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Home My WebLink About02-27-13J 1505610105 EX (oz- REV- ~ ~ o o u) (FI) ~ PA Department of Revenue OFFICIAL USE ONLY Pennsylvania INSOLVENT ESTATE a ~ Bureau of Individual Taxes PO BOX z8o6oi .v oE ~.,'o, INHERITANCE TAX RETURN County Code Year File Number Harrisbur PA 1'7128-o6oi 21 12 0875 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 08/05/2012 10/05/1931 Decedent's Last Name Suffix Decedent's First Name MI Myrick Nancy M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death O 4. Limited Estate O Prior to 12-13-82) 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O (Attach Copy of Will) 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLE N TED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD ~E. DIRECTED TO: ame Daytir~ Telephone I~ixrhber ~ ~ Jane M. Alexander (717~~4~-4514 ~ o rn First Line of Address _. 148 S Baltimore Street \ _ _ __ __ Second Line of Address City or Post Office State ZIP Code Dillsburg PA 17019 -r:~ ~, ~ (~ST OF ~LS U~ Y - ~ ~ ~..,.. a'.. ~C i °° ..;~ ~ t ~ '..., '~ 4.1 DATE FILED Correspondent's a-mail address: jmalexander.148 earthlink.net Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGLURE (~F PE~SON RESPONSI,L3LE FOR FILING RETURN _ _ ___ 12 Ea~Green Street, Mechanicsbur ~rPREPARER PA 17055 14~~BalCmore Street, D~Ilsburg, PA 17019 1505610105 PLEASE USE ORIGINAL FORM- ONLY Side 1 DATE 1505610105 J J 1505610205 REV-1500 EX (FI) Decedents Social Security Number oecedem•s Name: Nancy M. Myrick RECAPITULATION 1. Real Estate (Schedule A) ......................................... .... L 2. Stocks and Bonds (Schedule B) ................................... .... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . .... 3. 4. Mortgages and Notes Receivable (Schedule D) ....................... .... 4. _. _. 5. Cash, Bank Deposits and Miscellaneous Personal Property (schedule E).... ... 5. 4,952.14 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G} O Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. 4,952.14 9. Funeral Expenses and Administrative Costs (Schedule H) .. 9 ... .......... ... . 1,032.12 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 1 1,659.86 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 12,691.98 12. Net Value of Estate (Line 8 minus Line 11) ...... ........ 12 ........ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ... . -7,739.84 - - an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...... 14 ............... ... . -7,739.84 TAX CALCULATION • SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 - (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable _ _ _ at lineal rate X .0 45 -7,739.84 16. _ 0 00 17. Amount of Line 14 taxable . at sibling rate X .12 17. 18. Amount of Line 14 taxable ~ -- .. ._ .._ at collateral rate X .15 18. 19. TAX DUE ................... . .................................. .. 19. _ U.~O 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 ~~tttst `zii rz1t~ c~ r~tttmrnt Of Nancy M. Myrick I, Nancy M. Myrick, of the Borough of Mechanicsburg, County of Cumberland and Commonwealth of Pennsylvania, being of sound mind, memory and understanding, do herewith publish and declare this to be my last Will and Testament, hereby revoking and declaring null and void any and all Wills and Codicils heretofore written by me. ITEM I. I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient to the proper administration of my estate. ITEM II. I then give, devise, and bequeath to my Grandson, Anthony C. Brackbill, my 1998 Chevrolet automobile. ITEM III. I order and direct my hereinafter named Executrix to convert my entire estate, (except the above-mentioned specific bequest), into cash at either public or private sale, whenever in her discretion it may be most expedient for the proper administration of my estate. In the event of such conversion, I authorize my said Executrix to execute a good and sufficient Warranty Deed to the purchaser of any real estate of which I may die seized, in the same manner and capacity as I could if living. ITEM IV. I direct that all inheritance and estate taxes be paid on the proceeds of the above-mentioned conversion and all the rest residue and remainder of my estate from the residue of my estate prior to further distribution. ITEM V. I then give, devise, and bequeath all the rest residue and remainder of my estate, including the proceeds of the aforementioned conversion in equal shares to my children Larry Myrick, Linda M. Baldwin, Michael Myrick, Judy A. Killinger, and Nancy Walumas, per stirpes and per capita. ITEM VI. I nominate, constitute and appoint my daughter, Linda M. Baldwin, as Executrix of this my Last Will and Testament. Should my daughter predecease me or be unable or unwilling to serve I then nominate, constitute and appoint my daughter, Judy A. Killinger, as Executrix in her place and stead. I direct that my Executrix shall not be required to post bond other than her personal assurance for her duties as Executrix. Page I of 2 REV->5o8 EX+ (o8->z) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: Nancy M Myrick SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY FILE NUMBER: 21 12 0875 ----• --- __.......,,,,, ~,•,.,.~~ „• NaN~~ ui uie same size. Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivnra6ln n,~~~r tie a:~,.~,.,...~ __ ~_~_~__._ REV-t511 EX+ ;10-09} ~ ~ Pennsylvania DEPARTMENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Nancy M Myrick ITEM NUMBER Decedent's debts must be reported on Schedule I. A• FUNERAL EXPENSES: 1 Linda M Baldwin Reimbursement for Funeral Food 2. Funeral prepaid Cocklin Funeral Home, Dillsburg, PA B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Linda M. Baldwin Street Address 12 East Green Street city Mechanicsburg state PA zIP 17055 Years} Commission Paid: 2013 z~ Attorney Fees: Jane M. Alexander, Esquire 3 Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant None Claimed 4. 5. 6. 7. s. 9. ~ o. ~i. Street Address City - State _ Relationship of Claimant to Decedent Probate Fees: Register of Wills, Cumberland County Accountant fees: Tax Return Preparer Fees: Register of Wills, Cumberland County- Filing Inheritance Tax and Inventory Notary Fees Oath of Subscribing Witness Notary Fees Final Accounting Preparation of First and Final Accounting Narumol Alexander- Witness Fee ZIP TOTAL (Also enter on Line 9, Recapitulation) ~; 230.38 0.00 247.60 346.64 92.50 30.00 15.00 15.00 30.00 25.00 1,032.12 Ir more space is needed, use additional sheets of paper of the same size. SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMBER 21 12 0875 I REV-1512 EX+ (L2-OS) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERRANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ~alwie ur FILE NUMBER Nancy M Myrick 21 12 0875 Report debts incurred by the decedent prior to death that remained unpaid at the na~P ~f do~rti In~I~~e~.... ,......;_~..___~ __~:__~ ___ __ - ..._. _ ,. _......,..... „~~~~ a~~~~~~~~a~ ~nneis of cne same size. REV-1513 EX+ (O1-10) pennsylvania INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE BENEFICIARIES ESTATE OF: FILE NUMBER: Nancy M Myrick 21 12 0875 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RE oTN tSList Trustee(s)NT AMOOF ESTATE ARE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• Linda M Baldwin 12 E Green St. Mechanicsburg, PA 17055 Daughter 1/5residue 2. Michael Myrick 211 Scotch Pine St., Dillsburg, PA 17019 Son 1/5residue 3. Judy A. Killinger t7 E Countryside Dr., Boiling Springs, PA 17007 Daughter 1l5residue 4. Nancy Walumas 6341 Old Carlisle Rd., Dover, PA 17315 Daughter 1/5residue 5. Kimberly Myrick 70 Townhouse, Hershey, PA 17033 Granddaughter 1l5residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. N/A B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. N/A TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I ~ If more space is needed, use additional sheets of paper of the same size. '~G'w~ J. L'JIL L.i't~l~l fIVL DdfIK ~. ~~ty September 5, 2012 Jane M Alexander Esq. 138 S Baltimore St P O Box 42 ] Dillsburg, PA 17019-0421 ItE: Nancy M Myrick SSN: 203-24-9187 DOD: 08-OS-2012 Dear Ms. Alexander: iuo, o4i~ r, ~~ ~ Iz~ response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Checking Account Account # 5070089621 Established: OS-O1-1980 NANCY M MYRICI~ DOD balance: ~ 4,760.66 non intErest bearing please note that this office provides date of death balances for deposit accounts (1kAs, Cl7s, Checking and Savings). 'We do not process any financial transactions or provide statements. Tf you need assistance with any of these itctus, please call I-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch ofQce_ Sincerely, National Financial Services Center PNC Bank, N.A. Member FDIC This message is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, d'istrfbution or copying of this communications is strictly prohibited If you have received this communfcation in error, please notify me immediately by reply or by telephone at 800-762-1775 and immediately destroy this faxed document. ~.~ ` ~„s ~' ~'-~ r Page 1 of I ~ , , ..~f tF.~ ,~' PN CBAI\K PNC Bank, N.A. 040 Central PA CURRENCY - COIN Q DEPOSITS MAY NLii gE AvAILADLE FOR IMMEp1ATE WITHDRAWAL DATE _ CHECKS - ~/ /~ -';, "` d~ TOTAL FROM - OTHER SIDE USE OTHER SIDE FOR ADDITIONAL LISTING. BE SURE EACH ITEM IS /'~~ ~) / s 1 ~ PROPERLY ENDORSED. TOTAL ITEMS / J ~: 6 400~~i 40 20~: 500 3 5 7 7 28 911' CHECi:S AND OTHEP HEMS ARE RECEIVED fOR DEPOSIT SVRJELT i0 THE PROVISMJNS OF THE UNIFORM COMMERCIgL LOOE OR ANY aPPLILARLE OOLLEC iION AGREEMENT Date: 08/14/2012 This Month Gross payment amount 173.37 Net payment amount 173.37 0398485 Direct Pay Central Region:` Premium Refund'. oA?E 08/14/2012 *ONE HUNDRED SEVENTY-THREE AND 37/1.00 DOLLP,RS* PAY THE ESTATE OF NANCY MYRICK TO THE ORDER OF 12 E GREEN ST MECHANICSBURG PA 17055 ~~ re ~~ ~~ ~~,+ I AMOUNT 173.37 Void if not cashed within 1 year 11.Glr~t~ ~ rI~ N1tNOR12E0 9 WATURE 11'039848511' ~:036076i50~: 620545258111' B PNCBAIIK PNC Bank, N.A. 040 Central PA PAY TOT \ ' ORDER F Cf`-~- ~7 w~ ~/ NO. ~~ y - /~ ~ ~ 66-1273/313 DATE ESTATE OF ~ [fi,~--~~ ~j ~ ~~ FOR n ~~-/`l~`((~ ~:03L3L2738~: .~. ~~~~j -DOLLARS ~ ~ e (.. ~%r_,~G~_~__.VG~~t'- ._.~ ..I~ Execurow ADMINISTRATOR ._.. ---- _._.._ IYP \\\ PERSONAL REPRESENTATIVE ~~~~ -~" TRUSTEE 500 3 5 7 7 289ii' :..--~ .,~~ nn304U076377 5.97 ~' A /' ~ C ~( ~''° . ` ~~ c ~!'= -~ l~ ,,,(,sl t~. ` ~_.--yam ,~ ,~ -~°-- ,4-.,., ~-~.-~ ~t ~~,~ " i ~ .~~ ~~ ~: ~~ ~ , I~ /G-~._ ~~~~ ~s~~ .~.~ ~.~-- ~ ~ .fly ~~~ ~~ .~~ m~ _ ~ ~. ~~ --~_. pennsylvania DEPARTMENT OF PUBLIC WELFARE September 19, 2012 JANE M ALEXANDER ESQUIRE 148 S BALTIMORE ST DILLSBURG PA 17019 Re: Nancy Myrick SSN: ###-##-9187 Dear Attorney Alexander: Pursuant to your letter dated August 10, 2012, the Department of Public Welfare (DPW), Estate Recovery Program, has reviewed the information you provided regarding the above-referenced individual. DPW has determined that there is a claim against this estate. However, invoices have not been paid yet so we are unable to provide the amount of the Department's claim. As soon as we are able to determine the amount of the Department's claim, we will notify you in writing. If you have any questions, please feel free to contact me. Sincerely Y Vince A. PnrtPr Recovery Section Manager (717)772-6604 Fsurnau cr Program Int~agr;ry j Division of Third Party Liability j Recovery Sectie~; F~7 Rox 8486 Harrisbury, Pennsylvania 17105-848(; COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DMSION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG, PA 17705-8486 October 16, 2012 STATEMENT OF CLAIM SUMMARY Estate of MYRICK, NANCY 740 211 294 Page 1 of 2 :--~„ RESIDENT STATEMENT FROM CHURCH OF GOD HOME,:-INC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 NANCY M MYRICK clo .LINDA BALDWIN 12 E. GREEN STREET MECHANICSBURG, PA 17055 ®s ~• B~PN CBANC PNC Baalc, N.A 040 Central PA w~ PAY TO THE ORDER OF STATEMEN Statement Date Due Date ACCOUNT NUMBER 09/30/2012 Upon Receipt 803139 :. ~ ~ $1,1Q8.75 AMOUNT-PAID $ Q ::~ Please-make check payable to CHURCH OF GOD HOME;-lNC Remit To: CHURCH OF GOD HOME,-INC 801 N HANOVER:STREET CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. r:. nlo. /y ``ll 60-1273/313 DATE V LABS ~ ~., ESTATE OF -p% ,~j > ,.~- ~ ., 11 ~ ADM NISTRATOR . __._ __ _._-- FOR - . --- _ - . _ - . ._-- ~ ` PERSONAL ^ ;~ ~ (''~~~ ~ ~~ REPRESENTATIVI /' [~~`~ (-/}- CY7 ~ TRUSTEE x:03 L 3 ~ 2738: 500 3 5 7 7 28 911' RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 AMOUNT PAID $ NANCY M MYRICK c/o LINDA BALDWIN 12 E. GREEN STREET MECHANICSBURG, PA 17055 Comments Statement Date Due Date ACCOUNT NUMBER 01/31/2013 Upon Receipt 803139 00 Please make check payable to CHURCH OF GOD HOME, INC Remit To: CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. $0.00 $4.00 $0.00 $0.00 --- ------ ---- ---- _ $0.00 $4.00 - +,.~ k r~ +Y.- - M~ :~ 4-?i~`' ~ Pay C~8~ 08/01/12 - 08/04/12 Patient Liability $4.00 `$4.00 TOTAL BALANCE DUE: $4.00 FACILITY NAME RESIDENT NAME CHURCH OF GOD HOME, INC NANCY M MYRICK ACCOUNT NUMBER 803139