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Home My WebLink About95-0341.. a~LaS-o3~~ This is to certify that the certificate hereunto attached is a true and accurate copy of the original death record on file with the Division of Vital Records, and that Frank Yeropoli, whose name is subscribed thereto, was at the time of subscribing the same and now is Director, Division of Vital Records of the Department of Health, for the Commonwealth of Pennsylvania, duly appointed and commissioned as directed by Act 66 of the General Assembly, approved 29 June 1953, P.L. 304. AUG 16 2001 Date N,o5.,~3 Rev: ?/B7 7YPEIPRINr reNNANenr e~nacaxL Id Z _~ Fran eropoli, ' ect Division of Vital Records P.O. Box 1528 New Castle, PA 16103 COMMONWEALTH OF PENNSYLYAINA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH ~~C~.~$ ~ sWEI'IE NUNDER _ _ NANE DP OECEDENT~FieL Midda, , 1 sEx` 90cIAL 8ECURm NULISER DATE OF DEATN (1ImtlL Dq~, Mar) ' '' ~nn~ ~ ~~ R2~rv1 z ~m0.~t y 191 - 50 - 2991 .. January 21, 1995 MiEDar ~M uNOER/vrarl I,I+DEn1DAY D/OEORexrrN 91RTlIRI,GE~iyertl PLACEOPcearlpcneca er+r ar-ese il,trucxons on aMrrdy Moralr Dys Nona I NYaAas (MOm11,DaY.Ma~ SlrarFarrxnCOUna» onIER: 90 Yn~ 10/8/04 Greene Twp. Irlpadarx^ ERpupriaa^ DDA^ N'aal"x^ Raatlwlca® °Mi COUN,Y OFD6oH CRY, SORO,TWPOF DEATH FACILITY NAMEpno,ind'YNon. pve atrM and ram0or) WA9 DECEDENT OF NLSPANq ORgIN7 RACE•Mwken Yi6rl Slack.WNto, a,c ,,,Cumb¢nZand x,,Svutham .ton T X31 A.inpont Road, Sh~.ppen6burg, PA .~~.~""`'"°"`wh~.te DE(E:OENT'8 U8uAL000,IRC,DN IaAro of SUSNlESSANDUSTRY wA3 DECEDENTEVERW DECEDENT'e EDUCATiDN MARfPL $DVU$-,,,a„pd uinea.owaoned~mw u.s.ARNmFDRCEST ~ DaNpa N ~wr,w,waow.e, ro ms I aaddnp lxa; aona uae ,,., oue ew.c~ a „a ~~ M. ^ No I~ ,~. 8 ~~m ~,.~r5., ,.. w~.da T~ DE~ra-uiewADDRESSawe.I.rnv~m.smb.zocoaN ~or~EDE~'S ,T..slr. PA ,s. 331 A.inpart Road „~, ~.dNx ,T~GcI M..d.ae.axwdln- Southamp-ton I, ~~ S1u.ppene bung, PA 17257 a~:.~ ,Tb. Cumbeneand ~aT ,,,,^ ~,,, ~d FlO,IEn'S NMIE(FFaI, Nidda. Lm) NDRIEA'8 NANE (F7n1. Lidda. Naidsn 9urriams) le•ro. ,..W<,ZLi,am Pe~teneon Nettie Wa eman INFORMANT'S NANE Mr•~+nll Nan A IIce#ic i ch INFORNANT9 NALLMgADpESS (Strer. Ciy/Town, sIW. Zp Code) - . , . MET„ooocasFneRTDN DATE OFDISPOSITpN 331 ont Raad Shi eneb PA 17257 RucEORaeROS,TIDN-w~n.ac.nr«Y,c~.m.a,. ~oculaN-ay~a.sr..nacoa .Dar.~M oromor Rlw cnmrbn^ R.mow aae suu^ ~ ~ ^ y ~DOiWlon^ otl r (g ,,,, 1/26/95 ,~ehobe-th Ceme~teny ~. New.tvn Twp., Cumb. C~.,P ~~~ ACTINOAS SUCH L1CEN9EnIIMEEn NAMEANDADDRESSaFFACxTrv 0~ „d 011776-L Baiclzenf.H.Inc.,PCI Bax 336 PA 17257 , , V r~inrl~iaewreryr~awr~ba~ .arn rut ar..~aWusune. ucENSENUNeER DraESx~wED •.,wuwadwn. ~ - MOo 3 L "A"".DaY.""" ,Iema2F73 . ~ ~l ~--9 xa woonwNNd by DFDF/D,I wbaxnxua;ua.rn. DATEPRONOINICEDDEADpMM.D.Y.M.d cASERTFERREpmNEDICALE%AMINERIODRONEA) ~.. N. - 2 - q ~. ^ ,„ 27. IAIIT L• l.et' anlY arrlxad~ ~ elia~aueae tln daatll. DO mtamorlM nodaddyNp, wal as caMaear nagr•aYana~. alaa;kar llaon /aMn. IAppeaylre PART x: Ollw eipeAUlx aondllWn mrriDainpb daaxl. eul ^111®IATE CA1ME~f-mel jonarand dwm n01~gln Ula Ui4igiq CaxN xrwnb PARTI. ' ' ~° Co s ~ ~e k a. , DUE TO ASACONSEOUENCx:OF~: BapiN~Wy Yoonottlwr e. ' _ Margl badYgbbmaiala DUEroIDR ASACONSEOUENCE OF7: ~ I eaer. ErearNlO6rYx10 ; CAIMIIDirsaanlMY c. bri~ihlad nvb OllE70lpi ASACONSEOUENCE OF}. rasAFq r deatll) LAST d . WAS AN AUTOPSY WERE AUICW$Y FMDeIDS MANNER OF OE.QM DIPE OFINJURY TINE OF INIURY INJURY ATWORNT DESCRIBE /IOW NLxJRY OCCURRED. IrERPpgMEp7 AWa PRpRN (Mach Dar Met) , . ~C ~TqN OFCAUSE ~~ NankNa ^ Aad'Mm ^ Pan6p bvoatlpYbn ^ Ms ^ No ^ w ^ No M, ^ No ^ sdue. ^ M. CaYd noll»blwmlMd ^ PLACEOFIN,IUm~.arom. rrm aean ewmwdl~• Loca u ~ . . . ts a ra•I. car~.,,.swl ~ w. ra ISaaoM axe. xx ~ . D~RTCMa~avy a.e) 7Dt- 'COITFYND `~ TR ' RMY81tlAN(Pnyrian certiy LE OF E xgravaad tlaaM wfienaro0ier phYacian h•epma+~ee wem enE CanaeteE Ham2 TolM cram, anawbdxa. eaaYlexwroa OUab tlN OaewpJ are marxMr as rabd ..............................~...................... ~/4. e '7o~µDlugwbdxa, doom o«vr.e rrtMtlaw,bhini nciM G•slhaMCxtlyiripmu.wadeeeeq /y~/~ ,) '/ /~ / DATE STONED IMaeh. DaY. Marl P1eoa,maldwblMenma~al and manrmrr Nwe .......................... ^ 3, I ~LQY Y ~"i' /~ ata ~~ Z~''~ Y`~ . NANE AND ADORE830F PERSON WHO COM USE OF DEATN 'MEDICAL ExArINIrnoRDNEn xem 2T) Trw a Prim t-1-` ~ a n ~3 ¢ c~Ce r Ox Ula lealaamlemY,etbn d/ ^'r 5 an or ,In mY OpMIOrl. deaN, atwmdrNm Nme.dro. and plaeq and due fn Ula s 1C,h .~J.,,y, manrmr r ra,ad ................ . eauaq )and ^ I 1 . .... ..... .............................. „ .................................... JZ. T~DIST NATURE AN U R • ~ ~ Q ~'l V DATE INmM. DeY. lbep ~ ~ .~" ~ ~~"J ~ ~ 73. H. ~ ,REV-1500 ~X+(7-g4) I IJ~iERITANCE TAX RETURN CHECK HERE IFDa sPOUSa~ R t~~/91~~N 1 I~ RESIDENT DECEDENT POVERTY CREDIT IS CLAIMED 2 j COMDEPARTMEN OF REVENUEANIA (TO BE FILED IN DUPLICATE FILE NUMBER 21 ~~ 5 HARRISBURG, PA 87128-0801 WITH REGISTER OF WILLS COUNTY CODE Y~E,4R DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) DECEDENTS COMPLETE ADDRESS Helm, Anna M. 331 Airport Road SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH Shi DECEDENT pPenSk7LLY'g, PA 17257 197-50-2991 01/21/95 10/08/1904 County Cl~nberland Count RSTAND MIDDLERNITIAL) SPOUSE'S NAME (LAST, SOCIAL SECURITY NUMBER AMOUNT RECEIVED (SEE INSTRUCTIONS) CHECK APPRO- PRIATE BLOCKS CORRES- PONDENT RECAPIT- ULATION TAX COMPUTA- TION and 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach copy of Will) 2. Supplemental Return 4a. Future Interest Compromise (for dates of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach copy of Trust) U 3. Remainder Return (far dates of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes NAME Je A. Wei le, Es ire TELEPHONE NUMBER {717) 532-7388 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Sch. C) 4. Mortgages and Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) (Schedule L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses, Administrative Costs, Miscellaneous Expenses (Schedule H) 10. Debts, Mortgage Liabilities, Liens (Schedule I) 11. Totai Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests (Schedule J) COMPLETE MAILING ADDRESS Mark, Weigle and Perkins 126 East King Street Shippensbu~, PA 17257 (1) None (2) None (3) None (4) None (5) 22,000.00 (6) None (7) 2,559.25 (9) 11,217.33 (io) 1, 604.87 (8) 24,559.25 (11) 12, 822.20 (12) 11, 737.05 (13) None 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 11 737.05 15. Spousal Transfers (for dates of death after 6-30-94). See (15) X _ , Instructions for Applicable Percentage on Page 2. (Include _ values from Schedule KorSchedule M.) 16. Amount of Line 14 taxable at 6% rate (16) 11, 737. 05 x (Include values from Schedule K or Schedule M ) .06 704.22 . 17. Amount of Line 14 taxable at 15% rate (17) 0.00 x .15 - 0 00 (Include values from Schedule K or Schedule M.) . 18. Principal tax due (Add tax from Lines 15, 16 and 17.) (18) 704 22 19. Credits Spousal Poverty Credit Prior Payments Discount Interest . + * - (is) 0 00 ?0. If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMENT. i:i : ..i:;:ii: :i : :i ' (20) . ~ :.: f i. :i:ii:'r..:i:e::: ::i::::~.. ? .~ ~~yyII ~~yy~~ ... . .... :..: ,. 'E:i::i.iii.iii:::.:.:~~n•;•;,•.;•;;,.,•,.,. ...................:::::•::::. ;~€ .. NRI: ..... i .. .. ... ...... .... .. .... .. ...~R~• ' i .. .... .. ••. ..... .. eil•. i .. ~.... .. €iij`:iiiiiiiiiiil i:ii,i,.:.i;,:.: ~ >i. If Line 18 is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. (21) 704 22 A. Enter the interest on the balance due on Line 21 A. (21 A) . 0 00 B. Enter the total of Line 21 and 21A on Line 21 B. This is the BALANCE DUE. (21 B) . 704 22 Make Check Payable to: Register of 11VIIIs. Agent . »:anve Is eased on ail information of w RE OF PERSON RESPON~LE FOR FILING SI A7UREOFP ER OT RTH _- , 1`-'-1 _ ~ I Copyright Forms Software Only, 1994 Nelco, Inc.~~1~194PF that all real estate has market ADDRESS See Schedule attached. ADDRESS 126 East Kinq Street Shi-Ppensbuzg, PA 172! n of preparer 341 NUMBER mY Knowledge than the personal DATE._ =~~ DATE ~ ~ ~ ~ ? -~~`~~ • .. Estate of: Anna M. Helm S[7N~IARY OF ALL~OC'ATIONS 'IC) BENEFICIARIES Class A Nancy M. Dietrich 11,737.05 21-1995-341 0 Estate of: Anna M. Helm 21-1995-341 The following person(s) are signing the return as representative(s) of the estate: Nancy M. Dietrich 331 Airport Road Shippensburg, PA 17257 ` PA REV-1500 EX (7-94) Act #48 of 1994 provides for the reduction of the tax rates Imposed on the net value of transfers to or for the use of the spouse. The rates as prescribed by the statute will be: • 3% (.03) will be applicable for estates of decedents dying on or after 7/1/94 and before 1/1/96 • 2% (.02) will be applicable for estates of decedents dying on or after 1/1/96 and before 1/1/97 • 1% (.01) will be applicable for estates of decedents dying on or after 1/1/97 and before 1/1/98 • Spousal transfers occurring on or after 1/1/98 will be exempt from Inheritance tax. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK (v) IN THE APPROPRIATE BLOCKS. 1. Did decedent make a transfer and: 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 wthin one year of death without receiving adequate consideration? ................................................. 3, Did decedent own an 'in trust for' bank account at his or her death? ....................... . ..... . ........................ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. PA15002 NTF 8880 Copyright Forms Software Only, 1994 Nelco, Inc. N94PA002 REV-1508 EX+(2-87) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY tSIATE OF Anna M. Helm FILE NUMBER (All property Jointly-owned with the Right of Survivorship must be disclosed on Schedule F) ITEM NO. DESCRIPTION 1 (Account Receivable -from Larry Rosenberry on installment sale 21-1995-341 VALUE AT DATE OF DEATH 22,000.00 TOTAL (Also enter on line 5 Recapitulation) $ (Attach additional 8 1/2 x 11" sheets If more space is needed.) PA15081 NTF 1215 Copyright Forms Software Only, 1994 Nelcc, Inc. N94PA081 Please Print or 00. REV-~ s1 o EX + (2-$~) COMMONWEALTH OF PENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN TRANSFERS RESIDENT DECEDENT E TATS F PLEASE PRINT OR TYPE FILE NU BER Anna M. Helm THIS SCH. MUST BE COMPLETED & FILED IF THE ANSWER TO ANY OF THE QUESTIONS ON THE REVER SE 51DE OF COVER SHEET S YES. DESCRIPTION OF PROPERTY ITEM DECD. DOLLAR VALUE Include name of the transferee, their NO EXCLUSION TOTAL VALUE % OF DECEDENT'S , relationship to decedent, date of transfer. OF ASSET INT. INTEREST 1 PNC Checking Account #5080432075 3,000.00 2,559.25 100% 2 559 25 made joint with Nancy M. Dietrich, , . Daughter, on 5/5/94, date of death value of $5,559.25 TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of same size.) PA15101 NTF 1217A Copyright Forms Software Only, 1994 Nelco, Inc. N94PA101 .25 ~ REV-1511 EX+(7-88J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELLANEOUS EXPENSES ESTATE OF Anna M. Helm ITEM NO. DESCRIPTION A. Funeral Expenses: 1 Fogelsanger-Bricker Funeral Home 2 Rehoboth Cemetery Association 3 (Jeanette Gehrke -reception B. Adminlstrattve Costs: 7. Personal Representative Commissions Social Security Number of Personal Representative: 194-28-7682 Year Commissions paid 1996 Name: Nancy M. Dietrich 2. ~ Attorney Fees Please Prlnt or Type FILE NUMBER 21-1995-341 Name: Mark, Weigle and Perkins 3. Family Exemption Claimant Nancy M. Dietrich Relationship Daughter Address of Claimant at decedent's death Street Address 331 Airport Road City Shippexns State PA Zip Code 17257 4. ~ Probate Fees C. I Miscellaneous Expenses: 1 (Cumberland Law Journal -advertising Letters Testamentary 2 (Register of Wills, Cumberland County -filing Appraisement, and Statement of Debts and Deductions 3 Register of Wills, Cumberland County -filing Family Settlement Agreemexit 4 Mark, Weigle and Perkins -reimbursement for postage, xerox copies, and long distance telephone calls 5 (News Chronicle -advertising Letters Testamentary TOTAL (Also enter on line 9, Recapitul+ (If more space Is needed, Insert additional sheets of same size.) PA15111 NTF 1218 Copyright Forms Software Only, 1994 Nelco, Inc. N94PA111 AMOUNT 5,118.50 400.00 125.00 900.00 900.00 3,500.00 77.00 60.00 15.00 60.00 10.00 51.83 ~`~, 11,2,17.33 - -- REV-1512 EX+(1/93) COMMONWEALTH OF PENNSYLVANIA SCHEDULE INHERITANCE TAX RETURN DEBTS OF DECEDENT, RESIDENT DECEDENT MORTGAGE LIABILITIES AND LIENS Dlw~ a o~_a - . ~ _ Anna M. Helm FILE NUMBER. 21 1995 341 ITEM NO. DESCRIPTION 1 Chambersburg Imaging 2 Dr. James Hurley 3 Dr. Steven Becker 4 Professional Health Care -equipment rental 5 Mark, Weigle and Perkins -outstanding balance owed at date of death 6 CCS Financial Systems 7 Realty transfer tax paid at final real estate settlement 8 Mark, Weigle and Perkins -real estate settlement fee and costs 9 Nancy M. Dietrich -reimbursement for bill paid to Mark, Weigle and Perkins for services rendered to decedent prior to date of death AMOUNT 17.56 31.07 4.40 41.24 300.00 43.60 250.00 415.00 502.00 TOTAL (Also enter on line 10, Recapitulation) $ 1 604.87 (If more space is needed, insert additional sheets of same size.) PA15121 NTF 2aao Copyright Forms Software Only, 1994 Netco, Inc. N94PA121 REV-1513 EX+(2-87) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES FILE NUMBER Anna M. Helm None TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) (if more space Is needed, Insert addRlonal sheets of same size) PA15131 NTF 122oA Copyright Forms Software Only, 1994 Nelco, Inc. N94PA131 0.00 ITEM NO. NAME AND ADDRESS OF BENEFICIARY AMOUNT OR SHARE OF ESTATE B. Charitable and Governmental Bequests: LAST WILL AND TESTAMENT I, ANNA M. HELM, of 331 Airport Road, Shippensburg, Cumberland County Pennsylvania, being of sound mind, memory and disposition, do hereby make, publisl and declare this my Last Will and Testament, hereby revoking and making void al: (wills by me at any time heretofore made. FIRST. I order and direct the payment of all my just debts and funeral expenses a; soon as may be convenient after my decease. SECOND. I give, devise and bequeath all my estate, real, personal and mixed. whatsoever and wheresoever situate, to my daughter, NANCY M. DIETRICH. It is m~ (specific intent and desire to exclude my son, Clarence E. Helm, and my daughter; ..Helen A. Weber, from any distribution whatsoever under this my Last Will anc Testament. In the event the said Nancy M. Dietrich should predecease me or is not living on the sixtieth (60th) day following my death, I then give, devise any bequeath my estate to my son-in-law, GEORGE A. DIETRICH. THIRD. I nominate, constitute and appoint my daughter, NANCY M. DIETRICH, to be the Executrix of this my Last Will and Testament; if she be unable to fulfill the duties of Executrix, I then nominate, constitute and appoint my son-in-law, GEORGE A. DIETRICH, of 331 Airport .Road, Shippensburg, Pennsylvania, to be the Executor of this my Last Will and Testament. FOURTH. I direct that my personal representatives shall not be required to give pond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I, ANNA M. HELM, have hereunto set my hand and seal to this my Last Will and Testament, written this ~ day of,~y~/~ 3, ~ ~ / ~' SEAL ) MARK, WEIGLE AND PERKINS - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA. 17257 This instrument was by the Testatrix, ANNA M. HELM, on the date hereof, signed, published and decl=red by her to be her Last Will and Testament, in our presence, who at her request and in her presence and in the presence of each other, we believing her to be of soune and disposing mind and memory, have hereunto subscribed our names has witnesses. ~J~Zm7r/~t Y7 COMMONWEALTH OF P~TNSYLVANIA SS. COUNTY OF CUMBERL.?VD I, ANNA M. HELM, the Testatrix whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. C. ~ ~~~ , Sworn or affirmed to and acknowledged Before m by ANNA M. HEthe Tes trix, `his %j~day of , 19 v NA7ARIAL ~9EAL ~1~fty A: W@Ig~} Nnt~Rr publlo ~hlNtsc'1;~-~tlr~, ~A ~Nmb~dond County h~Y~t f.~;~irig~?g~ E~31f~#g,~liy 91, tfl94 MARK, WEIGLE AND PERKINS - ATTORNEYS AT LAW - 1 26 EAST KING STREET - SHIPPENSBURG, PA, ~ 7257 _. - -- COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. ~ and ~~ , the witnesses whose name are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw ANNA M. HELM, Testatrix, sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as witnesses; and that to the best of our knowledge the Testatrix was at the time eighteen (18) or more years of age and of sound mind and under no constraint .or undue influence. x n_~_ /~. ~ , Sworn or affirmed to and sub crib befo~e~e by, ~j~~,,~,~ ~/~ and i witneCs"ses, this /1 of ~~ e~°m~~ 1993 . ~ 1 /~ ~..~~'o NG51'AF~IAL ~~AL dsrry A: ~r~t~l~, Nbiary Public lrF,l~+ iis4~~!tg, pA f~ur~itt~ti~nd County My ~r~jrr('sii~f7 t~piro~ July 31, 10A4 MARK, WEIGLE AND PERKINS - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPi'ENSBURG, PA. 17257 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION INHERITANCE TAX DEPT. 280601 HARRISBURG, PA 17128-0601 STATEMENT O F A C C O U N T REV-1f 07 EX ~Fi (OS-971 DATE 03-17-97 ESTATE OF HELM gNNq M DATE OF DEATH 01-21-95 FILE NUMBER 21 95-0341 JERRY A WEIGLE ESQ COUNTY CUMBERLAND MARK ETAL ACN 101 126 E KING ST ~ Amount Remitted SHIPPENSBURG PA 17257 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS __~ ----------------------------- REV-1607 EX AFP ( 03-971 -- ---~~* ----'-'----------'-------------- INHERITANCE TAX STATEMENT OF ACCOUNT ~[*~ --------- ESTATE OF HELM ANNA M FILE N0. 21 95-0341 ACN 101 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATED SHOWN BELOW 97 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: 02-10-97 PRINCIPAL TAX DUE: ....................................................................................................................................................................................... .................................... PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 12-05-96 AA184922 71.49- 02-27-97 AA185205 704.22 • 1.48- 73.06 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. * IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) 704.22 704.31 .09CR .00 .09CR