HomeMy WebLinkAbout02-0315Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of Melba L. Payne
also known as
, Deceased
Terry Ray Payne
-3/5
Social Security No. 24-2-4-2-0217
Petitioner(s), who is/are 18 years of age or older, apply(les) for:
(COMPLETE 'A' or 'B' BELOW:)
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut or
the Decedent, dated 08/12/198 and codicil(s) dated None
named in the last Will of
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
B. Grant of Letters of Administration
(c.t.a.; db.n.c.ta; pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and
heirs:
Name Relationship Residence
Terry Ray Payne
Douglas Kirk Payne
S on
S on
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland
110 Diller Rd., New Cumberland
300 State St., Apt. 2F, West Fairvie
County, Pennsylvania with his/her last family
or principal residence at 203 South
Decedent, then 72 years of age. died
Second Street, Wormleysbur~
(list street, number, and municipality)
03/11/2002 at Wormleysbur~, PA
Decedent at death owned property with estimated values as follows:
(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
(Location)
20,000.00
situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of
letters in the appropriate form to the undersigned:
Typed or printed name and residence
Sic~nature ~
Terry Ray Payne
110 Diller Road, New Cumberland, PA 17070
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems, Inc.
Form RW-1 (1991)
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
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 Decedent, Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed
Terry~ Payn~__~
before me this 27thday of
No.
Estate of Melba L. PayTte Deceased
Social Security No: 242-42- 0217 Date of Death: 03/11/2002
AND NOW, ~CH 28, 2002 __, in consideration
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters E~ Testamentary [~ Of Administration T~ST--~VI-ENTAR¥
(c.ta.; d.b.n.c.ta.; pendente lite; durante absentia; durante minoritate)
are hereby granted to
Terry Ray Payne
in the above estate and that the instrument(s) dated 08/12/1989
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES . f~~~.
Letters ........... $ 60,00 Register of Wills
Short Certificate(s) ..... $ 15,00
Renunciation ........ $ Attorney:
Affidavits ( ) .... $ I.D. No:
Extra Pages ( ) .... $ 9.00 Address:
Codicil ........... $
Michael L. Banss
302 South 18th Street
JCP Fee .......... $ .5.00
Inventory .......... $
Telephone: 717/730 - 7310
FILED 3-28-2002 ~
MAILED TO ATTORNEY ON 3-28-2002
Other ........... $
TOTAL ......... $ Rg _ O0
Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc, Form RW- 1 (1991)
21-02-315
LAST WILL & TESTAMENT OF
MELBA L. PAYNE
2~-oz-$15
I, Melba L. Payne, of Fairview Township, York County, Pennsyl-
vania, being of sound and disposing mind, memory and understanding,
do hereby make, publish and declare this to be my Last Will &
Testament, hereby revoking and making void any and all prior wills,
codicils, writings thereto, by me at any time heretofore made.
ITEM I: I give, devise and bequeath unto my youngest son,
Douglas Kirk Payne, of Fairview Township, York County, Pennsylvania,
my mobile home, currently situated at Ramsey's Trailer Lot, Fairview
Township, York County, Pennsylvania. In the event of the sale of my
trailer prior to my death, the proceeds from said sale shall fall
into the residue of my estate and be divided in accordance with Item
II hereof.
ITEM II: Ail the rest, residue and remainder of my estate, i
give, devise and bequeath unto my two sons, Terry Ray Payne and
Douglas Kirk Payne, both of Fairview Township, York County,
Pennsylvania, to be divided equally between them. In the event one
son does not survive me, then the surviving son shall take the whole
residuary. In the event both sons do not survive me then the rest,
residue and remainder of my estate I bequeath unto my nephew,
Richard Archer of Mt. Laurel, New Jersey.
ITEM III: Ail taxes, interest, and penalties thereon payable by
reason of my death with respect to property comprising my gross
taxable estate, whether or not passing under this Will, shall be
paid from the principal of my residuary estate.
ITEM IV: I nominate, constitute and appoint Terry Ray Payne as
the Executor of this my Last Will & Testament. If he cannot for any
reason serve, then in that event, I nominate, constitute and appoint
my son, Douglas Kirk Payne to be and act as Executor of this my Last
Will & Testament. No fiduciary acting hereunder shall be required
to post bond or enter security in any jurisdiction.
IN WITNESS WHEREOF, I have set my hand and seal to this my Last
& Testament consisting of this and two other pages this /~
Will
/I
day of /~/~7-~ , 1989.
Melba L. Payne
We, the undersigned, hereby certify that the foregoing Will was
signed, sealed, published and declared by the abovenamed Testatrix
as and for her Last Will & Testament, in the presence of us, who, at
her request and in her presence and in the day and year above
written, have signed below as witnesses; and we certify, that the
- 2 -
time of execution thereof, said Testatrix was of sound and disposing
mind and memory.
Residing at
- 3 -
Commonwealth of Pennsylvania:
: SS
COUNTY OF CUMBERLAND :
.We, Melba L. Payne, CL//~ TO(Y A ~ ~. , and
PhrF~ /~. ~/~0 , the Testatrix and ~he witnesses,
Yespectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare to the under-
signed authority that the Testatrix signed and executed the instru-
ment as her Last Will and that she signed willingly, and that she
executed as her free and voluntary act for the purposes therein
expressed, and that each of the witnesses, in the presence and
hearing of the Testatrix, signed the Will as witnesses and that to
the best of their knowledge, the Testatrix was at the time eighteen
(18) years of age or older, of sound mind, and under no constraint
or undue influence.
Sworn to and subscribed before me
this /~ day of ~u&~T- , 1989.
/Notary Public
NOrARtAL SEAL
n~CH^,~ ^. C^~RO, NOT? ~UBL,C I
My Co~ission Expires: ~mSEU~G. gZ.U~H~CO,2NTy
Mom~. P~mylvania ~a~n ol Notari~
- 4 -
LAST WILL & TESTAMENT OF
MELBA L. PAYNE
Richard A. Cairo
Attorney-At-Law
71 Old Pioneer Rd.
Camp Hill, Pa. 17011
(717) 761-7194
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedem:
Date of Death:
Will No.:
To the Register:
MELBA L. PAYNE
March 11, 2002
21-02-0315
Admin. No:
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 April 3, 2002:
NAME
Terry Ray Payne
Douglas Kirk Payne
ADDRESS
110 Diller Road, New Cumberland, PA 17070
300 State Street, Apt. 2F, West Fairview, PA 17025
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: none.
Date: '~-3-~)Z Signature~/. l/ t~/~_ ,/j;;'
Michael L. Bangs, Attor~y-at-Law
302 South 18th Street /
Camp Hill, PA 17011 --
(717) 730-7310
Capacity: Counsel for Personal Representative
~ 0 ~
~o
MICHAEL L, BAN(iS
ATTORNEY AT LAW
302 SOUTH 18TM STREET CAMP HILL, PA 17011
PHONE 717-730-7310
FAX 717-730-7374
E-mail: bangslaw@paonlinc,com
June 21, 2002
Mary C. Lewis, Register of Wills
Cumberland County Courthouse
One Courthouse Squgre_--- ....
Carlisle~fO 13- ' ' -'"'~ ~'~'--- ........... , ......
I/RE: FileEStateNo.°f Melba21-O2-O315Payne '~
Dear Mrs. Lewis:
Enclosed for filing please find the original and one copy of a Pennsylvania Inheritance
Tax Return for the above-referenced estate together with a check in the amount of $944.59 to
pay the tax shown to be due.
I am also enclosing the original Inventory and a separate check in the amount of $25.00
to pay the filing fee for these documents.
Kindly return a paid receipt to me in the enclosed, stamped, pre-addressed envelope.
Thank you for your assistance.
:Very truly yours,
wsc
Enclosures
cc: Mr. Terry R. Payne
REV- 1500 EX + (6-00)
COMMONWEALTH Of PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. ;~80601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
21-02-0315
CO!JNTY CODE YEAR NUMBER
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
?dyne Melba L.
DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR)
03/11/2002 02/21/1930
(IF APPLICABLE) SURV VING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
242-42-0217
THIS RETURN MUST BE FILED IN DUPLICATE VVITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
1. original Return
4. Limited Estate
6. Decedent Died Testate
(Attach copy of Will)
[----] 9. Litigation Proceeds Received
2. Supplemental Return
4a. Future interest Compromise (date of death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach copy of Trust)
r-~ 10. Spousal Poverty Credit
(date of death between 12-31-91 and 1 - 1-95)
(date of death
3. Remainder Return prior to 12- 13-82)
5. Federal Estate Tax Return Required
, 0 8. Total Number of Safe Deposit Boxes
~ 11. Election to tax under Sec, 9113{A)
(Attach Sch O)
NAME
Michael L. Ban~s, Esquire
FIRM NAME (If Applicable)
TELEPHONE NUMBER
717/730- 73~0
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or (3)
Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11 )
13.
14.
COMPLETE MAILING ADDRESS
302 South 18th Street
Camp Hill, PA 17011
None
Nbne
None
30,005.96
None
None
8,873.39
141.58
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
Net Value Subject to Tax (Line 12 minus Line 13)
OFFICIAL USE ONLY
ti
(8)
30,005.96
9,014.97
(11)
(12)
(13)
(14)
20,990.99
20,990.99
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(aX1.2) X .0 0 (15)
16. Amount of Line 14 taxable at lineal rate 20,990.99 X .0 45 (16)
17. Amount of Line 14 taxable at sibling rate X .12 (17)
18. Amount of Line 14 taxable at collateral rate X .15 (18)
0.00
944.59
0.00
0.00
19. Tax Due (19) 944.59
Copyright (c) 2000 form software only T he Lackner Group, Inc. Form REV- 1500 EX (Rev, 6-00)
Decedent's Complete Address:
STREET ADDRESS
203 South 2nd Street
CITY
STATE
?A
Wormleysbur~
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(4)
Total Credits ( A + B + C ) (2)
ZIP
17043
3. Interest/Penalty if applicable D. Interest
E. Penalty
Total Interest/Penalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + 5A This is the BALANCE DUE.
944.59
0.00
0.00
0.00
944.59
0.00
944.59
(SB)
Make Check Payable 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; r-'"] ~-]
b. retain the right to designate who shall use the property transferred or its income; ...........
c. retain a reversionary interest; or ....................................
d. receive the promise for life of either payments, benefits or care? ................
If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ............................... ['--] r--]
Did decedent own an "in trust for" or payable upon death bank account or security at his
or her death? ............................................. [---] []
Did decedent own an Individual Retirement Account, annuity, or other non-probate property
which contains a benefc ary designation? ............................... ~ ~
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 Ps 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 Terry R. ?a.yne DATE
~--~ ~2~'~ _ 110 Diller Road'
SlGNAT~OFPREP~ROTH~T~N~EgENTATIVE Michael L Ban s, Es uire --
~ · g q DATE
I r 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. 9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statuto~requirements for disclosure of assets
and filing a tax return are still applicable even if the surviving spouse is the only beneficiau.
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. 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. 9116(1.2)
[~2 P.S. 9~6(~)(~)].
The tax rate imposed on the net value of transfers to or for the use of the decedent,s siblings is 12% [72P.S. 9116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Copyright (c) Z000 form software only The Lackner Group, Inc. Form ~EV- 1500 EX (Rev. 6-00)
REV- 1508 EX + (1-97)
COMMONWEALTH OFPENNSYLVANIA
INHERITANCETAXRETURN
RESIDENTDECEDENT
~STATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
Melba L. Payne SS# 242-42-0217 03/11/2002 21-02-0315
Include the proceeds of litigation and the date the proceeds were rece ved by the estate. All property jointly-owned with the right of
survivorship must be d sclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Allfirst Bank - Checking Account #0067738583
Blue Cross/Blue Shield - Blue Cross/Blue Shield
Central PA Teamsters Pension Fund Refund Pre-retirement
survivor benefit
Citizens Bank - Certificate of Deposit #00747649
Citizens Bank - Savings Account #00263-002196
Citizens Bank - Certificate of Deposit #264-807395
Mellon Bank CD Interest
Mellon Bank CD Interest /
Additional interest on Mellon Bank CD
Refund from State Farm (Policy #38-J6-5846-3)
Commonwealth of PA (Tax Refund)
IRS Tax Refund
Refund of Security Deposit
Social Security Administration - Death
1986 Chevy SW VIN #2G1AW35R1G1284936
Benefit
7,968.95
177.00
141.00
17,000.00
1,237.51
2,208.39
20 12
21 51
20 82
41 66
70 00
150 00
181.00
668.00
100.00
TOTAL (Also enter on line 5, Recapitulation) $ 30,005.96
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, inc. Form REV-1508 EX (Rev. 1-97}
allfirst
Michael L. Bangs
Attorney At Law
302 South 18th Street
Camp Hill, PA 17011
Allfirst Financial Center N.A.
P.O. Box 900
Millsboro, DE 1'9966
Phone (302) 934-2909
F ax (302) 934-2955
April 9, 2002
Re: Estate of Melba L. Payne
Social Security: 242-42-0217
Date of Death: March 11, 2002
Dear Sir or Madam:
Per your inquiry dated April 3, 2002, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
Type of Account
Account Number
Ownership ('Names o./)
Opening Date
Balance on Date of Death
Accrued Interest
Total
Relationship Checking W/Interest
0067738583
Melba L. Payne, Owner
09/28/75
$7,968.95
$ .94
$7,969.89
Type of Account
Account Number
Ownership (Names oJ)
Opening Date
Safe Deposit Box
1000535100000471
Melba L. Payne, Owner
Terry Ray Payne, POA
11/13/98
This letter does not include any accounts in which the deceased may have been listed as Power of .4ttorney,
Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written ~4greement.
For further account information, closures and/or reimbursement of funds refer to below branch:
HIGHLAND PARK OFFICE
344 SOUTH l0TM STREET
LEMOYNE, PA 17043-1707
717-737-3322
Sue Kimble
Assistant I
Cis Services, (302) 934-2909
05/29/2082 11:17 215-553-8714 HELLON EA~< PAGE D3/03
CITIZENS BANK
Account
Number A ccou~t Title
Wednesday, May29,2002
00263.002196 Melba Payne
Date Opened: 07/01/1987
Principal Bal iht from Last
as of DOD PogtJng to DOD
$1,237.51 $0,08
Account Type: SA
Account Bal YTD Iht fo
as of DOD DOD
$1,237.5@ $0.58
007a7649 Melba Payne
oate Opened: 06119t1998
Principal Bal Int from Last
a~ of DOD Posffng to DOD
$t7,000,00 $18.04
Account Type:
Account Bal YTD lift tO
as of DOD DOD
$I7,018,04 $61.08
264-,50739¢>.C.,/IRA Melba Payne
D~te Ope~d; 07/01/1993
tarincipa! Bal Inf fn)m La.st
as of DOD Posting to DOD
$2,208.39 $22.91
Account Type: TD
Account Bal rrD iht to
as of DOD DOD
$2231.30
Page 2 of 2
QTY. DESCRIPTION
PRICE
State Inspection
E & S GARAGE
8160 Bull Road · Lewisberry, PA 17339
Telephone: (717) 938-5995
Oil Change
& Tune-Ups
NAME
ADDRESS
IDATE
PHONE
STICKER NO.
YEAR & MAKE
IREGISTRATION NUMBER
LA/BOR
?/er:/---/, /0o, oo
IMILEAGE
AMOUNT
I hereby auihorize the above repair work to be done along wilh the
necessary material, and hereby grant you and/or your employees per-
mission to operate the car, truck or vehicle herein described on streets,
highways or elsewhere for Ihe purpose of testing and/or inspection An ex-
press mechanic's lien is hereby acknowledged on above car, truck or
vehicle to secure the amount of repairs thereto.
NOT RESPONSIBLE FOR LOSS OR DAMAGE TO VEHICLES OR ARTICLES
LEFT IN VEHICLES IN CASE OF FiRE THEFT, OR ANY OTHER CAUSE
BEYOND OUR CONTROL
Authorized by: X
TIRES BRAKES TOTAL LABOR
RF RF TOTAL PARTS
RR RR
LF
LR
LF
LR
TAX
SUB TOTAL
TOWING
REV- 1511 EX *(1-9-/)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Melba L. Payne SS~/ 242-42-0217
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
03/11/2002
FILENUMBER
21-02-0315
Debt: of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 Expense Neill
1
2
3
Expense - Terry
Funeral Home, Inc.
Payne Various funeral expenses)
Zipl7070
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) Terry R. Pa.~"te
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address 1].0 Diller Road
City New Cumberland '~ State PA
2002
Year(s) Commission Paid:
Attorney's Fees Michael L. Bangs, Esquire
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
State Zip
(Short Certificates)
Street Address
City
Relationship of Claimant to Decedent
Probate Fees Register of Wills
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
The Sentinel
Cumberland Law Journal
Expense - Register of Wills
3,225.00
369.08
2,000.00
3,000.00
89.00
100.31
75.00
15.00
TOTAL (Also enter on line 9, Recapitulation) $ 8,8 7 3.3 9
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, [nc. Form REV-1511 EX (Rev. 1-97)
REV-1512 EX + (1-97)
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
COMMONWEALTH OF PENNSYLVANIA
iNHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Melba L. Payne SS~/ 242-42-0217 03/11/2002
FILE NUMBER
21-02-0315
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
Expense - PP&L
Expense - UGI
Expense - Verizon
Expense Comcast Cable
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
AMOUNT
116.39
15.25
5.01
4.93
$ 141.58
Copyright (c) 1996 form software only CPSystems, inc. Form REV-1512 EX (Rev. 1-97)
REV-1513 EX * (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Melba L. Payne SS# 242-'42-0217
NUMBER
SCHEDULE J
BENEFICIARIES
03/11/2002
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outriBht spousal distributions):
Douglas Kirk Payne
300 State Street, Apt.
Enola, PA 17025
Terry Ray Payne
110 Diller Road
New Cumberland,
2F
FILE NUMBER
21-02-0315
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
PA 17070
Son
Son
AMOUNT OR SHARE
OF ESTATE
One-half
One -half
EN,TER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
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)
$ 0.00
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1513 EX (Rev. l-g?)
LAST WILL & TESTAMENT OF
MELBA L. PAYNE
I, Melba L. Payne, off Fairview Township, York County, Pennsyl-
vania, being of sound and disposing mind, memory and understanding,
do hereby mak~, publish and declare this to be my Last Will &
Testament, hereky revoking and making void any and all prior wills,
codicils, writings thereto, by me at any time heretofore made.
ITEM I: I give, devise and bequeath unto my youngest son,
Douglas Kirk [~ayne, of Fairview Township, York County, Pennsylvania,
my mobile home, currently situated at Ramsey's Trailer Lot, Fairview
Township, York County, Pennsylvania. In the event of the sale of my
trailer prior to my death, the proceeds from said sale shall fall
into the residue of my estate and be divided in accordance with Item
II hereof.
ITEM Ii: Ail the rest, residue and remainder of my estate, I
give, devise and bequeath unto my two sons, Terry Ray Payne and
Douglas Kirk Payne~ both of Fairview Township, York County,
Pennsylvania, to be divided equally between them. In the event one
Son does not survive me, then the surviving son shall take the whole
residuary. In the event both sons do not survive me then the rest,
residue and remainder of my estate I bequeath unto my nephew,
Richard Archer of Mt. Laurel, New Jersey.
ITEM III: Ail taxes, interest, and penalties thereon payable by
reason of my death with respect to property comprising my gross
taxable estate, whether or not passing under this Will, shall be
paid from the principal of my residuary estate.
ITEM IV: I nominate, constitute and appoint Terry Ray Payne as
the Executor of this my Last Will & Testament. If he cannot for any
reason serve, then in that event, I nominate, constitute and appoint
my son, Douglas Kirk Payne to be and act as Executor of this my Last
Will & Testament. No fiduciary acting hereunder shall be required
to post bond or enter security in any jurisdiction.
IN WITNESS WHEREOF, I have set my hand and seal to this my Last
Will & Testament consisting of this and two other pages this
day of .. ~/~~ , 1989.
Melba L. Payne
We, the undersigned, hereby certify that the foregoing Will was
signed, sealed, published and declared by the abovenamed Testatrix
as and for her Last Will & Testament, in the presence of us, who, at
her request and in her presence and in the day and year above
written, have signed below as witnesses; and we certify, that the
- 2 -
time of execution thereof, said Testatrix was of sound and disposing
mind and memory.
~~ Residing at ~ / ~ ~. ~ ..~./~~---
Residing at
- 3 -
Commonwealth of Pennsylvania:
: SS
COUNTY OF CUMBERLAND :
. ~e, Melba L. Payne, ~'~I/v~'OfV /~..~. , and
p~lF/c]~ ~, ~/'~o , the Testatrix and ~he witnesses,
respectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare to the under-
signed authority that the Testatrix signed and executed the instru-
ment as her Last Will and that she signed willingly, and that she
executed as her free and voluntary act for the purposes therein
expressed, and that each of the witnesses, in the presence and
hearing of the Testatrix, signed the Will as witnesses and that to
the best of ~heir knowledge, the Testatrix was at the time eighteen
(18) years of age or older, of sound mind, and under no constraint
or undue influence.
Sworn to and subscribed before me
this /~ day of /~E~u~ 7-- , 1989.
/Notary Public
NOTARIAL SEAL
RICHARD A. CAIRO, NOTARY PUBLIC
My Commission Expires: ~4'"'~SBU~G, DAU~H!f-!CO?,!TY
I EXPIRES DEC. 28, '1992
MY COMMISSION
Member, Pennsylvania Assodation ot Notaries
- 4 -
Register of Wills of
CUMBERLAND
INVENTORY
County, Pennsylvania
Estate of Melba L. Payne
also known as
, Deceased
No. 21-02-0315
Date of Death 03/11/2002
Social Security No. 242 -42 - 0217
Terry Ray Pa.yne,
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned
no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this
Inventory. I/We verify that the statements made in this Inventory are true and correct. I/VVe understand that false statements herein
are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Name of
Attorney: Michael L. Ban~s
Signature: ¢'"."~ ~
Terry ay~_~_~e~ ~
I.D. No.: 41263 SignatUre:
Address: 302 South 18th Street Address: 110 Diller Road
Camp Hill, PA 17011 New Cumberland, PA 17070
Telephone: 717/730- 7310 Telephone: 717/774- 6624
Dated:
Description Value
(See continuation page(s) attached)
(Attach additional sheets if necessary) Total: 30,005.96
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative,
include the value of each item, but such figures should not be extended into the total of the Inventory.
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems, Inc. Form #RW-7 (1992)
Social Security Administration
- Death Benefit
668.00
PERSONAL PROPERTY:
1986 Chevy SW VIN
#2G1AW35R1G1284936
100.00
TOTAL RECEIPTS OF PRINCIPAL ...............
29,905.96
100.00
30,005.96
-2-
Estate of:
Date of Death:
County:
Melba L. Payne
03/11/2002
Cumberland
INVENTORY
CASH:
Allfirst Bank Checking
Account #0067738583
Blue Cross/Blue Shield - Blue
Cross/Blue Shield
Central PA Teamsters Pension
Fund Refund Pre-retirement
survivor benefit
Citizens Bank - Certificate of
Deposit #00747649
Citizens Bank - Savings
Account #00263-002196
Citizens Bank - Certificate of
Deposit #264-807395
Mellon Bank CD Interest
Mellon Bank CD Interest
Additional interest on Mellon
Bank CD
Refund from State Farm (Policy
#38-J6-5846-3)
Commonwealth of PA (Tax
Refund)
IRS Tax Refund
Refund of Security Deposit
7,968.95
177.00
141.00
17,000.00
1,237.51
2,208.39
20.12
21.51
20.82
41.66
70.00
150.00
181.00
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
NO.
REV-1162 EX(11-96)
CD 001327
MICHAEL L BANGS ESQUIRE
302 SOUTH 18TH STREET
CAMP HILL, PA 17011
fold
ESTATE INFORMATION: SSN: 242-42-0217
FILE NUMBER: 2102-031 5
DECEDENT NAME: PAYNE MELBA L
DATE OF PAYMENT: 06/24/2002
POSTMARK DATE: 06/21/2002
COUNTY: CUMBERLAND
DATE OF DEATH: 03/1 1/2002
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $944.59
TOTAL AMOUNT PAID'
$944.59
REMARKS: TERRY R PAYNE
C/O MICHAEL L BANGS ESQUIRE
SEAL
CHECK//0100
INITIALS: SK
RECEIVED BY:
MARY C. LEWIS
REGISTER OF WILLS
REGISTER OF WILLS
BUREAU OF TNDZVZDUAL TAXES
TNHERTTANCE TAX DTVZSZON
DEPT. 280601
HARRTSBURg, PA 17128-0601
MICHAEL L BANGS ESQ
$02 S 18TH ST
CAMP HILL
COMHONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLO#ANCE OR DZSALLO#ANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
PA 170!.1.
DATE 08-05-ZOOZ
ESTATE OF PAYNE
DATE OF DEATH 03-11-2002
FILE NUHBER 21 02-0315
/~ii:!~OUNTY CUMBERLAND
ACN 101
I Amount Remitted
MELBA L
HAKE CHECK PAYABLE AND REMIT PAYHENT TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~- RETAIN LOWER PORTION FOR YOUR RECORDS *~
REV-154? EX AFP (01-0:~) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF PAYNE MELBA L F'rLE NO. 21 02-0315 ACN 101 DATE 08-05-2002
TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2}
5. CZosely Held Stock/Partnership Interest (ScheduZe C) ($)
q. Mortgages/Notes Rece/veble (Schedule D)
5. Cash/Bank Deposits/M/sc. PersonaZ Property (Schedule E) (5)
6. Jo/ntly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7}
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/M/sc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liab/1/t/es/L/ens (Schedule Z) (10)
11. Tote1 Deduct/ors
12. Net Value of Tax Return
30~005.96
.00
.00 NOTE: To /nsure proper
.00 cred/t to your account,
.00 submit the upper port/on
.00 of th/s form w/th your
tax payment.
.00
(8) 30,005.96
8,873.39
lql .58
(].1) 9 .nlq.97
(].2) 20,990.99
15.
14.
NOTE:
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spouse1 rate
].6. Amount of L/ne 14 taxable et Lineal/Class A rate
].7. Amount of L/ne Z4 at S/b].ing rate
].8. Amount of L/ne lq taxeb].e at Col].atera]./C].ess B rate
19. Pr/ncipa]. Tax Due
TAX CREDZTS:
PAYMENT RECE/PT D/SCOUNT (+)
DATE NUMBER ZNTEREST/PEN PAZD (-)
06-21-2002 CD001327 .00
Char/table/governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) . O0
Net Value of Estate Subject '1:o Tax (14) 20,990.99
If an assessment was lssued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that lnclude the tote! of ALL returns assessed to date.
(].~) .00 x 00 = .00
(16). 20,990.99 x 0q5 = 9qq.59
(17) .00 x 12 = .00
(].8) .00 x 15 = .00
(].9)= 9qq.59
AMOUNT PAZD
9qq.59
ZF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDZTZONAL INTEREST.
TOTAL TAX CREDIT
BALANCE OF TAX DUEI
INTEREST AND PEN.
TOTAL DUE
9qq.59
.00
.00
.00
( ZF TOTAL DUE ZS LESS THAN $]., NO PAYMENT ZS REQUIRED.
IF TOTAL DUE ZS REFLECTED AS A "CREDIT" ¢CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR ZNSTRUCTIONS.)
RESERVATION:
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMIN-
ISTRATIVE
CORRECT[OHS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 12, 1982 -- if any futura interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of tho decedent after the expiration of any estate for
Life or for years, the Coaaoneealth hereby expressly reserves tho right to appraise end assess transfer Inheritance Taxes
at the laeful Class 8 (collateral) rate on any such futura interest.
To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act ZS of ZOO0. (72 P.S.
Section 9140).
Detach the top portion of this Notice and submit aith your payment to the Register of Hills printed on the reverse side.
--Make check or money order payable to: REGISTER OF MILLS, AGENT
A refund oF a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications ara available et the Office
of the Register of Hills, any of the 25 Revenue District Offices, or by calling the special Z4-hour
answering service for forms ordering: 1-800-$62-Z050; services for taxpayers with special hearing and / or
speaking needs: 1-800-447-5020 (TT only).
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice oust object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Beard of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601
Phone (717) 787-6505. See page S of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
If any tax due is paid within three (5) calendar months after the decedent's death, a five percent (52) discount of
the tax paid is allowed.
The 152 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rata of
six (62) percent per annum calculated at a daily rate of .000164. AIl taxes which became delinquent on and after
January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 19SI through ZOOZ are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
m
1982 202 .000548 1992 92 .000247
1985 162. .000458 1995-1994 72. .000192
1984 llZ .000501 1995-1998 92 .000247
1985 152 .000556 1999 72 .000192
1986 lOZ .000274 ZOO0 82 .000219
1987 9Z .000247 ZOOl 92 .0002:47
1988-1991 Ill .000301 ZOOZ 62 .000164
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the data of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must bo calculated.
MICHAEL L, BAN S
ATTORNEY AT LAW
302 SOUTH 18TM STREET CAMP HILL, PA 17011
PHONE 717-730-7310
FAX 717-730-7374
E-mail: bangs]zw~paon]inc,com
September 26, 2002
Mary C. Lewis, Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Estate of Melba L. Payne
File No. 21-02-315
Dear Mrs. Lewis:
estate:
Enclosed please find the following documents that I file as a part of the above-referenced
1. The original Status Report Form; and
2. Four (4) Receipts and Releases together with a check in the amount of
$28 to pay the filing fee for these documents.
Please file these documents accordingly. This will conclude the administration of this estate.
If you have any questions or if you require anything further, please contact me directly.
Thank you very much.
V .~e~e~(ry truly yours,
1 L. Bangs
wsc
Enclosures
cc: Mr. Terry R. Payne
IN RE:
ESTATE OF
MELBA L. PAYNE
Deceased
) IN THE COURT OF COMMON PLEAS OF
) CUMBERLAND COUNTY,
) PENNSYLVANIA
)
) ORPHANS' COURT DIVISION
)
) NO. 21-02-0315
RECEIPT AND RELEASE
I, DOUGLAS KIRK PAYNE, the undersigned, being a legatee under the Will of
MELBA L. PAYNE, deceased, do hereby:
1. State and acknowledge that I am an adult individual;
2. Waive the filing of an Account or Schedule of Distribution by the personal
representative of the Estate;
3. Acknowledge that I have received the sum of $5,000.00, as a partial distribution to
which I am entitled as an heir of the Estate of MELBA L. PAYNE;
4. To the extent of said distribution, release TERRY RAY PAYNE, Executor, of the
Estate of MELBA L. PAYNE, and his heirs and personal representatives, from all liabilities,
whether due to his negligence or otherwise, which he may have by reason of his administration
of the Estate;
5. Agree to refund to the Estate and to the said TERRY RAY PAYNE, Executor, any
portion of the distribution to which I am not properly entitled, and, to the extent of said
distribution, to indemnify him and the Estate for claims made against him and to reimburse him
and the Estate all expenses and costs incurred in connection with any such claim; and
6. Declare that this instrument shall be legally binding upon me, my personal
representatives, and assigns.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~5~[
\ )/[ I ALQ~ ,2002.
__ day of
C OMMONWEAEH OF P~NN S J~V_IN~k~ )
( SS:
COUNTY OF ~.~.L'~i~~~ )
On this, the 01 day of ~/~ ,2002, before me, the
undersigned officer, personally appeare]a"DOUGLAS KIRK PAYNE, known to me (or
satisfactorily proven) to be the person whose name is subscribed to the within instrument and
acknowledged that he executed same for the~urposes therein contained.
IN WITNESS WHEREOF,, I~~u.~m~/~ld~offi~al.
Notary Public .,~ --
I i
IN RE:
ESTATE OF
MELBA L. PAYNE
Deceased
) IN THE COURT OF COMMON PLEAS OF
) CUMBERLAND COUNTY,
) PENNSYLVANIA
)
) ORPHANS' COURT DIVISION
)
) NO. 21-02-0315
RECEIPT AND RELEASE
I, TERRY RAY PAYNE, the undersigned, being a legatee under the Will of MELBA L.
PAYNE, deceased, do hereby:
1. State and acknowledge that I am an adult individual;
2. Waive the filing of an Account or Schedule of Distribution by the personal
representative of the Estate;
3. Acknowledge that I have received all sums of money to which I am entitled as an heir
of the Estate of MELBA L. PAYNE;
4. To the extent of said distribution, release TERRY RAY PAYNE, Executor, of the
Estate of MELBA L. PAYNE, and his heirs and personal representatives, from all liabilities,
whether due to his negligence or otherwise, which he may have by reason of his administration
of the Estate;
5. Agree to refund to the Estate and to the said TERRY RAY PAYNE, Executor, any
portion of the distribution to which I am not properly entitled, and, to the extent of said
distribution, to indemnify him and the Estate for claims made against him and to reimburse him
and the Estate all expenses and costs incurred in connection with any such claim; and
6. Declare that this instrument shall be legally binding upon me, my personal
representatives, and assigns.
~q, WITNESS WHEREOF, I have hereunto set my hand and seal this ~
(SEAL)
__ day of
COMMONWEALTH OF PENNSYLVANIA )
(SS:
COUNTY OF CUMBERLAND (-,, )
On this, the day of ',: 2002, before me, the
undersigned officer, personally appeared TERR~/RAY PAYNE, known to me (or satisfactorily
proven) to be the person whose name is subscribed to the within instrument and acknowledged
that he executed same for the purposes therein contained.
I and official seal
IN WITNESS WHEREOF, I havqh~reunto ~t my,~and,, . ' .
NotarfPublic ] -
!
WENDY S. CH~$~O, ),t~ry ~
IN RE:
ESTATE OF
MELBA L. PAYNE
Deceased
) IN THE COURT OF COMMON PLEAS OF
) CUMBERLAND COUNTY,
) PENNSYLVANIA
)
) ORPHANS' COURT DIVISION
)
) NO. 21-02-0315
RECEIPT AND RELEASE
I, DOUGLAS KIRK PAYNE, the undersigned, being a legatee under the Will of
MELBA L. PAYNE, deceased, do hereby:
1. State and acknowledge that I am an adult individual;
2. Waive the filing of an Account or Schedule of Distribution by the personal
representative of the Estate;
3. Acknowledge that I have received all sums of money to which I am entitled as an heir
of the Estate of MELBA L. PAYNE;
4. To the extent of said distribution, release TERRY RAY PAYNE, Executor, of the
Estate of MELBA L. PAYNE, and his heirs and personal representatives, from all liabilities,
whether due to his negligence or otherwise, which he may have by reason of his administration
of the Estate;
5. Agree to refund to the Estate and to the said TERRY RAY PAYNE, Executor, any
portion of the distribution to which I am not properly entitled, and, to the extent of said
distribution, to indemnify him and the Estate for claims made against him and to reimburse him
and the Estate all expenses and costs incurred in connection with any such claim; and
6. Declare that this instrument shall be legally binding upon me, my personal
representatives, and assigns.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
,2002.
.-"' ,:</_z~ ~ .... Z---~. ~-~'-~----'~ ...... (SEAL)
__ day of
COMMONWEALTH OF PENNSYLVANIA )
(SS:
COUNTY OF CUMBERLAND ~ ~ ) ~
Onthis, the i,~ dayof ~.~[.-'~l]~!~[~'' ,2002, beforeme, the
undersigned officer, per's~ally appeare~l DOtJ(~LAS KIRK PAYNE, known to me (or
satisfactorily proven) to be the person whose name is subscribed to the within instrument and
acknowledged that he executed same for the purposes therein contained.
IN WITNESS WHEREOF, I l~a~e ~ereuntc~ set my hand and official seal.
Notary Public ./
NOTA~J. ~
WENDY $. CH~$~O, ~ Public
Low~' .A~n Twp., Cumi:~,tand C..o~gy
IN RE:
ESTATE OF
MELBA L. PAYNE
Deceased
) IN THE COURT OF COMMON PLEAS OF
) CUMBERLAND COUNTY,
) PENNSYLVANIA
)
) ORPHANS' COURT DIVISION
)
) NO. 21-02-0315
RECEIPT AND RELEASE
I, TERRY RAY PAYNE, the undersigned, being a legatee under the Will of MELBA L.
PAYNE, deceased, do hereby:
1. State and acknowledge that I am an adult indixTidual;
2. Waive the filing of an Account or Schedule of Distribution by the personal
representative of the Estate;
3. Acknowledge that I have received the sum of $5,000.00, as a partial distribution to
which I am entitled as an heir of the Estate ofMELBA L. PAYNE;
4. To the extent of said distribution, release TERRY RAY PAYNE, Executor, of the
Estate of MELBA L. PAYNE, and his heirs and personal representatives, from all liabilities,
whether due to his negligence or otherwise, which he may have by reason of his administration
of the Estate;
5. Agree to refund to the Estate and to the said TERRY RAY PAYNE, Executor, any
portion of the distribution to which I am not properly entitled, and, to the extent of said
distribution, to indemnify him and the Estate for claims made against him and to reimburse him
and the Estate all expenses and costs incurred in connection with any such claim; and
6. Declare that this instrument shall be legally binding upon me, my personal
representatives, and assigns.
INk,WITNESS WHEREOF, I have hereunto set hand and seal this (~/
my
~~J~ , 2002.
'~'-~EQ~ '-,-'<~(SEAL)
__ day of
COMMONWEA,~TH OF PENNS ,YLVANIA )
COUNTY OF )
On this, the ~>2~[ day of ~ ,2002, before me, the
undersigned officer, personally appeared TERRY RAY PAYNE, known to me (or satisfactorily
proven) to be the person whose name is subscribed to the within instrument and acknowledged
that he executed same for the purposes there~n contained.
IN WITNESS WHEREOF, I have, h~reunto s~t my/hapsl land official seal.
Wt~NDY 5. C~:~, LL-q~ry ~ I
~o
o~
REGISTER OF WILLS OF CUMBERLAND COUNTY
REPORT OF STATUS OF ADMINISTRATION
(For Resident Decedents Dying after July 1, 1984)
ESTATE NO. 21 - 02 - 315
Name of Decedent:
Social Security No.:
MELBA L. PAYNE
242-42-0217
Date of Death:
March 11, 2002
Name of Personal Representative:
Terry Ray Payne
Capacity Executor
(check one) Administrator
X
Administrator c.t.a.
Administrator d.b.n.
Is the administration of the estate complete? Yes X No
If "Yes", how was the administration ended? (check one)
By court accounting
By account stated to parties in interest
Did the parties release the
personal representative? Yes
Other (explain)
X
Total amount paid to date to creditors and for funeral and $8,164.62
administrative expenses
Total value of distributions to date to beneficiaries
$17,562.42
If administration is not complete, estimated value of assets $
still in administration
NOTE: This status report is due no later than the due date for filing of the Pennsylvania
inheritance tax return or, if no inheritance tax return is required, ~ine (9) months after the
date of death; if the administration of the estate has not been concluded, a summary report
shall be filed annually thereafter until the administration is complete.
I certify under penalty of perjury that the foregoing info .rmation is correct to the best of my
knowledge, information and belief.
Attorney for Estate
REGISTER OF WILLS OF CUMBERLAND COUNTY
REPORT OF STATUS OF ADMINISTRATION
(For Resident Decedents Dying after July 1, 1984)
ESTATE NO. 21 - 02 - 315
Name of Decedent:
Social Security No.:
MELBA L. PAYNE
242-42-0217
Date of Death:
March 11, 2002
Name of Personal Representative:
Terry Ray Payne
Capacity Executor
(check one) Administrator
X
Administrator c.t.a.
Administrator d.b.n.
Is the administration of the estate complete? Yes X No
If "Yes", how was the administration ended? (check one)
By court accounting
By account stated to parties in interest
Did the parties release the
personal representative? Yes
Other (explain)
X
Total amount paid to date to creditors and for funeral and $8,164.62
administrative expenses
Total value of distributions to date to beneficiaries
$17,562.42
If administration is not complete, estimated value of assets $
still in administration
NOTE: This status report is due no later than the due date for filing of the Pennsylvania
inheritance tax return or, if no inheritance tax return is required, ni~ne (9) months after the
date of death; if the administration of the estate has not been concluded, a summary report
shall be filed annually thereafter until the administration is complete.
I certify under penalty of perjury that the foregoing info .rmation is correct to the best of my
knowledge, information and belief.
Attorney for Estate