ~.g. ~ .................. William A. Duncan, Esquire One Irvine Row Carlisle, PA 17013 (717) 249-7780 (22080) CERTIFICATE OF DEATH (OVERSEAS) NAMEOFOECEASED (Last, First, Middle) Nomdud~c~d~(Nometpr~nom$) GRADE Grade SRANCHOFBERVICE SOCIALSECUBITYNUMSER .~y.,..,,.~,-,or~'n, PauJ, Roland Arme Nurn~re de I'Assurance Sociale 0-4 Army 348749252 ORGANIZATION Organisation NATION (e.g., United State$) DATE OF BIRTH SEX Sexe HHC, 5th Special Forces Group (Airborne) Pays Date ~* na~ssa.oe Campbell, KY 42223 JSA 24 Oct 1971 M MALE M~se~lin --oFt ] FEMALE F~minin RACE Race MARITALSTATUS ~tatCivil RELIGION Cu~te PROTESTANT OTHER (Specify) X CAUCASOID Caucasique SINGLE CBlibataire DIVORCED Protestant Autre (Specifier) Divorce CATHOLIC NEGROID Negriode X MARRIED Mari~ X Catho~ique SEPARATED OTHER (Specify) WIDOWED Veuf S6par6 JEWISH Juif Autre (Specifier) NAME OF NEXT OF KIN Nora du plus proche parent RELATIONSHIP TO DECEASED Parent~ du dec, de avec le susdit Mrs. Jacquelyn E. Syverson Wife STREETADDRESS Domicile ~ (Rue) ClTY OR TOWN AND STATE (IncluCJe ZIP Code) Ville(Codepostalcempris) 1219B Coune Street Fort Campbell, KY 42223-3500 MEDICAL STATEMENT D~claration m~dlcale iNTERVAL BETWEEN CAUSE OF DEATH (Enter only once cause per line) ONSET AND DEATH Cause du daces (N'indiquer qu'une cause par iigne) Inte~valie entre DISEASE OR CONDITION DIRECTLY LEADING TO DEATH1 Shrapnel injuries of the head and torso Seconds Maladie ou condition directe~n responsable de la mort, ~ ~.~..-- ~? s~io~d. Kent E. Harshbarger, MA J, MC, USAR Homicide E~YES Oui [~NO Non 1330, 16 Jun 2004 Baled, Iraq CDR Dover AFB, DE 19902 FORM (REMOVE, REVERSE AND RE-INSERT CARBONS BEFORE COMPLETING THIS SIDE) DISPOSITION OF REMAINS NAME OF MORTICIAN PREPARING REMAINS WILLIAM D. ZWICHAROWSKI INSTALLATION OR ADDR ESS 436 SVS/SVD 116 26th Street, Dover AFB DE 19902-5116 NAME OF CEMETERY OR CREMATORY TYPE OF DISPOSITION LOCATION OF CEMETEf~dfl~R~F~MATORY ~// DATE OF DISPOSITION NAME OF FUNERAL DIRECTOR REGISTRATION OF VITAL STATISTICS REGISTRY (Town and Cou~tfy) DATE REGISTERED ADDRESS ~ SIGNATURE OF AUTHORIZED INDIVIDUAL DD FORM 2064, APR 1977 (BACK) USAPA V1.0 DEPARTMENT OF THE .&RMY REPORT OF CASUALTY ALEXANDRIA, vmcaNiA REPORT CONTROL SYMBOL 22331-0481 DD-P&R(AR) 1664 1. REPORT TYPE 2. DATE PREPARED Final 10 Aug 2004 3. SERVICE IDENTIFICATION Reserve USA HI-IC, 5th Special Forces Group (Airborne), Fort Campbell Ky 42223 4. CASUALTY INFORMATION Hostile Deceased Killed In ActionI 16 Jun 2004 31st Csh, Balad, Iraq Hostile Action: Shrapnel injuries of head and torso per DD form 2064 (Certificate of Death) ~ ~AmcSti*'~;] Present For Duty 5. BACKGROUND INFORMATION 24 Oct 1971 Warwick, RI United States White NoneI Male Roman Catholic Church Conflict: WAR ON TERRORISM / OPERATION IRAQI FREEDOM Jacquelyn E. Syverson, 1219B Coune Street, Fort Campbell, KY (Wife 1, 2, 3/SGLI 90°/~,,.. Amy E. and Paul R. Syverson, address same as above (Children) (Son/SGLI 10%) Paul R. and Joy H. Syverson, 148 Ash Street, Lake Zurich, IL 60047-1310 (Parents) > :': ~ ' ~; ~:~ Commander, HQ ARCENT-KU, ATT/q: PSS, APO AE 09889-9900[ 16 .tun 2004 DD Form 1300, MAR 2004 PREVIOUS EDITION MAY BE USED. LAST WILL AND TESTAMENT OF PAUL R. SYVERSON III Dated: October F/,2001 LAST WILL AND TESTAMENT OF PAUL R. SYVERSON III I, PAUL R. SYVERSON III, make, publish and declare this to be my Last Will and Testament, revoking all wills and codicils at any time heretofore made by mc. I am married to JACQUELYN E. SYVERSON. I presently have one child, PAUL R. SYVERSON IV. I reside and am domiciled in the State of Illinois. I am in the military service of the United States, currently stationed at Fort Campbell, Kentucky. FIRST: I direct that the expenses of my last illness and flmeral and the expenses of the administration of my estate shall be paid from my residuary estate without apportionment. I direct that all estate, inheritance and similar taxes payable with respect to property included in my estate, whether or not passing under this will, and any interest or penalties thereon, shall be apportioned among the people interested in my estate in the manner provided by law in the absence of a contrary direction in this will. SECOND: I give all real estate owned by me at the time of my death, and all rights that I have under any related insurance policies, to my wife JACQUELYN E. SYVERSON, if she survives me. THIRD: I give all tangible personal property owned by me at the time of my death, including without limitation personal effects, clothing, jewelry, furniture, furnishings, household goods, automobiles and other vehicles, together with all insurance policies relating thereto, to my wife JACQUELYN E. SYVERSON, if she survives me, or if she does not survive me, to those of my children (PAUL R. SYVERSON IV and any other children which I hereafter may have) who survive me, in substantially equal shares, to be divided among them as they shall agree, or if they cannot agree, or if any of them shall be under the age of eighteen (18) years, as my Executor shall determine. FOURTH: I give all the rest, residue and remainder of my property and estate, both real and personal, of whatever kind and wherever located, that I own or to which I shall be in any manner entitled at the time of my death (collectively referred to as my "residuary estate"), as follows: (a) If my wife JACQUELYN E. SYVERSON survives me, to my wife outright. (b) If my wife does not survive me, then to those of my children who survive me and to the issue who survive me of those of my children who shall not survive me, in equal shares per stirpes. (c) If my wife does not survive me and there shall be no issue of mine then living, my residuary estate shall be paid and distributed to those of my father PAUL R. SYVERSON JR and JOYCE SYVERSON who survive me, in equal shares. (d) If none of the beneficiaries described above shall survive me, then I give my residuary estate to those who would take from me as if I were then to die without a will, married and the absolute owner of my residuary estate, and a resident of the State of Illinois. FIFTH: If any property of my estate vests in absolute ownership in a minor or incompetent, my Executor, at any time and without court authorization, may: distribute the whole or any part of such property to the beneficiary; or use the whole or any part for the health, education, maintenance and support of the beneficiary; or distribute the whole or any part to a guardian, committee or other legal representative of the beneficiary, or to a custodian for the beneficiary under any gifts to minors or transfers to minors act, or to the person or persons with whom the beneficiary resides. Evidence of any such distribution or the receipt therefor executed by the person to whom the distribution is made shall be a full discharge of my Executor from any liability with respect thereto, even though my Executor may be such person. If such beneficiary is a minor, my Executor may defer the distribution of the whole or any part of such property until the beneficiary attains the age of eighteen (18) years, and may hold the same as a separate fund for the beneficiary with all of the powers described in Article SEVENTH hereof. If the bene- ficiary dies before attaining said age, any balance shall be paid and distributed to the estate of the beneficiary. SIXTH: I appoint my wife JACQUELYN E. SYVERSON to be my Executor. If my wife does not survive me, or shall fail to qualify for any reason as my Executor, or having qualified shall die, resign or cease to act for any reason as my Executor, I appoint my friend JAMES S. TRESOUTHICK as my Executor. If my friend JAMES S. TRESOUTHICK shall fail to qualify for any reason as my Executor, or having qualified shall die, resign or cease to act for any reason as my Executor, I appoint my friend PAUL A. ARNDT as my Executor. I direct that no Executor shall be required to file or furnish any bond, surety or other security in any jurisdiction. SEVENTH: I grant to my Executor all powers conferred upon executors wherever my Executor may act. I also grant to my Executor power to retain, sell at public or private sale, exchange, grant options on, invest and reinvest, and otherwise deal with any kind of property, real or personal, for cash or on credit; to borrow money and encumber or pledge any property to secure loans; to hold property in bearer form or in the name of a nominee; to divide and distribute property in cash or in kind; to exercise all powers of an absolute owner of property; to incorporate any business and hold any interests in corporations; to vote stock or securities, in person or by proxy; to exercise subscription and conversion rights, and to participate or refuse to participate in any reorganization, recapitalization, merger, consolidation, liquidation, dissolution or other action with respect to any corporation; to transfer any business or property to a partnership and to be a general or limited partner; to compromise and release claims with or without consideration; to execut& and deliver deeds and other instruments, 2 including releases; and to employ attorneys, accountants and other persons for services or advice. The term "Executor" wherever used herein shall mean the executors, executor, executrix or administrator in office from time to time. EIGHTH: I direct that for purposes of this will a beneficiary shall be deemed to predecease me unless such beneficiary survives me by more than thirty days. The terms "child", "children" and "issue", as used in this will, include children and issue hereafter born. NINTH: If my wife shall not survive me, I appoint my father-in-law DONALD KIRK to be the Guardian of the person and property of any children of mine who have not attained the age of majority. If my father-in-law DONALD KIRK shall fail or cease to act as Guardian, I appoint my father PAUL R. SYVERSON JR as Guardian. No Guardian shall be required to file or furnish any bond, surety or other security in any jurisdiction. TENTH: I have served in the Armed Fomes of the United States. I therefore request that my Executor make appropriate inquiries to ascertain whether there are any benefits to which I, my dependents or my heirs may be entitled by virtue of any military affiliation. I specifically request that my Executor consult with a retired affairs officer at the nearest military installation, the Department of Veterans Affairs, and the Social Security Administration. IN WITNESS WHEREOF, I, PAUL R. SYVERSON III, sign my name and publish and declare this instrument (consisting of four pages, including this page) as my last will and testament this t7 r~day of October, 2001. I also have affixed my initials on the bottom of each of the preceding pages hereof. PAUL R. SYVERSON III The foregoing instrument was signed, published and declared by PAUL R. SYVERSON III, the above-named Testator, to be his last will and testament in our presence, all being present at the same time, and we, at his request and in his presence and in the presence of each other, have subscribed our names as witnesses on the date above written. having an address at 3 having an address at 4 AFFIDAVIT OF WITNESSES WITH THE UNITED STATES ARMED FORCES AT FORT CAMPBELL, KENTUCKY, SS. Each of the undersigned, f~£,~_L~,~,..O- having an address at fi~.J~ ,,.'fl ~t~ ,_t~r-7'"~_n~- '.o havln an - -- -- - _'~_ _ _'~_ ....and ~-,'~Ozf_ff_. _~/40'~/,/~',~. _ _ _ 'g address at _ .~--_/._ d,z3~dd. ,~. ~f respectively, being individually and severally duly sworn, did depose and say that: The foregoing last will and testament was subscribed in our presence and sight by PAUL R. SYVERSON III, the Testator named therei,n.i~The undersigned witnessed the execution of said will of PAUL R. SYVERSON III on the [7 day of October, 2001. At the time the instrument was so subscribed, the Testator declared said instrument to be his last will and testament. The undersigned thereupon signed their names as witnesses at the end of said will at the request of the Testator, in the presence of the Testator and each other. At the time of so executing said will, in our respective opinions, the Testator was at least eighteen years of age, and was of sound mind, mcunory and understanding, under no constraint, duress, fraud or undue influence, and in no respect incompetent to make a valid will. In our respective opinions, the Testator was able to read, write and converse in the English language, and was not suffering from any defect of sight, hearing or speech, or from any other physical or mental impairment which would affect his capacity to make a valid will. Each of us was acquainted with the Testator, and we make this affidavit at his request. Said will was shown to us at the time this affidavit was made, and we examined it as to the signature of the Testator and our signatures. Said will was executed as a single, original instnnnent, and not in counterparts. Witness Subscribed, sworn to and acknowledged b.,0f~re me and subscribed and sworn to before me by the said _ ~r~,_ _c~_ ~_ _~0ad- _..2~Sg[,v_ lT~~,/_C ........ ............... _x,.l_ ..... ~er, 2001. I, the undersigned officer, do hereby ce~ify that I am, on the date of this certificate, a person with the power described in Title 10 U.S.C. 1044a of the grade, branc,~service, and organization stated below in the active service of the United States Armed Forces, and that by/fta~this certificate, under authority granted to me by Title 10 U.S.C. 10~a~7~~~~ _/~ FKA ~N~S. SH^W, Judge~,~cf'0'~ate CPT, ~.S. Army HHC, 5th SFG(A) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717)240-6345 Date: 01/10/2005 DUNCAN WILLIAM A 1 IRVINE ROW CARLISLE, PA 17013 RE: Estate of SYVERSON PAUL R III File Number: 2004-00869 Dear Sir/Madam: It has come to my attention that you have not filed the Certification of Notice Under Rule 5.7 (a) in the above captioned estate. 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 ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.7, shall file with the Register of Wills or Clerk of the Orphans' Court his/her Certification of Notice. This filing will become delinquent on 01/06/2005 Your prompt attention to this matter will be appreciated. Thank You. cc: File Personal Representative(s) Judge Sincerely, GLENDA FARNER STRASBAU~ Clerk of the Orphans' Court Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717)240-6345 Date: 01/10/2005 SYVERSON JACQUELYN E 56 FAIRVIEW STREET CARLISLE, PA 17013 RE: Estate of SYVERSON PAUL R III File Number: 2004-00869 Dear Sir/Madam: It has come to my attention that you have not filed the Certification of Notice Under Rule 5.7 (a) in the above captioned estate. 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 ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.7, shall file with the Register of Wills or Clerk of the Orphans' Court his/her Certification of Notice. This filing will become delinquent on 01/06/2005 Your prompt attention to this matter will be appreciated. Thank You. cc: File Counsel Judge Sincerely, GLENDA FARNER STRASBAS~q4 Clerk of the Orphans' Court CERTIFICATION OF NOTICE UNDER RULE 5.6 (e) Name of Decedent: Paul R. Syverson, III Date of Death: June 16,2004 Will No.: 21-04-0869 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: August 19,2004. Name Jacquelyn E. Syverson Address 56 Fairview Street, Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None. -4\1(U~ ~~^--- Duncan & Hartman, P.C. One Irvine Row Carlisle, Pennsylvania 17013 Telephone (717) 249-7780 Capacity:_ Personal Representative ..1L Counsel for Personal Representative 1''-'.',\ .,1'10 '"'..''' 'U. ..J :;,i '(1: ";CCJ >:IJlJ 10 :01 H'j 61 H\fr SGGl J i ,j liJ '\("1\ I \"': j;, J,--,i:':':,\.. :;- ~'M!lOO EX + e!-OO) '* COMMONWEALTHOF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 NO ADDL ~ROBATLDUE-. REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT 0FFlCIAI. USE ONlY FILE NUMBER 21 -0 4 0 8 6 9 COUNiYCOiiE -YEAR- - - NUMBER- - I- Z W C W o W C DECEDENT'S NAME (LAST, FIRST, AND MiDDlE INITIAl) S erson III Paul R. DATE OF DEATH (MM-oo. Yell') DATE OF BIRTH (MM-oo.Year) SOCIAl SECURITY NUMBER THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAl SECURITY NUMBER 532-80-3752 S :.::-(1) 00::.:: wG.o ~oo ofiif G. c: 06/1612004 10/24/1971 (IF APPLICABLE) SURVMNG SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) 00 1. Original Return D 4. Limited Estate 00 6. Decedent Died Testate (Allach copy ol WIll D 9. Litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise (d*oldealll aIler12-12-82) D 7. Decedent Maintained a Living Trust (Allach copyolTrust) D 10. Spousal Poverty Credit (daEoldealhbet!oeen 12-31-91 and 1-1-95) D 3. Remainder Return (dale oldealh pIior\o 12-13-82) D 5. Federal Estate Tax Return Required .Q... 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Allach Sch 0) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS William A. Duncan Es uire Duncan & Hartman, P.C. FIRM NAME (If Applicable) Duncan & Hartman P.C. One Irvine Row TELEPHONE NUMBER 717 249-7780 Carlisle PA 17013 ... z w o z o G. II) W 0: 0: o o z o ~ :3 ~ l- n: c( o W 0: 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, ParlnelShip or SoIe-Proprietorship 4. ~ages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous PeISOl1al 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 GlOSS Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (1) (2) (3) (4) (5) OFFICIAL USE ONLY 2,695.00 (.: (6) '. (7) 0.00 (9) 10. Debts of Decedent Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) (8) 2,695.00 4,559.00 14. Net Value SUbject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ ~ ~ D. ~ o o >< c( I- 15. Amount of Line 14 taxable at the spousal tax rate. or transfers under Sec. 9116 (a)(1.2) 19. Tax Due 0.00 X 0.00 (15) X _(16) X .12 (17) X .15 (18) (19) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 20.0 :;HE(:K: ..-;Eh;= ~ f':~ :'R~ ~~Q~'EST ~~::; ~ ~=r:.J~~D ':~ :''', 0v'::RPt.. ',1c:r~T > > BE SURE TO ANSWER ALL QUESnONS ON ReveRSE SIDE AND RECHECK MATH < < (11) (12) (13) 4,559.00 -1,864.00 (14) -1,864.00 0.00 0.00 0.00 o ecedent's Complete Address: STREET ADDRESS 56 Fairview Street CITY I STATE I ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN .X" IN THE APPROPRIATE BLOCKS 0.00 0.00 0.00 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ........................................................................... D 00 b. retain the right to designate who shall use the property transferred or its income; ........................................ D 00 c. retain a reversionary interest; or ...................................................................................................... D 00 d. receive the promise for life of either payments, benefits or care? ............................................................. D 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?............................ .............................. .................................... D 00 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. D 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... D 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. OlOOS o ~--- PA 17013 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)). For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)). The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)). The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)). A sibling is defined, under Section 9102, as an individual who has at least one oarent in common with the decedent. whether bv blood or adootion. BEV-15081iX + (6-98) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Syverson III Paul R. FILE NUMBER 21 04 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. 0869 ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 2,695.00 1995 Nissan pickup TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 2 695.00 REV-1510 IiX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Syverson. III. Paul R. SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER 21 04 0869 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REM.. ESTATE. VALUE OF ASSET INTEREST VALUE (IF APPlICABLE) 1. Thrift Savings Plan, Jacquelyn Syverson-beneficiary. 18,342.34 100. 18,342.34 0.00 "FOR INFORMATION ONLY" TOTAL (Also enter on line 7 Recapitulation) $ 0.00 (If mnl"Di C!:n~1"'O i<l: ng,ctfAti in<l:crt ~rlrlmnn~1 <l:nQlll~ nf the. <l:~mO C!:i7c.' REV-1511 IiX + (12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Syverson III. Paul R. SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Debts of decedent must be reported on Schedule I. 21 FILE NUMBER 04 0869 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of PelSOflal Representative (s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. AttomeyFees Duncan & Hartman, P.C. 1,000.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation) 3,500.00 Claimant JaCQuelyn E. Syverson Street Address 56 F airview Street City Carlisle Slate P A Zip 17013 Relationship of Claimant to Decedent Spouse 4. Probate Fees Costs to Date: $59. 59.00 In Reserve: $ 5. Accountants Fees 6. Tax Return Prepare(s Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 4.559.00 (If more space is needed. insert additional sheets of the same size) """"""'w COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER - n III P~III R. 21 04 ORA!:! 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 pnclude outright s~sal distributions. and transfers under Sec. 9116 (a) (1. )] 1. Jacquelyn E. Syverson Spouse 100 Percent 56 Fairview Street Carlisle, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) ~. LAST WILL AND TESTAMENT OF PAUL R. SYVERSON III Dated: October J..:L, 2001 LAST WILL AND TESTAMENT OF PAUL R. SYVERSON III I, PAUL R. SYVERSON III, make, publish and declare this to be my Last Will and Testament, revoking all wills and codicils at any time heretofore made by me. I am married to JACQUELYN E. SYVERSON. I presently have one child, PAUL R. SYVERSON N. I reside and am domiciled in the State of Illinois. I am in the military service of the United States, currently stationed at Fort Campbell, Kentucky. FIRST: I direct that the expenses of my last illness and funeral and the expenses of the administration of my estate shall be paid from my residuary estate without apportionment. I direct that all estate, inheritance and similar taxes payable with respect to property included in my estate, whether or not passing under this will, and any interest or penalties thereon, shall be apportioned among the people interested in my estate in the manner provided by law in the absence of a contrary direction in this will. SECOND: I give all real estate owned by me at the time of my death, and all rights that I have under any related insurance policies, to my wife JACQUELYN E. SYVERSON, if she survives me. THIRD: I give all tangible personal property owned by me at the time of my death, including without limitation personal effects, clothing, jewelry, furniture, furnishings, household goods, automobiles and other vehicles, together with all insurance policies relating thereto, to my wife JACQUELYN E. SYVERSON, if she survives me, or if she does not survive me, to those of my children (PAUL R. SYVERSON N and any other children which I hereafter may have) who survive me, in substantially equal shares, to be divided among them as they shall agree, or if they cannot agree, or if any of them shall be under the age of eighteen (18) years, as my Executor shall determine. FOURTH: I give all the rest, residue and remainder of my property and estate, both real and personal, of whatever kind and wherever located, that I own or to which I shall be in any manner entitled at the time of my death (collectively referred to as my "residuary estate"), as follows: (a) Ifmy wife JACQUELYN E. SYVERSON survives me, to my wife outright. (b) Ifmy wife does not survive me, then to those of my children who survive me and to the issue who survive me of those of my children who shall not survive me, in equal shares per stirpes. ~s (c) If my wife does not survive me and there shall be no issue of mine then living, my residuary estate shall be paid and distributed to those of my father PAUL R. SYVERSON JR and JOYCE SYVERSON who survive me, in equal shares. (d) If none of the beneficiaries described above shall survive me, then I give my residuary estate to those who would take from me as if I were then to die without a will, unmarried and the absolute owner of my residuary estate, and a resident of the State of Illinois. FIFTH: If any property of my estate vests in absolute ownership in a minor or incompetent, my Executor, at any time and without court authorization, may: distribute the whole or any part of such property to the beneficiary; or use the whole or any part for the health, education, maintenance and support of the beneficiary; or distribute the whole or any part to a guardian, committee or other legal representative of the beneficiary, or to a custodian for the beneficiary under any gifts to minors or transfers to minors act, or to the person or persons with whom the beneficiary resides. Evidence of any such distribution or the receipt therefor executed by the person to whom the distribution is made shall be a full discharge of my Executor from any liability with respect thereto, even though my Executor may be such person. If such beneficiary is a minor, my Executor may defer the distribution of the whole or any part of such property until the beneficiary attains the age of eighteen (18) years, and may hold the same as a separate fund for the beneficiary with all of the powers described in Article SEVENTH hereof. If the bene- ficiary dies before attaining said age, any balance shall be paid and distributed to the estate of the beneficiary. SIXTH: I appoint my wife JACQUELYN E. SYVERSON to be my Executor. If my wife does not survive me, or shall fail to qualify for any reason as my Executor, or having qualified shall die, resign or cease to act for any reason as my Executor, I appoint my friend JAMES S. TRESOUTHICK as my Executor. If my friend JAMES S. TRESOUTHICK shall fail to qualify for any reason as my Executor, or having qualified shall die, resign or cease to act for any reason as my Executor, I appoint my friend PAUL A. ARNDT as my Executor. I direct that no Executor shall be required to file or furnish any bond, surety or other security in any jurisdiction. SEVENTH: I grant to my Executor all powers conferred upon executors wherever my Executor may act. I also grant to my Executor power to retain, sell at public or private sale, exchange, grant options on, invest and reinvest, and otherwise deal with any kind of property, real or personal, for cash or on credit; to borrow money and encumber or pledge any property to secure loans; to hold property in bearer form or in the name of a nominee; to divide and distribute property in cash or in kind; to exercise all powers of an absolute owner of property; to incorporate any business and hold any interests in corporations; to vote stock or securities, in person or by proxy; to exercise subscription and conversion rights, and to participate or refuse to participate in any reorganization, recapitalization, merger, consolidation, liquidation, dissolution or other action with respect to any corporation; to transfer any business or property to a partnership and to be a general or limited partner; to compromise and release claims with or without consideration; to execute and deliver deeds and other instruments, 2 \~s including releases; and to employ attorneys, accountants and other persons for services or advice. The term "Executor" wherever used herein shall mean the executors, executor, executrix or administrator in office from time to time. EIGHTH: I direct that for purposes of this will a beneficiary shall be deemed to predecease me unless such beneficiary survives me by more than thirty days. The terms "child", "children" and "issue", as used in this will, include children and issue hereafter born. NINTH: If my wife shall not survive me, I appoint my father-in-law DONALD KIRK to be the Guardian of the person and property of any children of mine who have not attained the age of majority. If my father-in-law DONALD KIRK shall fail or cease to act as Guardian, I appoint my father PAUL R. SYVERSON JR as Guardian. No Guardian shall be required to file or fumish any bond, surety or other security in any jurisdiction. TENTH: I have served in the Armed Forces of the United States. I therefore request that my Executor make appropriate inquiries to ascertain whether there are any benefits to which I, my dependents or my heirs may be entitled by virtue of any military affiliation. I specifically request that my Executor consult with a retired affairs officer at the nearest military installation, the Department of V eterans Affairs, and the Social Security Administration. IN WITNESS WHEREOF, I, PAUL R. SYVERSON III, sign my name and publish and declare this instrument (consisting of four pages, including this page) as my last will and testament this 17 i"J:!day of October, 2001. I also have affixed my initials on the bottom of each of the preceding pages hereof. G::&t. ~ ~ PAULR. SYVERSON III The foregoing instrument was signed, published and declared by PAUL R. SYVERSON III, the above-named Testator, to be his last will and testament in our presence, all being present at the same time, and we, at his request and in his presence and in the presence of each other, have subscribed our names as witnesses on the date above written. ~w~ Co tI...:) .(::J~< r . having an address at t.MAA;.J d d ~ 3 TV c5Z~q7 having an address at -P-T (;"#/lIf i1Ft / j Je'{ 4 AFFIDAVIT OF WITNESSES WITH THE UNITED STATES ARMED FORCES AT FORT CAMPBELL, KENTUCKY, SS. Jll...k~ 1l;1J=~l,,~e_~~~~~ ~~~~ ~ ~ ~ ~ ~~~:' :~~~~ ~ = = = _ ~ _ _ _ , and JtJ-ZJd L j{u.tJ.ilIlE)(' _ _ _ havmg an address at _ FL._c.l.lJjj/b2L~t --------------------------------------------------- respectively, being individually and severally duly sworn, did depose and say that: The foregoing last will and testament was subscribed in our presence and sight by PAUL R. SYVERSON III, the Testator named therein-d- The undersigned witnessed the execution of said will of PAUL R. SYVERSON III on the 1.2.:.:.. day of October, 2001. At the time the instrument was so subscribed, the Testator declared said, instrument to be his last will and testament. The undersigned thereupon signed their names as witnesses at the end of said will at the request of the Testator, in the presence of the Testator and each other. At the time of so executing said will, in our respective opinions, the Testator was at least eighteen years of age, and was of sound mind, memory and understanding, under no constraint, duress, fraud or undue influence, and in no respect incompetent to make a valid will. In our respective opinions, the Testator was able to read, write and converse in the English language, and was not suffering from any defect of sight, hearing or speech, or from any other physical or mental impairment which would affect his capacity to make a valid will. Each of us was acquainted with the Testator, and we make this affidavit at his request. Said will was shown to us at the time this affidavit was made, and We examined it as to the signature of the Testator and our signatures. Said will was executed as a single, original instrument, and not in counterparts. ~k 4[}m~..f~ C// Witness ~(-:- -;) . ,z-, Subscribed, sworn to and acknowledged b before me by the said _ &-'-\- ~~c. _Q.~ 'J a wltnes I, the undersigned officer, do hereby ce ify that I am, on the date of this certificate, a person with the power described in Title 10 U.S.C. 1044a of the gra e, branc service, and organization stated below in the active service of the United States Armed Forces, and that by' a e seal' . this certificate, under authority granted to me by Title 10 U.S.C. 1044a. FRAN S. SHAW, Judge CPT, .S. Army HHC, 5th SFG(A) Kelley Blue Book - Private Party Pricing Report - Nissan, Pickup ~ USEOCARS RIYIIW. & RA 'f11tO. ADVlCI FINANeU'O " IN8URAJtCI r- r,:::p :'=:c.~~k:r :':')rc(' :~}"-(:l.'-' BLUE BOOK PRIVATE PARTY REPORT Pennsylvania · August 20, 2004 1995 Nissan Pickup XE Short Bed .. ~i~c:lr~ll_Listjnqs~LTbJs_Cgr ListY9JJr~.9-L_ FOJ.Sfl-'g_QnHDJ~ ~.!Jy-.a~w_~g[ t[e~J~,e~rc:L Check AlttlLloQflJ1S frQm2~~%8PB InsJ,J rctl1_~~_QlJQt~ Pri nt--"Eor~~J~~__~ign PaymeD~Calcul.~tor Engine: 4-Cyl. 2.4 Liter Trans: 5 Speed Manual Drive: 2 Wheel Drive Mileage: 100,000 Equipment Air Conditioning Power Steering Tilt Wheel AM{FM Stereo Cassette ABS (4-Wheel) Sliding Rear Window Bed Liner Consumer Rated Condition: Good "Good" condition means that the vehicle is free of any major defects. The paint, body and interior have only minor (if any) blemishes, and there are no major mechanical problems. In states where rust is a problem, this should be very minimal, and a deduction should be made to correct it. The tires match and have substantial tread wear left. A clean title history is assumed. A "good" vehicle will need some reconditioning to be sold at retail; however major reconditioning should be deducted from the value. Most recent model cars owned by consumers fall into this category. Private Party Value Sear~tU"Q~gLL..~ting~JQJ:J"Bj~J:~_~r $2,695 Private Party value represents what you might expect to pay for a used car when purchasing from a private party. It may also represent the value you might expect to receive when selling your own used car to another private party . ~_c;.L(L]J~~9hi:lLl@!:t~IIlYj:lJl,J_~ ~_f;!lJnvoic~lU1SBE- oni'JewhM;i G~t g_E~!~Qf!_.tQ_e.l'!I~_QJ)8illQh9gn Page lof2 _ :~':::.; '_ ;":',i ": :ip,~.y Get vehicle in! from the sour< Sei:lfch delllcr ~ Your car.1 ;, gmbu'I'power.con http://www.kbb.comlkb/ki.dll/kw.kc.ur?kbb.PA;1 05378;P A041&17013;+p&722;Nissan; 1... 8/20/2004 ('~......::..::..:..:.......:: * h>. 1liIlIfT . . SAVINGS I'I.AN Thrift Savings Plan National Finance Center . ... >p~o . BOX61500/Ne,^-, ()r1eans, LA 70161 .,.1500 JACQUELYN SYVERSON 56 FAIRVIEW STREET ....--.----C-ARL-ISLE;-PA170IT. -.. 10/18/2004 Dear Sir or Madam: . . A death benefit payment has beenproceS$edfr()mthe'ThrlffSavings Plan (TSP) account of: SYVERSON, PAUL 10/18/2004 Participant's Name: Date of Payment: Amount of payment: Tax-Deferred: Tax-Exempt: Total: Amount paid to you: Minus amount withheld: Net amount paid to you: Payment Method: Amount transferred: Plan truSteeIPlan name: '~gdd~f;.~~F\;<. . This payment is considered an "eligIole rollover distribution" for Federal income tax. withholding pmpo~es. Any portion of an eligible rollover distribution that is paid directly to you is subject to mandatory 20 percent Federal income tax. withholding; this tax. withholding cannot be waived.. Consult your tax. advisor or the Internal Revenue Service (IRS) if you have further questions about your payment $9,526.0~- $10,721.53 $20,247.54 $20,247.54 $1,905. 20~ $18,342.34 Check $0.00 The amoUIit paid to you by check or direct deposit will be'reported Jo the IntemalRevenue Service on Form I099-R Distributions from Pensions, Annuities, Retirement or Profit-Sharing Plans, lRAs, Insurance Contracts, etc. Amounts transferred to a traditional individual retirement account (IRA) or other eligible employee plan, if any, will be reported on a separate Form 1 099-R You will receive copies of these forms by January 31 of next year. If your address shown is not correct, please notify the TSPinunediately. Tax reporting forms mailed. toanincorrect address may not reach you. Mail your add.ressinformation to the address on the letterhead. . If you have questions, call the ThriftLine number shown~I(rw~(Callers outside the United States and Canada should call (504) 255-8777.) The ServiceOffi~ehours are Monday through Fridav. 7 a.m. to 9 D.m. eastern time. You can also write to tbeSetvice Qffice. Please include your -,.. '" ...... ";;-. ... ............ ....90~1\.,~~9,~~oll. ;~O~~O~;. 66 ..:~~I=t~~~~;~~~~~.~~~~927z> . Pay: to ..../:~,.,......,...... . ..:o.'Uu'. ::',i;>\:~:\:/< .'.'" ii:'::;.;:.'::::::":'''..:' !.he Order ~~_.~ ,. ~.~~l~'~I. '..S~-~!t~..~.' .~. _~_~... :....:.~........:.....n.=... .IJ.-.~~...........::.~...r...,.-....-....-.:..{.;..._.....;....;...........:.;r;;"::;l._.'...:.'......';:.':-. :.);.~....2_;>:'.~~~:~~_: -_.~:_~~~;,.. -- L~ rn Il~.. .i~,t1a34~*i4. '.::-:';-':,-::":.::.:. ....:..:---:.......': -," .... ",': ~.'" .... ,"0"';"':": . ,:....-.,. -........-.-.. . "-',' .: .... :..,..,-:...:..:.....,: -, .' , . -' ." -. . . . .,~ ......p...-..,.....,.-. ....-..,... ',',- .... : . - .' .' ,:""-:-,-;'"':.." ..": :. . .. ....... .," .-- ...-.... .... . . . -.... "',- . ."... .~ ",: .... . ". . ,"' - ",", . ',:' .-....".' ....... .:,.;...,.."'~tYOIn~FiER~NE~~;......:...;...:. . """.",/<..-,:::.., . "," '"-.",..-...- . ... ._~ ',.:: :., ..",'. >..' ,'.~ . ..':---.:..::.:.:..:.:. PER ENCLOSED HAtL_;~cE.' .,......-..' .~:...:---.... ":".:-:'<-. .,..... '.<?>:':::.\:::':','.: .....,..:.:,.'...:: \. 11130 Ii .Oil.. :.:.~:>\)::.:..:::.:::\:..:;;.::;:': -. ..,...:....:_...:.:..:.. n. ',...:..::,.:'. 1:000000 SJ.BI:SIi 25 Ii 2'(2 b /I. NOnCE TO' CHECK REtIPlEHT TRE'ASURY-FlHAHCIAL tIAHAGEJlEKT SERVICE 1FS FIIRtI 3190CRw.) VENIIllR tWE: SYVERSON, JACQUELYN I VEHIIllR X.D. 532803752 .. 1IUtlBER: AGENtY tWE THRI FT SAVINGS PLAN . u.s. TREASURY RES. KANSAS CITY, "0 USDA NATIONAL FINANCE CEN FINAHC:IAl canER: AND tILLING P.O. BOX 60000 CHECK IUlBER CHECK AHlIUNT ClEat DATE ADDRESS : NEW ORLEANS LA 70160-000 3091-59259272 $**18342.34 10-20-04 AGENCY SCHEDULE NUtIllER TSP: BeneficiarS Pa&ment FEDE'R'ALTHRIFT XVI GS PLAN DISTRIBUTION Of PROCEEDS 0000000831 FROM ACCOUNT OF DECEASED PARTICIPANT. TSP EIN 52-1529691 AGENCY TELEPHONE NUtlBER TO: JACQUELYN ADMIN./EXECUTOR SYVERSON, AMOUNT OF THIS CHECK TAX. EXEMPT AMOUNT FOR: PAYEE NAME SYVERSON, JACQUELYN PAYEE SSN 532803752 THIS TAXABLE DISTRIBUTION WILL BE REPORTED TO THE INTERNAL REVENUE.SERVICE ON FORM 1099-R. PLEASE DIRECT ANY INClUJRIES CONCERJllNG THIS PAYItEHT TO TIE AGENCY AT THE ADDRESS COR PHONE fUI8ER) INDICATED ABOIIE $18,342.34 $10,721.53 -' Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 4/25/2006 DUNCAN WILLIAM A 1 IRVINE ROW CARLISLE, PA 17013 RE: Estate of SYVERSON PAUL RIll File Number: 2004-00869 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 lS due by: 6/16/2006 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 Personal Representative(s) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 4/25/2006 SYVERSON JACQUELYN E 56 FAIRVIEW STREET CARLISLE, PA 17013 RE: Estate of SYVERSON PAUL RIll File Number: 2004-00869 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: 6/16/2006 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, ,b~~~ Glenda Farner Strasbaugh . Clerk of the Orphans' Court cc: File Counsel L. (~": l 1.. c..j ~ t~::; i ,e:'; ,'-. '----. ! r:::=; :. ?~\ " t~-: ;' c',' Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name of Decedent: Paul R. Syverson III Date of Death: 06/16/04 Estate No.: 21-04-0869 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rilles, 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 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: J. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 1il .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 m 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. D~: S ~ . ~_A~(" :;:- := Signature ~ -~ ~ L.-, I William A. Duncan Name )<.::0.-_ Address 1 Irvine Row, Carlisle, PA 17013 '-C) ~ 717-249-7780 Telephone No. Capacity: 0 Personal Representative ~ Counsel for personal representative '-. eg RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of wills One Courthouse Square Carlisle, PA 17013 Rece~pt Date: Rece~pt Time: Recelpt No. : 5/04/2006 15:40:10 1044264 HOWE ROBERT C Estate File No. : Paid By Remarks: 2004-00146 COSTOPOULOS FOSTER & FIELDS MG ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name INH TAX RETURN Check# 11206 Total Received......... 15.00 ---------------- $15.00 $15.00 CUMBERLAND COUNTY GENERAL FUN