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Home My WebLink About04-1107 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA : :SS. COUNTY Of CUMBERLAND --"- The Petitioner(s) above-named swear(s) and affirm(s) that the statements In the fol.,going Petition a e true and correct to the best of the knowledge and belief of Petitioner(s) and that, §S persor~l repreSentative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to and affirmed and subscribed Before methis ~r~L~ day of October ,2004. WILLIAM P. BELgKY--~ No, Estate of DIANE M. BELSKY , Deceased. Social Security No: 104-40-7923 Date of Death: October 1,2004 GRANT OF LETTERS OF ADMINISTRATION AND NOW,-~u~-~V,,, ~ , 2004, in consideration of the Petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that William P. Belsky is entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to William P. Belsk¥ in the Estate of Diane M. Belsky. FEES Letters ........................... $ ~ 05. Ct) Short Certificate(s) Renunciation .............. Affidavit ( ) .................. Extra Pages ( ) ....... Codicil ............................ JCP Fee ....................... Inventory ...................... Other......~,cc,~ .......... TOTAL ......... Register of Wills Attorney: Edmund G. Myers I.D. No: 20558 Address: Johnson, Duffle, Stewart & Weidner, 301 Market Street, P.O. Box 109, Lemoyne, PA 17043- Telephone: 717-761-4540 his is to certify that Ihe information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the Stale Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 10 85'607 Diane Cumberland 121 Hummel Ave, n CERTIFICATE OF DEATH (Coroner) Belsk¥ ,.104-40-7923 ~. October 1, 2004 M an.29,1948 ueens, NY ~.,~,..HD ~,'o~,.~O omo I~"~O ~..,~..JJJ~ ~q,}O ~ite ~]39 Fieldcrest Rd. ParsiDDan¥.NJ 07054 J~lling Green Hem. Park ,~amj> Hillt PA I~[~sselman FH&CS Inc.32~ Hummel ~Ave. William P. Belsky [] ,[0-8-04. ~ ,~ U] A . October ~. 2004 Diabetes Mellitus Hypertensive Cardiovascular Disease .October 4, 2004 Michael L. Norris, Coroner 6375 Basehore Road, Suite ~1 Mechaniceburg, Pa. 17050 BOND OF PROBATE Travelers Casualty and Surety Company of America Hartford, CT 06183 IN THE IN AND FOR ' IN THE MATTER OF THE Probate Court of Orphans Court of Cumberland County, Pennsylvania x Estate [] Guardianship OF [] Conser~atorship Diane M. Belsky BOND NO. 104419412 x Deceased I~ No. [] Incompetent J [] Minor KNOW ALL MEN BY THESE PRESENTS: That we, William P. Belsky as principal, and Travelers Casualty and Surety Com an of America, a Connecticut corporation, as Surety, are held and firmly bound unto the State of Pennsylvania, in the full and just sum of Six Hundred Sixty Thousand ......... 00/100 ($660,000.00) Dollars for the payment of which, well and truly to be made, we bind ourselves, our and each or our heirs, executors, administrators, successors and assigns, jointly and severally, by these presents. Sealed with our seals, and dated this 11th day of November, 2004 THE CONDITION OF THIS OBLiGATiON SUCH, That, WHEREAS Principal was by an order of said Court made on [] Guardian The day of October~ 27, 2004, appointed x Administrator of the above named Estate [] Executor [] Conservator [] Personal Representative NOW, THEREFORE, if the said principal shall faithfully execute the duties of the trust according to law th~n this obligation to be void; otherwise, to remain in full force and effect. /~ William P. Bel~ky ~ ~ ~ .,~ .Travelers Casualty and Surety Coml~ny of America J'e~epi~.G. I~yako~ V ~ OATH I DO SOLEMNLY SWEAR, That I will faithfully perform and discharge all the duties, as prescribed by law, of Sworn to and subscribed before me, this Administrator of the Estate of Diane M. Belsky _day of NOTARIAL SEAL DIANNE LEfllG, Notary Public Lemoyne Borough Cumberland Co. My Cummisslon Expires. Dec. 21, 2005 TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA TRAVELERS CASUALTY AND SURETY COM[PANY FARMI~GTON CASUALTY COMPANY Hartford, Connecticut 06183-9062 POWER OF ATTORNEY AND CERTIFICATE OF AUTHORITY OF ATTORNEY(S)-IN-FACT KI~OW ALL PERSONS BY THESE PRESENTS, THAT TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMPANY, coqx~ations duly organized under the laws of the State of Connecticut, and having their principal offices in the City of Hartford, County of Harff~xd, State of Connecticut, (hereinafter the "Compames") hath made, constituted and appointed, and do by these pr~seats make, constitute and appoint: A/son O. Wolcott, Jr., Beth A. Beamer, James R. Gould. Joseph G. Buyakowski, Edward L. James, of Camp Hill, Pennsylvania, their true and lawful Attorney(s)-in-Fact, with full power and authority hereby confen~d to sign, execute and acknowledge, at any place within the Uulted States, the following instrument(s): by his/her sole signature and act, any and all bonds, recognizances, contracts of indemnity, and other writings obligatory in the nature of a bond, recognizance, or conditional nnder~aking and any and all consents incident thereto and to bind the Companies, thereby as fully and to the same extent as if the same were signed by the duly authorized officers of the Companies, and all the acts of said Attomey(s)- in-Fact, pursuant to the authority heroin given, are hereby ratified and confirmed. _This. appointment is made under and by authority of the following Standing Resolutions of said Companies, which Resolutions are now in full force and effect: VOTED: That the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President, any Vice President, suy Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Seoretary or any Assistant Secreta~ may appoint Attomeys-in-Fac~ and Agents to act fur and on behalf of the company and may g~ve such appointee such authonty as his or her certificute of authority may prescnbo to sign with the Company' s name and seal with the Company's seal bonds, recognizances, contracts of indemnity, and other writings obligatory in the nature of a bond, recognizance, or conditional undertaking, and any of said officers or the Board of Dimcters at any time may remove any such appointee and revoke the power given him or her. VOTED: That the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President or any Vice President may delegate all or any part of the furegning authority to one ur more officers or employees of this Company, provided that each such delegation is in writing and a copy thereof is filed in thc office of thc Secreta~. VO'IED: That any bond, recognizance, contract of indemnity, or writing obligatory in the nature of a bond, recognizance, or ~',enditienal unde~,~tdnE shall bo valid and bi~clinE upon the Company when (a) signed by the President, any Vice Chan'man, any Executive Vice President, any Senior Vice President or any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Seuretary and duly attested end sealed v~th the Company's seal by a Secretary or Assistant Secretary, or (b) duly executed (under seal, if required) by one or more Attorneys-in-Fact and Agents pursuant to the power prescribed in his or her certificate or their certificates of authority ur by one ur more Company officers pursuant to a written delegation of authority. This Power of Attorney and Certificate of Authority is signed and sealed by facsimile (mechanical or printed) under and by authority of the following Standing Resolution voted by the Boards of Directors of TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FAR_MINGTON CASUALTY COMPANY, which Resolution is now in full force and effect: VOTED: That the signature of each of the following officers: President, any Executive Vice ?resident, an~ Senior Vice President, any Vice President, any Assistant Vice President, any Secreta~, any Assistant Seoreta~, and the seal of the Company may be affixed by facsimile to any power of attorney or to any cex-tificete relating thereto appointing Resxdent Vxce Presidents, Kesident Assistant Seeretsnes or Attorneys m Fact for purposes only of executing and attesting bonds and undertakings and other writings obligatory m the nature thereof, and any such power of atturaey or certificate bearing such facsimile signature or facsimile seal shall be valid and binding upon the Company and any such power so executed and ce~ified by such facsimile signature and facsimile seal shall bo valid end binding upon the Company in the future with respect to any bond or unde~-.t-hLu to which it is attached. (05-04) Unlimiled IN WITNESS WHEREOF, TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMPANY have caused this instrument to be signed by their Senior Vice President and their corporate seals to be hereto affixed this 30th day of August, 2004. STATE OF CONNECTICUT }SS, Hartford COUNTY OF HARTFORD TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA TRAVELERS CASUALTY AND SURETY COMPANY FARMINGTON CASUALTY COMPAI~'Y George W. Thompson Senior Vice President On fids 30fit da)' of August, 2004 before me personally came GEORGE W. THOMPSON to me lmovm, who, being by me duly sworn, did depose and say: that he/she is Senior Vice President of TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMPANY, the corporations described in and which executed the above instrument; that he/she knows the seals of said corporations; that the seals affixed to the said instrument are such corporate seals; and that hdshe executed the said iustnnnent on behalf of the corpomlious by authority of his/her office under the standing ResOlutions thereof. My commission expires June 30, 2006 Notary Public Marie C. Tetreault CERTIIqCATE I, the undersigned, Senior Vice President of TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMI3IGTON CASUALTY COMPANY, stock corporations of the State of ConnectiCut, DO HEREBY CERTii~'y that the foregoing and attached Power of Attorney and Certificate of Authority remains m full force and has not been revoked; and furthermore, that the Standing Resolutions of the Boards of Directom, as set fotth in the Certificate of Authority, are now in force. Signed and Sealed at the Home Office of the Company, in me City of Hartford, State of Connecticut. Dated this [ I~'l'~ day of Peter Schwartz Senior Vice President CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: DIANE M. BELSKY Date of Death: October 1, 2004 Will No.: To the Register: Admin. No.: 21-04-0'1107~g-r~ I certify that the Notice of Beneficial Interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on December 3, 2004. Name William P. Belsky, Brother & Administrator Address 139 Fieldcrest Rd., Parsippany, NJ 07054 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except None. Date: December ~0 ,2004 Signature Name: Edmund G. Myers, Attorney Johnson, Duffle, Stewart & Weidner Address 301 Market St. P. O. Box 109 Lemoyne, PA 17043-0109 Telephone: (717) 761-4540 Capacity: Personal Representative X_ Counsel for personal representative TO Register of Wills Office Cumberland County Courthouse I Courthouse Square Carlisle, PA 17013-3387 SUBJECT: Estate of Diane M. Belsky No. 21-04-01107 DOD: October 1, 2004 FROM 3OHNSON, DUFFIE, STEWART & WElrDNER Attorneys at Law P.O. Box 109 Lemoyne, PA 17043 (717) 761-4540 Fax: (717) 761-3015 DATE: December 27, 2004 8o Enclosed is a check in the amount of $40,000.00 as a payment on acco~t~f Inhe~nc~ Tax for the above-captioned Estate, being made within the 90 days to allow for i~ disE~unt. cdc ~ SIGNED: Edmund G. Myers csh r~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENTOFREVENUE BUREAU OFINDIVIDUAL TAXES DEPT 280601 HARRISBURG. PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004774 MYERS EDMUND G 301 MARKET STREET P O BOX 109 LEMOYNE, PA 17043 ........ fold ESTATE INFORMATION: SSN: 104-40-7923 FILE NUMBER: 2104-1107 DECEDENT NAME: BELSKY DIANE M DATE OF PAYMENT: 12/28/2004 POSTMARK DATE: 1 2/27/2004 COUNTY: CUMBERLAND DATE OF DEATH: 10/01/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $40,000.00 REMARKS: TOTAL AMOUNT PAID: $40,000.00 SEAL CHECK//93 INITIALS: JA RECEIVED BY.' GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV_1500H+16-001 .. REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT NUMBER 21 04 COUNTY CODE YEAR SOCIAL SECURITY NUMBER 01107 NU~tBJ~F_ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT.280601 HARRISBURG.PA 17128-0601 DECEDENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL) BELSKY, DIANE M. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 10/01/2004 01/29/1948 (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) 104-40- 7923 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 181 1. Original Return 0 2 Supplemental Return ~ ~ 0 4 Limited Estate 0 4, Future Interest Compromise (date Of death after u ~ 12-12-82} w u ~ 0 0 6 Decedent Died Testate (Attach copy 0 7 Decedent Maintained a Living Trust (Attach u ~ . of Will) copy of Trust) 0 9 Litigation Proceeds Received 0 10. Credit (date of death between EDMUND G. MYERS FIRM NAME (If applicable) JOHNSON, DUFFIE, STEWART & WEIDNER TELEPHONE NUMBER 717/761-4540 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Pr-oprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) o 3 Remainder Return (date of death prior to 12-13-82) o 5 Federal Estate Tax Return Required 8 Total Number of Safe Deposit Boxes o 11.Election to tax under Sec. 9113(A) (Attach Sch 0) 301 Market St. Lemoyne, PA 17043-0109 (1) None (2) 238,752.96 (3) None (4) None (5) 26,420.55 (6) None (7) None 1_ (8) (9) 18,690.32 (10) OfT:C,AI ;K': QNLY .,') , ) i"") ".';1 265,173.51 (11) 18,69032 246,483.19 (12) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax(Line 12 minus Line 13) (13) (14) 246,483.19 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due x .00 (15) x .045 (16) 246,483.19 x .12 (17) 29,577.98 x .15 (18) (19) 29,577.98 20. 181 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT uYhLhhhl;JC HHE;;1!E1 >:<1 '-'-",,,,>:,,, 77:1.,",'" >:,,, .' ....~~..~~!~!I~ii!Tc~J~~~~liiii!~~!~~l!~,m!~m!iiii!~!ii!iI*m~,~.Ll!iJ!i~~m!!!~!!t!j~1!J~~liil~1tiilllliWilliWiIll!ilim,,!'Hm!mm.. Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: .sTREET ADDRESS 121 HUMMEL AVE. CITY LEMOYNE ,STATE PA ZIP 17043 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 29,577.98 40,000.00 1,478.90 Total Credits (A + B + C) (2) 41,478.90 3. Interest/Penalty if applicable D. Interest E. Penalty TotallnteresUPenalty (0 + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is th€OVERPA YMENT 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. A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA. This is theBALANCE DUE (3) (4) 0.00 11,900.92 (5) (SA) (58) 0.00 Make Check Payable 10: 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;....... . ... ....................... ~ I 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?. ............................ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........ ... . .......... ..............n.. 0 o o ~ ~ ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death.?.. 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary 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 penallies of perjury, I declare that I have examined this return, including accompanying schedules and statements. and to the best of my knowiedge and belief, it is true, correct and complete. Declaration preparerotherthan the personal rep~esentativeisbasedonall information Of which preparer has any knowledge. ADDRESS SI%~~;i~~~~>;;S;87lF~ SIGNA~ON RESPON;'I~t:1'OR FILING RETURN SIG~E~J:~~;iAN REPRESENTATIVE E[):\111ND G. MYERS 139 FIELDCREST ROAD PARSIPPANY, NJ 07054 DATE 3-.::l1-05"" ADDRESS DATE ADDRESS ?/}-~IO[' DATE 301 Market St. Lemayne, PA 17043-0109 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~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 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. ~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) [72 P.S. ~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. ~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. ~.". .~ SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BELSKY. DIANE M. FILE NUMBER 21 - 04 - 01107 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER I DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 238,752.96 217 Series EE Bonds - issued (Rooald C. Belsky, Deceased 7112/1997 or Diane M. Belsky) (See statement attached for Face Amounts; issue tiMes and date of death values) Date of death value TOTAL (Also enter on line 2, Recapitulation) 238,752.96 ESTATE OF DIANE M. BELSKY 21-04-01107 Series EE Bonds Diane Belsky Estate Value - DaD 10/1/2004 1 - $200.00 - 03/1 990 $ 224.48 $ 224.98 1 - $200.00 - 09/1992 $ 203.28 $ 203.28 1 - $200.00 - 09/1989 $ 228.96 $ 228.96 1 - $500.00 - 03/1989 $ 583.80 $ 583.80 1 - $500.00 - 10/1 988 $ 595.60 $ 595.60 1 - $500.00 - 05/1988 $ 595.60 $ 595.60 I - $500.00 - 07/1989 $ 572.40 $ 572.40 2 - $200.00 - 09/1 993 $ 164.64 each $ 329.28 I - $200.00 - 08/1992 $ 203.28 $ 203.28 4 - $100.00 - 10/1993 $ 82.32 each $ 392.28 12 - $1,000.00 - 04/1987 $ 1,264.00 each $ 15,168.00 30 - $1,000.00- 01/1988 $ 1,214.80 each $ 36,444.00 1 - $ 500.00 - 04/1 987 $ 632.00 $ 632.00 30 - $] ,000.00 - 07/1988 $ 1,191.20 each $ 35,736.00 30 - $1,000.00 - 01/1989 $ 1,167.60 each $ 35,028.00 30 - $1,000.00 - 10/1 989 $ 1,144.80 each $ 34,344.00 30 - $1,000.00 - 01/1990 $ 1,122.40 each $ 33,672.00 30 - $],000.00 - 10/1990 $ 1,100.40 each $ 33,012.00 10 - $1,000.00 - 03/1991 $ 1,078.80 each $ 10,788.00 Total Bonds - 217 Total Value $238,752,96 ~ ~ SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BELSKY, DIANE M. FILE NUMBER 21 - 04 - 01107 Include the proceeds of litigation and the date the proceeds were received by the estatel\.1I property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER I DESCRIPTION VALUE AT DATE OF DEATH 1,969.62 M&T Bank - Checking Account No. 35626259 Date of death balance 2 M&T Bank - Savings Account No. 021000001124750 Date of death balance, plus accrued interest 24,450.93 TOTAL (Also enter on Line 5, Recapitulation) 26,420.55 ",~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REStDENTDECEDENT ESTATE OF BELSKY, DIANE M. Debts of decedent must be reported on Schedule I. DESCRIPTION AMOUNT ITEM NUMBER A. FUNERAL EXPENSES: Musselman Funeral Home 2 Rolling Green Cemetery - interment charges , ., Rolling Green Cemetery - Marker B. ADMINISTRATIVE COSTS: Personal Representative's Commissions 1. SCHEDULE H FUNERAL EXPENSES & ADMINlSTRAllVE COSTS FILE NUMBER 21-04-01107 Social Security Number(s) J EIN Number of Personal Representative(s): Street Address City Year(s) Commission paid State Zip 2. Attorney's Fees Johnson, Dnffie, Stewart & Weidner' 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent State Zip 4. Probate Fees Register of Wills - Cumberland County 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Other Administrative Costs The Patriot-News - advertising letters 2 Cumberland Law Joumal - advertising letters Total of Continuation Schedule(s) TOTAL (Also enter on line 9, Recapitulation) 6,199.00 895.00 1,672.00 7,500.00 345.00 110.32 75.00 1,894.00 18,690.32 ':* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Schedule H Funeral Expenses & Mninistralive Costs continued ESTATE OF BELSKY, DIANE M. .3 Register of Wills - file Inventory & Inheritance Tax Retum 4 Insurance & Surety, Inc. - Administrator's Bond 5 Vital Records - 10 Death Certificates for Ronald C. Belsky - re - Series EE Bonds FILE NUMBER 21-04-01107 ! 30.00 1,774.00 90.00 Page 2 of Schedule H REV.1513 EX+ (9-00) ;~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF IlRSKY, DIANE M. FILE NUMBER 21 - 04 - 01107 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) William P. Belsky 1]<J Flelderes! Road, Parsippany, NJ 07054 Brother Residue I Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover she t 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 I TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE1J" Register of Wills.of Cumberland County, Pennsylvania INVENTORY .. ,~ , Estate of BELSKY, DlANE M'. r:o NO.2] -04-0]]07 Date of Death 1011/2004 81so known as , Deceased Social Security No. ] 04-40- 7923 WILLIAM P. BELSKY Tile 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 located 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 the 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/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities. Attorney: EDMUND G. MYERS Personal Representative - ,;) '2?Jf. Signature: !f;~1 ;::;, . . WILLIAM P. BELSKY Signature: C!~,,~ 1.0 No.: 20558 Signature: Address: Address: ] 39 FTELDCREST ROAD PARSTPPANY, NJ 07054 301 Market St. Lemoyne, PA 17043-0109 Telephone: 717/761-4540 Telephone: (973) 463-0650 l1a;rcJe ,,20 d6cJr Dated: Personal Property 2 ] 7 Series EE Bonds - issued (Ronald C. Belsky, Deceased 7/12/1997 or Diane M. Belsky) (See statement attached for Face Amounts; issue dates and date of death values) Date of death value 238,752.96 \1&T Bank - Checking Account No. 35626259 Date of death balance 1,969.62 M&T Bank - Savings Account No. 02100000] 124750 Date of death balance, plus accmed interest 24,450.93 Total Personal Property $265,173.51 (Attach additional sheets if necessary) Total Personal Property and Real Estate $265.173.51 06-20-2005 BELSKY 10-01-2004 21 04-1107 CUMBERLAND 101 APPEAL DATE: 08-19-2005 ( See reverse side under Objections) Amount Rnitted I I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE _ RETAIN LONER PORTION FOR YOUR RECORDS _ REy:is4;-Ex-AFP-io3:osj-NoTIcE-OF-INHERITANCE-TAX-APPRAIsEMENT:-ALLowANCE-OR--------------- DISALLONANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DIANE M FILE NO. 21 04-1107 ACN 101 BUREAU OF INDIVIDUAl. TAXES . INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX F--.r:, , " ~ f ~ ,j..) DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN EDMUND G-:MYERS JOHNSON ETAL 301 MARKET ST LEMOYNE PA 17043 ESTATE OF BELSKY *' REY-1547 EX AFP (06-05) DIANE M TAX RETURN WAS: I X I ACCEPTED AS FILED I CHANGED DATE 06-20-2005 NOTE: I~ an assessment was issued previOUSly, lines 14, IS and,or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ abb returns assessed to date. ASSESSMENT OF TAX: IS. A~unt of Line 14 at Spousal rat. (IS) 16. Amount of line 14 taxable at Lineal/Class A rat. (16) 17. Amount of Lin. 14 at Sibling rete (17) 18. Amount of Line 14 taxable at Collateral/Class Brat. (18) 19. Principal Tax Due .00 X 00 = .00 .00 X 045 = .00 246,483.19 X 12 = 29,577.98 .00 X 15 = .00 1191= 29,577.98 RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule AJ 2. Stocks and Bonds ISchedule BI 3. Closely Hald Stock/Partnership Interest (Schedule C) 4. Hartgages/Notes Receivable (Schedule DJ S. Cash/Bank Deposits/Misc. Pers0n81 Property (Schedule El 6. Jointly Owned Property {Schedule fl 7. Transfers (Schedule G) 8. Total Assets III 121 131 I~I 151 161 171 .00 238.752.96 .00 .00 26.420.55 .00 .00 181 APPROVED DEDUCTIONS AND EXEMPTIONS: ,. Funeral Expenses/Adm. Costs/Hisc. Expenses (Schedule H) 10. Debts/Hortgage Liabilities/Liens (Schedule Il 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Government.l Bequestsi Non-elected 9113 Trusts (Schedule J) 14. Net Value of Est.t. Subject to Tax 191 1101 18,690.32 .00 1111 1121 1131 11~1 NOTE: To insure proper credit to your account, submit the upper portion of this for. with your tax P8Y11ent. 265,173.51 lR ;;90 3' 246,483.19 .00 246,483.19 fAX CREDITS: ,., AHOUNT PAID DATE NUNDER INTEREST/PEN PAID (-I 12-27-2004 CD004774 1,478.90 40,000.00 TOTAL TAX CREDIT 41,478.90 BALANCE OF TAX DUE 11,900.92CR INTEREST AND PEN. .00 TOTAL DUE 11,900.92CR ~ . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN 01, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOHN FOR INSTRUCTIONS.I Cf.'J:lDr'D rwl'\:.- ('C BUREAU OF INDIVIDUAt!1[lIIU"V: 0'" IV ,~" INHERITANCE TAX DIVISION rrr'lc"r'-...... PO 80X 280601 [^\C.\:>.,' i HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE XNHERXTANCE TAX STATEMENT OF ACCOUNT *' REV-}607 EX AFP (03-05) 2005 I:: 26 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 08-08-2005 BELSKY 10-01-2004 21 04-11 07 CUMBERLAND 101 AlIOunt R..i tted DIANE M EDMUND G ll:\'ERS JOHNSON ETAL 301 MARKET ST LEMOYNE PA 17043 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSet 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 BELSKY DIANE M FILE NO. 21 04-1107 ACN 101 DATE 08-08-2005 TNIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NANED ESTATE. SHOWN BELOW IS A SUHHARY DF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FISURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 06-20-2005 PRINCIPAL TAX DUE, 29,577.98 PAYMENTS (TAX CREDITS), PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 12-27-2004 CD004774 1,478.90 40,000.00 07-19-2005 REFUND .00 11,900.92- TOTAL TAX CREDIT 29,577.98 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 RElIUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORN FOR INSTRUCTIONS. I ~ PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE A 6.12 FORM YEARLY UNTIL COMPLETION. STATUS REPORT UNDER RULE 6.12 Name of Decedent: DIANE M. BELSKY Date of Death: OCTOBER 1, 2004 WHINo.: Admin No.: 21-04-01107 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes! No 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! B. The separate Orphans' Court No. (if any) for the personal representative's account is:. C. Did the personal representative state an account informally to the parties in interest? Yes No! The Administrator was the brother of the decedent and the sole beneficiary Date: D. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. /0/5/0<;' ~k~ Signature Edmund G. Myers, Attorney Johnson, Duffie, Stewart & Weidner 301 Market Street, P.O. Box 109 Lemoyne, PA 17043-0109 Address N 0J (717) 761-4540 Telephone No. Capacity: Personal Representative ! Counsel for Personal Representative c.~; \.-Vr c;J / (Y-( - II C 7 RELEASE I, WILLIAM P. BELSKY, Administrator of the Estate of Diane M. Belsky and sol~ heir of the Estate of Diane M. Belsky, do hereby confirm that all matters relating t~ the administration of the Estate of Diane M. Belsky have been concluded and all Inheritanc~ Tax assessed has been paid in full. As the sole heir, I am hereby confirming that all matters relating to the administration of the Estate of Diane M. Belsky are concluded and requesting that the Administrator's Bond issued by S1. Paul Travelers Bond Express be cancelled and not renewed. Sworn to and affirmed before me this 26 'f'I!-, day of Ju.-Iy ,2005. ~~1f:: William P. Belsky, sole h of: the Estate of Diane M. Belsky JUDITH A. SYLVIA A IJTMY PI&IC OF H JERSEY MY __ EXPIRES OCTOBER 29, 2007 r"\.,,) C,) -,.. ,":" i;':) .~:- co \)'