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Home My WebLink About02-1094PETITION FOR PROBATE and GRANT OF LETTERS Estate of Otto 0. Shields Ne. ~~'~~ ~~~ also known as To: Otto Shields Register of Wills for the Deceased. County of Cumberland in the Social Security No. 18 9 -18 - 6 2 7 5 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut r i x named in the last will of the above decedent, dated S~ptembPr 7 , 19 94 and codicil(s) dated ~t~ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumberland County, Pennsylvania, with h i s last family or principal residence at East Old York Road, Carlisle PA 17013 (list street, number and muncipality) Decendent, then $ ~- years of age, died October 2 4 ,~~9 2 0 0 2 , at Carlisle Re~,onal Medical Center Except as follows, decedent did not marry, was not dtvorced and dtd not have a chtld born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at deatri owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Fa.l 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 last will and codicil(s) presented herewith and the grant of letters t e s t ame~t a r y (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. .~~ t~fary A. Shields ~. x ~, c~° ~a .~ ~~ Na 4, ~ o ao 415 East Old York Road Carlisle PA 17013 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OI! C,1r4BERLAND The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best at the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed bef r me this ~~ day of ~~~ Regis er less than $5,000.00 .. -- - ~ A ... cp No. ~/- o~ - ioq~ Estate of OTTO 0 . SHIELDS ,Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW ~~~~ D9 2002 in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated September 7 , 19 9 4 described therein be admitted to probate and filed of record as the last will of Otho 0. Shields and Letters Testamentary are hereby granted to T9 a r y A . Shield s FEES Probate, Letters, Etc.......... $ Short Certificates( ) .......... $ Renunciation ................ $ $ TOTAL $ Filed ................................... Register of Wills t~ Patricia R. i3:~otiTn X27474 ATTORNEY (Sun. Ct. LD. No.) 10 [,lest Pomfret Street Carlisle PA 17013 ADDRESS 717-249-3024 PHONE his is to r_ertii~,~ rh~xt the ini~or(narion here given is correctly copied f~x~m an original certificat~c: or d; z,~ dui tied ~~°tl; (~~e s Local R~ i;lrar. ~? he oll~ina;` ce;titicare will be. forwarded ro the State ~'ical Kecords Office for perrn~~n(.(~tf(,n~,. WARNING: It is illegal to duplicate this copy by photostat ar photogru~~l,. k=,~~ .r(,r this ccrnhcar~, y~.O0 ___ P 87035.43 ~1~. ~'~# ~t Shoe c'~w\', ~~~ ~. 1~bu ss ~~ N 105.. U Rav. Yl87 yNT ENT Nac 1 I (_oca! Rre~,;lrara~ _0 ~T _ 3 ~ 2002 -- 1 ?,i tc' COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH NAME OF DECEDENT IFxg. Miyyla. LaRl SE% S1RE fRE NUMBER SOCIAL SECVRITY NUMBER DATE Of DEATN,M«Vl pry '.dar( ~ +. Otho O. Shields :.Male ,. 189 - 18 - 6275 , , .- October 24, 2002 AGE (Ug exyaayl UNDER , YEAq UNDER 1 DAY DATE OF BIRTH BUTfMPIACE (C.ry aM PLACE OF DEATN ICneCa orM one - +ee ~ngruClpy an alnN sbsl ' MIMIM • Days Moue • MMAw ~MOrun, ~, AMrI Slale «Faegn COUmrYI NOSPITAL: OTNER: June 81 Yro. ~ ~ Irpsliw ~ ERaoulWrism U OOA ^ N'"a"~0 , 1921 echanicsbu P Hama ^ Rouwrln ^ ^ _ . , (SpstMl COUNTY OF DERN CffY, BORO.TWPOF DEATN FACKITY NAME IIIn«inarvlUlgn. SP•e grl!N any naAraCal YMS DECEDEM OF NISPANK; ORIGIN) RACE-Amer•nnrayiarl.BMC%, YRMe art . . No ® w ^ pyss, epaeryCWen, ISbetlrl ' „ Cumberland ~ Carlisle ~ Carlisle Regional Med. Center M.arnrl,PlAMORItan,MC. White .. ,o. DECEDEM'S USUAL OCCUPATION KIND OF BUSINESS/INDUSTRV WAS DECEDENT EVER IN DECEDENT'S EDUCATION MARITµSTATUS-Martiw SURVIVING SPOUSE (Gwe Mnya.«s Don. yaar mog U.S.ARMEO FORCES? n n Ca NMr Hartley. Wamway. of narking Rb; m rlCl ane r aro.l ElMasnMrylSergnyary C«Nqa Diwrc.y (Spa~M Ip M. 9n~ maben runlet Farmer , Own Farm `'~ ~ Ne ^ „~ ,_ ,,. ro n 1,.a«s., „D, T'• +'• R DECEDENT'S MAp Ri ter ING A DR ' . . D ESS ($Ireal. Cirylioax•. Bars. Z9 Ctyel DECEDENT If~7 415 E. Old York Road ACTUAL ,)..sl„. PA S ~ t)e. ,y w. ysteesrr s..y an _ _ R _ M T dd1 t'OR - Il.p. RESIDENCE yacsyerr ~ '~ M•e n a ,. Carlisle PA 17013 °n°"'aiiOej ,,,. Cumberland ) ,,,-^, ~« FATHER'S NAME IFig, Miyyla. Lagl crY+Dao. MOTHER'S NAME (Fig, MgAe. Max1M 5«namel ,.. Jose h K. Shields „- Anna E. Noss INFORMANT'S NAME (TYPa'PrMI INFOFMANT'S MNUNG ADDRESS ISCasI, City/fpwn. $yN. Zip Cpyrl ,D.. Ma R. Shields ~,, 415 E. Old York Road, Carlisle PA 17013 . METNOOOF aSPOSITION GATE OF pSPOSITION PLACE OF dSPOSRION • Nama a Cemetery, Cramabry LOCATgN - Cily/TOwn, Slav, Zip Cow tMa,m. Da~A wr) «aMar PlaC. ® crMwiola^ R.rno.r,rom Sln.^ • ^ Do1rDw^ o « ,,,, „D October 28, 2002 Mt. Zion Cemetery Allen PA 17001 =~~ x,r. ' slaw FUN RVK:ELICENS OR T IK:EHSENUMBER NAME ANDADORESSOFFACILRV Hoffman-Roth Funeral Home ,a ns. - 32e 7 a>My IMrtKyiag my anowNegs, a ttM aloe, yeas ana pan Belay. ~ LICENSE NUMBER p1lyEloMl s rlel avapaeb al «rae «aam ro . any Tieal DATE SIGNED pp IMOrM, ar r/wl • w«yyuu..«e.aln. x,e. \.N .30 7 ~'L rJ zx l Q C. aMl.3a-,e mre a nmpaw Iy TIME aF D ATN ATE P NOUNCED DEAD /Homo, Day. Marl YMS CASE REFERRED Tp MEDICAL E%AMINERICORONER) pwaon •.Ilo proraaAac.. wa,n. oIgfT w ^ Hop ,1. I ~' ~ M. ,S. ~ HY „ ,). -ANT I: Einar tM yiaeawa, iMMes a CdrlpACaliorM a•IaKn nuaW lM Osaln. Do not smar IM moss of yyip, auto a c ac «rospiralay arras, gmtt «MaR la,un. a Apprpamge Lis Cnlyarr nrrw on eacn EM. PART p: filler ~,p MM. ~ aa0nilkalr e«gIC«y iMaNal Dalvroen rlol ~mr h MM urWnyiragcalNa 9i"era is PART 1. MIYE0111TE CAUSE (Fxag i Brunt any abMl °Miaa«COntl"°n ~/SSEY,•[N~}7tD My Al-TEYLJUA,.~. ups CULDStS ~ wIA«q no.glll-- , ~Dl 7f - . u1 I 5 DUE IOIOR ASACONSEOUENCE OF7 /~ NsO LYP °~ /T7,0 ~Ft/,¢ Beal+relwl'rw mrleiliom e. pargt 4r4gmir«npa,e DUE IOIOR ASACONSEOUENCE OF7: r UK~ claw. Enbr UNDERLYNp I - east inesby a« ~y ~ i t DIIE TO (OR AS A GONSEOUENCE OF rwllsrp n ywlnl LAST g a. VMS AN AUTOPSY PERFORMED) WERE AUTOPSY fINaNGS AMULABLE PRM7R TO MANNER OF DEATH DATE OFINJURY TIME OF INJURY INJURY AT VARK) DESCRIBE NOW INJURY OCCURRED COMPLETION OF CAUSE . (Mmm, Dry. Marl OF DEAN) ^ NM«V ® Homitae ^ w ^ No ^ AenyeM Panyig l/I•aallgalien ^ ~p1 w ^ No 1Q arp~p, w ^ No L^J• Suicaa ^ Cna np M yalarmaasy ^ PIACE OF INJURY -N soma hma greN Mao opks M LOCAT , , , ry, KN115treM, CM/TOwI, Slalel EaailQraq, ge. ISpecM) Ms. ,se. ,S. 70e. ,g,. - CEIRIf,ER ICMar orM anal 'CERTIfY1N6 PNYSKIAMIPnyaaSencMAyxp tauwaae.m.a•.n'n«ner MaYacan neapgl«.ntey yearn aro cam«NeO non ),I T e C l SH:NAT E A/NOD TIT OF C~ERT IER ~ o N wt e my krpvrNyga, yeah aaurtsy O,w b tlw uuw(a any manner ae aMIM .................................. ................... ® ~/J 7, `~ '-^ ~ wry" 'PRONOUNCING AND CERTIFYING PNYSN;IAM (PnyNtun taoM «onprntxlg yeatla any <Mdyxq ro tausa a yeaml ' To rN Coat W m %ra0 •ley e m o L NSE NUMBE DATE SK3NEDIMan. Dry, Marl ~ ~~ ~ ~ ~ ~ ~ ~ y • , r g a oeeureae al uro ynw, Oale, any place, any Ow to IM tauae(el ane mMMr as ata1M .......................... ^ ,1C. L`. „G ~ ~ ~ ~ Z NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH • 'MEDICAL EXAMINER/CORONER (Item 271 Typea PnM Q~~G_, f J' w-UJi,~, ~~ /~7 / F..*~af On the Dash oT enmintllon anNa inrestlgation, in my opinion, death xcurrey at,he,lme, date, and place, and due,a the eauae(s) and ^ manner as a,aby .................................................................................... . ~ /3.58 wll TDca/t/ it./J . ............. ,,.. ' ,,. • iLiN ~ 5 ,ti/v 6 S /.4 / 7U o ~ REGISTRAR S SMaNATURE AND DATE flLEDIMOnm.OaY. MMI N. LAST WILL AND TESTAMENT OF OTHO O. SHIELDS I, OTHO O. SHIELDS, of South Middleton Township, Cumberland County, Pennsylvania, being of sound mind and disposing memory and full legal age, hereby make, publish and declare this instrument to be my Last Will and Testament hereby revoking and making all former Wills and Codicils heretofore made by me. ONE: I direct my Executrix to pay all of my debts, funeral and administrative expenses as soon as may be done conveniently after my death. TWO: I direct my Executrix to provide a traditional funeral service for me in keeping with my station in life, with burial in the plots owned by me at Mt. Zion Cemetery, Monroe Township, Cumberland County, Pennsylvania. THREE: I give, devise and bequeath all estate of every nature and wherever situate to my wife, MARY R. SHIELDS. FOUR: In the event that my wife, MARY R. SHIELDS, and I should die simultaneously or under circumstances as to render it impossible to determine who predeceased the other, or within thirty (30) days of each other as the result of a common accident, my wife shall be deemed to have survived me. FIVE: If my wife, MARY R. SHIELDS, has predeceased me, I specifically give, devise and bequeath the sum of Fifty Thousand and no/ 100 ($50,000.00) Dollars to my daughter, MARY ANN BRYMESSER. SIX: L~ my wife, MARY R. SHIELDS, has predeceased me, I give, devise, aiid bequeath all of my estate of every nature and wherever situate as follows: To my daughter, MARY ANN BRYMESSER, twenty-five percent (25%) of my estate, per stirpes: To my son, OTHO A. SHIELDS, twenty-five percent (25%) of my estate, per stirpes: To my grandchildren, MICHAEL ALLEN BRYMESSER, REBECCA ANN VAN DER LINDEN, JULIE ELAINE BRYMESSER and MATTHEW DOUGLAS BRYMESSER, twenty-five percent (25%) of my estate, per stirpes; . ,~ C~,~~ ~ To my grandchildren, AMY LYNN SHIELDS, born April 7, 1982 and STACY MARIE SHIELDS, born January 16, 1984, twenty-five percent (25%) of my estate, per stirpes. SEVEN: If at my death, my wife, MARY R. SHIELDS, has predeceased me and AMY LYNN SHIELDS and STACY MARIE SHIELDS or either of them are less than twenty-one (21) years then I direct that their share of my estate shall be place in TRUST to the FARMERS TRUST COMPANY and SHELDON B. BRYMESSER, as CO-TRUSTEES, subject to the following conditions and provisions: A. Upon the creation of the Trust, the Trustees shall divide the Trust principal into as many shares as there are beneficiaries under the age of twenty-one (21) years and thereafter each beneficiary shall receive the income and principal solely from her portion of the Trust. B. Trustees shall hold the principal of each Trust for the benefit of AMY LYNN SHIELDS and STACY MARIE SHIELDS and shall distribute the income in such proportions as Trustees shall determine, for their health, maintenance, support and education, including college, graduate level or professional education. Education shall be defined broadly to include not only that available in college, but also trade school and other similar training. In the event the income shall be insufficient to provide each beneficiary with adequate maintenance, support, welfare or education, the Trustees may invade the principal of their Trusts for this purpose. The Trustees, in exercising their discretionary authority with respect to the necessity of making payments out of income or principal of the Trust estate to each beneficiary, shall take into consideration any income or other resources available from sources outside of the Trust that may be known to the Trustees. The determination of the Trustees with respect to the necessity of making payments out of income or principal to each beneficiary shall be conclusive on all persons however interested in the Trusts. The Trustees shall accumulate and add to principal any net income of the Trusts not paid out in accordance with the discretion herein above conferred on the Trustees. C. Upon the death of any beneficiary prior to the termination of her trust, the Trustee shall distribute the principal and accumulated interest to her issue, if any, and if none, to her sister. n ~ ~~~ ~~ C D. The beneficiaries of these Trusts shall not have any right to alienate, encumber or hypothecate their interest in the principal or income of their Trust in any manner, nor shall their interest be subject to claims of their creditors or liable to attachment, execution or other process of law. E. In order to carry out the purposes of these Trusts established by this Will, the Trustees, in addition to all other powers granted by this Will, or by law, shall have the following powers over each Trust estate, subject to any limitation specified elsewhere in this Will: 1) To retain any property, real or personal, received by the Trust estate for as long as the Trustees consider it advisable. 2) To spend funds for the maintenance and repair of real property. 3) To sell at public or private sale, exchange or lease for a period of time, any real or personal property and give options for sale of the lease. 4) To execute and deliver any deeds, assignments or other instruments as may be necessary to carry out the provisions of this Trust. 5) To borrow money and to mortgage or pledge any real or personal property. 6) The Trustees shall maintain accurate records and accounts showing receipts and disbursements of principal and income no less frequently than annually. The Trustees shall receive fair and reasonable compensation for administration of these Trusts. 7) To distribute property in kind. 8) To do all other acts that are in their judgment necessary or desirable for the proper management, investment and distribution of the Trust estates. F. The trust estates shall be administered until each beneficiary is twenty-one (21) years of age, at which time a calculation of the property and accumulated income remaining in her Trust shall be made, and the total thereof shall be distributed to her. EIGHT: I appoint my wife, MARY R. SHIELDS, to serve as Executrix of this my Last Will. If she should predecease me, fail to qualify, or cease to serve as Executrix, I appoint SHELDON B. BRYMESSER, to serve as alternate Executor in her place of this, my Last Will. NINE: My Executrix may, at her discretion, compromise claims, borrow money, retain property for such length of time as she may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as she may deem proper; and invest estate property and income without restriction to legal investments. TEN: All estate, inheritance and other death taxes, together with interest and penalties thereon payable with respect to property or interests subject to taxation by reason of my death and passing under my will or any codicil shall be paid out of the principal of my residuary estate without apportionment. ELEVEN: No Executrix, alternate Executor or Trustee acting hereunder shall be required to post bond or enter security in this or any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal this5 ~".~ - q y day of 1994. ~,.L.Zw ~ •,~ -- ,---- a ------(SEAL) OTHO O. SHIELDS SIGNED, SEALED, PUBLISHED and DECLARED by the above Testator as and for his Last Will, in the presence of us, who thereupon at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses. - ~ - ---------------- fitness ~~ Witness _~,~/51~f_P~ Address F _ ~~,~~ __.~--~-~-`---- ------------------ Address STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND SS We, OTHO O. SHIELDS, ____ James J__Kayer________________ and Patricia R . _ B r o wn__________________ the Testator and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and that he signed willingly, and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witnesses and that to the best of each witness' knowledge and belief the Testator was at that time eighteen years of age or older, of sound mind and under no undue constraint or influence. Testator _ -1-~-- itness Witness Subscribed, sworn to and acknowledged before me by OTHO O. SHIELDS, the Testator and subscribed and sworn to before me by _ J am e s _J_ K a y e r ______ and _P a t r i c i a R_ B r o wn__, witnesses, this __~ th __ day of _ S eft ember_____, 1994. ~ ^I Notary Public NOTARIAL SEAt- DENISE SNIDER. NOTARY PUBLIC CARLISLE BORO, CUMBERLAND COUNTY MY COMMISSION EXPIRES OCT. 28. 1096 Member, Pennsylvania Association of Notarlcs CERTIFICATION Or NOTICE UNDER RULE 5.6(a) Name of Decedent: OTHO 0. SHIELDS Date of Death: October 24, 2002 Will No. 21- 0 2 -10 9 4 ,.Admin. No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court.Rules was served on or mailed to the following beneficiaries of the above-captioned estate on December 30, 2002 Name Address Mary R. Shields, 415 E. Old York Road, Carlisle PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except December 31 , 2002 ~ ~~,_ C_ '' ~`' ,.z., Date: L_._. ~`ti y'` y ~ ,.. Signature Name Patricia R. Brown Address 10 West Pomfret Street Carlisle PA 17013 Telephone(~17) 249-3024 Capacity: Personal Representative X Counsel for personal representative FAMILY SETTLEMENT AND FINAL RELEASE IN OTHO O. SHIELDS (File No. 21-02-1094) KNOW ALL MEN BY THESE PRESENTS, that WHEREAS, Otho O. Shields. late of 415 E. Old York Road, South Middleton Township, Carlisle, Pennsylvania, deceased, died testate on October 24, 2002, WHEREAS, letters testamentary on the estate of the said decedent were duly issued by the Register of Wills of Cumberland County, Pennsylvania, to decedent's spouse, Mary R. Shields, hereinafter called personal representative; WHEREAS, the said personal representative has gathered the assets of the estate of the said decedent and the said assets consist of personal property to a total value of $10,954.82, as set forth in Exhibit A, which is a statement of account of the said personal representative, and which is attached hereto and made a part hereof, and marked Exhibit A; WHEREAS, the payment of inheritance tax in the said estate amount to 0 percent, leaving a balance for distribution of $3,985.16, also as set forth in the statement of the said personal representative, which is attached hereto and marked Exhibit A; NOW, THEREFORE, KNOW YE, that I, Mary R. Shields, being the heir under the last will and testament of said decedent, and being that person entitled to inherit thereunder do hereby acknowledge that I have this date had and received from the aforesaid personal representative in full satisfaction and payment of all sum or sums of money, which is due me for distribution of the decedent's estate, and which amount is in the amount set opposite my name in the table and schedule of distribution on said statement attached hereto and marked Exhibit A: AND, I do hereby stipulate that in order to avoid the expense and time involved in the filing of a formal account and schedule of distribution, I agree that no account is necessary and I do hereby agree that I do consent to distribution being made without the filing of an account and schedule of distribution, Page 1 of 4 l~ the same to be with the same force and effect as if it had been filed and confirmed by the Orphans' Court Division of the Court of Common Pleas ,Cumberland County. THEREFORE, I, do hereby remise, release, quitclaim and forever discharge the said personal representative, Mary R. Shields, her heirs, executors, and administrators and assigns, of and from the said estate and from all actions, suits, payments, accounts, reckonings, claims, demands whatsoever for or by reason thereof, or for any other use, matter, cause or thing whatsoever, touching upon the estate of said decedent, and I do further hereby covenant and agree that should any liability come due to the estate of the said decedent after the signing of this agreement. I do hereby covenant and agree that I will contribute pro-rata, my share of the estate to satisfy any and all claims demands, suits, or cause of action which may be successfully prosecuted against the said estate or the aforesaid personal representative after the signing, sealing and delivery of this Family Settlement Agreement and Final Release. IN WITNESS WHEREOF, I have hereunto set my hand and seal this .y ~ r.~. day of 2005. Witness: ,-~, ~~---~~~~M~-,.,....~ l~ ~. `j~'t~-~~~ `y ; ~ ~V ~ - (SEAL) MARY R. HIELDS Page 2 of 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. On this, the :~(~ day of ~,~- ~ 2005, before me, a notary public, the undersigned officer, personally appeared M Y R. SHIELDS (known to me or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. Notary Public ANN d. SENSENICN, NOTARY PUBLIC CARLISLE BORO. CUMBERLAND COUNTY ~ MIS I ~ PIRES MAY 13 2007 Page 3 of 4 EXHIBIT "A " STATEMENT OF ACCOUNT OF MARY A. SHIELDS EXECUTRIX ASSETS: A. Prudential Securities (Equiserve) $ 3,985.16 B. Prudential Financial Acct L ! ~ ,~ } $ 6,969.66 ~ N" o :J F'~~,~? ~ ;. ~- !- •'' . - TOTAL ASSETS FOR DISTRIBUTION $3985.16 Balance for Distribution to Heirs: NAME Mary A. Shields $3,985.16 DISTRIBUTION 100% Page 4 of 4 COMMONWEALTH Of PENNSYLVANIA ;DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INt#RITA C 'NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE N E TAX DIVISION Po sox zaobol OF DEDUCTIONS AND ASSESSMENT OF TAX HARRISBURG PA 17128-0601 REV-1547 EX AFP (06-O51 DATE 08-22-2005 ESTATE OF SHIELDS OTHO 0 DATE OF DEATH 10-24-2002 fILE NUMBER 21 02-1094 PATRICIA R BROWN ESQ COUNTY CUMBERLAND SALZMANN HUGHES ACN 101 P C APPEAL DATE: 10-21-2005 10 W POMFRET ST (See reverse side under Objections) CARLISLE PA 17013 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ----------------------- -~ RETAIN LOWER PORTION FOR YOUR RECORDS E- -------------------- REV-1547 EX AFP (03-05) _______ ------------------------------- NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SHIELDS OTHO D FILE N0. 21 02-1094 ACN 101 DATE 08-22-2005 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) b. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: (1) .00 NOTE: To insure proper (2) .00 credit to your account, (3) .0 0 submit the upper portion of this fora with your ( 4) . 0 0 tax payment . (5) 3,985.16 (6) .00 (n 6,969.66 (8) 10,954.82 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) .00 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10). .0 0 11. Total Deductions (11) _(~0 12. Net Value of Tax Return (12) 10 , 954.82 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule Jl (13) .DO 14. Net Value of Estate Subject to Tax (14) 10,954.82 NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 10,955.00 X 00 _ .00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) •00 X 045 . .0 0 17. Amount of Line 14 at Sibling rate (17) .0 0 X 12 - .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 - .00 19. Principal Tax Due (19)= .00 TAX CREDITS. DATE ~ NUMBER I INTEREST/PEN PAID (-) I AMOUNT PAID TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE 0 * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRE~f FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY..BEa.DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA INHERITANCE REV-1500 21-02-1094 DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 TAX RETURN RESIDENT DECEDENT COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~ z SHIELDS, OTHO O. 189-18-6275 W O DATE OF DEATH (MM-DD-YY) DATE OF BIRTH (MM-DD-YY) THIS MUST BE FILED IN DUPLICATE w U 10/24/2002 6/3/1921 WITH THE REGISTER OF WILLS W (IF APPLICABLE) SURVIVING SPOUSE'S NAME SOCIAL SECURITY NUMBER D Shields, Ma R. 211-52-2850 Q 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return H~ U a v 4. Limited Estate ~ 4a. Future interest Compromise ~ 5. Fed. Est. Tax Return Req'd = O O v a m X 6. Decedent Died Testate ~ 7. Decedent had Living Trust 0_ 8. Total number of SDB's o_ Q 9. Lit'g'tion Proceeds Recd 10. Spousal Poverty Credit 11. Election to tax w/ Sec. 9113(A) F- THIS SECTION IS REQUIRED. D'tRECT ALL CORRESPONDENCE AN D CONFIDENTIAL TAX INFORMATION Td: w NAME: COMPLETE MAILING ADDRESS: ~ Patricia R. Brown, Esquire ~ FIRM NAME: ~ Salzmann Hughes, P.C. ~ O TELEPHONE NUMBER 10 W. Pomfret St. , U 717 249-3024 Carlisle, PA 170:1 1. Real Estate (Schedule A) (1) $0.00 OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) $0.00 3.Closely Held Corporation, Partnership or Sole-Prop. (3) 4. Mortgages & Notes Receivable (Schedule D) (4) $0.00 z 5. Cash, Bank Deposits & Misc. Personal Prop.(Sch.E) (5) $3,985.16 . O ~ 6. Jointly Owned Property (Schedule F) (6) $0.00 Q ~ Separate Billing Requested F- a Q U W 7. Inter-Vivos Transfers & Misc. Non-Propate Prop. 3. Total Gross Assets (total lines 1-7) 3. Funeral Expenses & Administration Costs (Sch H) 10. Debts of Decedent, Mortgage liabilities, & Liens 11. Total Deductions (total lines 9&10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (s) $10,954.82 (9) (10) (11) $0.00 (12) $10,954.82 (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) $1 U,y54.tf1 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z O 15. Amnt of Line 14 taxable at the spousal rate, a or transfers under Sec.9116(a)(1.2) $10,955 x.o_ (15) $0.00 ~ 16. Amount of Line 14 taxable at lineal rate $0.00 x.045 (16) $0.00 0 17. Amount of Line 14 taxable at sibling rate $0 x.12 (17) $0.00 v 18. Amount of Line 14 taxable at collateral rate $0 x.15 (18) $0.00 F 19. Tax Due (19) $0.00 20 ~ CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT »BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH« Deceuent's Complete Address: STREET ADDRESS 415 E. Old York Road CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discounts Total Credits (A+g+C) (2) $~•~~ 3. Interest/Penalty if applicable D. Interest E. Penalty Total InteresUPentalty (D+E) (3) $~•~~ 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 1 Line 20 to request a refund 5 If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) $0.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPRO PRIATE BLOCKS 1. Did decedent make a transfer and: yeS n0 a. retain the use or income of the property transferred: b. retain the right to designate who shall use the property transerred or its income: c. retain a reversionary interest: or d. retain the promise for life of either payments or care? 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? 3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death? 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary disignation? IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE lO W~Sf U o~~ /' "~ ~ ~~D/'~ DATE ~ /u3/u~_ ADDRESS ~ ~ 10 West Pomfret Street. Carlisle, PA 17013 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 % [72 P. S. Sec. 9116(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 is 0 % [72 P.S. Sec. 911 Firatr~ ~ v~~~i The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax reti the only beneficiary. For dates of death on or after July 1, 2000: ~ ~'~U The tax rate imposed on the net value of transfers from a deseased child twenty-one years of age or younger at death to or for the use of a natur or a stepparent of the child is 0 % [72 P.S. Sec. 9116(a)(1.2)]. The tax 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. Sec. 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. Sec.9116(a)(1.3)]. A sibling is defir individual who has at least one parent in common with the decedent, whether by blood or adoption. ~ ~~~~ SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANIOUS PERSONAL PROPERTY ESTATE OF FILE NUMBER SHIELDS, OTHO O. 21-002-1094 (All property jointly-owned with Right of Survivorship must be disclosed on Schedule F) ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH Equiserve -Prudential Acct #3976-7970 $3,985.16 2 134 Shares @29.74 per share TOTAL (also on line 5, Recapitulation) $3;985.16 SCHEDULE G TANSFERS ESTATE OF 21-02-1094 SHIELDS, OTHO O. This schedule to be completed and filed if the answer of the question on the reverse of the cover is ves. ITEM DESCRIPTION NUMBER EXCLUSION TOTAL VALUE OF ASSET DECD.% INT DOLLAR VALUE OF DECD. INT 1 Prudential Financial Acct # IRA 100.0% $6,969.66 AAC - R69117-17 2 TOTAL (also on line 7, Recapitulation) $6,969.66 SCHEDULE J BENEFICIARIES ESTATE OF SHIELDS, OTHO O. 21-02-1094 ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR SHARE OF ESTATE 1 Mary R. Shields Wife 100% 415 E. Old York Road, Carlisle, PA 17013 2 3 4 ITEM (NAME AND ADDRESS OF BENEFICIARY I AMOUNT OR SHARE NUMBER OF ESTATE B. Charitable and Governmental Bequests: TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (also enter on line 13, Recapitulation) $0 JRD/June30,1992/17858 In Re: Estate ofOtho O Shields · ORPHANS' COURT DIVISION Late of South Middleton Township ' COURT OF COMMON PLEAS OF · CUMBERLAND COUNTY Estate No.: 21-02-1094 ' PENNSYLVANIA NO. 21-02-1094 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: Mary Shields Counsel for Personal Representative: Patricia Brown Date of Decedent's Death: 10/24/2002 Date of Delinquency Notice: 08/11/04 The undersigned, Glenda Farner-Strasbaugh, Clerk of Orphans' 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 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 Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orphans' Court Rules, was given by the Clerk of the Orphans' Court on April 30, 2004, 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 counsel for the delinquent personal representative. Date: 11/08/04 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 Status Report is filed prior to the hearing date, the hearing will automatically be canCelled.~. Geor~. H~ff~, STATUS REPORT UNDER RULE 6.12 NameofDecedent: O-7-~c> O. ~ ~ J a ~O 5 Date of Death: ~o 22_~ / tv ,2j Will No.: ~2 l-- c~)- -.- ! ~> q ctz Admin. No.: Pursuant to Rule 6.12 of the Supreme Court Os>hans' Court Rules, t repo~t the iu**o,~m~ with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes ['-] No ~ 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: )tr~,~ c~, '~c2o&- 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 _ No [-] b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes [-] No [-] c. Copies of receipts, releases, joinders and approval of formal or info~-Tnal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: 2_~ ~'/ Signature Name (7/7~) ~V ¢- 302q' Telephone No. Personal ~ ~n~-~e ~f~t~x/~ Counsel for personal representative FAMILY SETTLEMENT AND FINAL RELEASE IN OTHO O. SHIELDS (File No. 21-02-1094) KNOW ALL MEN BY THESE PRESENTS, that WHEREAS, Otho O. Shields. late of 415 E. Old York Road, South Middleton Township, Carlisle, Pennsylvania, deceased, died testate on October 24, 2002, WHEREAS, letters testamentary on the estate of the said decedent were duly issued by the Register of Wills of Cumberland County, Pennsylvania, to decedent's spouse, Mary R. Shields, hereinafter called personal representative; WHEREAS, the said personal representative has gathered the assets of the estate of the said decedent and the said assets consist of personal property to a total value of $10,954.82, as set forth in Exhibit A, which is a statement of account of the said personal representative, and which is attached hereto and made a part hereof, and marked Exhibit A; WHEREAS, the payment of inheritance tax in the said estate amount to 0 percent, leaving a balance for distribution of $3,985.16, also as set forth in the statement of the said personal representative, which is attached hereto and marked Exhibit A; NOW, THEREFORE, KNOW YE, that I, Mary R. Shields, being the heir under the last will and testament of said decedent, and being that person entitled to inherit thereunder do hereby acknowledge that I have this date had and received from the aforesaid personal representative in full satisfaction and payment of all sum or sums of money, which is due me for distribution of the decedent's estate, and which amount is in the amount set opposite my name in the table and schedule of distribution on said statement attached hereto and marked Exhibit A: AND, I do hereby stipulate that in order to avoid the expense and time involved in the filing of a formal account and schedule of distribution, I agree that no account is necessary and I do hereby agree that I do consent to distribution being made without the filing of an account and schedule of distributiOll, 'v ~=,J Page I of4 O"'! '.\ 'j'V ".....J ~,' '"'-;',";1 Q, C',,\ J l..,:'J!.. ...6.,)1' ...oJ jU :jJ~'~.~~!ij j~'j {~ the same to be with the same force and effect as if it had been filed and confirmed by the Orphans' Court Division of the Court of Common Pleas, Cumberland County. THEREFORE, I, do hereby remise, release, quitclaim and forever discharge the said personal representative, Mary R. Shields, her heirs, executors, and administrators and assigns, of and from the said estate and from all actions, suits, payments, accounts, reckonings, claims, demands whatsoever for or by reason thereof, or for any other use, matter, cause or thing whatsoever, touching upon the estate of said decedent, and I do further hereby covenant and agree that should any liability come due to the estate of the said decedent after the signing of this agreement. I do hereby covenant and agree that I will contribute pro-rata, my share of the estate to satisfY any and all claims demands, suits, or cause of action which may be successfully prosecuted against the said estate or the aforesaid personal representative after the signing, sealing and delivery of this Family Settlement Agreement and Final Release. IN WITNESS rr-,A1 WHEREOF, I have hereunto set my hand and seal this ~day of ,2005. Witness: "-P~ "f>,~ 'V)'\~ R. ~AL- MARYR. HIELDS (SEAL) Page 2 of 4 COMMONWEALTH OF PENNSYL VANIA SS. COUNTY OF CUMBERLAND d ~ On this, the c?r day of .~ , 2005, before me, a notary public, the undersigned officer, personally appeared M Y R. SHIELDS (known to me or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. a><- -/1 ~~ Notary Public - llENsEllIClf IlOTARI' I'U8UC CARI.l8Ii BORG CUMBERlAND COUNTY 2 Page 3 of 4 EXHIBIT "A" STATEMENT OF ACCOUNT OF MARY A. SHIELDS. EXECUTRIX ASSETS: A. Prudential Securities (Equiserve) B. Prudential Financial Acc't {/ Iff'.) $ 3,985.16 $ 6,969.66 (tV D,.J PR.:)(j "- -,-;;: F!<:oPCf<-f'-/) TOTAL ASSETS FOR DISTRIBUTION $3985.16 Balance for Distribution to Heirs: $3,985.16 NAME DISTRIBUTION Mary A. Shields 100% Page 4 of 4 COMMONlIEAL THOFPEHNSYL VANIA :DEPARTMENT OF 'REVENUE 1IDT1CE OF _","~.a.IMCE TAX API'RAUEIIENT, ALLIIlIAIICE DR DISALLOlIANCE OF DEDUCTIONS AND ASSESSHENT OF TAX BUREAU OF INDIIIXDUAL TAXES lHHERITANCE TAX DIVISION PO BDX 288601 HARRISBURG PA 17128-0601 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN o8-ZZ-Zoo5 SHIELDS lo-Z4-ZooZ Zl OZ-1094 CUMBERLAND 101 APPEAL DATE: lo-ZI-Zoo5 ( See reverse side under Objections) Amount R_.i:t1:ed 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:is47-EX-AFP-coi:os'-NOTicE-OF-iNHERiTANCi-TAX-APPRAisEHENT:-ALLOWANCE-OR--------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX OTHO 0 FILE NO. ZI OZ-lo94 ACN 101 PATRICIA R BROWN ESQ SALZMANN HUGHES P C 10 W POMFRET ST CARLISLE PA 17013 ESTATE OF SHIELDS .. REY-!S47 EX AFP (06-05) OTHO o DATE 08-ZZ-Z005 TAX RETURN liAS: (X) ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Est.t. (Schedule A) 2. Stocks ~ Bonds (Schedule B) 3. Clo..ly Held StocklPartn.rship Int.rest (Schedule CJ 4. MortsJll8es/Notas Receivable (Schedule DJ 5. c.sh/Bank D.posits,"isc. PersORB1 Property (Schadule E) 6. .Jointly _ Property ISchedule F) 7. Tr8nsfers (Schedule G) 8. Total Assets ) CHANllED 11) IZ) (3) 14) (,5) (6) 17J .00 .00 .00 .00 3.985.16 .00 6,969.66 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expens.s/~. Costs/Misc. EKPBnSes (Schedule H) (9) 10. DebtslKortgage Liabilities/Liens (Schedule I) (10) 11. Total Deductions 12. Net Value of Tax Return 13. Ch8ritabl./Gover~nt.l Bequests; Non-elected 9113 Trusts (Schadul. JJ 14. "-t Value of Est.te Subject to Tax I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect ~igures ~ha~ include ~he ~ata1 of ALL re~urns assessed ~a da~e. ASSESSMENT OF TAX: IS. Anount of Line 14 at SPousal rete (IS) 16. Amount of Line 14 taxable at Lineal/Class A rat. (16) 17. AIlount of Line 14 et Sibling rate (171 18. A.uunt of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due C D T : NOTE: T + DATE NUH8ER INTEREST/PEN PAID 1-) . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .00 00 (11) llZI (13) 114) 10,955.00 X .00 X . DO X . DO X AIIOUNT PAID TOTAL TAX CREDIT BALANCE DF TAX DUE INTEREST AND PEN. TDTAL DUE NOTE: To insure prop.r credit to your account, sub.it the upper portion of this form with your tex ...._t. 10,954.82 DO 10,954.8Z .00 10,954.8Z 00 = 045 = lZ = 15 = .00 .00 .00 .00 .00 1191= .00 .00 .00 .00 IF TOTAL DUE IS LESS THAN $1, NO PAYIIENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU "AY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOR" FOR INSTRUCTIONS.) STATUS REPORT UNDER RULE 6.12 Name of Decedent: Otho o. Shields Date of Death: 10/24/02 Will No.: 21-02-1094 Admin. No.: 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 [] 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. I is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes ]I: No 0 Filed Family Settlement Agreement b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes JKJ No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attsched to this report. Date:.xPs/zoDs' ~~~ ~ Signature Patricia R. Brown, Esq. Name 10 West Pomfret Street, Carlisle, PA 17013 Address A ;,J <J'~O 717-249-3024 Telephone No. O. .-2 Lid "]. ,', Capacity: 92 ~nv SOUZ n Personal Representative {] Counsel for personal representative ':' . '.-- :-,0 .32:I~JQ C3:JbDJ:Jc w COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE n'-i;>{l.Iil~Cn "C'-'''E m NOTICE OF INHERITANCE TAX BUREAU OF INDIVlDU"":\~~~j Ui r'v . !f APPRAISEHENT, ALLOWANCE DR DISALLOWANCE ~":~~T~:~~oIAX DIVISION ~ '. i ( OF DEDUCTIONS AND ASSESSMENT OF TAX HARRISBURG PA 1712&-0601 08-22-2005 SHIELDS 10-24-2002 21 02-1094 CUMBERLAND 101 APPEAL DATE: 10-21-2005 ( See reverse side under Objections) A.ount Remitted I I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE _ RETAIN LOWER PORTION FOR YOUR RECORDS - REY:is47-EX-AFP-C03:0S'-NOTicE-OF-iNHERiTANCE-TAX-APPRAisEMENT:-ALLOWANCE-OR--------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX OTHO 0 FILE NO. 21 02-1094 ACN 101 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 2"" "1'~ e'n nl)'" _, ," -' i ...':.:~ I', _'.J ,j U ',: 24 T'>-_' rji C~" _L_'_.,','. ,'1: I PATRICIl(:iRBROWN ESQ SALZMANN HUGHES P C 10 W POMFRET ST CARLISLE ~, '. PA 17013 ESTATE OF SHIELDS DATE 08-22-2005 TAX RETURN WAS: (X J ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estete (Schedule AJ 2. Stocks and Bonds (Schedule BJ 3. Closely Held Stock/Partnership Interest (Schedule C) 4. "ortgas.s/Notes Receivable (Schedule DJ S. CashlBank Oeposits/Hlsc. Personal Property (Schedule EJ 6. Jointly Olmed Property (Schedule FJ 7. Transfers (Schedule G) 8. Totel Assets J CHANGED (11 (21 (31 (41 (51 (61 (71 .00 .00 .00 .00 3.985.16 .00 6,969.66 (81 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Hisc. Expenses (Schedule H) (9) 18. Dabts/Kcrtll_ Liabilities/Liens (Schedule II 1101 11. Totel Deductions 12. Net Value of rax R.turn 13. Charitable/Governnental Bequests; Non-elected 911~ Trusts (Schedule ~) 14. Net Value of Estate Subject to Tax I~ an assessment was issued preViously, lines 14, IS and/or 16, 17, 18 and 19 will re~lect figures that include the total of ~ returns assessed to date. ASSESSMENT OF TAX: 15. A.ount of Line 14 at Spousal rate (IS) 16. Amount of Line 14 taxable at Lineal/Class A rat. i16} 17. AlIOUI1t of Line 14 at SibUng rate (171 18. Aaount of line 14 taxable at Colleteral/Class B rate (18) 19. Principal Tax Due NOTE: .00 .00 111) (121 1131 (141 10,955.00 X .00 X .00 X .00 X '* REV-15~7 EX AFP (D6~05) OTHO o NOTE: To insure proper credit to your account, sublait the upper portion of this fora with your tax pay-.nt. 10,954.82 00 10,954.82 .00 10,954.82 00 = 045 = 12 = 15 = .00 .00 .00 .00 .00 1191= TAX CAED~T'" rftonc" , '+J AIlDUNT PAID DATE NUHBER INTEREST/PEN PAID (-J TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ~ . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1. NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YOU HAY BE DUE A REFUND. SEE REVERSE !;TnA:' nl:' TIITC" r,u,.u ""1'0'" ....~._-_.._--_._-