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CUMBERLAND COUNTY, PENNSYLVANIA , � ,� , �
ORPHANS' COURT DIVISION ° ::� ` ' - . '
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ESTATE OF Edward S. Smith , DECEASED
No. 21-12-0880
PETITION FOR ADJUDICATION/
STATEMENT OF PROPOSED DISTRIBUTION
PURSUANT TO Pa. O.C. RULE 6.9
This form may be used in all cases involving the Audit of the Account of a Decedent's Estate. If
space is insufficient, riders may be attached. Aitach the spouse's election, if any; the papers
required under items 8-19 inclusive; and any instrument pertinent to the adjudication.
INCLUDE ATTACHMENTS AT THE BACK OF TH/S FORM.
Name of Counsel: Bradley L Griffie
Supreme Court I.D. No.: 34349
Name of Law Firm: Griffie 8�Associates, P.C.
Address: 200 North Hanover Street
Carlisle, PA 17013
Telephone: 717-243-5551
Fax: (717) 243-5063
E-mail: bgriffie griffielaw.com
Form OC-O'I Rev.10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. P89B'I Of'I O
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Estate of Edward S. Smith , Deceased
1. Name(s) and address(es) of Petitioner(s):
^�ame: Jay E. Srfl'Ith Pamela S. Tate
Add�ss: 436 Goodyear Road 4100 Carlisle Road
Gardners, PA 17324 Gardners, PA 17324
Identify any executors or administrators who have not joined in the Petition for
Adjudication and Statement of Proposed Distribution and Account and state reason:
Is this the first accounting by this fiduciary?......................................................................... � Yes ❑ No
If not, identify prior accountings, the accounting periods covered, and the date of
adjudication of the prior accounting.
2. Decedent died on 07112/2012
� Letters Testamentary or ❑ Letters of Administration were granted to Petitioner(s) on
08/13/2012
Date of Will (if applicable): 02/02/1999
Date(s) of Codicil(s) (if applicable):
Date of probate (if different from date Letters granted):
Was a bond required? ❑ Yes ❑ No If yes, state amount:
Are proofs of advertising of the grant of Letters attached? .......................................... � Yes ❑ No
Dates of advertising of the grant of Letters:
08/28/2012 09/04/2012 09/11/2012 08/31/2012 09/07/2012 09/14/2012
Form OC-01 Rev.10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. P8g2 2 Of'I O
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Estate of Edward S. Smith , Deceased
3. Was decedent survived by a spouse?....................................................................... � Yes ❑ rvo
If yes, name of the surviving spouse:
4. Has the surviving spouse filed to take an elective share?......................................... ❑ Yes � No
(� Section 2201 gt s�. of the Probate, Estates and Fiduciaries Code)
If yes, date of election:
5. In the case of an intestacy, state the names of the decedent's surviving children or
surviving issue of deceased children (if none, so state):
6. Did the decedent marry after execution of Will or Codicil(s)?.............................................. ❑ Yes � No
Were any children born to decedent after execution of
Will or Codicil(s)? ❑ Yes � No
...............................................................................................................
If yes, give names and dates of birth:
Name: Date of Birth:
7. If required by the Medical Assistance Estate Recovery Act,
62 P.S. §1412, was a request for a statement of claim sent to
the Department of Public Welfare? ..................................................................................... ❑ Yes � No
Form OC-01 Rev.10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. P89B 3 Of'I O
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Estate of Edward S. Smith , Deceased
8. Written notice of the Audit as required by Pa. O.C. Rules 6.3, 6.7 and 6.8 has been or will
be given to all parties in interest listed in item 9 below, all unpaid creditors and all
claimants listed in item 10 below. In addition, notice of any questions requiring
Adjudication as discussed in item 14 below has been or will be given to all persons
affected thereby.
A. If Notice has been given, attach a copy of the Notice as well as a list of the names
and addresses of the parties receiving such Notice.
B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and
addresses of the parties receiving such Notice shall be submitted at the Audit
together with a statement executed by a Petitioner or counsel certifying that such
notice has been given.
C. If any person entitled to Notice is not sui juris(e.g., minors or incapacitated
persons), Notice of the Audit has been or will be given to the appropriate
representative on such party's behalf as required by Pa. O.C. Rule 52.
D. If any charitable interest is involved, Notice of the Audit has been or will also be
given to the Attorney General as required under Pa. O.C. Rule 5.5. In addition,
the Attorney General's clearance certificate (or proof of service of Notice and a
copy of such Notice) must be submitted herewith or at the Audit.
9. List all parties (charitable and non-charitable)of whom Petitioner(s) has/have notice or
knowledge, having or claiming any interest in the estate as beneficiaries under the Will or
Codicil(s) or as intestate heirs if there is a complete or partial intestacy:
A. State each party's relationship to the decedent and the nature of each party's
interest(s):
Name and Address of Each Part in Inte2st Relationship and Comments,if an Interest
Pamela J.Tate Daughter Pursuant to
4100 Carlisle Road decedent's Will and
Gardners, PA 17324 the survival of
Margaret R. Smith
beyond 30 days of
Jay E. Smith Son Pursuant to
436 Goodyear Road decedent's Will and
Gardners, PA 17324 the survival of
Margaret R. Smith
beyond 30 days of
Form OC-01 Rev.10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. P89e 4 Of 1 O
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Estate of Edward S. Smith , Deceased
Name and Address of Each Party in Interest Relationship and Comments,if any Inte2st
Margaret R. Smith Spouse One Hundred percent
Cumberland Crossings of distributable estate
1 Longsdorf Way, Room 22
Carlisle, PA 17013
B. Identify each party who is not sui juris (e.g., minors or incapacitated persons).
For each such party, give date of birth, the name of each Guardian and how each
Guardian was appointed. If no Guardian has been appointed, identify the next of
kin of such party, giving the name, address and relationship of each.
C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for
this Audit(�PA. O.C. Rule 12.4).
D. If distribution is to be made to the personal representative of a deceased party,
state date of death, date and place of grant of Letters and type of Letters granted.
Form OC-01 Rev.10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. P898 5 Of'I O
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Estate of Edward S. Smith , Deceased
10. Other than the claim for the family exemption, list the names of all known claimants and
the amount of their claims and state whether each claim is admitted.
Name and Address of Each Claimant Amount of Claim Claim Will Claim
Admitted? Be Paid in
Full?
Above
Attachment
Total
If the estate is insolvent, attach a schedule setting forth the order of preference under
20 Pa.C.S. § 3392 and the proposed payments.
11. Was family exemption claimed?.......................................................................................... ❑ Yes � No
Was family exemption allowed?.......................................................................................... ❑ Yes � No
Family exemption ctaimanYs name and relationship:
Name: Relationship:
Form OC-01 Rev.10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. P89B B Of 1 O
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Estate of Edward S. Smith , Deceased
12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate
Tax paid, the date(s) of payment(s), and the interest(s) upon which paid, are as follows:
Date Payment Interest
09/25/2012 4,245.37 0.00
13. On the date of death, was the decedent a fiduciary
(personal representative, trustee, guardian, agent under power
of attorney) or surety on the bond of a fiduciary?................................................................ ❑ Yes � No
If yes, provide the name of the estate, indicate whether an account has been filed and
confirmed abso�utely and all awards performed, or, in the alternative, how the
decedent's estate will be discharged for the decedenYs fiduciary administration of the
estate.
14. A. Describe in detail any questions requiring adjudication and state the position of the
Petitioner(s) as to each question:
B. Has notice of the question requiring adjudication been given
to the parties identified in Paragraph 9 above?............................................................ ❑ ves � No
15. If Petitioner(s) has/have knowledge that a share has been assigned, renounced, disclaimed
or attached, provide a copy of the assignment, renunciation, disclaimer or attachment,
together with any relevant supporting documentation.
Form OC-O�Rev.10-13-2006 Copyright(c)2D06 form software only The Lackner Group,Inc. P89B 7 Of'I O
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Estate of Edward S. Smith , Deceased
16. Had the decedent been adjudicated an incapacitated person?........................................... ❑ Yes � No
If yes, attach a copy of the Order if available; otherwise state Court, term, number,
date, and name of Hearing Judge.
17. A. List or attach a separate list of additional receipts and disbursements since the closing
date of the Account.
Date Description Amount
B. Has notice of the additional receipts and disbursements been
given to the parties identified in Paragraph 9 above?................................................... ❑ Yes � No
18. If a reserve is requested, state amount and purpose.
Amount:
Purpose:
If a reserve is requested for counsel fees, has notice of the
amount of fees to be paid from the reserve been given to the
. . � Yes � No
partiesin mterest?.................................................................................................
If so, attach a copy of the notice.
19. Is the Court being asked to direct
the filing of a Schedule of Distribution?................................................................................ ❑ Yes � No
Asto real estate only?......................................................................................................... ❑ Yes ❑ ►vo
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Estate of Edward S. Smith , Deceased
Wherefore, your Petitioner(s) ask(s)that distribution be awarded to the parties entitled
and suggest(s)that the distributive shares of income and principal (residuary shares being stated
in proportions, not amounts) are as follows:
A. Income:
Proposed Distributee(s) Amount Proportion
Pamela J.Tate 50%
Jay E. Smith 50%
B. Principal:
Proposed Distributee(s) Amount Proportion
Pamela J.Tate 50%
Jay E. Smith 50%
Submitted By:
(All petitioners must sign. ?
Add additional line ' ecessary): -�'"�
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Name of Petition : ay E. Smith
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Name of Petitioner: Pamela S. Tate
Name of Petitioner:
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Estate of Edward S. Smith , Deceased
Verification of Petitioner
(Verification must be by at least one petitioner.)
The undersigned hereby verifies* [that n�sne is r;r�e
of the above-named nameotcorporation
and]that the facts set
forth in the foregoing Petition for Adjudication/Statement of Proposed Distribution which are
within the personal knowledge of the Petitioner are true, and as to facts based on the
information of others, the Petitioner, after diligent inquiry, believes them to be true; and that any
false statements herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to
unsworn falsification to authorities). -
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Signature` f P itioner ,Jay E. Smith
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Signature of Petitioner Pamela S. Tate
Signature of Petitioner
*Corporate petitioners musf comp/ete bracketed information.
Certification of Counsel
The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/
Statement of Proposed Distribution is a true and accurate reproduction of the form Petition
authorized by the Supreme Court, and that no changes to the form have been made beyond the
responses herein.
� Signa o nsel etitioner
L Griffie
Form OC-O�Rev.10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. P89@'I O Of 1 O
PRC?OF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
{Under Act No. 5$7, approved May 16, 1929),P. L.1784
COlYtMONWEALTH OF PENNSYLVANIA ;
. ss.
COUNTY OF CUMBERLAND .
Lisa Marie Coyne,Esquire, Editar of the Cutnberland Law Journal, of the County and
State aforesaid, being duly sworn, according ta law, deposes and says that the Cumberland Law
Journat,a legai periodicai published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the locai courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been xegularly
issued weekly in the said County, and that the printed notice or pubiication attached hereto is
exactly the same as was printed in the reguiar editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
August 31. September 7, and September 14, 2012
Affiant further deposes that he is authori�ed to verify.this statement.by the Cumberiand
Law Journal, a Iegai periodical of general circulation, and that he is nat interested in the subject
matter of the aforesaid notice or advertisement,and that all allegations in the foregoing
statements as to time, place and character of publication are true.
C'
..�-�'�
Li Marie Coyne, Editor
SWORN TO AND SUBSCRIBED befare me this
14 da�of Sebtember, 2012
r
9mith,Edtvard S.,dec'd,
Late of Carlisle Borough. NOt�T,
Ca-Executars: Jay E. 5�nith and y
Pamela S. Tate c/a Bradley L.
Gritfie,Esquire, C,riflie&Assaci-
ates, 200 North Hanover Street,
Carlisie, PA i7013, {717} 243-
5551, (800j 347-5552.
Attorneys: Bradley L. Ciriffie, Es- ��"
quire, Gri�ie&Associates. NqTARlAi.SEAL
DE$t3RAH A C4LLiNS
Notary Public
CARl.IS�.E BOROUGH,CUMSERLANA COUtVTY
My Commission Expires Apr 28,2014
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Tackie Cox,Sales Director, of The Sentinel, of the County and State aforesaid,being duly
sworn, deposes and says that THE SENTINEL,a newspaper of general circulation in the
Borough of Carlisle,County and State aforesaid,was established December 13th, 1881,
since which date THE SENTINEL has been regularly issued in said County, and that the
printed notice or publication attached hereto is exactly the same as was printed and
published in the regular editions and issues of
THE SENTINEL on the following day(s):
August 28,S�tember 4& 11, 2012
COPY OF NOTICE OF PUBLICATION
Affiant further deposes that he/she is not
interested in the subject matter of the
aforesaid notice or advertisement, and that
all allegations in the foregoing statement as
to time,place and character of publication
e true.
�
Sworn to and subscri ed be ore me this
1 � 2 alZ
Notary Public
My commission expires:
..��
NOTARIAL SEAL
BAMBI ANN HECKENDORN
Notary Public I
CARUSLE BDROUGH, CUh18ERLAND CNTY �
��ly Commission Expires Jan 27,2p�q I
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In the Court of Common Pleas of Cumberland County, Pennsylvania
Orphans' Court Division
File No. 21-12-0880
Estate of Edward S. Smith, Deceased
Late of Borough of Carlisle
First and Final Account
Jay E. Smith and Pamela S. Tate, Executors
Date of Death: 07/12/2012
Date of Incapacity, if any: None
Date of Executors'Appointment: 08/13l2012
Date of First Complete Advertisement: 09/14/2012
Accounting for the period: 07/12/2012 to 09I06/2013
Purpose of Account: Jay E. Smith and Pamela S. Tate, Executors, offer this Account to acquaint
interested parties with the transactions that have occurred during the Administration.
It is important that the Account be carefully examined. Requests for additional information or questions
or objections can be discussed with:
Bradley L Griffie
Griffie 8�Associates, P.C.
200 North Hanover Street
Carlisle, PA 17013
717-243-5551 �-�
, _ ,.
Supreme Court I.D. No. 34349 � `-'' ' �
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SUMMARY 4F ACCOUNT
Estate of Edward S.Smith, Deceased
ESI� hp neriod of.�{�y�, 2�12�hro��,h �ent�r 6, ?01� Fiduci8ry
Gurrent Acquisition
pAGES Vaiue Vaiue
Proposed Distributions
to Beneficiaries �'��
PRINCI�'AL
Receipts: This Account A 10,622.03
Net Gain (or Lass�on Sales p.pp
or G#her Dispositions
10,622.03
Less Disbursements: �
Debts of Decedent 1,289.25
Funeral Expenses ���.��
Administration Expenses 5,097.78
Federal, State&Lacal Taxes ����
Commissions o.00
Fees `�,���.��
Family Exemption 0.00 10,622.03
Balance Befare Distributions �'��
Transfer to(from}Principal T� �.��
Distributions to Beneficiaries p.0o
Principal Balance on Hand pBOH 0.00
For Infarma#ion:
Investments Made
Changes in Holdings �
l�5'�.ONIE
Receipts This Accaunt ��a�
Net Gain (or Loss)an Sales 0.00
or 0!ther Dispositians Q.00
Less Disbursements a.�a
Balance Before Distribu#ions q.00
Transfer to(fram) Income T� �'��
Distributions to Beneficiaries �,��
Income Balance on Hand 0.00
Far Information:
Investments Made
Changes in Holdings
Ct'3MBINED BALANCE t7N HAND CBOH �`a4
Signature
Verification
SCHEDULE A
RECEIPTS OF PRINCIPAL
Assets Listed in Inventory Fiduciary
(Valued as of Date of Death) Acquisition
Value
��V
Contribution to Estate by Executors 4,059.00
Internal Revenue Service refund(2012 tax return) 1,225.00
Medical expense refund from CRMC 117.49
Prudential Distribution-(Correction of interest 6.00
payment error for 2009)
Refund from Chapel Pointe at Carlisle -(Refund of 5,214.54
Nursing Home overpayment)
Total Cash 10,622.03
Total Receipts �o,s22.os
Total Receipts of Principal �o,s22.os
A-1
SCHEDULE C
DISBURSEMENTS OF PRINCIPAL
Debts of Decedent
Carlisle Regional Medical Center(2 statementsl
07/12/2012 234.38
234.38
Cumberland Goodwill Fire 8� Rescue (,�statementsl
07/12/2012 781.89
781.89
Darrvl Guistwite(Medical�(2 statements)
07/12/2012 145.26
145.26
Millennium Pharmacy Systems (Medicall
07/12/2012 79.66
07l12/2012 36.86
116.52
Philhaven (Medicall
07/12/2012 11.20
11.20
Total Debts of Decedent 1.289.25
Funeral Ex ep nses
Hollinggr Funeral Home
07/12/2012 235.00
235.00
C-1
SCHEDULE C
DISBURSEMENTS OF PRINCIPAL
Continued
Total Funeral Exnenses 235.00
Administration Ex ep nses
Advertising to The Sentinel
07/12/2012 200.16
200.16
Advertisina to the Cumberland Law Journal
07/12/2012 75.00
75.00
Bank Fees
07/12/2012 15.75
15.75
Cohick 8�Associates
07/12/2012 (Professional fees/2012 Personal Tax Return) 314.00
314.00
Inheritance Tax
08/19/2013 4,245.37
($4,468.81 less discount$223.44)
4,245.37
Probate Fees
07/12/2012 247.50
247.50
Total Miscellaneous Administrative Exnenses 5,097.78
C-2
SCHEDULE C
DISBURSEMENTS OF PRINCIPAL
Continued
Fees
Griffie 8�Associates
07/12/2012 4,000.00
4,000.00
Total Fees 4,000.00
TOTAL DISBURSEMENTS OF PRINCIPAL 10,622.03
C-3
In the Court of Common Pleas of Cumberland County, Pennsylvania
Orphans' Court Division
File No. 21-12-0880
Estate of Edward S. Smith, Deceased
Signatures
,�- �.
B �R
y
Jay . S ith, Co-Executor
AND
By ����c
Pamela S. Tate, Co-Executor
� In the Court of Common Pleas of Cumberland County, Pennsylvania
Orphans' Court Division
File No. 21-12-0880
Estate of Edward S. Smith, Deceased
Verification
Jay E. Smith and Pamela S. Tate, Executors under the Last Will and Testament of Edward S.
Smith, Deceased, hereby declare under oath that they have fully and faithfully discharged the
duties of their office; that the foregoing Account is true and correct and fully discloses all
significant transactions occurring during the accounting period; that all known claims against the
Estate have been paid in full; that,to his/her knowledge,there are no claims now outstanding
against the Estate; that all taxes presently due from the Estate have been paid; and that the grant
of Letters Testamentary and the first complete advertisement thereof occurred more than four
months before the foregoing Account.
This statement is made subject to penalties of 18 Pa. C.S.A. Section 4904 relating to unsworn
falsification to authorities.
�
Dated: �'f y 13
J . ith, Co-Executor
Dated: �J �3 ��R��d-��'
Pamela S. Tate, Co-Executor
I hereby certify that written notice of the filing of this Account, and of the date, time and place when
the same will be presented to the Court for confirmation and of the last day to file written objections
to said Account, has been given to every unpaid claimant and to every other person known to the
accountant to have or claim an interest in the estate as creditor, beneficiary, heir, or next of kin.
B e e, Esquire