HomeMy WebLinkAbout04-0710PETITION FOR PROBATE and GRANT OF LETTERS
Estate of' An~ ~.:
also known as A~
No. 2 -o%--11o
Social Security No. ;~ o I ~ ~ ~ · D. '~ 21.~ceased'
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the executSt"
in the last will of the above decedent, dated AJ o ~ <-,~. ~ ~
and codicil(s) dated
To:
Register of Wills for the
County of ~ in the
Commonwealth of Pennsylvania
named
,19 /oC~
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in (_ut n,~ [~ ~.~ [~t~t~{
he.r- ]~st famil~ or principal residence at ~o~ t,~r-°cz.o:lt,~
(list street, number and muncipality)
Decendent, then ~ ye~s of age, died ~ ~ ~ , ~ ZOO ~
Except as fofiows, decedent d~d not marry, was not ~vorced 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: ~ 0...
County, Pennsylvania, with
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $ ~., 000
(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 request(s) the probate of the~ willY, nd cold'ices)
presented herewith and the grant of letters -'/'~.a~ a,'~.~a-,t ~ ~ ~ ; q~
(testamenta~; admin strut on c t ~; admiMst on d b fi'~Ai:a )
theron. "-~ ~ ''., ~'
, ~
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~
COUNTY OF ~_~-.~c~e~,~.J~ s~
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.
,Swoorn to .or aftf~m~and subscribed
oe~orexme t~is ~i~,L~ ~ day of J
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW Q~'~'~- c ~(~ ~[~(''3L~ ~, . in consideration of the PetitiOn°n
· e reverse side ~eof, sat~facto~ proof having been presented before me,
IT IS DEC~ED that the inst~ment(s) dated ~c3X~ 0 ~ ~
descried therein be a~mitted to vrobate and filed of record as the last will of
FEES
Probate, Letters, Etc ..........
Short Certificates( ) ..........
TOTAL
Filed ~1' 3 O- .~. ..............
ATTORNEY (Sup. CL I.D. No.)
ADDRESS
PHONE
__ ~ ~egister of ~iI1~ of CumberIanl~ Caunt¥
Estate of
Also known as
OATH OF NON-SUBSCRIBING WITNESS
,Deceased
(each) a subscriber hereto, (each) being duly qualified ac,cording to law, depose(s) and say(s) that
(one of~he subscrib/ng wimesses to) the codicil/Mil presented herewith and that .. believes
the signature on the codicil/will is in the handwriting of (.'~ e~_ ~, ~dA ~
,~to the be~:pf ~ knowledge and beliefi
Sworn to or affirmed and subscribed
Before me this ~ d~.~o f
For the Register ~ t'- 0C- (~oq' "~
(Address)
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Of{ice for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
P 8206589
No.
Local Registrar
nAY 0 $ 2002
CERTIFICATE OF DEATH -,,.I
76 v~ :
Cumberland
,,, Housewi fa
"' m Whlte
~. . (,,. I,,. ' .... Uflk ....... h~ Married h,. Edwin
603 Wertzville Road ~-~,m'~'~=~' ~,~
,,. Eenr~ Reichert ,,. Kathryn Cooper
~.603 Wertzville Rd. oEnola. Pa 1702~
....~-0 o~.~ O,,~May 8, 2002
· ,,. . ,~tone. Church Cemetery ,~ilver. Spring Twp,Pa
~$UCN
011897-L
Enoll
L~ W~LL ~D TEET~TT
~ ~L~BRT~ GI~-~
I, ANN ELIZABETH GIVLER, residing in Enola, Ctumberland County,
Pennsylvania, being of sound and disposing mind, memory and under-
standing, do hereby make, publish and declare this as and for my
Last Will and Testament, hereby revoking any and all Wills and/or
Codicils heretofore made by me.
FIRST: I hereby direct my Executor hereinafter named to
pay my just debts and funeral expenses and expenses of my last
illness as soon after ray death as can conveniently be done.
SECOND: I give, devise and bequeath all of the rest and
remainder of my estate, both real and personal, of whatsoever
kind and character, and wheresoever situated, to my husband, Edwin
George Givler, to be his absolutely.
THIRD: I nominate and appoint my husband, Edwin George
Givler, to be Executor of this my Last Will and Testament. If he
shall predecease me or for any reason car~uot act as Executor, then
I nominate and appoint Dauphin Deposit Trust Company to be Executor.
FOURTH: In the event that my said husband, Edwin George
Givler, shall predecease me, then I hereby give, devise and bequeath
the whole of my estate, both real and personal, of whatsoever kind
and character, and wheresoever situated, to my children, Gary Wayne
Givler and Ailsa Kay Givler, share and share alike. In the event
that my children, or either of them, are minors at the time of my
decease, then I hereby appoint as guardian of the persons and
estates of said minors my husband's brother, Gilbert Wayne Givler,
of Mounted Route Enola, Cumberland County, Pe~sy.~vania.
IN WITNESS WHEREOF, I have herettuto set my hand ~ seal
this
day of November, 1969.
T~tatrix
The foregoing instrument, consisting of two (2)
pages, was signed and subscribed by the said ANN ELIZABETH GIVLER
in the presence of us, both present at the s~rae time, and was
at the tLme of her so subscribing the same, acknowledged and
declared by her to us to be her LAST WILL AND TESTAM~T, and
thereupon we, at her request and in her presence and in the presence
of each other, subscribed ou~ n~mes as witnesses thereto.
- 2 -
POWER OF ATTORNEY
OF
EDWIN G. GIVLER
NOTICE
0
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE
PERSON YOU DESIGNATE (Your "Agent") BROAD POWERS TO HANDLE
YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR
OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY
WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU.
THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON
YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS
ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR
YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF
ATTORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME
INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF
THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT
ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR
AGENT'S FUNDS.
A COURT CAN TAKE AWAY THE POWERS FROM YOUR AGENT IF
IT FINDS YOUR AGENT IS NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF
ATTORNEY ARE EXPLAINED MORE FULLY IN 20 Pa. C.S. Ch. 56.
IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN
CHOOSING TO EXPLAIN IT TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE
UNDERSTAND ITS CONTENTS.
EDWIN G. GIVLER
AND I
KNOW ALL PERSONS BY THESE PRESENTS, that I, Edwin G. Givler
of 603 Wertzville Road, Enola, Pennsylvania 17025, have made, constituted and
appointed and do hereby make, constitute and appoint my daughter, Ailsa K.
Wilson, of 504 Wertzville Road, Enola, Pennsylvania 17025, and my son, Gary W.
Givler, 2 Helen Street, Enola, Pennsylvania 17025, as my true and lawful co-
agents. My agents may, for me and in my name and on my behalf, do and perform
all matters things, transact all business, make, execute and acknowledge all
contracts, orders, deeds, writings, assurances and instruments which may be
requisite or proper to effectuate any matter or thing appertaining or belonging to
me, without limitation:
I. the right to make gifts,
II. to create a trust for my benefit,
III. to make additions to an existing trust for my benefit,
IV. to claim an elective share of the estate of my deceased spouse,
V. to disclaim any interest in property,
2
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.
XIV.
XV.
XVI.
XVII.
XVIII.
XIX.
XX.
XXI.
XXII.
to renounce fiduciary positions,
to withdraw and receive the income or corpus of a trust,
to sell or transfer ownership of insurance policies on my life,
to represent me in all matters involving federal, state, and local taxes,
to engage in real property transactions,
to engage in tangible personal property transactions,
to engage in stock, bond and other securities transactions,
to engage in commodity and option transactions,
to engage in banking and financial transactions,
to borrow money,
to enter safe deposit boxes,
to engage in insurance transactions,
to engage in retirement plan transactions,
to handle interest in estates and trusts,
to pursue claims and litigation,
to receive government benefits, and
to make an anatomical gift of all or part of my body,
with the same powers, and to all intents and purposes with the same validity as I
could, if permanently present; hereby ratifying and confirming whatsoever my
agent shall and may do, by virtue hereof.
This Power of Attorney shall not be affected by any disability on my behalf,
including the event that I become incompetent to handle my affairs.
In the event that legal proceedings concerning my incapacity within the
meaning of Chapter 54 of the Pennsylvania Probate, Estates and Fiduciaries Code,
or for the appointment of a guardian of my estate and/or person are commenced, I
nominate the agent appointed by this Power of Attorney for consideration by the
court having jurisdiction of those proceedings for appointment as the guardian of
my estate and/or persons, and I request the court to make its appointment in
accordance with this nomination, except for good cause or disqualification.
My agents may delegate any one or more powers granted herein to one or
more persons and on such terms as the agent may designate and specify.
IN WITNESS WHEREOF, and intending to be legally bound hereby, I have
hereunto set my hand and seal this
qESS:
-$ day of ,2002.
EDWIN G. GIVLER
4
ACKNOWLEDGMENT
I, Ailsa K. Wilson, have read the attached Power of Attorney and am in the
person identified as the co-agent for the principal. I hereby acknowledge that in
the absence of a specific provision to the contrary in the Power of Attorney or in
20 Pa. C.S. when I act as agent:
1. I shall exercise the powers for the benefit of the principal.
2. I shall keep the assets of the principal separate from my assets.
3. I shall exercise reasonable caution and prudence.
4. I shall keep a full and accurate record of all actions,
disbursements on behalf of the principal.
receipts, and
AILSA K. WILSON
ACKNOWLEDGMENT
I, Gary W. Givler, have read the attached Power of Attorney and am in the
person identified as the co-agent for the principal. I hereby acknowledge that in
the absence of a specific provision to the contrary in the Power of Attorney or in
20 Pa. C.S. when I act as agent:
DATE:
1. I shall exercise the powers for the benefit of the principal.
2. I shall keep the assets of the principal separate bom my assets.
3. I shall exercise reasonable caution and prudence.
4. I shall keep a full and accurate record of all
disbursements on behalf of the principal.
actions, receipts, and
6
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
On this, the t c>~ day of . .~TX.x~ ,2002, before me, the undersigned
officer, personally appeared Edwin G. Givler, who being duly sworn according to
law, deposes and says that the foregoing Power of Attorney is his act and deed and
that he desires the same to be recorded as such.
1N WITNESS WHEREOF, I hereto set my hand and notarial seal the day
and year aforesaid.
(SEAL)
BARBARA STUMP, Notagt Public
Camp Hill Bom, Cumbe~and County
My Commission Expires:
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 11/01/2004
WILSON AILSA KAY AGENT FOR
504 WERTZVILLE RD
ENOLA, PA 17025
RE: Estate of GIVLER ANN E
File Number: 2004-00710
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of Wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 11/09/2004
Your prompt attention to this matter will be appreciated.
Thank You.
CC:
File
Counsel
Judge
GLENDA FARNER STKASBAUGH
Clerk of the Orphans' Court
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 11/01/2004
GIVLER EDWIN G
RE: Estate of GIVLER ANN E
File Number: 2004-00710
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPH~NS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of Wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 11/09/2004
Your prompt attention to this matter will be appreciated.
Thank You.
cc:
File
Counsel
Judge
GLENDA FARNER STRASBAUGH
Clerk of the Orphans' Court
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 11/01/2004
GIVLER GARY W AGENT FOR
603 WERTZVILLE RD
ENOLA, PA 17025
RE: Estate of GIVLER ANN E
File Number: 2004-00710
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of Wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 11/09/2004
Your prompt attention to this matter will be appreciated.
Thank You.
cc:
File
Counsel
Judge
GLENDA FARNER STRASBAUGH
Clerk of the Orphans' Court
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 11/01/2004
GIVLER EDWIN G
RE: Estate of GIVLER ANN E
File Number: 2004-00710
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPH3~NS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of Wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 11/09/2004
Your prompt attention to this matter will be appreciated.
Thank You.
CC:
File
Counsel
Judge
GLENDA FARNER STP~ASBAUGH
Clerk of the Orphans' Court
JRD/June 30, 1992/17858
DECO6?o!?
In Re: Estate of Ann E. Givler
Late of East Pennsboro Township
Estate No.: 21-04-0710
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 21-2004-0710
NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT
ORPHANS' COURT RULE
Personal Representative: Ailsa Kay Wilson And Gary W. Givler, Agents for Edwin G.
Givler
Counsel for Personal Representative:
Date of Grant of Original Letters: 07-30-2004
Date of Delinquency Notice: 11-09-2004
The undersigned, Glenda Farner-Strasbaugh, Clerk of the Orphans' Court, in accordance
with Rule 5.6, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court
Division, Court of Common Pleas of Cumberland County, that neither the above named personal
representative nor the above named counsel for the personal representative have filed with the
Register of Wills or Clerk of the Orphans' Court his, her or its certification required by Rule
5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e),
Supreme Court Orphans' Court Rules, was given by the Clerk of the Orphans' Court on
November 9, 2004, and that the ten (I 0) day notice to file the certification has expired.
Accordingly, in accordance with Rule 5.6(e) the Court is hereby notified of such delinquency
and the undersigned requests that a Court conduct a hearing to determine whether sanctions
should be imposed upon the delinquent personal representative or counsel for the delinquent
personal representative.
Date: 12-06-2004
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
A hearing is scheduled for at in Courtroom No. 3. If the Certification of Notice is
filed prior to the hearing date, the hearing will automaticallybe c~el~d~l
G eorg(E .~)ffe~/U .~.-/~/~qJ/J~t~ ,, ~:
JRD/June 30, 1992/17858
DEC 0 6
In Re: Estate of Ann E. Givler
Late of East Pennsboro Township
Estate No.: 21-04-0710
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 21-2004-0710
NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT
ORPHANS' COURT RULE
Personal Representative: Ailsa Kay Wilson And Gary W. Givler, Agents for Edwin G.
Givler
Counsel for Personal Representative:
Date of Grant of Original Letters: 07-30-2004
Date of Delinquency Notice: 11-09-2004
The undersigned, Glenda Famer-Strasbaugh, Clerk of the Orphans' Court, in accordance
with Rule 5.6, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court
Division, Court of Common Pleas of Cumberland County, that neither the above named personal
representative nor the above named counsel for the personal representative have filed with the
Register of Wills or Clerk of the Orphans' Court his, her or its certification required by Rule
5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e),
Supreme Court Orphans' Court Rules, was given by the Clerk of the Orphans' Court on
November 9, 2004, and that the ten (10) day notice to file the certification has expired.
Accordingly, in accordance with Rule 5.6(e) the Court is hereby notified of such delinquency
and the undersigned requests that a Court conduct a hearing to determine whether sanctions
should be imposed upon the delinquent personal representative or counsel for the delinquent
personal representative.
Date: 12-06-2004
Clerk of the Orphans' Court
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
, ,~ed~,0~, ~h~~ 9,oo~5 q: ~o P~lq
A hearing is scheduled for at in Courtroom No. 3. If the Certification of Notice is
filed prior to the hearing date, the hearing will automatically be~d~i ~ ~
/ll/Fl/
GeorgekE. l~o~fer,vP.I. ~
Name of Decedent:
CERTIFICATION OF NOTICE UNDER RULE 5.6(a~
Will
Admin. No.
To the Register:
I certify that notice of (beneficial interest) ~ required by Rule 5.6(a) of the O~phans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on
Nanle
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
Name
Telephone( )7/7
Capacity: ~ Personal Representative
Counsel for personal representative
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 4/07/2005
WILSON AILSA KAY AGENT FOR
504 WERTZVILLE RD
ENOLA, PA 17025
RE: Estate of GIVLER ANN E
File Number: 2004-00710
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:
5/02/2005
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
b~~~
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
cc: File
Counsel
Judge
~
REV-tWOE)((~]
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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DATE OF DEATH (MM-DD-YEAR) ATE OF BIRjH (MM-DD-YEAR)
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(IF APPLICABLE) SUR IVI G POUSE'S NAME (LAST, FIRST, AND MID LE IN~L)
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D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
OFFICIAL USE ONLY
FILE NUMBER
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COUNTY CODE YEAR
(L -:L LD _
NUMBER
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SOCIAL SECURITY NUMBER
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THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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o 3. Remainder Return (date of deafh prior 10 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (AtlachSch0)
COMPLETE MAILING ADDRESS \\
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D 2. Supplemental Return
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D 7. Decedent Maintained a Living Trust (Attach copy of Trust)
D 10. Spousal Poverty Credit (date ofdealh between 12-31-91 and 1-t-95)
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1. Real Estate (Schedule A)
(1)
(2)
(3)
(4)
(5)
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2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G 0' L)
8. Total Gross Assets (total Lines 1-7)
(7)
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(B)
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(6)
9. Funeral Expenses & Administrative Costs (Schedule H)
(9)
(10)
5.5
(11)
(12)
(13)
(14)
CYtf'O 155
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
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)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x,O_ (15)
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(19)
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16. Amount of Line 14 taxable at lineal rate
x ,0_ (16)
x ,12 (17)
17. Amount of line 14 taxable at sibling rate
18. Amount of line 14 taxable at collaleral rate
x ,15 (1B)
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
I ,"m~_
CITY
I STATE
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
I ZIP
Total Credits (A+ B +C) (2)
3. InteresUPenalty if applicable
D.lnterest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enler the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due.
(SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
~~.;#-~&~,,~~.r.~~;~~~~~o~~~i'~;:,lW.kl~~~~~"151l~~?r~'
-- =",,,,,~:--_._"'=""'~it{"ID'=o'''''~~Jl;
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or.......................................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0
No
o
o
o
o
o
o
o
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
DATE _
t.. -('8 .()..>
, ~
1/C'7.~
DATE
ADDRESS
G tlJ i) I ;)..
d
,..
SIGNATURE OF PREPARER OTHER THAN REPRES
ADDRESS
;,.,., umL~,,~, n - ~r ~;~_ :il" ~'!,wJUF-~ .1\'"':"-:; _~;lI!:;.:!V_~:J_., _.,_~L: :::it'
For dates of death on or after Juiy 1, 1994 and before January 1, 1995, the lax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. {i9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse ~ 0% [72 P.S. {i9116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of dealh on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. {i9116(a)(I.2)].
The lax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(I)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. {i9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent. whether by blood or adoption.
REV-1502 EX+ (6-98)
" '.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
FILE NUMBER
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value 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.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
Nf\PD
:J:Av.g
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV"""".''''',.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
FILE NUMBER
All property jointly~wned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
TOTAL (Also enteron line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
""'l,&J4EX'IIOn..
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSEL Y.HELD CORPORATION,
PARTNERSHIP or SOLE.PROPRIETORSHIP
ESTATE OF
FILE NUMBER
Sdledule C-1 or C-2 (Induding all supporting inlonTlation) must be attached for each dosely-held corporation/partnership interest of the decedent other than a sole-propnetor.;hip.
see instructions for the supporting information to be submitted for sole-proprietorships.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, msert additional sheets of the same size)
~1~"'.". '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C.1
CLOSEL Y.HELD CORPORATE
STOCK INFORMATION REPORT
ESTATE OF
FILE NUMBER
1. Name of Corporation
Address
City
2. Federal Employer I.D. Number
3. Type of Business
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
Zip Code
State
Product/Service
4.
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OFTHE
STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common $
Preferred $
Provide all rights and restrictions pertaining to each class of stock.
5. Was the decedent employed by the Corporation? D Yes D No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? D Yes D No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? DYes D No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years n the date of death was prior to 12-31-1121
D Yes D No If yes, D Transfer D Sale Number of Shares
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
Consideration $
Date
9. Was there a written shareholders agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
Dyes
D No
10. Was the decedent's stock sold? DYes
If yes, provide a copy of the agreement of sale, etc.
II. Was the corporation dissolved or liquidated after the decedent's death? DYes D No
n yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
D No
12. Did the corporation have an interest in other corporations or partnerships? DYes D No
If yes, report the necessary information on a separate sheet, including a Schedule C-I or C-2 for each interest.
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies offtnancial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years.
C. If the corporation owned real estate, submij a list showing the complete address/es and estimated fair market valuels. If real estate appraisals have been
secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
REV-1506EX: (9-0.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF
FilE NUMBER
1_ Name of Partnership
Address
Date Business Commenced
Business Reporting Year
City
Slate
Zip Code
2. Federal Employer 1.0. Number
3. Type of Business
Product/Service
4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $
5.
A.
B.
C.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent? .... _ . . . . . . . . _ . . . . . _ . . . . . . . . . . . .. 0 Yes 0 No
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
DYes DNa
If yes, 0 Transfer 0 Sale
Percenlage transferred/said
Consideration $
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
Date
10. Was there a written partnership agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
11. Was the decedent's partnership interest sold? ................
If yes, provide a copy of the agreement of sale, etc.
DYes DNa
DYes 0 No
12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners?
If yes, explain
.....................__.. DYes DNa
14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedenfs partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax retums (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedenfs partnership interest.
R~V-1507 EX+ (1-97)
....
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
FILE NUMBER
All property iointly~owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
~'~M"'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF r' I /)
\;,.7/ V I J;;;. ,c...
w I
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be di5Closed on Schedule F.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
illJ {lJ
E.
FILE NUMBER
ITEM
NUMBER
1.
DESCRIPTION
/1<<., lJ'IOOD7'80/5 5~"\~J
VJ A-j(?C 'fJ-€; \3 "\0 ~
VALUE AT DATE
OF DEATH
Cf (Jeff!) 65
TOTAL (Also enter on line 5, Recapitulation) $ 9 d 7l:%.55
(If more space IS needed, Insert additional sheets at the same size)
""~EX'(l.n..
COMMONWEALTH OF PENNSYLVAN(A
INHERITANCE TAX. RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
FILE NUMBER
"an aaset waa made joint _in one yeer of the decedenfa date of death, K must be ..ported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
B.
c.
JOINTLY-OWNED PROPERTY:
LmER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name offinancial institution and bank account number or similar identifying number. A~h DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT cleedforjointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV""EX",.n.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON.PROBATE PROPERTY
ESTATE OF
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OF THE TRANSfERt:E. THEIR RELATIONSliIP TO DECEDENT MID THE DATE OF TRANSFER DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
ATTACHACOPVOF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLiCABlE)
NUMBER
1,
TOTAl (Also enter on line 7. Recapitulation) $
..
(If more space IS needed. Insert additional sheets of the same size)
'EV''''J'''.'''''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE HUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representa1Ne's Commissions
Name of Personal Representative (5)
Sodal Security Numbe~s) I EIN Numberof PelSonal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
''''''''''''''''''.
COMMONWEALTH OF PENNSYLVANtA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
DESCRIPTION
AMOUNT
TOTAL (Also enter on line 10, Recapitulation) $
(If more space IS needed, Insert additIOnal sheets of the same siZe)
REV-1513 EX+ 19-00.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON IS) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 I') 11.2)]
1.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
,.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-150D COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
REV1514"'I~<n.
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on Rev.1500 Cover Sheet
FILE NUMBER
This schedule is to be used for all single life, joint or. successive life estate and term certain calculations. For dates of death
prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5 -1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax retum.
o Will 0 Intervivos Deed of Trust 0 Other
....I.IFESS'tATEINtERES'1'.CAI.CU!.AlICJN
NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS
LIFE TENANTfSl DATE OF BIRTH DATE OF DEATH PAYABLE
D Life or D Term 01 Years
DLifeorDTermolYears _
D Life or D Term olYears
D Life or D Term olYears
1. Value of fund from which life estate is payable $
2. Actuarial factor per appropriate table
Interest table rate - 0 3 1/2% 0 6% 0 10% 0 Variable Rate %
3. Value of life estate (Line 1 multiplied by Line 2) $
.......... ....~~tlAl..ClQl.A._.i.
NAME(S) OF NEAREST AGE AT TERM OF YEARS
ANNUITANTfSl DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE
D Lileor DTerm of Years _
DLileorDTermolYears _
D Lileor DTerm 01 Years _
D LileorD Term 01 Years
1. Value of fund from which annuity is payable
2. Check appropriate block below and enter corresponding (number)
Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26)
o Quarterly (4) 0 Semi-annually (2) 0 Annually (1)
3. Amount of payout per period
4. Aggregate annual payment, Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate 031/2% 06% 010% 0 Variable Rate
6. Adjustment Factor (see instructions)
7. Value ofannuity -If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period,
calculation is : Line 4 x Line 5 x Line 6
If using variable rate and period payout is at beginning of period, calculation is :
(Line 4 x Line 5 x Line 6) + Line 3 $
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on
Schedules A through G of this tax retum. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on
Lines 13, 15, 16 and 17.
$
o Monthly (12)
D Other ( )
$
%
$
(II more space is needed. insert additional sheets of the same size)
REV.I6M EX+ (3-84)
. INHERITANCE TAX
SCHEDULE "L"
COMMONWEALTH OF PENNSYlVANIA REMAINDER PREPAYMENT OR INVASION
INHERITANCE TAX RETURN
RESIDENT DECEDENT OF TRUST PRINCIPAL FILE NUMBER
I. Estate of
(lost Nome) (First Name) (Middle Initial)
This schedule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions
of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal.
II. Remainder Prepayment:
A. Election to prepay filed with the Register of Wills on (Date)
(attach copy of election)
B. Nome(s) of Life T enantls) Date of Birth Age on date Term of years income
or Annuitant!s) of election or annuity is payable
e. Assets: Complete Schedule L.l
1. Real Estate S
2. Stocks and Bonds S
3. Closely Held Stock/Partnership S
4. Mortgages and Notes S
5. Cash/Misc. Personal Property S
6. Total from Schedule L-l S
D. Credits: Complete Schedule L-2
1. Unpaid Liabilities S
2. Unpaid Bequests S
3. Value of Unincludable Assets S
4. Total from Schedule L-2 S
E. Total value of trust assets (Line C-6 minus Line 0-4) S
~
F. Remainder factor (see Table I or Table II in Instruction Booklet)
G. Taxable Remainder value (Line E x Line F) S
(Also enter on Line 7, RecaDitulation)
III. Invasion of Corpus:
A. Invasion of corpus (Month, Day, Year)
B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income
or Annuitant(s) corpus consumed or annuity is payable
e. Corpus consumed S
D. Remainder factor (see Table I or Table II in Instruction Booklet) S
E. Taxable value of corpus consumed (Line C x Line D) S
(Also enter an Line 7, Recapitulation)
REV-1646 EX+ (3-84) INHERITANCE TAX
*
SCHEDULE L-2
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -CREDITS- FilE NUMBER
.. Estate of
(Last Name) (First Name) (Middle Initial)
II. Item No. Description Amount
A. Unpaid liabilities Claimed against Original Estate, and payable Iram assets
reported on Schedule L- 1 (please list)
Total unpaid liabilities S
(include on Section II, line 0-1 on Schedule l)
B. Unpaid Bequests payable Irom assets reported on Schedule L-l (please list)
Total unpaid bequests S
(include on Section II, line 0-2 on Schedule L)
C. Value 01 assets reported on Schedule L-l (other than unpaid bequests listed under
"B" above) that are not included for tax purposes or that do not form a part
01 the trust.
Computation as follows:
Total unincludable assets S
(include on Section II, line 0-3 on Schedule L)
III. TOTAL (Also enter on Section II, line 0-4 on Schedule L) S
(II more space is needed, attach additional 8Y, x 11 sheets.)
~""7EX'(1"'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
ESTATE OF
Check Box 4a on Rev.1500 Cover Sheet
FILE NUMBER
This schedule is appropriate only for estates of decedents dying after December 12, 1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession
and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
o Will 0 Trust 0 Other
I. Beneficiaries
NAME OF AGE TO
BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months
of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such
withdrawal right
o Unlimited right of withdrawal o Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amount of Future Interest $
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) $
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One 06%.03%, 0 0%
(also include as part of total shown on Line 15 of Cover Sheet) $
4. Value of Line 1 Taxable at 6% Rate
(also inciude as part of total shown on Line 16 of Cover Sheet) $
5. Value of Line 1 Taxable at 15% Rate
(also include as part oflotal shown on Line 17 of Cover Sheet) $
6. Totai value of Future Interest (sum of Lines 2 thru 5 must equal Line1) $
..
(If more space IS needed, Insert additional sheets of the same size)
REV-1648 fX 11-92) ..
COMMONWEALTH OF PENNSYlANIA
INHERITANCE TAX DIVISION
ESTATE OF
SCHEDULE N
SPOUSAL POVERTY CREDIT
AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91)
I FilE NUMBER
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
PART I - CALCULATION OF GROSS ESTATE
1. Taxable Assets total from line 8 (cover sheet) .........._......_.........................................h....... 1.
2. Insurance Proceeds on life of Decedent ............................................................................ 2.
3. Retirement Benefits........ ..... .......... .... ......... ....... ....... ....... ...'.... ..... .......... ..... .......... ..... ..... 3.
A. Joint Assets with Spouse ......................................__......................................................... 4.
5. PA lottery Winnings ........ ............... ..... .......... ..... ........ ....... ....... ........ ....... ..... ........... ...... 5.
6b_
60. Other Nontaxable Assets: list (Attach schedule if necessary).. 60.
6c.
6d.
6. SUBTOTAL (lines 6a, b, c, d) ... ..................................................................................... 6.
7. Tatal Grass Assets (Add lines 1 thru 6)...___............_.......................................................... 7_
8. Total Actual liabilities ........ ..... .......... ..... .......... ..... ......... ...... ....... ........ ........ ....... ........ .... 8.
9_ Net Value al Estate (Subtract line 8 Iram line 7).........._.......___..___......____...___....._......___....... 9.
If line 9 is greater than $200,000. STOP. The estate is not eligible to claim the credit. If not, continue to Pori 1/.
PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies af Federal Individual Income
Tax Returns for decedent and spouse.)
Income: 1. TAX YEAR: 19 2_ TAX YEAR: 19 3. TAX YEAR: 19
a. Spouse ..... ...... ... ........ 1a. 2a. 3a.
b. Decedent ................... lb. 2b. 3b.
c. Joint .......................... 1c. 2c. 3c.
d_ Tax Exempt Income..... ld. 2d_ 3d.
e. Other I ncome not
listed above ........... le_ 2e. 3e.
I. Total.......................... 11. 21. 31.
4. Average Joint Exemption Income Calculation
40. Add Joint Exemption Income from above:
(11)
+ (21)
+ (31)
=
(+ 3)
4b. Average Joint Exemption Income ..................................................................................... =
If line 4(bJ is greater than $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Port III.
PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT
ESTATES
1. Insert amount of taxable transfers to spouse or $100,000, whichever is less.......................... 1.
2. Multiply by credit percentage lsee instructions) .................................................................. 2.
3. This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ............................................ 3.
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate...... .................................................................. ......................... 4.
5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. 5.
~'~~'I"n *'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE 0
ELECTION UNDER SEC. 9113(A)
SPOUSAL DISTRIBUTIONS
FILE NUMBER
Do not complete this schedule unless the estate Is making the election to tax assets under Section 9113(A) 01 the Inheritance & Estate Tax Act.
if the eiection applies to more than one trust or similar arrangement, a separate form must be filed for each trust.
This election applies to the Trust (mantal, residual A, B, By-pass, Unified Credit, etc.).
If a trust or similar arrangement meets the requirements of Section 9113(A), and:
a. The trust or similar arrangement is listed on Schedule 0, and
b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,
then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or
similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the
personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to
the amount ot the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's
survivin souse under a Section 9113 A trust or similar arran emen!.
DESCRIPTION VALUE
Part A Total $
PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made.
DESCRIPTION VALUE
Part B Total
(II more space is needed, insert additional sheets of the same size)
Register of Wills of Cumberland County
STATUS REPORT UNDER RULE 6.12
Name of Decedent: At,.l' 1=. G, u(C /G
Date of Death: jC-~ ;) ~ t' g..,
Estate No.: ~ /... t!J ~ t!:-'f(' D
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 whether administration of the estate is complete:
Yes W No 0
2. If the answer is No, state when the personal representative reasonably believes that
the administration will be complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes B-No 0
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the person~ r~sentative state an account informally to the parties in
interest? Yes ~ No 0
c. Copies of receipts, releases, joinders and approval of formal
accounts may be filed with the Cle k of . e Orphans' C
attached to this report. '
r--
Date: &....l'3 L (Il .)
Signa e
~4a~ W ~\U\~tt-
Name
_{~O"3 Li)J2I6"'~\<'(.~ ~
A~t1/~ 1/4- (7c!J 'U.)-
7(/- '>32. . $'/70
~phone No.
, Capacity: ~onal Representative
o Counsel for personal representative
informal
d ma be
V ~Jd )
t"" t-
~
u:A
Inre:
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
ESTATE OF RUSSELL G.
ERNEST, DECEASED
: NO. 2004-0909
: ORPHAN'S COURT DIVISION
INVENTORY
Willliam S. Moyer, being duly sworn according to law, deposes and says that he is
Executor of the Estate of Russell G. Ernest late of West Pennsboro Township,
Cumberland County, Pennsylvania, deceased and that the within is an inventory made by
him, the said assets of the entire estate of said decedent, consisting of all the personal
property, and that the figures opposite each item of the Inventory represent it's fair value
as of the date of decedent's death and that the decedent owned no real estate at the time of
death.
~ -;/ ~~~
William S. Moyer, Executor
Date of Death: September 13,2004
Social Security No.: 193-18-2726
c
c~_."
:-1
John D. Killian, Esquire
Attorney I.D. No. 7068
Killian & Gephart
218 Pine Street
Harrisburg, PAl 710 I
.~.,.
C/',
Telephone: 717-232-1851
Estate of Russell G. Ernest
Estate Inventory
Valued as of Date of Death
Cash & Cash Equivalents
Better Homes & Gardens Mag.
Cash
$
19.00
33,000.00
Farmers National Bank Checking
Act. #183-997
Interest at Date of Death
FNB - Matilda Ernest
1,841.85
0.24
966.50
1,548.10
43.16
68,922.96
23.93
Green Ridge Village
Ladies Home Journal Mag
Merrill Lynch Bank Deposit
Interest at Date of Death
Merrill Lynch Retirement Money
Market
Interest at Date of Death
Westernbank of Puerto Rico CD
Interest at Date of Death
31,002.42
10.87
176.93
265.00
35.06
25.30
4.67
47,841.50
84.65
Money Magazine
PA Department of Revenue
Reader's Digest
Smithsonian Magazine
Verizon Wireless
Total Cash & Cash Equivalents
$
185,812.14
No. of
Shares
Stocks
7,051
438
Exxon Mobil
$
335,098.78
20,509.35
179.58
PPL Corp
Dividend at Date of Death
Total Stocks
355,787.71
Page 1
(1 )
Estate Inventory
Par
Value Bonds, Debentures & T-Bills
22,000 Bell Atlantic Corp Debentures $ 21,750.30
Interest at Date of Death 528.53
20,000 Coco Cola Enterprises Inc. 25,238.20
Interest at Date of Death 791.23
34,000 Cocoa Cola Enterprises Inc. 44,583.52
Interest at Date of Death 344.83
26,000 Columbia Gas Systems
Notes Ser-G 27,664.00
Interest at Date of Death 566.84
70,000 Commonwealth Edison Notes 71,856.40
Interest at Date of Death 479.79
111,000 FHLMC 17 0164 547.00
Interest at Date of Death 3.75
50,000 FHLMC 17 0170 232.29
Interest at Date of Death 1.52
72,000 FHLMC 17 0181 610.00
Interest at Date of Death 4.16
10,000 FHLMC 45 0077 2,801.01
Interest at Date of Death 17.77
25,000 FHLMC 54 6548 178.00
Interest at Date of Death 1.12
1,900 Fleet Capital Trust VIII 50,255.00
Interest at Date of Death 836.41
38,000 Fleet Financial Group
Debentures 41,412.78
Interest at Date of Death 410.64
60,000 General Motors 63,648.00
Interest at Date of Death 696.77
35,000 GNM P035021 232.00
Interest at Date of Death 1.50
Page 2
(2)
Estate Inventory
Par
Value Bonds, Debentures & T-Bills
45,000 GNM P037350 $ 1,830.00
Interest at Date of Death 12.53
40,000 GNM P037400 584.00
Interest at Date of Death 4.65
25,000 GNM P041945 152.00
Interest at Date of Death 1.19
55,000 GNM P042049 719.00
Interest at Date of Death 5.58
75,000 GNM P126101 896.00
Interest at Date of Death 7.32
25,000 GNM P189958 268.00
Interest at Date of Death 1.77
100,000 GNM P353859 2,021.00
Interest at Date of Death 11.54
62,592 GNM P392291 2,330.00
Interest at Date of Death 23.11
50,000 GNM P417770 2,193.89
Interest at Date of Death 13.69
108,465 GNM P447202 10,933.00
Interest at Date of Death 64.09
90,103 GNM P485540 6,363.00
Interest at Date of Death 32.50
50,000 GNM P518088 4,998.00
Interest at Date of Death 28.56
35,000 GNM P525469 780.00
Interest at Date of Death 4.24
40,000 GNM P557484 8,654.00
Interest at Date of Death 49.11
65,184 GNM P563345 11,134.00
Interest at Date of Death 53.41
Page 3
(3)
Estate Inventory
Par
Value Bonds, Debentures & T-Bills
60,000 GNM P587223 $ 25,471.00
Interest at Date of Death 116.90
2,000 Harris Preferred Cap Cor
Non-Cum Exch Pfd Ser A 50,500.00
Interest at Date of Death 130.27
50,000 Hertz Corp 47,574.00
Interest at Date of Death 564.51
70,000 NM Household Fin Corp BE 70,131.60
Interest at Date of Death 349.25
60,000 Hydro Quebec Debentures 80,366.40
Interest at Date of Death 812.90
37,000 JP Morgan Cap Trust 40,499.46
Interest at Date of Death 449.97
1,900 JP Morgan Chase Cap X 50,103.00
Interest at Date of Death 252.99
100,000 NM Bk of America Corp
Sbnt Ser Notz 99,011.00
Interest at Date of Death 1,443.28
65,000 NM Bk of NY Co Inc 63,799.45
Interest at Date of Death 857.02
62,000 NM Caterpillar Fin Serv 61,477.96
Interest at Date of Death 550.00
45,000 NM General Elec Cap Corp BE 45,714.60
Interest at Date of Death 638.47
50,000 NM Marshall & Isley BE 49,128.50
Interest at Date of Death 959.27
4,300 Tenn Valley Authority 107,930.00
Interest at Date of Death 226.03
55,000 us Treasury Bond 60,446.10
Interest at Date of Death 401.97
Page 4
(4)
Estate Inventory
Par
Value Bonds, Debentures & T -Bills
100,000 US Treasury Note $ 100,996.00
Interest at Date of Death 2,582.96
Total Bonds, Debentures & T-Bills $ 1,373,347.40
Tangible Personal Property
Automobile - Toyota $ 21,000.00
Total Tangible Personal Property 21,000.00
Total Inventory $ 1,935,947.25
Page 5
(5)
Estate No.: 21-04-00710
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
Estate of GIVLER ANN E
Late of EAST PENNSBORO TOWNSHIP
Date:
6/10/2005
NO.: 21-04-00710
GIVLER GARY W AGENT FOR
603 WERTZVILLE RD
ENOLA PA 17025
NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 6. 12, SUPREME COURT ORPHANS' COURT RULE
Personal Representative: GIVLER GARY W AGENT FOR
Personal Representative Counsel: ** NO INFORMATION FOUND **
Date of Decedent's Death: 5/02/2002
Date of Delinquency Notice: 5/02/2005
The undersigned, Glenda Farner Strasbaugh, Clerk of Orhans'
Court, in accordance with rule 6.12, Supreme Court Orphans' Court
Rules, hereby notifies the Orphans' Court Division, Court of Common
Pleas of Cumberland County, that neither the above named personal
representative nor their counsel, have filed with the Register of
wills or Clerk of Orphans' Court, his/her Status Report required by
Rule 6.12, Supreme Court Orphans' Court Rule, and that the
requisite notice, pursuant to Rule 6.12, Supreme Court Orhans'
Court Rules, was given by the Clerk of Orphans' Court on 4/07/2005
and that the ten (10) day notice to file the status report has
expired. Accordingly, in accordance with Rule 6.12 the Court is
hereby notified of such delinquency and the undersigned requests
that a Court conduct a hearing to determine whether sanctions
should be imposed upon the delinquent personal representative or
their counsel. ~~~
cc: File
Personal Representative
Counsel
Glenda Farner Strasbaugh
Clerk of Orhans' Court
A hearing is scheduled for July 08, 2005 at 9:30 AM In
Courtroom No. 03. If the Status Report is filed prior to the
hearing date, the hearing will automatically be cancelled.
i/../M. 1 A A&r\
GeOrglEf/lKX'~.J. ,
uR
CERTIFICATION OF NOTICE UNDER RUJ,E 5.6!al
Name of Decedent:
q tiP /..r
/::;,
a." ,,( e.L
,,~:J
Date of Death: /11/1 r
Will No. ::/I...C''f ..('\110
,;z
Admin. No.
To the Register:
I certify th.t notice of (beneficial interest) estate administration required by Rule 5.6(.) of the Orphans' Court RuJes was
served on or mailed to the following beneficiaries of the .bove-captioned estate on
~
b1tHffD ~.~ruletL
Address
~ t. v.p.6T~IIf., tJ F~jj- (70 1.S""
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
{("-/3~~S-
(~
'In:)
i,__~:J d:l -,I I
f'li\Pc{IJr1,t.lO
0,1,. ,~,o
""'Tin
;JlJ J
Name 6A~)
Address~..3 u\el~r~\((~
EudA Rt-
f
Telephone ()I? '7'P b
LV ~"1\Y(GIt
~
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Capacity: /'Personal Representative
Ie
C' I nor' ~nn7
u j 1"\ ,I ..\JVv
_Counsel for personal representative
.7-
08-29-2005
GIVLER
05-02-2002
21 04-0710
CUMBERLAND
101
APPEAL DATE: 10-28-2005
( See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE _ RETAIN LOWER PORTION FOR YOUR RECORDS -
REY:is4;-Ex-AFP-io3:osl-NOTICE-PF-INHERITANCE-TAX-APPRAIsEHENT:-ALLowANCE-OR---------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ANN E FILE NO. 21 04-0710 ACN 101
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
.nr::r.D_':."'Cn' r.rr-["r- rr- NOTICE OF INHERITANCE TAX
BUREAU OF INDIVIDUAlt1il'lll!JRVLj ur~,vt ,_fAPPRAISEHENT, ALLOWANCE OR DISALLDMANCE
INHERITANCE TAX DIVISION .'- ~- . ,', OF DEDUCTIONS AND ASSESSMENT OF TAX
pO BOX za06Dl - - i '-,
HARRISBURG PA 171Z8-0601
2D05 t~L'S 30 Pl,j !i: 22
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
Ie
""';
Or-~-
"1""--
I: '
GARY W G[V.lE~
603 WERTZVILLE RD
ENOLA PA
17025
ESTATE OF
GIVLER
'*
REY-lS47 EX AFP (06-95)
ANN
E
TAX RETURN MAS: I X I ACCEPTED AS FILED
I CHANGED
DATE 08-29-2005
I~ an assess.ent was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
r~lect ~igures that include the total o~ ~ returns assessed to date.
ASSESSMENT OF TAX:
15. Aaount of Line 14 at Spousal rat.
16. Amount of Line 14 taxable at Lineal/Class A rat.
17. A.aunt of line 14 at Sibling rat.
18. ABOunt of Line 14 taxable at Collateral/Class Brat.
19. Principal Tax Due
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R..I Est.t. (Schedule Al
2. Stocks and Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
S. Cash/Bank Deposits/l1isc. Personal Propert.y (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Trensiers (Schedule Q)
8. Total Assets
III
121
131
141
IS)
161
171
.00
.00
.00
.00
9.090.55
.00
.00
181
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adn. Costs/Hisc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule X) (10)
ll. Total Deductions
12. Net Value of Tax Return
13. Charitable/Govern.ental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
.00
.00
IllI
U21
U31
U41
NOTE:
USI
Il61
U7I
U81
9,090.50 X
.00 X
.00 X
.00 X
NOTE: To Insure proper
credit to your account I
subnit the upper portion
of thIs for. with your
tax pay_nt.
9,090.55
00
9,090.55
.00
9,090.55
00 =
045 =
12 =
15 =
.00
.00
.00
.00
.00
U91=
TAX CRIl:DITS:
,., AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID I-I
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
~
IF PAID AFTER DATE INDICATED, SEE REVERSE
FDR CALCULATIDN OF ADDITIONAL INTEREST.
IF TDTAL DUE IS LESS THAN $l, ND PAYHENT IS REQUIRED.
IF TDTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FDR INSTRUCTIONS. I