HomeMy WebLinkAbout04-1058
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of HAZEL M. DAVIS No. oJ.. ,- '\)'\ - ,,~S ~
also known as To: Register of Wills for the
Deceased. County of Cumberland in the
Social Security No. \., a..t .. '20 -,9' \ L/ Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner is 18 years of age or older and the Executrix named in the last will of the above
decedent, dated January 7,1999 and codicil(s) dated [none].
Decedent was domiciled at death in Cumberland County, Pennsylvania, with her last family or
principal residence at 1313 Pine Road, Dickinson Township, Carlisle.
Decedent, then 92 years of age, died November 2, 2004, at Carlisle Regional Medical Center,
Carlisle, Pennsylvania.
Except as follows, decedent did not marry, was not divorced and did not have a child born or
adopted after execution of the will offered for probate; was not the victim of a killing and was never
adjudicated incompetent:
Decedent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $ unestimated
(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: None
WHEREFORE, petitioner respectfully requests the probate of the last will and codicil( s) presented
herewith and the grant of letters testamentary thereon.
;- '" '17l ~ ~
'. .' Mary Crull -
2323 Ritner Ighway
,-", Carlisle, P A 17013
;.::: (717) 249-3603
==========~~=============================================================
OATH OF PERSONAL REPRESENTATIVE
COMMONW~L TH OF PENNSYLVANIA )
. - SS
~ .~-'~ : .
COUNTY OF CUMBERLAND )
The petitioner above-named swears or affirms that the statements in the foregoing petition are true
and correct to the best of the knowledge and belief of petitioner and that as personal representative of the
above decedent, petitioner will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed )( Lfl7 O/vrf- ~
before me this , ~ ~\.. day of Mary Crull
~~~~~ , ~~~,\.
~~ '::.;~'- ~~~
~ I\<.. '\(~.~..'" ~~ Registe I
No. J.. \ -~~ ~ ~ , 5 ~
Estate of Hazel M. Davis, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW, ~~'i~~ ..., . )..~~~ , in consideration of the petition on the reverse side
, hereof, satisfactory proof having been presented before me,
ITIS DECREED that the instrument(s) dated January 7,1999 described therein be admitted to probate and
filed of record as the last will of Hazel M. Davis and Letters Testamentary are hereby granted to Mary
Crull.
Will Book # ~~ ~~ ~~~ ~~
Page Register of Wills ~ ~~ '). ~'U ~
.....::~
FEES John B. Fowler, III (06273)
Probate, Letters, Etc. $ S~ . ATIORNEY (Sup. Ct. I.D. No.)
Short Certificates( ) $ \,0. MAR TSON DEARDORFF WILLIAMS & OTTO
-ReRHRciatioa)l...lrc"" ~,';. $ <=\. 10 East High Street
~~~ ~'(.~ $ '\~ . Carlisle, P A 17013
TOTAL $ "'\'5 .~~ (717) 243-3341
Filed
F:\FlLESIDA T AFILEIEST A TESI9769 l.petition.1tr
Thi, is to certify that the information here given is correctly copied from an original ee~'~ificate of death du~r filed with me as
Lucal Registrar. The original certificate will be forwarded tu the State Vital Records OtlIce for permanent tIling.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00 ",'1111"""""""'" '&- <:o:~,:~~
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H10S. 1<1.3 Rev. 2/87 COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
'YPElPRINT
IN STATI FlU: NUMBER
ERMANENT NAME OF DECEDENT (First. Midde, LU, SEX SOCIAL. SECURITY NUMeeR OATEN DEATHIMcnlh.o..,. .....,
!l&.ACKINK 1- Hazel M. Davis 2. Female 3.174 - 20 Nov. 2, 2004
AGE {llllst8itttldayt UNDER 1 YEAR UNDER 1 DAY
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DeCEDENT'S USUAl OCCUPRIQN MARITAL SMUS. Married SURVIVING SPOUSE
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< REGISTRAR'S SIGNATURE AND NUMBER
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F:\FILESIDA T AFILE\ WILLS\9769. WIL
. .' , . .
,
LAST WILL AND TESTAMENT
I, HAZEL M. DAVIS, of Dickinson Township, Cumberland County, Pennsylvania, being
of sound and disposing mind and memory, do hereby make, publish and declare this to be my Last
Will and Testament, hereby revoking any and all former Wills or Codicils by me made.
1.
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and
all inheritance taxes (whether such taxes may be payable by my estate or by any recipient of any
property) shall be paid from my residuary estate as soon as practicable after my decease and as part
of the administration of my estate. My personal representative shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other
property not passing under this Will.
2.
I bequeath my personal effects, my household goods and furnishings, and other tangible
personal property, as follows:
A. To my daughter, MARY CRULL, providing she survives me, my radio and record
stereo comb~nation system, all of my record albums and all of my jewelry.
B. To my son, GEORGE WAGNER, providing he survives me, my bedroom suite.
C c.~ To my son, IRA E. WAGNER, providing he survives me, my antique dining room
. .--
table and dining room chairs.
D.::; To my son, ROBERT WAGNER, providing he survives me, my oval marble top
stand, my large pink and white parlor lamp, my living room suite and living room chairs.
E. I direct that any automobiles or motor vehicles I may own at my death, my personal
effects, such other household goods and furnishings, and other tangible personal property of like
nature (not including cash or securities) shall be sold at public sale by my personal representative,
provided, however, that any automobiles or motor vehicles may be sold at private sale in the sole
discretion of my personal representative, and I further direct that the net proceeds thereof shall be
administered and distributed as a part ofthe residue of my estate.
1-4- m.{9
H.M.D.
Page 1 of 4 Pages
3.
I give, devise and bequeath all the rest, residue and remainder of my estate, both real and
personal property, in equal shares, unto my children, MARY CRULL, GEORGE WAGNER, IRA
E. WAGNER and ROBERT WAGNER, absolutely, provided that the share of any child who
predeceases me or dies on or before the thirtieth day following my death shall be distributed to his
or her issue per stirpes living on the thirty-first day following my death, and in default of any such
then living issue, such share shall be added to the shares for my other children.
4.
I nominate, constitute and appoint my daughter, MARY CRULL, as Executrix of my estate.
In the event she is unwilling or unable to so act, then I appoint my son, GEORGE WAGNER, as
Executor of my estate. In the event he is unwilling or unable to so act, then I appoint my son, IRA
E. WAGNER, as executor of my estate.
5.
I direct that my personal representative shall not be required to file a bond to secure the
faithful performance of her or his duties in any jurisdiction.
6.
I authorize and empower my personal representative, in her or his sole and absolute
discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any
real or personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose
of or grant options in regard to any or all property of any kind forming a part of my estate for such
terms and such prices as she or he may deem advisable; to borrow money for any purposes
connected with the protection and preservation of my estate; to mortgage or pledge any real or
personal property forming a part of my estate or to join in or secure the partition of same; to
compromise any claims or demands of my estate against others or of others against my estate; to
make distribution in kind and to cause any share to be composed of cash, property or undivided
fractional shares in property different in kind from any other share; to employ agents, attorneys and
proxies and to delegate to them such power as my personal representative considers desirable and
to pay reasonable compensation for such services as may be rendered by such agents, attorneys and
)t)1,B
R.M.D.
Page 2 of 4 Pages
proxies; and to execute and deliver such instruments as may be necessary to carry out any of these
powers. In addition, I direct that my personal representative shall have the power to conduct an
inventory of any safe deposit box necessary to the administration of my estate.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 1#t day of
~ ,199Q.
~ M. F;~/ (SEAL)
Haz M. Davis
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testatrix, as and
for her Last Will and Testament, in the presence of us, who at her request, have hereunto subscribed
our names as witnesses thereto, in the presence ofthe said Testatrix and of each other.
~~.~ 1~(1 Ca7-tr~~
Page 3 of 4 Pages
"
. . .
COMMONWEAL TH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
I, Hazel M. Davis, Testatrix, whose name is signed to the attached or foregoing instrument,
having been duly qualified according to law, do hereby acknowledge that I signed and executed the
instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary
act for the purposes therein expressed.
~I ~ M 18D.ll..l-4.1
Hazel . Davis
~ Sworn or affirmed to and acknowledged before me by Hazel M. Davis, the Testatrix, this
'1 dayof ~ ,1991.
(' JYtA..~( N: ~
Notary Public
Notarial Seal
Corrine L. Myers, Notary Public
'Carlisle Boro, Cumberland County
COMMONWEALTH OF PENNSYLVANIA ) L My Commission Expires May 27, 1999 __
: SS.
COUNTY OF CUMBERLAND )
We,~/6L l . 0;<- and mAre;,,- . C
the witnesses whose names are signed to the attached or foregoing instrument, being dul qualified
according to law, do depose and say that we were present and saw Hazel M. Davis, the Testatrix,
sign and execute the instrument as her Last Will; that the Testatrix signed willingly and that the
Testatrix executed it as her free and voluntary act for the purposes therein expressed; that each of
us, in the hearing and sight ofthe Testatrix, signed the Will as witnesses; and that to the best of our
knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
VJtn<<U
Address
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Addrek/ / 3'1 (, fg,ijj bU 1Gf.,
6cz.-L ~J ...tL.....Y:J< t~ (760,T
Sworn or affirmed to and subscribed before me this 7flc day of ~ ' 1991.
~'~~J
Notary Public r
I Notarial Seal I'
Corrine L. Myers, Notary Public
Page 4 of 4 Pages Carlisle 80ro, Cumberland County .
i My Commission Expires May 27, 1989 ,
I ,
F:\F1LES\DA T AFILE\EST A TES\9769.1.notice.cert
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Hazel M. Davis
Date of Death: November 2, 2004
File No. 21-04-1058
To the Register:
I certify that notice of estate administration required by Rule 5.6(a) ofthe Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate on or
about December 29, 2004.
Ms. Mary Crull Mr. Robert A. Wagner
2323 Ritner Highway 2551 Walnut Bottom Road
Carlisle, P A 17013 Carlisle, P A 17013
Mr. IraE. Wagner,$r. Mr. George H. Wagner
1243 Pine Road 820 Pine Road
Carlisle, P A 17013 Carlisle, P A 17013
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: N/A
Date: December 29,2004 Signature .~~
Name J hn B. Fowler, ill, Esquire
ARTSON DEARDORFF WILLIAMS & OTTO
Ten East High Street
Carlisle, P A 17013
(717) 243-3341
Attorneys for Personal Representative
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COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96l
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 28060 1
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 004894
CRULL MARY
2323 RITNER HIGHWAY
CARLISLE, PA 17013
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
__nnn fold ___n_nn n__Un
101 I $350.00
ESTATE INFORMATION: SSN: 174.20-7914 I
FILE NUMBER: 2104-1058 I
DECEDENT NAME: DAVIS HAZEL M I
DATE OF PAYMENT: 01/28/2005 I
POSTMARK DATE: 01/28/2005 I
COUNTY: CUMBERLAND I
DATE OF DEATH: 11/02/2004 I
I
TOTAL AMOUNT PAID: $350.00
REMARKS:
CHECK# 96
INITIALS: CCP
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
MARTSON DEARDORFF WILLIAMS & OTTO
MDW&'O ATTORNEYS & COUNSELLORS AT LAW
WILLIAM F. MARTSON CARL C. RISCH
INFORMATION. ADVICE. ADVOCACY
JOHN B. FOWLER III DAVID A. FITZSIMONS
EDWARD L. SCHORPP DAVID R. GALLOWAY
10 EAST HIGH STREET DANIEL K. DEARDORFF ANTHONY T. LUCIDO
CARLISLE, PENNSYLVANIA 17013 THOMAS 1. WILLIAMS. CHRISTOPHER E. RICE
TELEPHONE (717) 243-3341 Ivo V. Orro III JENNIFER L. SPEARS
FACSIMILE (717) 243-1850 GEORGE B. FALLER JR.'" HILLARY A. DEAN
INTERNET w\VW.mdwo.com *BOARD CERTIFIED CIVIL TRIAL SPECIALIST
January 28,2005
HAND DELIVERED
Office of Register of Wilts
Cumbertand County Courthouse
Carlisle. PA 17013
RE: Estate of Hazel M. Davis
Estate No. 21-04-01058
Date of Death: March 6, 2001
Dear Clerk:
Enclosed with this letter is estate check number 096 in the amount of$350.00 representing
payment of Pennsylvania Inheritance Tax in the above-referenced estate.
Wilt you please issue the appropriate receipt and forward it to me at the above address. [
thank you in advance for your prompt attention to this matter.
Very truly yours,
MARTSON DEARDORFF WILLIAMS & OTTO
/5.~~..-
J
JBF, IIVvlo
Enclosure
F\FILES\DA T AFILE\EST A TES\9769 l.row.taxpayment
INFORMATION . ADVICE . ADVOCACY SM
"JAtJO
""'""'.:'." '* REV-1500 L""""""(t@~~
COMMO'W,^,OHoeeENN",VAN,^ INHERITANCE TAX RETURN 'FILE NUMBER .../
- omR:;~;~',~~fvE,"E RESIDENT DECEDENT 21 04 01058
HARRISBURG. PA 17128-0601 _ _ _ _______ __ __________ __ _______ G9!dt-!:rYC.QQE_ Y!"AR__ N_U~!!!=R
-----------.. ---------
DECEDENTS-NAME(lAST:-FIRST, ANO-MIODLEINITiALj-- ------,-- SOCIAL SECURITY NUMBER
DAVIS, HAZEL M. 174-20-7914
ffi DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) --------.THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
c
~ 11102/2004 07/2611 9 1 2 REGISTER OF WILLS
o (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST. FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~ Original Return 0 2 Supplemental Return 0 3 Remainder Return (dale of death prior to 12-13-82)
w
~ Ul D 4 Limited Estate 0 4a Future Interest Compromise (date afdeath after 0 5 Federal Estate Tax Return Required
~~~ 12.12~)
w.u
13 ~ g ~ 6 Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach 0 8 Total Number of Safe Deposit Boxes
It c::t of Will} copy of Trust)
<( 0 9 Litigation Proceeds Received 0 10 Spousal Poverty Credit (date of death between 0 11.Election to tax under Sec. 9113(A) (Attach Sch 0)
J_~:~ 1~~1 ~_~ H~~.ID._
,THIS SECTION MUST_BE C_~MPLETE[). AL,L C()RRESPONP5~C"'~"~CON!'l!1J!~!~~1,.TAlll&_~RM...rloJ:l~H2:YhO!!EOIIlSC!l;D TO"-___ _..
NAME COMPLETE MAILING ADDRESS
d'! ~ John B. Fowler, III, Esquire
Ww
et:" 0 FIRM NAME (If applicable) .
:5 i5 Martson Deardorff Williams & Otto Ten East HIgh Street
U . Carlisle, P A 17013
iTELEPHONE NUMBER
717/243-3341
---------. - ------------ ----------
----------------- -
----------
1, Real Estate (Schedule A) (1) None
-----------
2. Stocks and Bonds (Schedule B) (2) None
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) None
4. Mortgages & Notes Receivable (Schedule D) (4) None
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 18 121.31
(Schedule E) ,
6. Jointly Owned Property (Schedule F) (6) None
~ 0 Separate Billing Requested -------
~ 7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property (7) None
~ (Schedule G or L)
~ 8 Total Gross Assets (totaJ Unes 1-7) (8) 18,121'.31
U
~ 9 Funeral Expenses & Administrative Costs (Schedule H) (9) 11,856.67 ...1::-
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 33 O. 20
11. Total DeductionB (total Lines 9 & 10) (11) 12,186,87
12. Net Value of Estate (Line 8 minus Line 11) (12) 5,934.44
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 5,934.44
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2) -
~ 16.Amount of Line 14 taxable at lineal rate 5.934.44 x .045 (16) 267,05
~ -
~
~
~
~ 17. Amount of Line 14 taxable at sibling rate x .12 (17)
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g 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19 Tax Due (19) 267.05
20 ~ CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
...._____~~=~_..-~>".liij;$~~Tq:AN.:$wiRAf~9g~$1'Q~~~~Il.~VERS.E&1i5i;_Ai'lp'li!eCHSCK MArHc<~ _.
Copyright 2000 form software only The Lackner Group, Inc. Form REV.1500 EX (Rev. 6-00)
~
Decedent's Complete Address:
STREET ADDRESS
1313 Pine Road
CITY Carlisle STATE PA ZIP 17013
Tax Payments and Credits:
1 Tax Due (Page 1 Line 19) (1) 267.05
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments 350.00
C. Discount 13.35
TotaICredits(A+B+C) (2) 363.35
3. InteresVPenalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPAYMENT. (4) 96.30
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 theTAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + SA. This is theBALANCE DUE (58) 0.00
Make Check to: REGISTER OF WILLS. AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;. ....... ......... ........................... 0 ~
b. reta~n the right. to des~gnate who shall use the property transferred or its income;.. .. ........................ ~ ~
c. retarn a reversionary rnterest; or ................................. ........ ....... ~
d. receive the promise for life of either payments, benefits or care?. ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ......... .......... ...on.. ........... D ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ D [8J
4. Did decedent own an Individual Retirement Account, annuity, or other non.probate property which
contains a beneficiary designation? ................ ....... .................. .. .m......... .. ..... ....n.. 0 [8J
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 Ihat I have examined this relurn, including accompanying schedules and slalemel11s, and 10 Ihe besl of my knowledge and belief, it is Irue, correct and complete. Declaration
preparer other than the personal represenlalive is based on allm/ormation of which preparer has any knowledge
SiGNATURE OF PERSON RESPONSIBLE FOR FiLING RETURN ADDRESS DATE
Mary Crull -'J _, /7 2323 Ritner Highway ~, .....-
, 7)1 a....HC..,._~F . Carlisle. P A 17013 :.? ,_ / c - t- oJ
SrGNATUR~ OF P'ON RESPONSIBLE FolrFJLlNG RETURN ADDRESS DATE
DATE
_ Ten East High Street -:>/.. j. /'
i::!:--- Carlisle, PA 17013 :;; /0 C.{
Foy'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. ~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. 99116 (a) (1.1) (ii)l. The statutedoes not exemota transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty~one years of age or younger at death to or for the use of a natural
parent, an adoptive parent. or a stepparent of the child is 0% [72 P,S. 99116 (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, 99116
12)[72 P.S. 1)9116 (a) (1 )1.
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. 99116 (a) (1,3)]. A sibling is defined.
under Seelion 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
*' SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY
iNHERITANCE TAX RETURN
RESIDENTOECEDENT
ESTATE OF FILE NUMBER
DAVIS, HAZEL M. 21-04-01058
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
----------- ---- -- ----- - -------..----- -.---------- - ------ .--------- -----------. -- ------ - --- -- ----
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 M&T Bank checkmg account #2677033033 1,97095
2 M&T Bank MM account #15004198283390 8,933.46
3 Orrstown Bank CD #5060061109 4,003.96
4 Orrstown Bank CD #5060061109, Sept. & Oct. interest 12.67
5 Orrstown Bank CD #5060059019 1,502.87
6 Orrstown Bank CD #5060059019, Sept. & Oct. mterest 8.75
7 Personal property retained by heirs 200.00
8 Rowes Auction Service, proceeds from sale of household goods 258.00
9 Social Security, October benefits 846.00
]0 American Red Cross, refund 15.50
]1 PPL Gas Utilities Corp., refund 10978
12 SPX, retirement benefits 53.86
I3 Continental Insurance Company, refund of unearned premium ]82.99
14 News Chronicle, refund 6.26
15 Comcast, refund 16.26
_.~- ----- -_.._-----~--- - -- --- .----- --._-- ------------
TOTAL (Also enter on Line 5, Recapitulation) 18,121.31
'* SCHEDULE H
FUNERAL EXPENSES &
COMMONWEALTH OF PENNSYLVANIA ADMINISTRATlVE COSTS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
-----" --- -----. .-------- --------- -
ESTATE OF 'FILE NUMBER
DAVIS, HAZEL M 21-04-01058
Debts of decedent must be reported on Schedule I-
-----
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
I Hoffman-Roth Funeral Home, Carlisle, PA 7,342.00
2 Whimsical Poppy, Mt. Holly Springs, PA, funeral flowers 148.00
3 United Church of Christ, Carlisle, P A, funeral reception 50.00
B. ADMINISTRATIVE COSTS: 906.00
1. Personal Representative's Commissions
Mary Crull
Social Security Number(s) J EIN Number of Personal Representative(s):
210-26-5279
Street Address 2323 Ritner Highway
City Carlisle State PA Zip 17013
-
Year(s) Commission paid 2005
2. Attorney's Fees Martson Deardorff Williams & Otto (estimated) 3,200.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Cumberland County Register of Wills 75.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Register of Wills, short certificate 3.00
2 Recorder of Deeds, copies 1.50
Total of Continuation Schedule(s) 131.17
TOTAL (Also enter on line 9, Recapitulation) 11,856.67
'* ScheckIIe H
Funeral Expenses &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN Adninistralive Costs continued
RESIDENT DECEDENT
---- ------ ------ --- ------- ----- --- ----
--
-------- --------------- ----
ESTATE OF DAVIS, HAZEL M. FILE NUMBER
21 - 04 - 01058
3 Certified mailing. Department of Public Welfare 4.42
4 Register of Wills, filing fee, Inheritance Tax return 15.00
5 Estate checks 1175
6 Reserved for miscellaneous expenses 100.00
Page 2 of Schedule H
,. SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
, ,
COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS
INHERITANCE TAX RETURN
RE$IDENTOECEDENT
ESTATE OF FILE NUMBER
DA VIS, HAZEL M. 21-04-01058
Include unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 Outstanding checks on date of death, M&T account #2677033033 247.98
2 Forest Park Health Center, account payable 65.20
3 Sprint, account payable 17.02
TOTAL (Also enter on Line 10, Recapitulation) 330.20
REV-1513 EX+ (9-00) .
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF DAVIS, HAZEL M. FILE NUMBER
21 - 04 - 01058
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE
- ---------------- .- ------ ---.------------ .-.-_. __J:m.H.Qj_UsLT~(s.L_
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1 Mary Crull Daughter One-fourth of estate
2323 Ritner Highway residue
Carlisle, PA 17013
2 George Wagner Son One-fourth of estate
820 Pine Road residue
Carlisle, P A 17013
3 Ira E. Wagner Son One-fourth of estate
1243 Pine Road residue
Carlisle, PA 17013
4 Robert Wagner Son One-fourth of estate
2551 Walnut Bottom residue
Carlisle, PA 17013
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover she~l
II. 'NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
COMMONWEALTH OF PENNSYLVANIA '*
DEPARTMENT OF REVENUE
BUREAU OF INDIVloUlIOrAXES. NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
INlERITAr<<:E TAX DIVISIDH-,-- OF DEDUCTIDNS AND ASSESSMENT OF TAX
PO BOX 280601
HARRISBURG PA 1712:8-0601 REV-IS47 EX AFP (03-05)
0"0' P' Y ~O Pli 12: 40 DATE 05-23-2005
LGl.5J -,Ii - t- ESTATE OF DAVIS HAZEL
M
CLERK OF DATE OF DEATH 11-02-2004
FILE NUMBER 21 04-1058
OR'" ""0 ~OI'RT
r'1~V.\I\j Ii L 0- COUNTY CUMBERLAND
JOHN B Otl)~jlliER Xl) rl'SQD\ ACN 101
' >.-\
MARTSON ETAL I AlIOUni R_l tied I
10 E HIGH ST
CARLISLE PA 17013
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 ....
1t~V-"MI:,.yt.~.m~'1I!'.Wtm.W.!rMtltrfJlmM.m.AwnTftMMf~.YCtWJlmM.llrr.............. ...
DISALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF DAVIS HAZEL M FILE NO. 21 04-1058 ACN 101 DATE 05-23-2005
TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R..1 Estate (Schedule A) III .00 NOTE: To insure proper
2. Stocks and Bonds (Schedule B) (2) .00 credit to your account,
3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 s~it the upper portion
of this forn with your
4. Mortgages/Notes Receivable (Schedule D) I~) .00 tax pay_nt.
S. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) (5) 18 .121. 31
6. Jointly Owned Property (Schedule F) (6) .00
7. Trensfers (Schedule G) 17l .00
8. Total Assets (8) 18,121.31
APPROVED DEDUCTIONS AND EXEMPTIONS: 11 ,856.67
9. Funeral Expanses/Adm. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 330.20
11. Total Deductions Ill) l? . 1 86 87
12. Net Value of Tax Return (12) 5,934.44
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule ~) (13) .00
1~. N.t Value of Estate Subject to Tax 11~) 5,934.44
NOTE: I~ an assessment was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will
reflect ~igures that include the total of ~ returns assessed to date.
ASSESSMENT OF TAX: .00 X 00
15. A.ount of Line 14 at Spousal rate (15) = .00
16. A~t of Line 14 taxable at Lineal/Class A rate (16) 5,934.44 X 045 = 267.05
17. ADOUnt of Line 14 at Sibling rat. 117l .00 X 12 = .00
18. Anount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 = .00
19. Principal Tax Due (19)= 267.05
TAX CREDTT":
,+) AIIOUNT PAID
DATE NUllBER INTEREST/PEN PAID (.)
01-28-2005 CD004894 13.35 350.00
05-16-2005 REFUND .00 96.30-
~ TOTAL TAX CREDIT 267.05
....
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FO~ FDR INSTRUCTIONS.)
--
REGISTER OF WILLS OF ,CUMBERLAND COUNTY
STATUS REPORT UNDER RULE 6.12
(For Resident Decedents Dying After July 1, 1992)
Name of Decedent: HAZEL M. DAVIS
Date of Death: November 2, 2004
File No.: 21-04-1058
Social Security No. : 174-20-7914
Pursuant to Rule 6.12 ofthe 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 x No
2. If the answer is No, state when the personal representative reasonably believes that the
administration will be complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes No x
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 x No
d. Copies of receipts, releases,joinders and approvals offormal or informal accounts
may be filed with the Cler. of the Orphans' Court and may be attached to this report.
Date:" July 6, 2005 S' /})'~_
19nature: '.. , J _'- I
Name: John B. Fowler, III. Esquire ~
Address: .~/ MARTS ON DEARDORFF WILLIAMS & OTTO
Ten East High Street
Carlisle, PAl 70 13
(717) 243-3341
Counsel for personal representative
F:\F1LESIDA TAFlLE\6ST ATES\9769.1 ,srep
0
V ~
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION .
PO BDX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
*'
REV-16D7 EX AFP (03-05)
,,~ "'/
., '..-'
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
05-31-2005
DAVIS
11-02-2004
21 04-1058
CUMBERLAND
101
AlIIount R_itt.d
HAZEL
M
JOHN B'FOWlER III ESQ,
MARTSON HAL
10 E HIGH ST
CARLISLE PA 17013
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, sub.it the upper portion of this for. with your tax payment.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
.......................................~........................................................................
REV-1607 EX AFP (03-05) ~~~ INHERITANCE TAX STATEMENT OF ACCOUNT KKK
ESTATE OF DAVIS HAZEL M FILE NO.21 04-1058 ACN 101 DATE 05-31-2005
THIS STATE"ENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE N~ED ESTATE. SHOWN BELOW
IS A S~RY DF THE PRINCIPAL TAX DUE, APPLICATIDN OF ALL PAY"ENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 05-23-2005
PRINCIPAL TAX DUE, 267.05
PAYMENTS (TAX CREDITS),
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
01-28-2005 CD004894 13.35 350.00
05-16-2005 REFUND .00 96.30-
TOTAL TAX CREDIT 267.05
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 PA~ENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRl,
YOU ~Y BE DUE A REFUND. SEE REVERSE SIDE OF THIS FO~ FOR INSTRUCTIONS. )
~