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Home My WebLink About02-0511 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of VCLLLI A. PcpkSr. a/so known as No. 2, - 0 z. - 511 To: Register of Wills for the County of ('>,Lrnb.pdancl in the Commonwealth of Pennsylvania Ibl 10 Deceased. 0510'7 Social Security No. The petition of the undersigned respectfully represents that: , Your petitioner(s), who is/are]8 years of age or older, applle.<; for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Oecendent was domiciled at death in C.U-,.,~ dCLnd . Co...uqty, Pepnsylvania, with h t<. last family or principal residence at 1 '70, 'i! ("(t'f'K Ii 1<.+1I \)nvi' Nev.) CuxYber'b.xo1 p.-\ (list street, number and mumclpahty) kv\JerA.t l-eA'I 'fw..r (i~J20 ,..}'J:;W[}{j , Oecendent, then 53 at rc:c;;deA'l[P~ years of age, died Oecendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property (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: /'frY!. Orel'k It l<io J.....,...i;;."~ fJeAA:: II) Ow(es h'lolAl'1ta,-"lo rr:l=ru (i1Jh ('J) $ ...-"r.. ODD ... $ $ $ fJfl. -:t:-. ~ CWYnhe. FA /'fo'"0 Petitioner_ after a proper search ha_ ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Na e Relationship - THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration m the appropriate form to the undersigned. ~ , or u C " :g3 "" "'" C -00 1:";: <":S"';:: 3~ "~ 00 :;; c 00 Vi r2t/YI ~i,;{.r.i' A:3 Pap) -L "\ . ( 0 lc L> OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF ~~ 5:tt } ss d c-' 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 representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. .-.....} Sworn to or affirmed and subscribed f before me this 1 7t h day of ~~r~~~1f'r:~~~/~~4'JV Y LEW RegIster ~ /j/I d-tfA' ..fl ~41 ~ ~ '0;' ~ :l :;; C Cl) Cii No. 2J-07--5U Estate of PAm, A POPIK ,TR , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW MAY 24. 2002 Xi'9XX_, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that CANDACE BETH POPIK is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to CANDACE BETH POPIK in the estate of PAUL A POPIK JR '~//if?~/L/J ~/v/ A7~/ . Y C, EWHi. isterofWills /~1 FEES Letters of Administration $ Short Certificates( ).......... $ Renunciation ................ $ jcp $ 5.00 TOTAL _ $ 270.00 Filed 1~~-:213:-.2.~22....... A.D. 19__ mai eu to a~[[ on 5-24-2002 235.00 30.00 ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE I'hls is to cenifv that the informatiol~ here given is correctly Local Registrar.' The origlllal u:Ttiflcate wi!'1 he forwarded to copied rrolll <In original c(~'~tiflc:l.f(:.' of de,uh dLL!~ filed tile Sl;lte 'Vital Records Office tor pcr1l1anenr filmg. with me as WARNING: It is illegal to duplicate this copy by photostat or photograph. I'ee t~H this cerritlutc. $2.00 ,(,i;;;;\.'.(Q'Ii"of'pr);..... ;;.l~\"/"-- -"<'4'J'.---"- ?'i<</ ~~'\;~\ I~:EE:', ~aii, 'I~% 1~5: .j~:'i ,.i:~ \, *.. ~>*i \~ a\' -'.,~-" ''''~l 7:.<Q>-__-~,,\ \~ :.tp",- " ,,~"'t:./ .'~..<!rMf.-N1.~'i~."'., -- 1,ly F"~""'NOH''''I/ !)atc a ?; f;:" .1t..--t...- , ;: F ;2.i/!.Ll..:YJ7'-.('-""-- Local Keglstrar J'/ P 8206511 MY 0 ~ 2002 l'\o. ,S,144Rev, 1191 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (Coroner) NAME OF DECEDENT ~Firot, M<ldle, LaSl) Paul STAIEFllENU'-lBEIl SOCIAL SECURITY NUMBER DATE OF DEATH IMonlh, Day, Year) .. April 30, 2002 m 2. Male A Popik, Jr. ,. 161-40-0567 Cumberland SURVIVING SPOUSE (II wile, (j",emaodanname) UNDER 1 DAY Hours DATE OF SIRTH 8lRTHPLACE ICily a"d PLACE OF DERH (C~""k only one """l"WUCtlOn.or. Ol~er "del (MOf'1II1,Day, Yaar) SlalaorForeognCounlry) HOSPITAL Sharon, PA If\PatientD ERIOutJlllli"nlO DOAe) . . FACllITYNAIlAE(llnOllnSllIUI,on,"'ve'lfeel~fl<ln"mbe') R&'idence~ g~'ly)D RACE.Amer;canlr>dian,8Iack.wtlil&.eIC ISpoc,IYI White CITY,80f1 .. 1728 Creek Vista Drive DECEDENT'S USt)AL OCCUPATiON K1ND OF 8USINESSI1NDUSTRY (Give IlIndol work dO<>edu"og mOSl upp1~y"~y'nes'1emsr.r~ha 1 1 . ~t- US Government DECEOE:NT'S IIAAllING ADDRESS(SUOOl. Cllyfk>wfl Slale, ZJpCooel DECEDENT'S 1728 Creek Vista Drive ~~~i~E New Cumberland,PA :_7070 ;;:I~:r~~~~n. ". WAS DECEDENT EVER IN U,S. ARMED FORCES? YeaD No[;\';J MAAITAL STATUS. Married Ne....rMarried.Wklowed, DivlI,oed ~Spoc,IYJ Married Candace B. Lane " " PA l7c.[2l:Y"a.d"Ced-entliv"din l7a.Stata Lower Allen ., de<:ed-ent live ifl a Cumber land lown:oi1'p? l7d.o ~~;'=:~~:~ot MOTHER'S NAME iF"'I, Middle, Ma'denSwnam"J ". FATHER'SNAME(FlISI,MIddle.Last) ". Paul A. Popik, Sr. INFORMANT'S NAME (Type/p,,"I) Matthew D. Popik METHOD OF DISPOSITION 8u,iatD cremallonffi R.mo"alhomSlaleD OthltflSpeo;;dyl l7b.Counl 18. Ann Tarba INFORMANT'S MAILING ADDRESS ~Slr""l, C'lyfTown. Slal~. l.p Cooe) 1728 Creek Vista Drive New Cumberland PA17070 PLACE OF DISPOSITION - NameoICam.tary, C,emalory LOCATiON .CityfTo"'n, Sial". Zip Code or Dtha, Pie"" 2002 21C~on-O Lite Crematory NAMEANDADDAESSOFFACiLITY L DATEPRONOUNCEDDEAD(MQ{lth.Day, Year) 24. 9: 00 25. April 3D, 2002 27. PART I; Enle'lhedi........lnjurle.orcompllcalion."'hichcau.8dlh8death,Donotenterlhemodoo>otdying.SUChaBCardiacor,e.piralo,yerreot,6hockOrhear11aiIW8 lilli 001)0 """""..... on eaCh line 23b. Uc. WASCASEREFERREDTO:iL~INERICORONER? NoD ". r-U- ,Approximata PART I!; Olhers<gnilicantcondilionocont,Obutingl0d8alh,twl lime",.lbal",...n notresulli"9intheundeflyil>(j~au...giveninPARTI ion"'" and d-eath 1 Pending Investigation DUE TO (OA AS A CONSEOUENCE OF) , DUE TO (OR AS ACONSEQUENCE OF) , OUETO{QR AS ACONSEQUENCE OF) , WERE AUTOPSY FINDINGS _1lA8LE PRIOR TO COMPLETION OF CAUSE OF-DEATH? MANNEAOFDEATH DATE OF INJURY (Monlh.Day,Yea'l TiME OF INJURY INJURY AT WORK? DESCRISE HOW INJURY OCCURRED o o o o )(130.. 3{)b. O PLACEOfINJURY-All'Iome.larrn,.tr....l,li'clory.oM,ce bu,ldmg,eIC,(Spoc"-,l ,... Na'ulal HomlciOll Y"S [] NoD '" 0 '0 )S Ace.,.nt Pendingln"eBllgalioo Couldnolbacletermln.d M. 300. 30<1. LOCATION (Slreel,CllyfTown, Slatel Suickle " BoI. 21b. CERTIFIEFI(CheckorWyona) .CERTIFYIHG PliYSIClAH (Phy$ICian c",j~1""O cause 01 aaalh wI1en anoth", p/1ySIC.." ha. pionounc<ld daalll and cornplalad lIam 13) To tIM ....1 of my knowledtl.. d...lh occurnd duelo lh. caUH(.) .nd mam..r.. .lalad. . o Coroner .PFlDNOUNCING AND CERTlFYIMG PHYSICIAN tPhYOICoan bol" IHOOOl'nc,"9 daalh arod ~erj,jV"\{II" cao<e 01 daalll) TOIh.....loImYk_IMIgoI.~IhOCCUrnd.ltlMtl....,dal...nclpl.ca,andd...toIIMC.....(.I.ncl""'n........lalad.. DATE SiGNEDIMor"ll,Oay, Yaar) D lC. 31d. May 2, 2002 NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (Jlam27)TypaorP'inl Michael L. Norris, Coroner 6375 Basehore Road, Suite #1 ~ 32. Mechanicsburg, Pa. 17050 OATEFILED(Mont~.{1oy, Year) .MEDICAL EXAMINERICORONEA On 1h'~1 ot..ernlnetlon .ndlorlnveaflg.llon, in illY opinIon, dllth occurred .11'" lime. ctIt., end plllee, end due IOlh. caU"(I' .nd m.noar..at.ted.................................................................................................. :s,.. RE9"JRAR'S SIGNATURE AND ~~ " U?t4Y ..?t o/4'-t .~'>>"- .b.V"", /1/ I " -. . Name of Decedent: Date of Death: Will No. To the Register: / j/ Hi,( ! If / CERTIFICATION OF NOTICE UNDER RULE 5.6Ia) IZ jJ; I; ) i<: ~l ( q (11(( -:.;;c >0,">-'--- Admin. No. ).,'/ n1AY 10"'- ;) (? - 0 )- eJ 0)) ( 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 Name !J/~ j 7/VClj' Ii,; ( Ii. J( Ie C Lv ~ Do"'- ) Address / 7 J. V C CC';_I< i6!LJ I)? /7(.7 u \ tlfJUU(2.. frcl Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: c j, I 1/" JI-- / / /4/YldCl~f ~ Signature Name 7 ' 1J7~ / ell ( ;" " ) ~ ( ;r irmf)U:' / 15, i (; ;?YfjIL77)t. )(/c.. I,; I Ij/R /f,S?; 7 / Address /tJ) J?A(s/c , Telephone ('5p 3'1 ~3j~J/ Capacity: /' Personal Representative _Counsel for personal representative F7-bb-b ~ BUREAU OF INDIVIDUAL INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 TAXES JOANN K POPIK 133 S CRESCENT DR HERMITAGE PA COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE *' NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOHANCE OR DISALLOHANCE OF DEDUCTION5, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS REV.1548EX....FP(Ol-03l DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY SSN/DC ACN 06-16-2003 POPIK 04-30-2002 21 02- 0511 CUMBERLANO 161-40-0567 03111020 PAUL A Amount Remitted 16148 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 ... ---------------------------------------------------------------------------------------------------------------- REV-1548 EX AFP C01-03J NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 06-16-2003 ESTATE OF POPIK FILE NO. 21 02-0511 TAX RETURN WAS: PAUL CUMBERLAND A DATE OF DEATH 04-30-2002 COUNTY S.S/D.C. NO. 161-40-0567 CX) ACCEPTED AS FILED C) CHANGED JOINT OR TRUST ASSET INFORMATIDN 03111020 ACN FINANCIAL INSTITUTION: SKY BANK ACCOUNT NO. 3800788233 TYPE OF ACCOUNT: DATE ESTABLISHED C ) SAVINGS C ) CHECKING C ) TRUST C X) TIME CERTIFICATE 06-04-1998 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due TAX CREDITS: PAYMENT DATE 04-07-2003 RECEIPT NUMBER CD002405 X 34,780.89 0.050 1,739.04 .00 1,739.04 .45 78.26 NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." X DISCOUNT C+) INTEREST/PEN PAID C-) .00 AMOUNT PAID 78.26 78.26 .00 .72 .72 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE * IF PAID AFTER THIS DATE, 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" ( CR), YOU HAY BE DUE A REFUND. SEe REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) "" *' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOHANCE OR DISALLOHANCE OF DEDUCTIONs, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS PAUL A POPIK SR 133 S CRESCENT DR HERMITAGE PA 16148 ~-1548EX"'FP(OI-03) DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY SSN/DC ACN 06-16-2003 POPIK 04-30-2002 21 02-0511 CUMBERLAND 161-40-0567 03111021 PAUL A Amount Remitted 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 ~ ---------------------------------------------------------------------------------------------------------------- REV-1548 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DEDUCTIONS. AND ASSESSMENT OF TAX ON JOINTLY HELD OR DISALLOWANCE TRUST ASSETS DATE OF 06-16-2003 ESTATE OF POPIK PAUL A DATE OF DEATH 04-30-2002 COUNTY CUMBERLAND ACN 03111021 FILE NO. 21 02-0511 TAX RETURN WAS: S.S/D.C. NO. 161-40-0567 (X) ACCEPTED AS FILED () CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SKY BANK ACCOUNT NO. 3800788233 TYPE OF ACCOUNT: DATE ESTA8LISHED ( ) SAVINGS ( ) CHECKING ( ) TRUST (Xl TIME CERTIFICATE 06-04-1998 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due 34,780.89 0.050 1,739.04 .00 1,739.04 .45 78.26 x x TAX CREDITS: PAYMENT DATE 04-07-2003 RECEIPT NUM8ER CD002405 DISCOUNT (+) INTEREST/PEN PAID (-) .00 NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." AMOUNT PAID 78.26 78.26 .00 .72 .72 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE . IF PAID AFTER THIS DATE. 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" ( CRJ, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) '\. *' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION OEPT. 280tiOl HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOMANCE OR DISALLOMANCE OF DEDUCTION~, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS KEVIN M POPIK 133 S CRESCENT DR HERMITAGE PA 16148 REV-1548 0: "FP (Ol-O~) DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY SSN/DC ACN 06-16-2003 POPIK 04-30-2002 21 02-0511 CUMBERLAND 161-40-0567 03111022 PAUL A Amount Remitted 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 ...... ---------------------------------------------------------------------------------------------------------------- REV-1548 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 06-16-2003 ESTATE OF POP IK PAUL A DATE OF DEATH 04-30-2002 COUNTY CUMBERLAND ACN 03111022 FILE NO. 21 02-0511 S.S/D.C. NO. 161-40-0567 TAX RETURN WAS: eX) ACCEPTED AS FILED C) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SKY 8ANK ACCOUNT NO. 3800788233 TYPE OF ACCOUNT: DATE ESTABLISHED e ) SAVINGS e ) CHECKING e ) TRUST e Xl TIME CERTIFICATE 06-04-1998 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due 34,780.89 0.050 1,739.04 .00 1,739.04 .12 208.68 X X TAX CREDITS: NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." PAYMENT DATE 04-07-2003 RECEl PT NUMBER CD002405 DISCOUNT e+) INTEREST/PEN PAID e-) .00 208.64 AMOUNT PAID 208.64 .04 1.92 1.96 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE * IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. * C IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) INTEREST IS CHARGED THROUGH 06-24-2003 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM "-v *' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280&01 HARRISBURG. PA 17128~0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOHANCE OR DISALLOHANCE DF DEDUCTIONs, AND ASSESSHENT OF TAX ON JOINTLY HELD OR TRUST ASSETS VICTOR M 1405 GRANIT CHULA VISTA POPIK SPRINGS CA DR 91915 REV-1548EX,I,.FP(OI-03l DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY SSN/DC ACN 06-16-2003 POPIK 04-30-2002 21 02 - 0511 CUMBERLAND 161-40-0567 03111023 PAUL A Amount Remitted 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 ~ ---------------------------------------------------------------------------------------------------------------- REV-1548 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS. AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 06-16-2003 ESTATE OF POPIK PAUL A DATE OF DEATH 04-30-2002 COUNTY CUMBERLAND ACN 03111023 FILE NO. 21 02-0511 S.S/D.C. NO. 161-40-0567 TAX RETURN WAS: (X) ACCEPTED AS FILED () CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: SKY BANK ACCOUNT NO. 3800788233 TYPE OF ACCOUNT: DATE ESTA8LISHED ( ) SAVINGS ( ) CHECKING ( ) TRUST (Xl TIME CERTIFICATE 06-04-1998 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due 34.780.89 0.050 1.739.04 .00 1.739.04 .12 208.68 x x TAX CREDITS: NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT. SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS. AGENT." PAYMENT DATE 04-07-2003 RECEIPT NUMBER CD002405 DISCOUNT (+) INTEREST/PEN PAID (-) .00 AMOUNT PAID 208.64 208.64 .04 1. 92 1. 96 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE * IF PAID AFTER THIS DATE. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. * ( IF TOTAL DUE IS LESS THAN $1. NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) INTEREST IS CHARGED THROUGH 06-24-2003 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT POPIK PAUL SR 133 S CRESCENT DRIVE HERMITAGE, PA 16148 u______ fold DUPLICATE ESTATE INFORMATION: SSN: 161-40-0567 FILE NUMBER: 2102-0511 DECEDENT NAME: POPIK PAUL A JR DATE OF PAYMENT: 04/09/2003 POSTMARK DATE: 04/07/2003 COUNTY: CUMBERLAND DATE OF DEATH: 04/30/2002 REMARKS: PAUL POPIK SR CHECK# 7974 SEAL ACN ASSESSMENT CONTROL NUMBER 03111020 03111021 03111022 03111023 TOTAL AMOUNT PAID: INITIALS: CW RECEIVED BY: REGISTER OF WILLS REV-1162 EX(11-96) NO. CD 002405 AMOUNT $78.26 $78.26 $208.64 $208.64 $573.80 DONNA M. OTTO DEPUTY REGISTER OF WillS - BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 VICTOR M 1405 GRANIT CHULA VISTA POPIK SPRINGS CA COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOHANCE OR DISALLOHANCE OF DEDUCTION~, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS '03 JUL-2 P 1 :05 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY SSN/DC ACN 06-16-2003 POPIK 04-30-2002 21 02- 0511 CUMBERLAND 161-40-0567 03111023 * REV-I548 EX AFP (Dl-O~) PAUL A DR 91fJ}5; {~\ i-lrl;_,:'~ Amount Remitted /.9 b MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 - BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 KEVIN M POPIK 133 S CRESCENT OR HERMITAGE PA 16148 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLONANCE OR DISALLONANCE OF DEDUCTIONs, AND ASSESSHENT OF TAX ON JDINTLY HELD OR TRUST ASSETS '03 JUL-Z DATE ESTATE OF DATE OF DEATH FILE NUMBER "C,OIl{'l,1Y I slSNYbC ACN 06-16-2003 POPIK 04-30-2002 21 02- 0511 CUMBERLAND 161-40-0567 03111022 l~:. , Cl:'IY-;!:_,; Amount Remitted j, 9 f:, *' REV-1548 EXAFP COI-03) PAUL A MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE~ . r BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION OEPT. 280601 HARRISBURG, PA 17128-0601 PAUL A POPIK SR 133 S CRESCENT OR HERMITAGE PA 16148 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOHANCE OR OISALLOHANCE OF DEDUCTION~, AND ASSESSHENT OF TAX ON JOINTLY HELD OR TRUST ASSETS '* .OJ JUL-2 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY P l1M1{DC R8I'1S48 QiI<F'P (01-031 06-16-2003 POP IK 04-30-2002 21 02-0511 CUMBERLAND 161-40-0567 03111 021 PAUL A c: ell Ct!lnt< Amount RQIh!tted .72-- ~AkE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 . BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. '280601 HARRISBURG, PA 17128.0601 JOANN K POPIK 133 S CRESCENT DR HERMITAGE PA COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT. ALLOMANCE OR OISALLOMANCE OF DEDUCTION~, AND ASSESSHENT OF TAX ON JOINTLY HELD OR TRUST ASSETS '03 n-2 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY P 1 S:$.$/DC ACN 06-16-2003 POPIK 04-30-2002 21 02-0511 CUMBERLAND 161-40-0567 03111020 * REV.1S411EXAFP(OI-031 PAUL A Amount Remitted 16148lM"_,J C\ 11",. ~7?-- MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 .... - . Paul & JoAnn Popik 133 S. Crescent Oriye Hermitage. PA 16148 ~" /',-.- ,~, -.' \ l.i! ,.... '--~'----r- "--.-. ,- . .... ___ I . -. . ""'\. Q\.. D'd: 511 i &J ./1 . ~,~, L:~ ell sLe y)/f / '\.~"'..)'\.~/'!I.':1f,1~ I " J "? /) /" ~ '" 1".III,(,,,,U(,II.!-:rl.f.,hd. " I I , _111.,,1.1,,1,1111 - J~ -c?5if tY5/E R.. ..L"~ . / ~U/>1~~R //1ND COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT POPIK PAUL A SR 133 S CRESCENT DRIVE HEWMITAGE, PA 16148 -------- fold ESTATE INFORMATION: SSN: 161-40-0567 FILE NUMBER: 2102-0511 DECEDENT NAME: POPIK PAUL A JR DATE OF PAYMENT: 07/02/2003 POSTMARK DATE: 06/30/2003 COUNTY: CUMBERLAND DATE OF DEATH: 04/30/2002 NO. CD 002759 ACN ASSESSMENT CONTROL NUMBER AMOUNT 03111021 I $.72 03111020 I $.72 03111023 I $1.96 03111022 I $1.96 I I I I I TOTAL AMOUNT PAID: REMARKS: PAUL A POPIK SR-JO ANN K POPIK VICTOR M POPIK & KEVIN M POPIK CHECK#8014 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS $5.36 DONNA M. OTTO DEPUTY REGISTER OF WillS 0 E~ 0 rj E~ 0 ~n ~.. $70-842-0944 ll~n~: 570.842-4574 November 15, 2004 Cumberland County Courthouse Register of Wills 1 Courthouse Square Carlisle, PA 17013 Re: Paul A. Popik, Jr. Estate No: 21-02-00511 Dear Register of Wills: Enclosed is an original and one copy of the Inheritance Tax Return for the above captioned estate. Also enclosed is payment of the inheritance tax in the amount of $111.91. John J. Mercuri JJM/ms enclosures COMMONWEALTH OF PENNSYLVANIA DEPARTMENTOFREV£NUE BUREAU OFINDIVIDUAL TAXES DEPT2$0601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004643 PQPIK CANDACE BETH 106 RYAN DRIVE MOOSIC, PA 18507 ....... fold ESTATE INFORMATION: SSN: 161-40-0567 FILE NUMBER: 2102-051 1 DECEDENT NAME: POPIK PAUL A JR DATE OF PAYMENT: 11 / 17/2004 POSTMARK DATE: 11 /17/2004 COUNTY: CUMBERLAND DATE OF DEATH: 04/30/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $111.91 TOTAL AMOUNT PAID: $111.91 REMARKS: SEAL CHECK# 821 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INOIVIOUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REY-ln1EX AFP (Ol-OJ) JOANN K POPIK 133 S CRESCENT DR HERMITAGE PA .'UL 21 DATE ESTATE OF DATE OF DEATH FILE NUMBER :':2cOUNTY ACN 07-14-2003 POPIK 04-30-2002 21 02- 0511 CUMBERLAND 03111020 PAUL A .OJ j~ (, c Allount Re..itted 16148 C.:tL. MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account) submit the upper portion of this for.. with your tax payment. CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=i60TEX-AFP-[oFii3Y------...--iNifERi'rANCE--TAiCSTAYEME-NT-O"-ACfciiuiif--.-...--------------------- ESTATE OF POPIK PAUL A FILE NO.21 02-0511 ACN 03111020 DATE 07-14-2003 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROjECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 06-16-2003 PRINCIPAL TAX DUE,.. 78.26 PAYMENTS (TAX CREDITS), PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-07-2003 CD002405 .00 78.26 06-30-2003 CD002759 .72- .72 TOTAL TAX CREDIT 78.26 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. I BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 260601 HARRISBURG~ PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REY-1601EXAfP[Ol-D3l '03 lUL 21 DATE ESTATE OF DATE OF DEATH \ 8' .n'J FILE NUMBER \ .,L COUNTY ACN 07-14-2003 POPIK 04-30-2002 21 02-0511 CUMBERLAND 03111021 PAUL A PAUL A POPIK SR 133 S CRESCENT DR HERMITAGE PA 16i48 ~':,t '~' Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account~ submit the upper portion of this forn with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV: i6i1TEx--AFP--[(iFii3r-----....--iNifERIi:ANciCi'Aic-5TA-iEME-N"i'-i1-"-Ac-ciiUiii--.-i..--------------------- ESTATE OF POPIK PAUL A FILE NO. 21 02-0511 ACN 03111021 DATE 07-14-2003 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUHHARY DF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT DR RECORD ADJUSTMENT, 06-16-2003 PRINCIPAL TAX oUE,_ 78.26 PAYMENTS (TAX CREDITS), PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-07-2003 CD002405 .00 78.26 06-30-2003 CD002759 .72- ,72 TOTAL TAX CREDIT 78.26 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG~ PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REV-IU1ElrAFP [01-05> '03 DATE ESTATE OF DATE OF DEATH FILE NUMBER ': 8 :D2 COUNTY ACN 07-14-2003 POPIK 04-30-2002 21 02-0511 CUMBERLAND 03111022 PAUL A KEVIN M POPIK 133 S CRESCENT DR HERMITAGE PA c:lJL 21 Allount Remitted 16l!i8 C\:IC': MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account} submit the upper portion of this for.. with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ Rif"=ir.iWEx-iif'p-("oFo3Y------....--iiii.fERIi:ANci:--TAx-STAYEMENT-cfF-AC-COljii'f--....----n-----------m- ESTATE OF POPIK PAUL A FILE NO.21 02-0511 ACN 03111022 DATE 07-14-2003 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-16-2003 PRINCIPAL TAX DUE: ... 208.68 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-07-2003 CD002405 .00 208.64 06-30-2003 CD002759 1. 92- 1.96 TOTAL TAX CREDIT 208.68 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. I IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. J J1-66-t '\.: BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG~ PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REV-IU7EX AFP (Ol-On POPIK SPRINGS CA ,.iUL 21 DATE ESTATE OF DATE OF DEATH FILE NUMBER "COUNTY ACN 07-14-2003 POPIK 04-30-2002 21 02-0511 CUMBERLAND 03111023 PAUL A VICTOR M 1405 GRANIT CHULA VISTA 'OJ c ( DR 919,15 Allount Re..itted i;, MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account} subllit the upper portion of this for.. with your tax pay.ent. CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=i60TEx--AFP--fiiFo:3Y------JJ..--iNHERI':ANc'Ci'Ax-sTA-iEME-N"'r-i:lF-AC-COUNi--.-.JJ--------------------- ESTATE OF POPIK PAUL A FILE NO.21 02-0511 ACN 03111023 DATE 07-14-2003 THIS STATENENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NANED ESTATE. SHOWN BELOW IS A SUNNARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYNENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE, DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-16-2003 PRINCIPAL TAX DUE:. 208.68 PAYMENTS (TAX CREDITSJ: PAYMENT RECEIPT DISCOUNT (+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-J 04-07-2003 CD002405 .00 208.64 06-30-2003 CD002759 1. 92- 1.96 TOTAL TAX CREDIT 208.68 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAYNENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ, YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORN FOR INSTRUCTIONS. J RU:1IOOEX+(MO) , , REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT : \~ ~ .", A Ilfl ~ .)1\. .J. F"7 Ii"'. ~"'.'''1': ' l~.('i. ~. ;.,--. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPl 280601 HARRISBURG, PA 17121l-{J6()1 DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) ~ W o W U w o POPIK PAUL A. JR. DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) 0413012002 (F APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDOLE INITIAL) I!! da G,iiI [K] 1. Original Retum o 4. Um~ed Estate o 6. Decedent Died Testate I'..."'....WI) o 9. litigation Proceeds Receiyed o 2. StJpPemenlal Retum o 4a Future Interest Compromise (clalieddelithaAer12-12-82) o 7. Decedent Maintained a Uving Trustl__"T""'l o 10. Spousal Poverty Credill.....__12~1.91..H95) Cf'FlClAl..la CN.Y FILE NUMBER 21 -0 2 005 1 1 ""5.5:Mv"CiXE -YEAR- - - iiiiER-- SOCIAL SECURIlY NUMBER 161-40-0567 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURIlY NUMBER 03. RemainderRetum (datllddBalhpri:Jr1012-13-82) o 5. Federal Estate Tax Retum Required _ B. Total Number of Safe Depos~ Boxes o l1.ElectiontotaxunderSec.gl13(A)~""0) COMPLETE MAILING ADDRESS PO Box 310 i I TELEPHONE NUMBER 570 8424574 Moscow (1) (2) (3) (4) (5) z o 5 :;) ~ ii: c( u w a:: 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership ex SoIe-Proprietcxship 4. Mcxtgages & Notes Receivable (Schedule D) 5. Cash, Bank ~ & 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 ex L) B. TotaIGmnA_(toIaiUnes 1.7) g. Funera Expenses & AdministraliYe Costs (Sch....1e H) 10. Debts of Decedent Mcxtgage liabilities, & Uans (Schedule I) 11. Total Deduction. (total Unes 9 & 10) 12. Net Valua of EIlIIe (Une B minus Une 11) 13. Charitallle and Governmenlal BequeslslSec 9113 Trusls fex which an election to tax has not baen made (Schadule J) (6) (7) (9) (10) 14. Net Valu. Subjact to Tax (Une 12 minus Une 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ ~ :;) Q. :E o U ~ ~ 15. Amount of Une 14 taxable at the spousal tax rate, ex transfers under Sec. 9116 (a)(1.2) x ..00 (15) 2,486.85 X .045 (16) X .12 (17) X .15 (IB) (19) 1 B. Amount of Une 14 taxllIlle at ~neaI rate 17. Amount of Une 14 taxable at siblin9 rate lB. Amount of Une14 taxable at coIla1era rate 19. Tax Due 20. 0 C~ECk f-JEP~ I;:: YJU APE REOU~STING A PEFU'W CF.'I.N C'/EPP'::'d,1~!or if- 105;340.00 I PA 18444 . OFFICIAL USE ONLY ~ -J ~ I _J (8) 105,340.00 2,558.92 67,807.39 (11) (121 (13) 70,366.31 34,973.69 (14) 34,973.69 111.91 111.91 ~cedetlfs Cc'implete Address: STREET ADDRESS 1728 Creek Vista Drive CITY I STATE I liP New Cumberland PA 17070 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. ClllditslPayments A. Spoosal Poverty Credij B. Prior Payments C. Discount (1) 111.91 Total Credits (A + B + C) (2) 3. Interest/Penalty ~ ~icabIe O. Interest E. Penalty TotallnteresVPenalty (0 + E) (3) 4. K Une 2 is !16ater thoo Une 1 + Une 3. enter the difference. This is the OVERPAYMENT. Check box on Page 1 Un. 20 to request. refund (4) 5. II Une 1 + Une 3 is QI'IlOO!f !han Line 2, enter the difference. This is the TAX DUE. (5) 111 .91 A. Enter !he interest on the tax due. (5A) B. Enter Ihe total of Une 5 + 5A. This is !he BALANCE DUE. (5B) 111.91 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "J(" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain Ihe use or income oflhe properly transfened;......................................................................... 0 ~ b. retain Ihe right to desi!Jlate \\i1o shall use Ihe properly transfened or its iocome;...................................... 0 IZI c. retain a reversionary interest;.or.................................................................................................. 0 ~ d. receive the promise for I~e of OOher payments, benefits or care?......................................................... 0 [sa 2. K death occurred after December 12, 1982, did decedent transfer properly within ooe yea of death without receiving adequate coosideralion?......................................................................................... 0 ba 3. Did decedent own 00 'in trust for' or payable upon death book account or security at his or her death2............... 0 IiQ 4. Did decedent own an Individual Retirement Account, annuity, or o!her non-probate property which contains a beneficiary desilJlatiOJJ?.................................................................................................. 0 f!g IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Und8f penaties of peljwy, I decln that I have 8X8fTlined this return, i1cUding ~ schedules and statements, iIWId 10 the best of my kncrM9dge 8I1d beief, it is true, correct and compktte. DedinItlf1 of prepnr other than the personal representative is based 00 aI information of wtJicI1 prepnr has lily knowledge. SIG RE OF PERSON RESPONSI E FO ING R TURN OATE //-/F-c OATE / /-/ S--O r O. 'S I cJ fL1? 5 G:Tt./>J f/I For dates of death on or after July 1, 1994 ood before January 1, 1995, the tax rate imposed on Ihe net value of transfers to or for the use of !he surviving spouse is 3% [72 P.S. ~116 (a) (1.1) (ill. For dales of death on or alter Jaooary 1, 1995, the tax rate imposed on the net value of tr.mfers to or for the use of the SlIViving spouse is 0% [72 P.S. ~116 (a) (l.l)(ii)]. The stalule does not exernol a transfer to a surviving spouse from tax, and the stalulory requirllments for disclosure of assets and filing a tax mlum are still applicable even ~ the surviving spouse is the oniy beneficiary. For dates of death on or alter July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-{)ne years of age or younger at death to or lor the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~116(aX1.2)]. The tax rate imposed on the net value of transfers to orlorthe use of the decedent's lineal beneficiaries is 4.5%, except as noted in n P.S. ~9116(1.2) [72 P.S. ~9116(a)(I)]. The tax rate Imposed on the net value of transfers to or for !he use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an inttlvlrll ~ who h::tRi At IAActt nnA MrAnt in I"'J'II11mnn \Mth thA rfAMtiAnt whAthAt' tw hInnrt or Mnnlinn "':1_'("~'. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DE EDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER POPIK PAUL A JR 21 02 00511 All ...1 property ownod solely 0' II . tenant In common mull be roportod II IIi' morkelVllue. Fair market value Is defined as the price at which prq>erty would be exchonged __ a wiIIi1g buyar and a wining seller, neither being compelled 10 buy or sell, both having caasonabIe knowledge of the relevant facls. Real property which Is jol~nod with right 01 lll..ivGnhlD mull be dloc:l..... on Sohodul. F. ITEM NUMBER 1. DESCRIPTION Real estate located in Lower Allen Township, Cumberland County, Tax Parcel Number 13-25-0008-021, Market value date of death - $105,340.00 (see attached) VALUE AT DATE OF DEATH 105,340.00 TOTAl. (Also enteron line 1, Recapitulation) $ 105 340.00 II~ ____ _____ =_ ___.J_.J =___... _......:&:___1 _'-__&_ _,c"L._ ____ _:__, ""''''''''''''1''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF POPIK PAUL A JR Debts of decedent must be reported on Schedule I. FILE NUMBER 21 02 00511 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Stone and Murray Funeral Home, New Cumberland, PA 1,800.00 B. ADMINISTRATIVE COSTS: 1. Penlonal Representative's Commissions Name of POISonal Represenlative (s) Social Security Numbe<<s) I EIN Numbefof POfSOI1aI Representalive(s) Street Address City Slate Zip Yea~s) Commission Paid: 2. Altomey Fees John Mercuri 450.00 3. Family Exemption: (If decedenfs address is not tI1e same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant 10 Decedent 4. Probate Fees Cumberland County Courthouse - Register of Wills 278.00 5. Accountant's Fees 6. Tax Relum Prepa....s Fees 7. certified mail 3.92 8. Register of Wills - Short Certificates 13.00 9. Postage 14.00 TOTAL (Also enfer on line 9, Recapitulation) S 2 558.92 (If more space is needed, insert additional sheets of the same size) ':_"0,.. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF POPIK PAUL A JR FilE NUMBER 21 02 00511 Include "nreimbursed medical .xpon.... ITEM NUMBER DESCRIPTION AMOUNT 1. Beacon Hili Property Management Association 360.00 2. AT&T Wireless 51.39 3. Sovereign Bank - Mortgage payments on residence - 1728 Creek Vista Drive. New Cumberiand. PA. Township of Lower Allen (fll'fYtJI'F) 67,396.00 TOTAl (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 67807.39 ,.~ _"13"'.('~n~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESVENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER lA.II A .IR 71 n? OOfi11 RELATIONSHIP TO OECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Us! Trustae(l) OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Candace Beth Popik wife 30,ooo.OOcjf intestate 106 Ryan Drive estate and 50% of Moosic, PA 18505 balance 2. Matthew Popik son 50% of intestate estate 1728 Creek Vista Drive after the first $30,000.00 New Cumberland, PA 17070 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, 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 MAOE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) Nov.12 2004 11:30 Nov 12 '0'1 ~ 1 : 25a :::J,_:.::.::: _.... School. -I: WE':'t SHORE .sD I.,acat1c~l! : 1128 c il'X ~t.ST^ DRIVS BIACC>>I ILl. VILLAQ!: 1.0'1' 57 pH 1 , iI& &4 PC 51 Bill's AFtermarket Autobo 570-689-7335 p.s The Plum 1717J232-5594 p.2 THIS IS NOT A TAX BilL Parcel Identifier: 13-25-0008-021. I TllJUWZ ! , UNl~/LO~1 10..: L-QOS7 l.&n$ SiZ~, . . .;: .10 ae:cea PLopereyl Typ.; 1\ llCII.i.d.n~~.l Slui.1.din'31 I . , , , Old .........d V./ue 2004 New AsI85,.d 'Value (2OOC MIjIII'Ut; )It 100%') Marklltt VI:IlI\lO 1>00' Mo"'c' . 1001'01 Lana - 9 850 26,600 26,600 Building. "r' ."" 96,150 96,150 TOTI'.L / 105,340 '" 122,750 122.750 2004 Cleal'l and Green V:lIlue5 Lind -" N<l'l NOT NOT 6lJildil\gs APPLICMlLE APPLICABLE APPLICl\Sx.E TOTI'.L Clean and G,"ll values apply to so,,,,, farm and foreslland. Such vllues become effecUve onlY upon a8Plicauon .od approval. All applicalions must be r<>Cl!lved by \he Assessment fflce ~ 4:30 p.m. on October 15, 2004. Those previously approved 'or Clean an Green do nol need to ",.apply. I , , pennSYIVaJ~'a 'aVy requires thai slf mal !>Stale be valued BS of flul mo&l ",ceN county-Wide ",assessment The lasf reassqssm I. or I"" base year, was 2000. Since the lest ",esse.sment jn 2000. proPBl1les hBVe bIXIn A.','MSM 0"00% of Year lOoo alue (lite '~CleIBrmiMd Ratio'). The new tax base yr>a,. will be Ihe y"",. 2004, wilh the new ..s<>saecf value. becoming ~"ectiv.. forlhe 200518. year. The Pre..lJetetmined Retlo rrtmalns at 100%. Your lIew BSs.sseel value equals you, Yaa,2004 matl<et vslUIJ. WIlen the lew 2004 lu base ;s derermlned afIR, this reas$8S$menl, all laxing dlsrrlcts tire requt",d by law to towar !he mlllego "'; by the ..ame ",oporoon thaI the t.x ba.. wvnf up. The law provides that 1ft the firsl 1/1ar 81'1e, l'!toss..ss",en' (lOOS), thelcounty alia 811 lownshlps aM boroughs mey not increase oV/lrali revenue nn tl'A"r e.I.~'ng t...bue by mo..s tI1an five percen (S%) and school districls may not incress.. ove,aU ",vsnua on //rei' existing lsJrbase by more thon len percenl (10%). Tn county anel the other/axing bodies will make Ih8S/1 cfecis;ons nl1xt year, and may choose nat Co Increase overall ",venua, f course, ~ome individuel's raxes will ga U/J or rioWtl by mare than IIlOSB perr:enlages, The ess"ntlal point Is that a,n InCf'6418 in rTllIlrk.t v.lues dOC6 not IleCd$iIlffly mean a corresponding IncreUC!lln taxes. Individual changes in taxes will pend upon a $plIciflc property's change as compared to the overall thange for the laxing dlslrlct. Tha ESTIM TED impact slatement printed belolV is OUt best eslImAI. (lr ch~nD'" baud On 2004 COUNTY 1'1> "g"'o" THIS ESTIMATE ODES NOT INCLUOE f>.NV BOROUGH. TOWNSHIP. OR SCHOOL DISTRICT IMPACT. STIMATIl:O COUNTY :i:AX lMPACT: CurrQnt 2004 County cills - Adju.~.d 2004 County mill. 2.352 2.l38 ~ 4B 2004 County Tax BEFORE Reasses..ent. $ 62 : 2004 ~nvnty Tax AFTER RC3Do~o~.n~. 'Nov. 12 -, 2004 11: 29 I I Bill's AFtermarket Autobo 570-689-7335 p.1 $ 0, e>b OJ 76574085 CUMBEIUAND I 10/23102 i ##2-04 I 706 I , I I~&)U i I , I -:..!;....,.,..~_..; :.'C~:~;(T P. ZJEGL[~ . 0 'I" "'-R ' "~"". ~1,,,; \ vF DEEDS "EERLAND COUNn< MORTGAGE SATISFACTION PIEC~~2 NOU 15 AI'l11 32 i I . Made thlS 24TH jay at OCTOBER, 2002 Name/sofMort agorls: PAULA. POPIK Name/s of Mort agee/s: COMMERCE BANKlHARRISBURG N.A ASSIGNED TO SOVEREIGN BANK Date Recorded: 12/27101 Book, 683 Page: 1724 ."...~ --- Date ofM rtgage: 12/,7/01 MOI1 on: 12/27/01 ng. MortgagO\Debt~: 67,5 , . 0z;J In the om of/he Recorder of D~eds of: In Mortgag~ BooJ,1l i Pag~# Mortgage Prbmise's: I I lax ~arcel # I ' I ; The undersigned fueleby certifies that the debt by the .bove mentioned mortg.ge has been fully paid or otherwise discharged and that upon the recordinh hereof said mortgage shall be hereby fully and forever 5ttt1sfied and discharged. I In Witness WheT~of, the said corporation has caused its common or corporate seal to be hereto affixed the 24TII of OCTOBER, A.D., 2002. I '.. ,~;.i~l iV'''' . ./ .,Iii:, , ,~, ..", ''4",., ~-, ", . ~ < .'~' '\ ..,"'...-..... . , '. ,. ejl" " srglio,d, ~ ..., i'.'" ~ ,~';- "{~nt ' 'it:: ';:rt. ~,;i :,; ""';''''''''..'''' - !'Fl:,t-'i>~i''ri~ ,.ti'" .<.;.: ,~:'t- "- .. "', '._~l.:"!~.;"".i'.~,:#'"" \~}.' _..~'~ ~;"'i. '_:~",' '{{-~\"';',/.J.:"\.~" 14~':;~~;?~:~.:.;.." 1;:; CUMBERLAND 1743 3805 1728 CREEK VISTA DR NEW CUMBERLAND TO\I/NSHIP OF LOWER ALLEN PA 17070 SOVEREIGN BANK A Federal Savings Bank ATTEST: COMMONWEA(TH OF PENNSYLVANIA COUNTY OF 81~}<KS . , By: IIbtlt#~ Nicholas J. Badame, Assistant Vice President Sovereign Bank , I : I ! On the 241'11 day pfOCTOBER, 2002, before me. the undersigned officer, personally appeared Nichol.s J Badame, who acknowledged hlltelf to be the ASSlStant Vice President of SOVEREIGN Bank, a Federal Savings B.nk, a corpora1lon, and th.t he as su:h VIce PreSide t being authonzed to do so, executed the foregoing instrument for the purposes therem contained by the Slgnmg the name of the corpo, abon, by mrr-::;elf as Assistant Vlce PreSIdent. :t70:{_~~AtJi1"' " ') & ;p [; ~,ffi.fi..".r!li;-,{,'",\ ! --.;>,-r;>/" _S<ial, ~',f0' ,":~"". '"',''' , \J. , r/ (,.- ~ u-w.. 0 Holfn'-~ .........p .t.ll~ ....., c~, :(-"1'". 'JI\: 'l.i' '\l: ,fII, ~~...aw, ~.er,,_, l_ ,I It'' .,,<f',lk";""~" ~~' in Witness WherepC, I have hereto so my and and Seal. G1tyOf_g,I3QrlIs(,"".\Iy~~:i" "'~~'\Ji~i>I~~ ,,",,( "'~ i MyCorrrnisslon ""res July 8 2006 11\~,'iI't .' , ",,' ,i": l:~ ' Manu..-.Pamsy~.~;~...'.m~r~11os ~,t \~";'1'1\'\Il't~W"._' i/f!j.'- ~. '{ ".?> .". .;;a:~)) ',f( t ~::' ""~:,,,,,~'~-:'{<;:~'I:j'.':.a.;,~\\ ,h,,;~,ff> ':;;4i~f.'t.ij.l#;~~'~;'..".".' '\.""';:> -~""'l~!"'\':"!~"? B9Di\ 691 fAGE401? .r' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDI~!l(llr.UPt){l@. S0~F.',.CE OF INHERITANCE TAX D1Ytn6f'"r.-..-. 1 10 PO BOX 280601 )-:,.,,1,>- ','.-.1 HARRISBURG PA 171Z8-b6~I ' NDTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ZOOS Jft,N III Pi! 3: 14 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 01-17-2005 POPIK 04-30-2002 21 02-0511 CUMBERLAND 101 Ci r.DK nr: ,-' II \''''" O~r' 1".;:1'(.... r""'.lli."::T h(:,'--,[' ,:_~I'_/'j'): I I JOHN IfIl~URI Arty' v'.,.. PO BOX 310 MOSCOW PA 18444 *' REV-1547EX AFP U2-D4l PAUL A Allount Rellitt.d 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 ~ flE.V :rA4"'f.lx..AFp..r~1.-.6J'--NalYcE.oF.iNHii.ifAN.cl!.YAX.A.PPRA.isEMir~T:..ALtOWANCf.OR......_.._._.. --- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF POPIK PAUL A FILE NO. 21 02-0511 ACN 101 DATE 01-17-2005 TAX RETURN WAS: I X I ACCEPTED AS FILED I 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. Hortgages/Notes Receivable (Schedule DJ 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets III 121 131 141 [51 (6) (71 105,340.00 .00 .00 .00 .00 .00 .00 181 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax 191 1101 2,558.92 67.807.39 1111 1121 1131 1141 NOTE: If an assessment was issued previously, lines reflect figures that include the total of ALL ASSESSMENT OF TAX: IS. Amount of Line 14 at Spousal rate (15J 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due NOTE: To insure proper credit to your account~ submit the upper portion of this form with your tax payment. 105,340.00 70.366 3) 34,973.69 .00 34,973.69 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. 32,486.85 X 00 = 2,486.85 X 045= .00 X 12 = .00 X 15 = 1191= .00 111.91 .00 .00 111.91 TAY ''''EDITS: " ,+! AMOUNT PAID DATE NUMBER INTEREST/PEN PAID I-I 11-17-2004 CD004643 .00 111.91 BALANCE OF UNPAID INTEREST/PENALTY AS OF 11-18-2004 TOTAL TAX CREDIT 111.91 BALANCE OF TAX DUE .00 INTEREST AND PEN. 9.10 TOTAL DUE 9.10 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. I IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)~ YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. I c ~ q...= Cumberland County - Register Of Wills One Courthouse Square Carlislel PA 17013 Phone: (717) 240-6345 Date: 3/15/2005 POPIK CANDACE BETH 106 RYAN DRIVE MOOSICI PA 18507 RE: Estate of POPIK PAUL A JR File Number: 2002-00511 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 I NO. 103 SUPREME COURT RULES DOCKET NO. 11 for decedents dying on or after July 11 19921 the personal representative or his counsell within two (2) years of the decedent1s deathl shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 4/30/2005 Your prompt attention to this matter will be appreciated. Thank You. SincerelYI ~~~ GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Counsel Judge ~ - Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name ofDecedent: (Pt11-< ( Ii Po Pi !< J f2.- Date ofDeath: HI^'/ L 50 -::2-eo '"L- Estate No.: ;;>00 L - OcJ -S-II 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. Sta~ether administration of the estate is complete: . Yes}b' 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 ~personal representative file a final account with the Court? Yes f{ No 0 b. The separate Orphans' Court No. (if any) for the personal representative's account is: 1lii::'V~ c. Did the pers~~presentative state an account informally to the parties in interest? YeX 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 y be . attached to this report. ; v-/l Date: ~ In ' IJ1. e Capacity: Atv (..f \ 'k: Name J:!,,~ Py~llJ.we I tr!Oa5IG f~ 'S7U 3~ 3 3S")) Telephone No. ~ Personal Representative o Counsel for personal representative ~