Loading...
HomeMy WebLinkAbout03-1069PETITION FOR PROBATE and GRANT OF LETTERS Estate of '~.~_... ~ ,~~,~ No. also known as /x.~g:a~ ~ ~ To: Deceased. Social Security No. ~ ~ ~ ~ ~ ~ ~/ ~ The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the~execut in the last will of the above d¢cedent~ dated ~ /~ and codicil(s) dated /~ z//~ ~ ? Register of Wills for the County of ~'~-~/d/wd/in the Commonwealth of Pennsylvania named (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ~.~9~ ~ ~ County, Pennsylvania, with ha-~ last family or principal resic~ence ~t ;~'~'~'~ ~' ~_.~/~n_~ ~ 6 / (list street, number and muncipality) Decende~nt, then ~7'ff.~ __y~arsofage, died /~_/' q G~,/~ tO .~ , at -/~-/~ '~'~ ~/~~'ff-'~ ' Except-as follows, ~edent 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: ./-~ff~ . . Decendent 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(s) respectfully presented herewith and the grant of letters theron. request(s) the probate of the last will and codicil(s) (testamentary; admYnistration c.t.a.; administ at'o d.b.n.c.t.a.) OATH OF' PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer~ the estate according to law. Sworn to or affirmed and subscribed /.'>~;~~' /~. ~ c~ befi~re me this c~.~zr9 T,~/ d..ay of /" Estate Of No. ~/-/'~q-- / DECREE OF PROBATE AND GRANT OF LETTERS AND NOW ~e.o ?~e--~--~ t ~ .~.2~, 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 described therein be admitted to probate and filed of record as the last will of and Letters are hereby granted to FEES S~or~ Certificates( ) .......... ~ o. ~,~ _Renunciation ................ $ ~' . ~ TOTAL ~9~ ~ Fi~a~~. ~..~ .... - ...... ATTORNEY (SuP~ Ct. I.D. No.) ADDRESS PHONE his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local..Kegistrar. The original certificate will be forwarded tt; 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~_~ ~/~. , /. ,~ I Local Registrar ff d P 8 6 414 3 3 ~/ ~_~~ ~ ~ a~ ~ No. ~ D~te H105 143 Rev 2~7 ~(PE/PRINT PERMANENT NAME OF DECEDENT (FIr~, Mk~, L~M) BLACK INK COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH AGE (Lam DATE OF BIRTH BIRTHPLACE (Cily amJ (Manlh. Oeg, Year) Slate ~' Foreign Counlly) COL/NTt OF DEATH DECEDENTS U~UAL OCCUPATION Book 4833 ~.. ~rind.le Road l~:~'um'ntcsburcj, PA 17050 FATHER~ NAME (FIRM. M idl~e, L~I) Ulsh G. Boliq U.S ARMED FORCES? .~.Retail Store ¥.1'"i .o~ 1~,~> DEDEDE,vE ,.. st,. Pennsylvan±a ~ DATE OF DISPOSITION suc. UtE.SE .UMSE. ~.FD-014889 ~O ~-~0 o. [] MOTHER'S NAME (FIr~, MiG~II, MlJdl~ ~mame) INFORMANTS MNUNG ADO~SS (SU~. c~q/r~,~, s~. 2~p co~) NAME AND ADORE,SS OF PERSON ~ COMI~.ETED CAUSE OF (Mo~h, Da¥,Ye~) WAS ~ REFERRED TO A MEDfDAL EXAMINER/CORONER? T,~S OF DE~T. DATE~RONOURDED DEAD (Mo~. PA 1701 1 Fedz~i~h~g, PA 17055 CODICIL OF BETTY M. FORNEY I, Betty M. Forney, being of sound mind do hereby declare this to be a Codicil to my Last Will and Testament. I hereby ratify and reaffirm all of the bequests in my Last Will and Testament with the exception of the naming of the Executor, Gilbert Scheibelhut. 2. I hereby nominate, constitute, and appoint Annabelle G. Bolig as Executrix of my estate. 3. By executing this Codicil to my Last Will and Testament, I hereby revoke the Executor, Gilbert Scheibelhut, to act as Executor at the time of my death, said Executor being previously listed in my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of December 2003. /~ etty M. Forney .(SEAL) The preceding instrument consisting of this and one (1) other typewritten page was on the date hereof signed, published and declared by Betty M. Forney, the Testatrix herein named to be her Codicil to her Last Will and Testament, in the presence of us, who at her request and in the presence of each other, have hereunto set our names as witnesses hereto. ~'~ ~~'/~?__. residing ~'~ /Q-cx'q['5}:~, ~:A~/~f/// /d ~~~',~~ residing c,q~-S'6' ~~,v_ ~ COMMONWEALTH OF PENNSYLVANIA Before me, the undersigned authority, this day personally appeared be~fore me, Betty M. Forney, Testatrix, and ~2'-~( ~ and h~/~dcj.~ known to me to be ~he Testa~ and Witnesses respectively, whose names are signed to the foregoing instrument and all of these persons being by me first duly sworn, Betty M. Fomey, the Testatrix, declared to me and to the Witnesses in my presence that the instrument is her Codicil to her Last Will And Testament and that she willingly signed the same and executed it in the presence of the Witnesses as her free and volunta~ act for the pu~oses therein expressed; that the Witnesses stated before me that the foregoing Codicil was executed and ac~owledged by the Testatrix as her Codicil to her Last Will And Testament in the presence of said Witnesses who, in her presence and at her request, and in the presence of each other, did subscribe their names thereto as attesting Witnesses on the day of the date of the Codicil, and that the Testatrix was over the age of eighteen (18) years, of sound mind and under no constraint or undue influence. (SEAL) Betty M. Forney, Testatrix Witness Witness Subscribed,.swom, and acknowledge~l before me by Betty M. Forney, the Testatrix, and by,~e~ ~~./.~ and ~,~b.g bfl~ Witnesses, on the ~/.z~. day of: z~///~ ,2003. anal Seal Rita C. Anste~d' Nolary Public )' ~.,umrmss~o. ~ ~-xpires Apr. 18, 2005 Member, Pennsv~v~ r~i:~ ~ssociation of Notaries CODICIL OF BETTY i-~. FOP, NEY ATTORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 LAST WILL AND TESTAMENT OF BETTY M. FORNEY I, Betty M. Forney, of 20 Kevin Road, Mechanicsburg, Cumberland County, Pennsylvania 17050, being of sound mind and body declare this to be my Last Will and Testament, and revoke any and all prior Wills and Codicils previously made by me. ITEM I: I hereby direct that all of my just debts, funeral expenses, all administration expenses, including inheritance tax shall be paid from the assets of my estate as soon as practicable after my decease. ITEM II: I hereby direct that all of the assets of my estate, including any real estate that I may own at the time of my death and all personal property, including household furnishings and personal items shall be sold and the proceeds thereof, I hereby give, devise, and bequeath to the following four (4) great-grandchildren: Josie Lyn Forney, Deidre Ann Forney, Christine Marie Gopear, and Emily Lyn Gopear, in Trust; however, naming Allfirst Bank or its successors, as Trustee under the following terms and conditions: (a) I hereby direct my Trustee, herein named, shall not utilize any of the funds in the Trust Account for the support, maintenance, educational or medical purposes of my following great-grandchildren, Josie Lyn Forney, Deidre Ann Forney, Christine Marie Gopear, and Emily Lyn Gopear; (b) Any and all payments of any sum or sums, whether in cash or in kind, whether for principal or income payable to such person shall may be made free from anticipation, alienation, attachment, pledge or control by any creditor of theirs and shall not be subject to execution or attachment; (c) I hereby direct my Trustee to disburse the entire Trust assets, including principal and interest upon the youngest of my four great-grandchildren named herein, reaching the age of thirty (30) years, said great- grandchildren being Josie Lyn Forney, Deidre Ann Forney, Christine Marie Gopear, and Emily Lyn Gopear. I hereby direct that said Trust, when dissolved, shall be paid to my four great-grandchildren named herein in equal shares, one-fourth each. ITEM III: I hereby acknowledge, through the execution of this Will, that this Last Will and Testament does not contain any provisions for my son, Gary Forney, or any of his children to receive any portion of my estate. It is my desire that neither my son, nor any of his children receive any portion of my estate, in that, my son and his children have caused me great heartache and unpleasantness. ITEM IV: I hereby nominate, constitute, and appoint Gilbert Scheibelhut, of Cumberland County, Pennsylvania, as Executor of my estate. ITEM V: I hereby direct that my Executor shall not be required to give bond for the faithful performance of his duties in any jurisdiction. IN WITNESS WHEREOF, /~-~fday of,~. ~,.~/~/'/ I have hereunto ,2003. set my hand and seal this (SEAL) The preceding instrument consisting of this and three (3) other typewritten pages was on the date hereof signed, published and declared by Betty M. Fomey, the Testatrix herein named to be her Last Will and Testament, in the presence of us, who at her request and in the presence of each other, have hereunto set our ..~ as witnesses hereto. COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN Before me, the undersigned authority, this day perso, nally appeared before me, I~etty M. Forney, Testatrix, and ..~.rq.,C~,~,,~x/j/ ~r, and _~J/'.~/~./??,/o)/~-~ known -to me to be' the Testatrix and Witnesses respectively, whose names are signed to the foregoing instrument and all of these persons being by me first duly sworn, Betty M. Forney, the Testatrix, declared to me and to the Witnesses in my presence that the instrument is her Last Will And Testament and that she willingly signed the same and executed it in the presence of the Witnesses as her free and voluntary act for the purposes therein expressed; that the Witnesses stated before me that the foregoing Will was executed and acknowledged by the Testatrix as her Last Will And Testament in the presence of said Witnesses who, in her presence and at her request, and in the presence of each other, did subscribe their names thereto as attesting Witnesses on the day of the date of the Will, and that the Testatrix was over the age of eighteen (18) years, of sound mind and under no constraint or undue influence. B~,~/.~orney, Te~{atrix,.~. / (SEAL) Witness Witness Subscribed, sworn and acknowledged before me by Betty M. Forney, the Tes. t, atrix, ~a.n, cl..z by ,./..,~.JZ/d?/d;,~'.,~/~_fand j'~/.~_,"Z4"///.,~.'/'¥ Witnesses, on me /,'-,ff,~'.9 day of . 4~_..~/// ..~- , 2003. - N?tar}, Public "1 LAST WILL AND TESTAMENT OF BETTY M. FORNEY ATTORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Date of Death: Will No. To the Register: Betty M. Forney December 4, 2003 Adm. No. 21-03-1069 I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on January 21, 2004: Name Address City Gary Forney, Jr. 463 Old York Road New Cumberland, PA 17070 Parent of Josie & Deidre Forney Dennis C. Gopear, II 386 East Front Street Lewisberry, PA 17339 Custodial Parent of Christine & Emily Gopear Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: Date~r- ~.~. ~¢' [~ignature) Name: Diane M. Dils, Esquire Address: 1017 North Front Street Harrisburg, PA 17102 Telephone: (717) 232-9724 Capacity: __ Personal Representative X Counsel for Personal Representative ARTHUR K. DILS DIANE M. DILS ATTORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 '04 ~/~R-3 /177:06 March 2, 2004 Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 PHONE: (717) 233-8743 FAX: (717) 233-2567 RE: Estate of Betty M. Forney Dear Sir or Madam: Enclosed is a check in the amount of $14,000.00 representing an advance depos!t towards inheritance tax,, rio retix:<; Thank you for your assistance in this matter. DMD/daf Enclosure Very truly yours, Diane M. Dils ATTORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 Rec,,wded_,T '04 M~R -3 A1~1 .~ Register of Wills CumbeFland County Cou~hoU~e One Courthouse Square Carlisle, PA 17013 i~0i3~33'='.Z., COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003629 DILS DIANE M 1017 N FRONT STREET HARRISBURG, PA 17102 fold ESTATE INFORMATION: SSN: 162-22-5714 FILE NUMBER: 2103- 1069 DECEDENT NAME: FORNEY BETTY M DATE OF PAYMENT: 03/03/2004 POSTMARK DATE: 03/02/2004 COUNTY: CUM BERLAN D DATE OF DEATH: 12/04/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $14,000.00 REMARKS: ..... SEAL DIANE M DILSM ESQ CHECK//1003 TOTAL AMOUNT PAID: $14,000.00 INITIALS: AC RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS ARTHUR K. DILS DIANE M. DILS A~FORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 September 28, 2004 PHONE: (717) 233-8743 FAX: (717) 233-2567 Cumberland County Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 RE: Estate of Betty M. Forney No. 21-03-1069 Dear Sir or Madam: Enclosed are an original and three copies of an Inheritance Tax Return to be filed in your office regarding the above-captioned estate. Please time-stamp a copy and return it to me in the enclosed, self-addressed, stamped envelope. Your prompt attention to this matter is greatly appreciated. DMD/daf Enclosure .~.x~5~,tmly yours, ~'~ I~r~e M. Dils COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND being duly according to law, deposes and says that s~e --A~e C. 'Bolt~ E::ccutrix of fha Estate of B~ty M. ~orn~y late of -~nmpRen__To~mah.~p. , Cumberland Count, Pa., deceased and fha+ the within is an inventory made by -Annabelle G. Bolig , the said of the entire estate of said decedent, consisting'of all the personal propeHy and real estate, except real estate oufslde the Commonwealth of Pen~,sylvanla, and that the figures opposite each item of +he Inventory represent it's fair value as of the date of decedent s death. Sworn and subscribed before me,  - ' NOTARIAL SE~L I IIEB~/L tiKE, NOTARY PLIBUC I CI1YOF HARRISBURG, DAUPHIN COIJ__I~Y_. / m COMm~ON EXmRES OCT. 24, ZO0~ ~ Execufo~'. Administrator 785 Lancaster Avenue Eno] n.. PA ]. 7025 Address Date of Death Day December 4, 2003 Month INSTRUCTIONS I. An inventory must be filed within three months after appointment of personal representative. 2. A supplement inventory must be filed within thirty days of discovery of additional assets. 3. Additional sheets may be attached as +o personalty or realty 4. See Article IV, Fiduciaries Act of 1949. o Inventory of the real and personal estate of BETTY H- FORNEY deceased Numerous coins and silver certificates Checking account - M&T Bank Allstate Life Insurance Company variable annuity Desk, television and knicknacks 90: $ 1E $ 17,0C '~105,0~ '$ 0.00 ).00 ~:. O0 .00 ARTHUR K. DILS DIANE M. DILS ATTORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 October 5, 2004 PHONE: (717) 233-8743 FAX: (717) 233-2567 Cumberland County Register of Wills ATTN: Christine Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 RE: Estate of Betty M. Fomey No. 21-03-1069 Dear Christine: ---4 Enclosed is my check in the amount of $15.00 in connection ~ith the ~iling of the Inheritance Tax Re~rn in the above-captioned matter. Thank you for your assistance in this matter. DMD/daf Enclosure /.V.eW truly yours, ARTHUR K. DILS DIANE M. DILS ATTORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 September 28, 2004 PHONE: (717) 233-8743 FAX: (717) 233-2567 Cumberland County Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 RE: Estate of Betty M. Forney No. 21-03-1069 Dear Sir or Madam: Enclosed are an original and three copies of an Inheritance Tax Return to be filed in your office regarding the above-captioned estate. Please time-stamp a copy and return it to me in the enclosed, self-addressed, stamped envelope. Your prompt attention to this matter is greatly appreciated. DMD/daf Enclosure ARTHUR K. DILS DIANE M. DILS ATTORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 October 5, 2004 PHONE: (717) 233-8743 FAX: (717) 233-2567 Cumberland County Register of Wills ATTN: Christine Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Estate of Betty M. Forney No. 21-03-1069 Chri ti Dear s ne: . Enclosed is my check in the amount of $15.00 in connection ~ith the $iling of the Inheritance Tax Return in the above-captioned matter. ' Thank you for your assistance in this matter. Very truly yours, DMD/daf Enclosure DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG) PA 17128-0601 I- Z uJ 0 z o 0 Z O UJ r,, z INHERITANCE TAX RETURN RESIDENT DECEDENT ! 21 - 03 - 1069 SOCIAL SECURITY NUMSER DATE OF OEATH DATE OF BIRTH 162 - 22 5714 ~''~'''~12 ........ 04': .... ~2003" 09 / 14 ¢/ 1927 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST. ANO MIDDLE INITIAL) SOCIAL SECURITY NUMSER ] THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ' ' I REGISTER OF WILLS ~ 1. onginal Return [] 4. Limited Estate '~ 6. Decedent Died Testate (,~ach copy of wiu) [] 2. Supplemental Retum [] 4a. Future Interest Compromise (~ of ~ m~ 12.12-82) [] 7. Decedent Maintained a Living Trust (Aamch c~y o(Trust) [] 3. Remainder Return (~aa o~ ~ea~ pr~ ~o ~2- E~5. Federal Estate Tax Return Required __ 8. Total Number of Safe Deposit Boxes [] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit {da~ of ~ beaten 12-31-91 and 1-1.~5) [] 11. Election to tax under Sec. 9113(A) (A~:, sen o~ THIS SECTION MUST BE COM~LET .ED;A~}GO~S~NDEN. C~[~,D.~FJ,~NT!~!~'~A~/~OR~TION: SHOULD BE DIRECTED TO: NAME I COMPt~E ~LI~ ~DRE~ Diane M. Dils, Esquire 1017 North Front Street ~s[ ~s Harrisburg, PA 17102 2-9724 1. Real Estate (Schedule A) (1) ~! O: , 2 Stocks and Bonds (Schedule B) (2) ~ ;~ 0 ~. 3 Closely Held CorporaUon.Partnership or Sole-Proprietorship (3) 0 4 Mortgages & Notes Receivable (Schedule D) (4) ~ O ~ 5 Cash, Bank De.sits & Miscellaneous Personal Property (Schedule E) (5) ,, 28 ,. 193 · 83 6 Jointly Owned Property (Schedule F) (6) " 0 7. inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 121 451 78 (Schedule G or L) ~ ~ 8. Total Gross Asset~ (total Lines 1-7) (8) 9. Funeral Expenses & AdministraUve Costs (Schedule H) (9) ! ................ ~i ..... . .J7 ,.~!....Z 7.4 · 49 10. Debts of Decedent Mortgage Liabilities. & Liens (Schedule I) (10) ~. , 9 , 093 , 44 11. Total Deductions (total Lines 9 & 10) 12 Net Value of Estate (Line 8 minus Line 11) 13 Charitable and Governmental BequestsJSec 9113 Trusts for which an election to tax has not been made (Schedule J) (11) , 26 , 867 93 (12) , 122 , 777 68 (13) 0 149 , 645 61 122 777 68 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 15. Amount of line 14 taxable x .0 (15) , at the spousal tax rate ~ See instructions on reverse side for applicable percentagfi 16 Amount of line 14taxable ~' ' ......~ a~ rate 4.5% ~ ] X .06 (16) ~ 5 , 525 . 00 17. Amount of line 14 taxable at 15% rate ~ , X .15 (17) ~ , 16. Tax Due (18) , 5 , 525 ' O0 ~ · >;;BE!$~RE~N~,/E.~Q'E~j~iN~RE3ZERBE!$1DE~AND RECHECK MATH < < m~ me ~na reFe~n~Sve i~ ~ ~ al in~ ~ ~ hm my S~NAT~RE OF PERSON RESPONSIBLE FOR ~LING RE~RN ADDRESS DATE ADDRESS ~U;EOFPREPA:~~PRESr'~'TIVE 1017 North Front Street, Harrisburg, PA 17102AT~/28/04 DECEDENT'SHAME LAST FIRST ANOMIDDLEINITIN. u~,,~,,~,~, .,mr,~ , , -, Decedent's Complete Address: STREET ADDRESS 4833 East Trindle Road cl~ Mechanicsburg ISTATE PA 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 18) 2 Credits/Payments A. Spousal Poverty Credit B. Pdor Payments C. Discount Total Credits ( A + B + C ) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) 4. If line 2 is greater than line 1 + line 3, enter the difference, This Is the OVERPAYMENT, Check box on Page I Line 19 to request a refund 5. If line 1 + line 3 is greater than line 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 Pa' $ 5,525.00 (2) $14,276.25 (3) 0 (4) $ 8,751.25 (5) o (5A) o (5B) to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTION8 BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ............................................................. [] [] b. retain the right to designate who shall use the property transferred,or its income; ................ [] r~ c. retain a reversionary interest; or ............................................................................................. [] [] d. receive the promise for life of either payments, benefits or care? ......................................... [] [] 2. If death occurred on or before December 12, 1982, did decedent within two years preceding death transfer property without receiving adequate consideration? 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? .... [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN II I I 72 P.S. §9116 (a) (1.1) (i) provided for the reduction of the tax rate imposed on the net value of transfers to or for the use of the surviving spouse from 6% to 3% for dates of death on or after July 1, 1994 and before January 1, 1995. 72 P.S. §9116 (a) (1.1) (ii) provided for the reduction of the rate imposed on the net value of transfers to or for the use of the surviving spouse from 3% to 0% for dates of death on or after January 1, 1995. The statute does not exempt 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 ,~FTER JANUARY 1, 1995 - Please answer the following question by placing an "x' in the appropriate space. Did the decedent create a trust or similar arrangement which is solely for the surviving spouse's benefit for his or her entire lifetime? Yes [] No [] If you answered yes to the above question, the tax on the trust or similar arrangement is postponed until the death of the second spouse, at which time it will be fully taxable at the rate(s) applicable to the remainder beneficiary(les). Enter the value of the trust on Schedule J, Part II, in order to remove it from the calculation of the tax due In this estate. You may wish to file Schedule O in order to make the election available under Section 9113. If the election is made, the trust or similar arrangement is taxed in the estate of the first decedent spouse, the portion of the trust or similar arrangement which benefits the surviving spouse is taxed at the zero tax rate, and the remainder is taxed at the rate(s) applicable to the remainder beneficiary(les). If you choose to make the election, you must attach Schedule O to a timely-filed tax return, along with Schedule(s) K and/or M in order to show the apportionment of the trust or similar arrangement between the surviving spouse and the remainder beneficiary(les). COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 (Property jointly-owned with Right of Survivorship must be disclosed on Schedule F) All real estate should be reported at fair market value which is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.) ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. None. 0 TOTAL (Also enter on line 1, Recapitulation) 0 (If more space is needed, insert additional sheets of same size. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS AND BONDS ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 (All property jointly-owned with Right of Survivorship must be disclosed on Schedule F.) ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 0 TOTAL (Also enter on line 2, Recapitulation) 0 (If more space is needed, insert additional sheets of same size.' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY HELD STOCK PARTNERSHIP AND PROPRIETORSHIP ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 Schedule C-1 or C-2 must e attached for each business interest of the decedent, other than a proprietorship. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 0 TOTAL (Also enter on line 3, Recapitulation) 0 (If more space is needed, insert additional sheets of same size.) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES AND NOTES RECEIVABLE ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 (All property jointly-owned with Right of Survivorship must be disclosed on Schedule F.) ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 0 TOTAL (Also enter on line 4, Recapitulation) 0 (If more space is needed, insert additional sheets of same size.) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 (All property jointly-owned with Right of Survivorship must be disclosed on Schedule F.) ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Certificate of Deposit $9,993.28 2. Sale of television and personal property $45.00 3. Refunds: Verizon $1.26 4. Old coins $154.00 5. Checking Account - M&T Bank 33721971 $18,000.29 TOTAL (Also enter on line 5, Recapitulation) $28,193.83 (If more space is needed, insert additional sheets of same size. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT ADDRESS RELATIONSHIP TO TENANT(S) NAME DECEDENT JOINTLY-OWNED PROPERTY ITEM LETTER DATE DESCRIPTION OF PROPERTY DATE OF DEATH % OF DATE OF NUMBER FOR MADE Include name of financial institution and VALUE OF DECD'S DEATH JOINT JOINT bank account number or similar ASSET INTEREST VALUE OF TENANT identifying number. Attach deed for DECEDENT'S jointly-held real estate. INTEREST TOTAL (Also enter on line 6, Recapitulation) $ -0- (If more space is needed, insert additional sheets of the same size.) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G TRANSFERS ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 THIS SCHEDULE MUST BE COMPLETED AND FILED IF THE ANSWER TO ANY OF THE QUESTIONS ON THE REVERSE SIDE OF THE COVER SHEET IS YES. ITEM DESCRIPTION OF PROPERTY EXCLUSION TOTAL DECD DOLLAR NUMBER Include name of the transferee, their VALUE OF % VALUE OF relationship to decedent, date of ASSET INT. DECEDENT'S transfer INTEREST 20 Kevin Road None $121,451.78 100% $121,451.78 Mechanicsburg, PA 17050 Sold on June 12, 2003 to Andrew J. Portmann and Stephanie A. Kramer (no relationship to decedent) Sold within one year prior to death - see settlement sheet attached. TOTAL (Also enter on line 7, Recapitulation) $121,451.78 (If more space is needed, insert additional sheets of same size.) A. Settlement Statement B. Type of Loan U.S. Department of Housin~l and Urban Development ~ -ir' OMB No. 2502-0265 1. [] FHA 2. [] FmHA 3. [] Conv. Unins ~ ~ C. NOTE:This form TS furnished to g ye you a statement of actual settlement costs. Amounts pa d to and by the settlement agent are shown. terns marked "p.o.c" were paid outside of Closing; they are shown here for informational purposes and are not included in Ule lotsls. D. NAME AND ADDRESS OF BORROWER: ANDR£WJ, PORTMANN Number ,PA E. NAME AND ADDRESS OF SELLER: BETTY M. FORNEY ,PA F. NAME AND ADDRESS OF LENDER: MEMBERS 1ST FEDERAL CREDIT UNION 5000 LOUISE DRIVE, MECHANICSBURG, PA 17055 G. PROPERTY 20 KEVlN ROAD LOCATION: MECHANICSBURG, PA 17050 H. SETTLEMENT AGENT: STEPHANIE A. KRAMER ,PA PLACE OF SETTLEMENT: TIN: 23-2133165 I. SETTLEMENT DATE: 06/12/2003 J. SUMM,~ 100. ~ 101. Contract Sales Price 102. Personal Prop.~erty 103. Settlements charges to borrower: (from line 1400) 104. 105. CEDAR CLIFF ABSTRACT AGENCY, INC. 414 Bridge Street, New Cumberland, PA 17070 $4,299.25 ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: lO6. City/town taxes lo 107. County Taxes 06/12/2003 to 01/01/2004 108. Assessments06/12/2003 lO 07/01/2003 109. 110. SEWER/REFUSE/RECYCLE PRORATIo~ 111. 112. DATE: 400. GROSS AMOUNT DUE TO SELLER: 01. Contract Sates Pdce 403. 404. 405. ~DJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: I 4o~. $132.60 120. GROSS AMOUNT DUE FROM BORROWER: 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 201. Oeposil or earnest money ~ $2,000. O0 202. Principal amount of new loan(s) $97~ 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 501. Excess deposit (see instructions) $49.60 $19.58 $121,451. 78 203. Existing lean(s) taken subject to 204.219DMORTGAGE 205. 206, 207. 208. 209. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: 210. City/town taxes 211. County taxes to 212. Assessments to 213. 214 215. 216. 217. 218. 219. 220. TOTAL PAid BY/FOR $12, I25.0.~0 502. Settlement charges to seller (line 1400) 503~ng loan(s) taken subject to ~age loan 505. Payoff of second mort age roan 506. 507. 508. 509. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: ~ taxes to 511. Countyta. xes to 512. Assessments lo 513. 514. 515. 516. 517. 518. 519. $8,765.50 BORROWER: 301· Gross amount due from borrower (line 120) 302. Less amount paid by/for borrower (line 220) 303. CASH ( J~FROM ) ( ["] TO) BORROWER: $111,125. O0 520. TOTAL REDUCTIONS ~ Sa, ?~5.50 ( [_J FROM ) ( J~ TO ) SELLER: ~ HUD-1 (3-86) - RESPA, HB 4305.2 PAGE 1 HUD-1 (Rev. 3/86) ~ SETT~ 700. TOTAL SALES/BROKER'S COMMISSION BASED ON PRICE $121,250.00 ~ 6 %= $7,275,00 DIVISION OF COMMISSION (LINE 700) AS FOLLOWS: ~ 612.50 to PRUDENTIAL THO~PSON WOOD 702. $3,662.50 to ERA_NRTz__iNC. 703. $0.00 to 704. $0.00 to 705. Commission paid at setllemenl 706. 800~E IN C NNECTION WITH LOAN: 808. APPLICATION ~ - ~ 15T - P0C$325. O0 OMB No. 2502-0265 BORROWER'S I SELLER'S FUNDS I FUNDS __ AT I AT SETTLEMENTI SETTLEMENT $7,275.00 $75. O0 0. E V I WI N R: months ~ 1007, SCHOOL TAXES 13. O0 months ~ 1009. Aggregate Accounting Escrow Adjustment 110. I L HARGES: (includes above ilems Numbers: ~ASIC RAg 1109. Lenders coverage 1110. Owns,'s ~vem..~ 1111..~;N'DO.R.~E3,,Z~T$ _ 300/ 100, 1112. 1113. &8.1 $97,000.00 $121,250.00 1201. Recording lass:Deed $38.50 ;Mortgage 64.50 ; Retoases 1202. C~ty/co~nty taxis[amp.: Deed $2.425. 00; Mortgage 1203. Slate lax/stamps: Deed ; Mortg,ge 1204. ABC. 1 00. D ITl NAL TrLEMENT HARGES: 1301. Survey to $81.51 $97.10 ($132.05) per month per month $19. ~2 per monlh per month per r~on[h $73.49 per m0nlh per rr~nlh $968.75I $150.00 .00 $125.~'~- $20. go $99.00 $75.00 $I00.00 1400. TOTAL SETTLEMENT CHARGES I have carefully reviewed the HUD-1 .qAtfl~_.T~nt Statement and to the best ~' ~,, ~---., .... $4,299.25 $8. 765.50 v. ,,,:, ~,,uw~euge eno belief, is a true and accurate statement of al receipts and disbursements made on my account or by me in this tmn ~D~g~-;~ th.ti have received, copy o! the HUD-I Setfl .... t Stat .... t. BETTYM, FORNE~ ~°~' ~ Agent: ~ ~'~EPHA"h//E A. KRA~f~,,R Date: The HUD-1 Se~ernent Statement which ~ have prepared is a true and accurate account of this transaction. ~ have ,_--n,, a Date: SettJemenl Agen>~-ERTLL/S~H~? WARNING: It is a crime to knowingly make false statements to the Unitad States on this or any cther similar form, Penalties upon conviction can include a fine and imprison- ment. For details see: TitJe 18 U.S. Code Section 1001 and Section 1010, RE¥-15! 1E~( + (1-97} ~ I ' COMMONWEALTH OF PENNSYLVAN A J FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS 21-03-1069 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A FUNERAL EXPENSES: AMOUNT 1. Malpezzi Funeral Home $8,878.32 5. 6. 7. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal RepresentatJve (s) Annabelle G. Bolig Social Security Number(s) / EIN Number of Personal Representative(s) Street Address 785 Lancaster Avenue Enola PA 17025 City State Year(s) Commission Paid: 2004 AttomeyFees Diane M. Dils, Esquire Family Exemption: (11: decedent's address is not the same as claimant's, attach explanation) Claimant Zip Street Address City Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees Carlisle Sentinel State. Zip Cumberland Law Journal $6,885.00 $1,500.00 $ 344.32 $ 91.85 $ 75.00 TOTAL (Also enter on line 9, Recapitulation) $ 17,774.49 (if more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT MORTGAGE LIABILITIES & LIENS ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. Verizon 2. Med. $25.04 3. Pace $40.00 $262.90 4. Settlement Costs from sale of real estate $8,765.50 TOTAL (Also enter on line 10, Recapitulation) $9,093 44 ;t nee, :I, additional sheets of same size.) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: BETTY M. FORNEY FILE NUMBER: 21-03-1069 ITEM DESCRIPTION RELATIONSHIP AMOUNT OR SHARE NUMBEl~ OF ESTATE 1. Josie & Deidre Fomey Great- 50% 463 Old York Road Granddaughters New Cumberland, PA 17070 Christine and Emily Gopear Great- 50% 2. 386 East Front Street Granddaughters Lewisberry, PA 17339 3. ITEM NAME AND ADDRESS OF BENEFICIARY AMOUNT OR SHARE NUMBER OF ESTATE B. Charitable and Governmental Bequests: TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) -0- space d, insert additional sheets of same size. LAST WILL AND TESTAMENT OF BETTY M. FORNEY COPY I, Betty M. Forney, of 20 Kevin Road, Mechanicsburg, Cumberland County, Pennsylvania 17050, being of sound mind and body declare this to be my Last Will and Testament, and revoke any and all prior Wills and Codicils previously made by me. ITEM I: I hereby direct that, all of my just debts, funeral expenses, all administration expenses, including inheritance tax shall be paid from the assets of my estate as soon as practicable after my decease. ITEM II: I 'hereby direct that all of the assets of my estate, including any real estate that I may own at the time of my death and all personal l property, including household furnishings and personal items shall be sold and the proceeds thereof, I hereby give, devise, and bequeath to the following four (4) great-grandchildren: Josie Lyn Fomey,. Deidre Ann Fomey, Christine Marie Gopear, and Emily Lyn Gopear, in Trust; however, naming Allfirst Bank or its successors, as Trustee under the following terms and conditions: (a) I hereby direct my Trustee, herein named, shall not utilize any of the funds in the Trust Account for the support, maintenance, educational or medical purposes of my following great-grandchildren, Josie Lyn Forney, Deidre Ann Fomey, Christine Marie Gopear, and Emily Lyn Gopear; (b) Any and all payments of any sum or sums, whether in cash or in kind, whether for principal or income payable to such person shall may be made free from anticipation, alienation, attachment, pledge or control by any creditor of theirs and shall not be subject to execution or attachment; (c) I hereby direct my Trustee to disburse the entire Trust assets, including principal and interest upon the youngest of my four great-grandchildren named herein, reaching the age of thirty (30) years, said great- grandchildren being Josie Lyn Fomey, Deidre Ann Fomey, Christine Marie Gopear, and Emily Lyn Gopear. I hereby direct that said Trust, when dissolved, shall be paid to my four great-grandchildren named herein in equal shares, one-fourth each. ITEM III: I hereby acknowledge, through the execution of this Will, that this Last Will and Testament does not contain any provisions for my son, Gary Fomey, or any of his children to receive any portion of my estate. It is my desire that neither my son, nor any of his children receive any portion of my estate, in that, my son and his children have caused me great heartache and unpleasantness. ITEM IV: I hereby nominate, constitute, and appoint Gilbert Scheibelhut, of Cumberland County, Pennsylvania, as Executor of my estate. ITEM V: I hereby direct that my Executor shall not be required to give bond for the faithful performance of his duties in any jurisdiction. IN WITNESS WHEREOF, /,..~f~'4day of,d,~'/~/'/ I have hereunto ,20O3. set my hand and seal this (SEAL) The preceding instrument consisting of this and three (3) other typewritten pages was on the date hereof signed, published and declared by Betty M. Fomey, the Testatrix herein named to be her Last Will and Testament, in th~ presence of us, who at her request and in the presence of each other, have hereunto set our nati:i'~ as wimesses hereto. COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN Before me, the undersigned authority, this day personally appeared before me, Betty M. Forney, Testatrix, and ~',4~,~,~,,~x/J/~"~ and ,~)/'.fi, q',/72 Z~/~"_5' khbwn-to me to be' the Testatrix and Witnesses respectively, whose names are signed to the foregoing instrument and all of these persons being by me first duly sworn, Betty M. Forney, the Testatrix, declared to me and to the Witnesses in my presence that the instrument is her Last Will And Testament and that she willingly signed the same and executed it in the presence of the Witnesses as her free and voluntary act for the purposes therein expressed; that the Witnesses stated before me that the foregoing Will was executed and acknowledged by the Testatrix as her Last Will And Testament in the presence of said Witnesses who, in her presence and at her request, and in the presence of each other, did subscribe their names thereto as attesting Witnesses on the day of the date of the Will, and that the Testatrix was over the age of eighteen (I 8) years, of sound mind and under no constraint or undue influence. Betty,,b~orney, Te~{atrix ,~ (SEAL) Witness Witness Subscribed, sw. om and aclqno,.wl,edged befor,e me by Bet.ty M. Forney, the Testatrix, 'and, by .~~1~. ~/,d_.J/'Jif and ff'-~/_i,q_//i~//'/..,~}/?/g' Witnesses, on the /~...~,¢.}'1 da~, Of' ._~,t~.~// f-.,2.~03. -' Notar~ Pu.bli9 ,. 5 CODICIL OF BETTY M. FORNEY being ~un mind ~o" l~ereby d~la~e this to be a I, Betty M.' Fomey-' 'of~ s d Co,cfi to my L~t Will ~d T~ont. 1. I hereby mfi~ ~d roa~m ~1 of ~o boqu~s~ ~ my Last Will ~d T~s~ont wi~ ~o ~xc~tion of ~o n~ng 0f ~ Ex, cuter, Gilbe~ Sch~ib~ut. 2. I h~roby no~nato, constitute, ~d appoint ~bell~ G. Bolig as Execu~x of my ~smt~. 3. By execu~g ~s Codicil to my ~t Will ~d Tes~nt, I hereby mvok~ · ~ Ex,cuter, Gflb~ Sch~ib~ut, to act ~ Ex~tor at ~ fim~ of my dea~, . s~d Ex~utor b~g previously.listed ~ my ~t Will ~d T~s~ent. ~ W~SS ~~OF, I have h~m~to s~t my h~d ~d seal t~s ~ ~y of D~mber 2003. etty M. Fomey The preceding instrument consisting of this and one (1) other typewritten page was on the date hereof signed, published and declared by Betty M. Fomey, the Testatrix herein named to b~ her Codicil to her Last Will and ~Testament, in the presence of us, who at her request and in the presence of each other, have hereunto set our names as witnesses hereto. COMMONWEALTH OF PENNSYLVANIA Before me, the undersigned authority, this ~lay personally appeared be~fore .re, e, Betty M. Forney, Testatrix, and x~,~.~~}4.~ and /~,~/o2,a.z:~ known to me to be the Te.statrix(Jand Witnesses respectively, whose names are signed to the foregoing instrument and all of these persons being by me first duly sworn, Betty M. Fomey, the Testatrix, declared to me and to the Witnesses in my presence that the instrument is her Codicil to her Last Will And Testament and that she willingly signed the same and executed it in the presence of the Witnesses as her free and voluntary act for the purposes therein expressed; that the Witnesses stated before me that the foregoing Codicil was executed and acknowledged by the Testatrix as her Codicil to her Last Will And Testament in the presence of said Witnesses who, in her presence and at her request, and in the presence of each other, did subscribe their names thereto as attesting Witnesses on the day of'th:e date of the C0dieil, and that the Testatrix .was over'the age of eighteen (18)'years, of sound mind and under no constraint or undue influence. (SEAL) Betty M. Fomey, Testatrix Witness Witness Subscribed, sworn and acknowledge~l be_fore me by Betty M. Fomey, the Testatrix, and by'~ and ~.~4~/o1~ Witnesses, on the J-/'.,~ !dayo{~ ,2003. BUREAU OF ZNDTVZDUAL TAXES THHERITANCE TAX DZVTSZON PO BOX 280601 HARRZ$BURG, PA 171Z8-0601 COMMONHEALTH OF PENNSYLVANZA DEPARTHENT OF REVENUE NOTZCE OF ZNHERZTANCE TAX APPRAZSEMENT, ALLONANCE OR DZSALLOHANCE OF DEDUCTZONS AND ASSESSMENT OF TAX REV-l;47 EX 4FP ¢09-04) DIANE M DILS ESQ DILS & DILS 1017 N FRONT ST DATE 11-29-200q ESTATE OF FORNEY DATE OF DEATH 12-0q-2005 FZLE NUHBER 21 05-1069 COUNTY CUMBERLAND ACN 101 Amount Remitted BETTY M MAKE CHECK PAYABLE AND REMZT PAYMENT TO: REGISTER OF HILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THZS LZNE ~.~ RETAZN LOHER PORTZON FOR YOUR RECORDS ~ ~V: ~g~Y ' ~' ~P~"f §~='~ ~Y ~'8~ ~¢ ' ~'~ ~'f ~[ ' ~ ' ~P R~'~ ~kY~ ~- ~ EL~'['b~' ................. DZSALLOHANCE OF DEDUCTZONS AND ASSESSMENT OF TAX ESTATE OF FORNEY BETTY M FZLE NO. 21 05-1069 ACN 101 DATE 11-29-200q TAX RETURN NAS: (X) ACCEPTED AS F/LED ( ) CHANGED RESERVATTON CONCERNZNG FUTURE [NTEREST- SEE REVERSE APPRAZSED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule D) $. Closely Held Stock/Partnership Interest (Schedule C) ($) q. Mortgages/Notes Receivable (Schedule D) E. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets APPROVED DEDUCTZONS AND EXEMPTZONS: 9. Funeral Expansas/Adm. Costs/M/sc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/L/ohS (Schedule 1) (10) 11. Total Deduct/ohs 12. Net Value of Tax Return .00 .00 .00 .00 Z8~,195.85 .00 NOTE: To insure proper credit to your account, submit ~he upper por~/on of ~h/s fore wi~h your tax payeen~. 17,77q.q9 9~095.qq (11) 26.867.93 (12) 122,777.68 15. lq. NOTE: ASSESSMENT OF TAX: 15. Amount of L/ne lq at Spousal rata 16. Amount of Line lq taxable at Lineal/Class A rate 17. Amount of L/no lq at S/bling ra~e 18. Amount of L/ne lq taxable at Collateral/Class B rata 19. Principal Tax Due TAX CREDITS: PAYMENT RECEZP1 DZSCOUNT (+J DATE NUMBER INTEREST/PEN PAZD (-) 05-02-200q CD00~629 276.25 ZF PAID AFTER DATE ZNDZCATED, SEE REVERSE FOR CALCULATZON OF ADDZTZONAL ZNTEREST. (15) .00 x 00 = .00 (16) 122,777.68 x Oq5= 5,525.00 (17) . O0 X 12 = . O0 (18) .00 x 15 = .00 (1~)= 5,525.00 AMOUNT PAZD I lq,O00.O0 reflect figures that include the total of ALL returns assessed to date. TOTAL TAX CREDZT 1~,276.25 BALANCE OF TAX DUEI 8,751.25CR ZNTEREST AND PEN.I .00 TOTAL DUEI '751'25CRI ( ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS REQUIRED. ~ ZF TOTAL DUE ZS REFLECTED AS A "CREDZT' (CR), YOU MAY BE DUE~ A REFUND. SEE REVERSE S/DE OF TNZS FORM FOR 1NSTRUCTZONS.) Char/table/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) Net Value of Estate Subject to Tax Zf an assessaent ~as issued previously, 1/nes lq, 15 and/or (15) .00 (1~.) 122,777.68 16, 17, 18 and 19 w/.11 121~51.78 (8) 1q9,6qS.61 RESERVATION: PURPOSE OF NOTICE: PAYMENT: REFUND [CR): OBJECTIONS: ADMIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 1Z, 198Z -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such futura interest. To fulfill the requirements of Section ZlqO oF the Inheritance and Estate Tax Act, Act Z3 of ZOO0. (7Z P.S. Section 91qO). Detach the top portion of this Notice and submit with your payment to the Register of Mills printed on the reverse side. --Make check or money order payable to: REGISTER OF NILLS, AGENT A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications ara available online at www.revanua.state.oa.us, any Register of Mills or Revenue District Office, or from the Department's 2q-hour ansaering sarvlca for Forms orders: 1-&00-362-20S0; services for taxpayers with special hearing and/or speaking needs: 1-BO0-46`7-30ZO (TT only). Any party in interest not satisfied with the appraismant, alloaanca or dismlloaanca of deductions or assessment oF tax (including discount or interest) as shown on this Notice may object aithin 60 days of the date of receipt of this notice by filing Dna oF the Following: A) Protest to the PA Department of Revenue, Board of Appeals. You amy object by filing a protest online at wwa.boardofappaals.stata.pa.us on or before the expiration of the sixty-day appeal period. In order for an electronic protest to be valid, you must receive a confirmation number and processed date from the Board of Appeals aebsita. You may also send a written protest to PA Department of Revenue, Board of Appeals P.O. Box ZBIOZ1, Harrisburg, PA 17IlS-lOll. Petitions may not be faxed. B) Election to have the matter determined at the audit of the account of the personal representative. C) Appeal to the Orphans' Court. Factual errors discovered on this assessment should bm addressed in eriting to: PA Department of Revenue, Bureau oF Individual Taxes, ATTN: Post Assessment Review Unit, P.O. Box Z80601, Harrisburg, PA 17128-0601 Phone [717) 787-650S. Sea page 5 of the booklet "Instructions For Inheritance Tax Return for a Resident Decedent" (REV-lBO1) for an explanation of administratively correctable errors. If any tax due is paid within three (3) calendar months after the dacadent's death, a five percent (SI) discount of the tax paid is allowed. The 1SI tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same tiaa period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one [1) day from the date of death, to the date of payment. Taxes ahich became delinquent before January 1, 1982 bear interest at the rate of six (6Z) percent par annum calculated at a daily rate of .O0016q. All taxes ahich became delinquent on and after January 1, 198Z will bear interest at a rate ehich will vary free calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOO6` ara: Interest Daily Interest Daily Year Rate Factor Year Rate Factor ~ 207. .0005q8 ~'8-1991 117. .000301 1983 167. .0006,38 1992 9Z .00026`7 198~ 117. .000301 1993-1996` 7Z . O00XgZ 1955 137. .000356 1995-1998 9Z .000Z6`7 1986 10Z .000276` 1999 77. .00019Z 1987 lOZ .000276` ZOO0 72 .000192 --Interest is calculated as folloas: INTEREST = BALANCE OF TAX UNpATD Interest Daily Year Rate Factor ~ 97. .000Z6`7 200Z 6Z .000166` ZOO3 5Z .000137 2006` 6`7. .000110 X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to TiFtaen (15) days beyond the date oF the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. BUREAU OF IIIQMll~:''''M';;:,r'~ n~ INHERITANCE TA>d'-:j'.wiSIDN",~) '.... ' ,'0,_ vi PO BOX 280601 ,~,r~"",;,--"-'- 1 ('. HARRISBURG~ PA lid~:a~'06D:( _.A" COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REV-l'D7EXlFI'UI'-04) CLEF:'(<', ODS'r,.It,\!'<, III ,',".... DIAN~U"!'DlLS IOSIl ,", DILS II DILS 1017 N FRONT ST HBS PA 17102 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-20-2004 FORNEY 12-04-2003 21 03-1069 CUMBERLAND 101 BETTY M ?nn," I?,,'~,' I!, O',! 3: 39 _~J;} .,.;El,'l -f I I) Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: RESISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account~ submit the upper portion of this for.. with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ 1~:r&~,r'!5r'J~~"ral~1S~""""i;.':rA~!~e1r",A5r.~tl"ft~'~'Aelr~oJrr"..'i"""""""""". ESTATE OF FORNEY BETTY M FILE NO. 21 03-1069 ACN 101 DATE 12-20-2004 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE~ APPLICATION OF ALL PAYHENTS} THE CURRENT BALANCE, AND, IF APPLICABLE} A PRDJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 11-22-2004 PRINCIPAL TAX DUE:, 5,525.00 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 03-02-2004 CD003629 276.25 "'-.. 14,000.00 12-03-2004 REFUND .00 8,751. 25- TOTAL TAX CREDIT 5,525.00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 . SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J s"- <;/.. Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 11/01/2005 DILS DIANE M 1017 NORTH FRONT STREET HARRISBURG, PA 17102 RE: Estate of FORNEY BETTY M File Number: 2003-01069 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.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: 12/04/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~A ~ J ~k. If,; ~,~;;""k~ ~~- "," <>- v_ =-.J /(a'Z.- -27"" GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge \f~ 0~&0~ ATTORNEYS AT LAW 1017 NORTH FRONT STREET HARRISBURG, PENNSYLVANIA 17102 ARTHUR K. OILS DIANE M. OILS PHONE: (717) 233-8743 FAX: (717) 233-2567 November 3, 2005 Cumberland County Register of Wills ATTN: Glenda Farner Strasbaugh Cumberland County Courthouse One Courthouse Square Carlisle, P A 17013 C-) RE: Estate of Betty M. Forney No. 2003-01069 ~e~. Dear Ms. Strasbaugh: Enclosed are an original and~opitt'of a Status Report Under Rule 6.12 to be filed in your office regarding the abovJlcaptioned Estate. c.n -.I Also enclosed is a self-addressed, stamped envelope to return a clocked-in copy to me. Thank you for your assistance in this matter. --- Ve~Jruly yours, ../;< ) ~// / . / ,.,/ / " " it / / 'tel/{ "'iane M.' :bils DMD/daf Enclosures STATUS REPORT UNDER RULE 6.12 Name of Decedent: Betty M. Forney Date of Death: December 4, 2003 Will No. 2003-01069 Admin. No. 2003-01069 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 whet~dministration of the estate is complete: Yes V No 2. If the answer is no, state when the personal representative reasonably believes that the administration will be complete: Within 60 days. 3. If the answer to No.1 is yes, state the following: (a) Did the personal represegtative file a final account with the Court? Yes No L./" . (b) The separate Orphans' Court No. (if any) for the personal representative's account is: (c) Did the pe;ponal representative state an account informally to the parties in interest? Yes ~ No . Date: (d) Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. 11/5/(/)/ tfd~~ Ignature r- l.n Diane M. Dils, Esquire 1017 North Front Street Harrisburg, P A 17102 (717) 232-9724 J.D. No. 71873 c ~~u... , Capacity: _ Pgsonal Representative l..----'Counsel for Personal Representative fi;;