HomeMy WebLinkAbout95-0058H105.9(`5 RF.V.Ir,!n(,~ __- _- _.__ -__ _. _ _ ^ I ~j./'..~.y /~~~..~/',
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Recor.i< 7i accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~.~-~, ~~10~
Calvin B. Johnson, M.D., M.P.H. Frank Yeropoli
Secretary of Health State Registrar
~ P ~~ ~; r, ~ ~ AUG 2 8 2QQ1
No.
iii H105144 Rav. 1/91
TVPE/PRINT
IN
PERMANENT
BLACK INK NAME
O
w
Date
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~ V
CERTIFICATE OF DEATH jv; ~ ~ i)
(Coroner)
RTATF is F u„unc°
r utVtutNl (YVSI, MWtlle. Lag)
JENNIFER S HERVEY SE%
Female SOCIAL SECURITY NUMBER DATE OF DEATH (Mmm, Day, Year)
,. x , 227_13-8034 ,January 8, 1995
AGE (Last BilhMy) UNDERIVEAR UNDERI DAV DATE OF BIRTH BIRTHPLACE (Cay antl
Da
Fear) Stale
r F
r
i
C
l
M PLACE OF OEATN (Che ck only one-see inslruclions on omen side)
2 5 onlns Days Hours Minutes y
NOV
'
/ ~n
o
O
e
Wn
ly) HOSPITAL'
OTHER:
-
Yra
19
6 9 Denver , Colors r
~
lisnl ^ ERIOulpalient ^ DOA ^
poet
9 ^
r
s. ~ T Ho
ma
Resitlonce
w. ~ fspe°ar) ^
COUNTY OF DEATH CI BORO OF DEATH FACILITY NAME(Il nd insMdron. give Strad ar~d number) WAS DECEDENT OF HISPANIC ORIGIN? RACE ~Amerkan Indian, Blazk
While
etc
,
,
.
No ~ vea ^ u tea, apedN aban, lspatnyl
.~ Cumberland Carlisle 266 S. Hanover Street
M.akan,Pw„oRitan,etc. White
:.n~ w. ae. ed. s
. ,o.
DECEDENT'S USUAL OCCUPATION KIND OF BUSINESSIINDUSTRV WAS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS~Manied SURVIVING SPOUSE
(Giw kintldv,whdone dur sl U.S. ARMED FORCES? 1 on hi reM COm etl Never Married
Wbosved
~~
,
,
I worklrlq Nh; do not use
.) Manbers First Feder 1 Elam.me al w,le, g~.e maiden name)
ry/S•eorM.ry Colle
e Divorcee lS
~Nl
^
g
l
Yea
No ®
Teller
C
(012'
('`°`S«'
,,,.
,,.
redit Union ,x. „
4
,.Never Married -
i7
'
.
DECEDENT
S MAILING ADDRESS (sired, Cay/Frvrl, Salle. Zip Code) DECEDENT'S
PA
ddK.e.m 17e.^ `ka, decedent lived In IwV.
266 S. Hanover Str. , Apt. 10 RE81)DENCE 17e. Slat.
(see instructions live In e
Carlisle, PA 17013 onpsbr&de) Qmlberland Idvnehro? No d«.„.mww
" +~~ ,Te
® witinn edlw ltmae°, Carlisle Boro
FATHER'S NAME (FVSI, M,rl01e, Last) .
. ckyfbp"
MOTHER'S NAME (First. Middle, Maitlen Surrvme)
,.. Robert F, Herve „. Barbara L. Roddis
INFORMANT'S NAME (TypelPrid) INFORMANT'S MAILING ADdiESS (ShtM. own, Slate. Zip Cotle
Robert F. Herve 640 Belvedere ~
t
~
li
P
l
'
ree
;
ar
s
e,
A 17013
METHOD OF DISPOSRION DATE OF dSPOSITION PLACE OF dSPO$ITION. Hanle d Cemetery Crematory LOCATION ~ Ciryrtown, State, Zip Coda
ew.l® °r.matbn^ Remov°"mmStue^ (M~.~H~ar) "dh«PMd. Cumberland Valley
^
oon.tbn
QMr,Speci"' ^ ,,, 1 12/1995 x,e.Memorial Gardens
t
Carlisle
PA 17013
x„
,
SIGNQ EOF l1N RAL SERVICEL E RSON ACTING AS SUCH LICENSE NUMBER NAME AND ADDf1E$S OF FACILITY
xa. u,,FD 012633 L gg°,Ewin Brothers Funeral Ham; Carlisle, PA 17013
Corrlplste eema 23tc ony when To I my knowledge, Mam occurred st IM dms, Mta and pleca Malsd. LACENSE NUMBER DATE SIGNED
physbian's not ava9eble etdmadMamro wm vw Title)
rMrnly caws d Malh. (Month, DaY. Year)
x7.. x70. x7c.
a 2~mu~~t mad Oy TIME OF DEATH prx, DATE PRONOUNCED OEAD(Mmm. Day, ltsar) vaS CASE REFERRED TO MEdCALE%AMINERICORONER7
g4. 9:00 A. M
Januar 9, 1995 Y•a® N°^
xs
.
.
xe.
x7. PART I: EMer lM dieewa, inlurba or COmdiGtiern whkm cauead ma MeM. Do not edsr tM mods d dying, such as grdiac or espiretory arrest, shock a I"a„ hilure. IApproalmale PART II: Olney signilicenl twMhbna contriMMng to Ham
Lal ony one uwa on eacn Nts.
Orrt
,
, imervN Wlwsen nd rosuking In the unM„yirtg cause given b PART I.
onset en0 Meth
MIMEDIATE CAUSE (Final ,
di.~"`°"tl"bn As h xis
resdNq in deem)-. a.
DUE TO (pi ASACONSEQUENCE OF):
s.gawttl.llyuadendtbr~ b Han i '
e~
MO d1E TO( ASACONSEOUENCE OF): ~
N~`p
X
E
I
IDY
CAUSE (Dlsuese a ropey c.
i
met inaialatl eveds WE TO (OR AS A CONSEQUENCE OF):
reaueirtg b deem) LAST
e
~
.
VaAS AN AUTOPSY WERE AUTOPSY FINdNGS MANNER OF DEATH DATE OFIWURY TIME OFINJURY INJURY RT WORK7 DESCRIBE HOWINJURY OCCURRED
PERFORMED? AMUlAOLEPR10RT0
.
(Mmm,Day,lber) Aprx.
COMPLETION OF CAUSE
OF DEATH? Natural ^ HnmiciM ^ Jan.8, 1995
`"° ^ "°~ Hanging
pQ
IIqq
Va ^ No yry Yee ^ No U Accident ^ PeMkl9lmreatigalbn ^ 70e. 70W : 0 0 A • M. 70e. ]Oe.
PLACE OFINJURY - AI home, larm, UreeL ladory, o0ica LOCATION (Street. CiIYR n, Sale)
Sukide ~ Could notMMlerminetl ^ Ouildrp
etc
(Spacily)
,
.
~•~ x~~ x9. ,ge. Home ,g~1a over St. Carlisle PA
CERTIFIER (Check only one) SIGNATURE ANO TIT CE
'CERTIFYING PMYBICIAN (Physican cerlilyirp cause d Mam vd"n andher physican has pronouncetl deem antl compleletl Item 20) ^
T° the Dot of my anowNdga, aeelh occurred cue to the cwee(e) end mwr"r as eUted
..................................................... C O r O n e T
7,0.
LICENSE NUMBER GATE SIGNED (Month. Day Hear)
'PRONOUNCING AND CERTIFYING PHYSICIAN(Physeian both pronouncing death and cerldying to cause of death)
To the Ma w my knowleage, M.m otennw.t tM txn., Mte, end Pleee, ens ew to tin eausel.) end manner a at.ted ............... ^ 7te.
3/e
...........
Jan. 10, 1995
.
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
'MEDICAL E%AMINERICORONER (Item 27)Type or Print Michael L. Norris C
On toe beets of eaemMation and/or Investigation, In my opinion, death occurred et the time
d F o ro n e r
date
sod
lace
eM due to the
,
,
p
,
cauea(a) w
manner as stated........ ........................................................... 405 Fairway Drive
J1i
~
'
3z. Mechanicsbur Pa. 17055
REGISTRAR'S SIGNATURE UMBER
DATE FILED(MOnlh, Day. Year)
~Q
__-_ .. _,
_ 4
.f~~~
r 'vF:> ~ r ~~'~'~~~.f'C'7:' Ji~ k~'-'~~r._~._~~______ 110. _.. ~ i
`~'~~ ~ ~~° ~~~~ Tu: '
______._..__.._...-A______-.._-- --____^---_._ l~e,~tster of i~%ills for the ;
_ _lJecesvsed. County of ~~ __ in t'rr4
;, ~ r~ ,), , ,, .;L'7-1=+ Cor~lsrtonwealth of Pennsylvania
The pe:itior_ ~~;' the undersigned respectfully represents that:
Yc:;~r pri;tioner{s), who is/are 18 yeazs of age or older, appl fee for letters of administration
on the estate of
(d.~.n.; ;ti:rderu tit,.; durante absentia; durance minoritate)
C31° ~?~. vv ,_ slit.
~:.::~;~,i.~~t •:, as;i~~., idled at death in ~r~-~ County, Pennsylvania, with
h. ~~=' _ 1:?st fa*riy ar principal residence ai ~ ~. ~~ ,
(list street, numtrr and munieipatity)
]`P;:«;~d?nt, Then _~ years of age, died _ Jt~,y~v f3 , 19~___,
at si;x;~.a~, 1Z~~J.~a<~sia y
~.c•nd.:~~ <t ric<:th e~vned property with estimated values as folllorrs:
{.li do;rt~ci?ed in Pa.) A,ll personal property ~ 100.00
elf not •.,'o~nciie in ?a.} Personal property in Pennsylvania $ i~ -
- {I r:o~: t;o:siciiLd :in Pa.) Personal property in County $_~
`v'alae o` rc°zil ~statc in z~ennsylvania ~ ~
situated a~ foii~•,~s:
Petitioacr-_ after a proper search ha_._ ascertain:d that decedent left no will and was survived by
iii:' ~c!'? -,vr~,5 si,c•~.e {if any) and heirs:
rya>~e
~A_r_`••_ , C_.: 1-c~..r/ y~tteiat:ortsh~r~
~~~ _.. a Residence
V'':d.ll~.Jl.`~[.g c.frr~1a;:~1P
^-,_,~`~ r,_ ~.~~_ =,,
- Y!_ , I'~ek~'~t'---- ~ Ell. , (~r]3~3~
~~rlEi?~1~Cy1;~, ~,:;;itioaer{s) respectfully request{s) the grant of letters of administration in the
pfro*?r=:;-:te :`errn to ti?e undersigned.
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s h~ ;^~titic~:cr(:s) zbove-named swear(s) or affirm(s) that the
sta;,eTr~c:?"s n t~,: iorrucing petition are true and correct to the best
a~ :f:c scno°r>'.,dg;; and belief of petitioner(s) and that as personal
rer^;:.r;.tativc(s) of the above decedent petitic
tit!I;' ~~:r°f'.ti.ni+t%r tee estate according to law.
Swcsn 'c ~ affirmed and subscribed
hefo,e Jne ti~is _ 20TH da of
~-~-_
~;
~'`.~+~V''' ~. L ~ bd I S
Regisler
ia~. - %1 - 95 - 53 ~-
~~ta~?~ ~ID~ JENNIFER SUE HERUEY ' D@C~~S~(~
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:~
_,~;.:~ i~,~~,- _ JANUARY 7.4 ~ - 19 95 , in consideration of the
petition on
tie rep ers-: site cr.°of, satisfactory proof Navin been resented before me,
x5 i3x:,CisL~irLa that ROBERT Fg HER~/EY
is/kre entitiF"Ci to :Letters of Administration, and in accord with such finding, Letters of Administration
~.re ?tereb: ~; a;?t~ai to `
i^ t;~.~: esl~,te nt' __._ ~ENt~~E~l t, t
// R stez of wills
'/ ~~IA~Y C. LEWIS
E1rS
..,tter~ Ui .':drninistratior. ..... ~ 18.00 _
si?Oil ~':rtiiiC~~IF~I; ~ .......... ~ ~-~~ nT~'Oi2NEY (S~a. Ct. I.D. ;Vo.)
nt,nUn:cir~t:cr . ................ ~ 5.00
JCP _ $ 5.su
~.u.,,i ....JN?Jr1RY..?4a.... A.I3. 19 95
PHONE
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L~t~~Y~s ~:-~~ o!'d`r put in attorrey~ f il~ in Prothy. on 1-2~-95. ~ ,~.a~'
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Ta the ~~,,i:;f,^r of 5~;~ii3s of ' ~~t~i;.A'~ County, Penns?~lvania.
~'tze ~~ders;~rt~ BARBR~RA,~ ~1FRYf.Y- ThF~ _ of
tine above dau°°u~.;,t, i~ereby rer<au~n~e(s) ttae riGht to administer the estate and raspectfuliy ask(s) that Letters
(1F ~;'~.j.iLSTRATION
.. `
i~r;lls:.~ to _ RORF~T F _ NFRUFY
ti
'W?TN;/5~ _ M!Y hand this 24TH day of JANUARY ~ lg 95 ,
~ ~
(Signature)
(Address)
(Signature)
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(Signature)
(Address)
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Rev=traoex.(1L )~'~!
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coMlat+weALnt of Pera+svt.vANIA
tJePARTt[!NT of Reveraie
__-- oewr. uoeol /
FIARRISeURO, PA 171260x01
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT 21
v ,..vac Iv,o [, nr~:
Jennifer Sue
§OCIAL SSECURITY NUA
~~~jjj -13-8034
IIC AGDi 11•so1 ea cl ~e,i
USE ONLY
use a Dlank block
8/1995 11/07/1969
rhea return must be filed In duplicate with the
REGISTER OF WILLS
1. Original Return 0 2. Supplemental Return
x ~ 4. Limited Estate 0 4a. Future Interest Compromise (tar dates of death
o ~
~
°
~
6. Decedent Died Testate (Attach Dopy
~ afler 12-12.82)
7. Decedent Malntairted a Living Trust (Attach
0 or wllq copy or Tnsq
~ 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death between
---- ._ -..- _._: 12-31-91 and 1-1-95)
~o
8g
z
0
5
g~
W
0
a
t
y,.
• e ( Ina menus Llne 11) (1~)~~,, ~~s. o
13. Charitable and Govemmt3ntal Bequests/Sec 9113 Trusts for which an election to tax has not »~-~----_-~;
been made (Schedule J) (13)~
14. Net Value Subject to Tax (Line 12 minus Line 13) (14)"
95
~.
~,, _. . --..+.. ~.v, .,vw... pw ua[va m uvam pnor IO 1Z-13.82)
~ 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
~ 11.EIecUon to tax under Sec. 9113(A) (Attach Seh O)
ae J. Hanft, Esquire --
M NAME (I1 applicable)
Law Office of Michael J. Hanft
19 Brookwood Avenue, Suite 106
TELEPHONE NUMBER Cazlisle, PA 17013
(717)249-5373
1. Real Estate (Schedule A)
(1) ~"'~ '
oFFtc
2. Stocks and Bonds (Schedule B) (2) ~~ ~;" ~ " ` " "" ` "~`";
3. Closely Held Corporation, Partnershi or Sole-Pro rietorshi
P P P ~
(3) ~ ~~ =--1
t~~,
~ ~
"
4. Mortgages & Notes Receivable (Schedule D) (4) ~ -"~
-
5. Cash, Bank Deposits 8 Miscellaneous Personal Property
(Schedule E) A ~ 542.36
~~~ ~~
6. Jointl Owned Pro a
Y P -IY (Schedule F)
Is) ~~ "'" ~ "'
-, I
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (7) ' ~ ~ ~ ~~~ ~~~ ~'~~~`
[
(Schedule G or L) r._ ,
8. Total Gross Assets (total Lines 1-7)
9: Funeral Expenses 8[ Administrative Costs (Schedule H)
/~ 8,190,pp J
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I
~~ -- . _ _ ; .~_ ...
5,655.44
11. Total Deductions (total Lines 9 & 10) (11)
12 Net Value of Estat L' 8 '
15. Amount of line 14 taxable at the spousal tax rate ~ ~ " '~" "°~ `~ ""~
See instructions on reverse side for percentage x .00
16. Amount of line 14 taxable at 6% rate ~~ ~~'"""'`
x .os
,.
17. Amount of line 14 taxable at 15% rate ' ^ x .15
18. Tax Due
19. p Check here if you are requesting a refund of your overpayment.
f>~
s or t declare that 1 ave examined this return, Including accompanying sdledules and statements, and to the best of my knowledge ~
of e n the al representative Is based on all Inform 014U 13 1 prpparer~as any knowledge.
n 4U Jje(veC(1lere treat
~__s1. ,.,< A Q M Cazlisle, PA 17013
(15) ~...~-.~..
(16)~W
(17) ~~-
(18)
d, A is true, correct end a
542.36
3,845.44
solvent
~~
3 okwood Avenue, Suite 106, Cazlisle, PA DA1~
3-~t:-e v
becedent's Complete Address:
i
266 South Hanover Street, Apt. 10
PA ~ "` 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 18)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C) (2)
Total Interest/Penalty (D + E) (3)
q, If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT. (q)
Check box on Page 1 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. (5)
A. Enter the interest on the tax due.
(5A)
(1)
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
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 ................................. ^
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.
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 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 on or after January 1, 1995. The statute does not exempt a fransfer 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 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 beneflciary(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(ies). If you chose to make the election, you must attach schedule O to atimely-filed tax return, along with schedule(s) Kand/or M in order
s
'~
WM~IONVVEALTN Of PENNSnvAN1A
INHERRANCE TAX RETURN
RE8IDENT OEClDENT
ESTATE OF
Hervey, Jennifer Sue
FILE NUMBER
21 - 95 - 00058
Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly-owned with the Nght of
survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1 Members 1st Federal Credit Union checking account balance of $359.52 minus offset for loan of $317.16 42.36
2 Miscellaneous Personal Property 500.00
Schedule E
Cash, Bank Deposits, 8 Misc. Personal
Property
Schedule E TOTAL
r
OOI.MONWEALTN OR aENNSnwwu~
IMIERITANCE TA7C RETURN
RE810ENTOECEpENT
Sd~edt~ie H
wF~neral E>q~er't,,9es ~
~1. ^~i~~
cv~r~c yr
Hervey, Jennifer Sue
wnnBeR
21 - 95 - 00058
uee>ns of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES
1 Ewing Brothers Funeral Home, 630 South Hanover Street, Carlisle, PA 17013
2 (Cumberland Valley Memorial Gardens, 1921 Ritner Highway, Carlisle, PA 17013
13. ADMINISTRATIVE COSTS
1. Personal Representative's Commissions
Robert F. Hervey, Executor
Social Security Number(s) / EIN Number of Personal Representative(s):
476-38-6935
Street Address 640 Belve ere Street
City Carlisle State PA Zip 17013
Year(s) Commissions paid
2. omey Fees Michael J.Hanft, Esquire
3. Family Exemption (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State ZIP Code
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7. Other Administrative Costs
Cumberland Law Journal -Fee to advertise Petition for Grant of Letters Administration
AMOUNT
6,500.00
1,350.00
300.00 ^~
40.00
Schedule H TOTAL
r
cowwaNwEU.tN of PE-~ISrwANu
N~MERITANCE TAX RETUIW
RESIDENT DECEDENT
c~rwrr i.~
Schedule I
Debts of Decedent, Mortgage
Liabilities, $ Liens
~....-.. ~ yr -
Hervey, Jennifer Sue
FILE NUMBER
21 - 95 - 00058
ITEM
NUMBER
1
2
3
4
5
6
DESCRIPTION AMOUNT
'~ America Mastercard -Account No. 5329 021'7 5606 3383 (not paid)
543.65
l of PA for (717) 243-8348 (not paid)
82.47
bia House Record Club (not paid)
15.69
- Customer No. 521 7554 712 (not paid)
14.10
ors 1st Federal Credit Union Visa Cazd -Account No. 4121449991327797 (not paid)
1,050.53
t Loan Servicing Center -Account No. 227-13-8034-403 (not paid)
3,949.00
Schedule I TOTAL
pennsyLvania
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
INHERITANCE TAX D6VISION STATEMENT OF ACCOUNT
PO BOX 28 0 R D E D 0 F Fil CE OF,
HARRISBURG PA 17128-0601
REG;lS0TE-,-. CF WILLS
DATE 02-09-2015
?015 FEB 17 M 1 13 ESTATE OF HERVEY JENNIFER S
DATE OF DEATH 01-08-1995
C LE F FILE NUMBER 21 95-0058
HANFlORWAll,"O" 1,ky6kkEL J COUNTY CUMBERLAND
ACN 101
SUIOVV1"Pr6R� % Amount Remitted
19 BROOKWOOD AVE
CARLISLE PA 17013
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment.
CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS ---& --- - - - --- - ----
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- -H i i f fA�N E g 7 Al STATEMENT O� ACCOUNT
ESTATE OF:HERVEY JENNIFER S FILE NO. : 21 95-0058 ACN: 101 DATE: 02-09-2015
THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL
TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-05-2000
PRINCIPAL TAX DUE: .00.
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-3
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM
FOR INSTRUCTIONS.