HomeMy WebLinkAbout12-06-13 i 5
J 15D5610143
REV-1500 EX`°2_,,, �
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania ca,r,ry coae rear File Number
Bureau of Individual Taxes D°""TM�NTOF"�"E""'
Po aox.2aoso� INHERITANCE TAX RETURN 21 13 0130
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
166 74 7032 03 29 2011 05 07 1988
DecedenYs Last Name Suffix DecedenYs First Name MI
FAIRCLOTH JONATHAN D
(If Applicable)Enter Survivfng Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRtATE OVALS BELOW
a 1. Original Retum � 2. Supplemental Retum ❑ 3' prior to�12r 3eBZ�m(Date oi Death
4. Limited Estate qa,Future Interest Compromise � 5. Fedefel Estate Tax Retum Requlred
❑ ❑ (date M death aftx 12-12�82)
� g. DecedeM Died Teatate � 7. �AttacheGOpy of��j Livin9 Truat � 8. TOt21 Nurtlbef Oi Sef9 D@pOSlt BOxeS
(Attach Copy o!Will)
� 9. LitigaGon Proceeds Received � 10.S�°�"�P���'�j�e��t{�a��M Deau, � ��,Electlon to tax under Sec.9113(A)
(Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAI TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
BRUCE J WARSHAW3KY 717 238 6570
�:.-, a�
REGI3TER OF�LLS USE Olq]�f � �
r�'t t'�
C C� � �'? C�
First Line of Address � � � �'� �
f�'1 :�: � �..`,,� C°�"{
2320 NORTH SECOND STREE � �� n �-� ;;� �-=�
.__ , � ,-;,
Second Line of Address �' .'�" ""�+
. -i. ,,,t..� —v}
.. �;7 �w� -`;3 "'�
_� <,, .._.� : �>
DATE F.14�ED= ' ��"•
City or Poat Office 3tate ZIP Code . „ul ��.� v
HARRISBURG pA �' � i�
CorrespondenYs e-mail address: bjw�cclawpc.CO�fl
Under penalties of pe�ury,1 deciare that I hava examined this retum,induding accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaratlon of preparer other than the personai representative is based on ali intormation of which preparer has any knowledge.
SIGNATUR°OF PERSON RESPONSIBLE FOR FILING RETURN DATE
,�Q,�r� ��> �-��,��,��t,�.�. Alicia D. Faircloth � � �v1� t?, _
ADORESS
716-B Car enter Park Patuxent River D 20670
SIGNATU F REPARER OTHER THAN REPRESENT DATE
Bruce J.Warshawsky Z �
ss
2320 North Second Street, Harrisburg, PA
Side 1
� 150561�143 1505610143 � ` ';
� 150561U243
REV-1500 EX
DecedenYs Social Security Number
DecedenCsName: FaIrCIOtII, Jonathan Dean 166 74 7032
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. � . ��
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous��q Probate Property
(Schedule G) U Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. � . ��
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 1�848 . 50
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10.
11. Total Deductions(total Lines 9 and 10)................................................................ ��. 1, 848 . 50
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -1 , 84$ . 5�
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subjectto Tax(Line 12 minus Line 13)............................................... 14. -1, 84$ . 5�
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 �5 0 . 0 0
(a)(1.2)X.00
16. Amount of Line 14 taxable 0 . 0 0
at lineal rate X .045 0 . 00 16.
17. Amount of Line 14 taxable � . 00
at sibling rate X.12 0 . 0 0 17.
18. Amount of Line 14 taxable � . 0 0
at collateral rate X.15 � . �� 18.
19. TAX DUE................................................................................................................ 19. O . O O
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
� 1505610243 150561D243 �
REV-1500 EX Page 3 File Number 21-13-0130
Decedent's Complete Address:
DECEDENT'S NAME
Faircloth,Jonathan Dean
STREET ADDRESS
11 Greenway Drive
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
3. Interest �3�
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5, If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 0.�0
Make Check Pa able to REGISTER OF WILLS, AGENT
�� � ° ' ��'�!�� �, ��. ;. �`�� �` ` �:� ,;;�''a ,
, ..
���.�.�� ,��;�° �y:�- .. �,- ,;v.. ,_. �,.F,: ,;.� ,:�.., , e:� ,. ����.. ���_�,,,�,.,
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:............................................................................... ❑ ❑X
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 Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ ❑X
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ 0
4. Did decedent own an individual retirement account,annuity,or other non-probate property which � ❑
containsa 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.
.'��r„�i`,� �°�. ""�i �� ',', ��� �" ;' a"�,.� /�v��..�<
For dates of death on or after July 1, 1994 and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent[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 percent
[72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a 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 21 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 percent[72 P.S.§9116(a)(1.2)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in
[72 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[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.
Rav1508 EX+(11-10)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENTDECEDENT
ESTATE OF FILE NUMBER
Faircloth,Jonathan Dean 21-13-0130
Include the proceeds of litigation and the dale the proceeds were received by the estate.
All property Jointly-ownedwith the right ofsurvivonhip must be disclosedon schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Estate opened for litigation purposes only---litigation in California---no proceeds paid to
Estate
TOTAL(Also enter on Line 5, Recapitulation)
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10)
REV-1151 EX+(�0-09)
SCHEDULE H
COMIN�ERWIATAT�°,�,��"�T�RNAN�A FUNERAL EXPENSES AND
RE3�o�'N DE ED N ADMINISTRATIVE COSTS
ESTATE OF FI�E NUMBER
Faircloth,Jonathan Dean 21-13-0130
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
N R
q, FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
Z, Attornev's Fees Cunningham 8�Chernicoff, P.C. 1,200.00
3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zi�
Relationshio of Claimant to Decedent
4. Probate Fees 323.50
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. OtherAdministrative Costs 325.00
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 1,848.50
Copyright(c)2009 form software only The Lackner Group,inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Faircloth,Jonathan Dean 21-13-0130
ITEM
NUMBER DESCRIPTION AMOUNT
Other Administrative Costs
1 Legal Advertising 225.00
2 Surety Bond 100.00
H-B7 325.00
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
REV-1513 EX+(01-70)
SCHEDULE J
COMINHEy�/ED NTDECED�N�RLNANIA BENEFICIARIES
RE T
ESTATE OF FILE NUMBER
Faircloth,Jonathan Dean 21-13-0130
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions,and transfers
under Sec.9116 a 1.2
Alicia D Faircloth Spouse
716-B CarpenterPark
Patuxent River,MD 20670
Total
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
THE CENTRAL PENN BUSINESS JOURNAL
Proof of Publication
Under the Pennsylvania Newspaper Advertising Act
45 Pa.C.S. §101, et seq.
Commonwealth of Pennsylvania}
ss}
Counry of Dauphin }
Jerome Zary,being duly sworn according to law,deposes and says:
That he is the Controler of and duly authorized agent for JOURNAL MULTIMEDIA CORPORATION,a corporation
organized and existing under the laws of the Commonwealth of Pennsylvania,with its principal office and place of business at 1500
Paxton Street,in the ciry of Harrisburg,Counry of Dauphin,State of Pennsylvania;that the THE CENTRAL PENN BUSINESS
JOURNAL,a newspaper of general circulation distributed and circulated in Dauphin,Cumberland, Lancaster,Lebanon and York
counties, is published by the said JOURNAL MULTIMEDIA CORPORATION at 1500 Pa�cton Street, in the City,County and State
aforesaid;and that THE CENTRAL PENN BUSIIYESS JOURNAL was established September 9th, 1984 and has been continually
published ever since;
That the printed notice or publication which is securely attached hereto is exactly as printed and published in the weekl�
editions/issues of the CENTRAL PENN BUSMESS JOURNAL which appeazed on the 22"d and 29�'day(s)of March and the 5
day(s)of April 2013. T'hat neither he nor said Corporation is interested in the subject matter of said printed notice or advertising,and
that all of the allegations of this statement as to the time,place and character of publication are true;and
This is a statement published by JOURNAL MULTIMEDIA CORPORATION:
PUBLICATION
COPY � / Jerome Z
N0110E IS HEREBY GIVEI��that Lett��
Administratlan have been granted i� 1�e
toltowin9 Estate. All persons indebted ot
tl1g Safd ESffite�!B f9qulted ta�'►►3k8 PaY" Swom to and subscribed before me this �day of 2012 A.D.
m���haviny claims a demands
Admin�f 83Vdtrbt ot amltomaY��Ibelow.the
ESTATE OF Jonathan D.Faircloth, late of IYOTARY P� BL[C
M��purg�Cumbe�land County,Penn- /
sylvan�(dfed Marct►•29, 2011),Adminis-
tratrbc-a►�ia D.Fairciot�.Attomey-eruce Cp F PENN YLVANIA
�, yyarshawsky, Esquire, Cunningham &
Chemicoff,P.C..2320 NoN►Second Street, NOTARIAI.SEAL
Har�isburg,P14171 t Q j DONNA SCHANKWEILER,NOtery Pob1�
City of Hartlsburg,Dauphin Courtty
My Commisabn Expires OctoDer 03,2018
Publisher's Receipt for Advertising Cost
JOURNAL MULTIMED[A CORPORATION,publisher of the CENTRAL PENN BUS[NESS lOURNAL,newspaper of general circulation,
distributed and c'vculated in Dauphin,Cumberland,Lancaster,Lebanon and York counties,hereby acknowiedges receipt of the aforesaid
notice and publication cosu and certifies that the same have been duly paid.
THE CENTRAL PENN BUSINESS JOURNAL
Re:ESTATE OF Jonathan D.Faircioth By... ... . . .. . .......... . ........... .................
CUNNINGHAM&CHERN[COFF,P.C.
2320,North Second Street
Harrisburg,PA l7l 10
Attention:Bruce J.Warshawsky,Esquire
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA :
. ss.
COUNTY OF CUMBERLAND .
Lisa Marie Coyne,Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law,deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Cazlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices,and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Joucnal on the following dates,
viz:
March 22 March 29 and A�ri15 2013
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not 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 aze true.
� (I�V1M
��isa arie Coyne, Editor
SWORN TO AND SUBSCRIBED before me this
5 dav of April,2013
�
Notary
Faiscloth,Joaathaa D.,dec'd.
Late of Mechanicsburg.
Administratrix:Alicia D.Fairdoth.
Attorneys: Bruce J.Warshawsky �OTAAIAL SEAL
Esquire, Cunningham � Cher� OEBORAH A COLLINS
nicoff, P.C., �320 North Second Notary Pub�ic
Street,Harrisburg,PA 17110. CARLISLE OOROUGN,CUMBFRIAND COUNTY
My Commission Expires Apr 2a,2014
�1 .
J�-,-,°"'_,.
�
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (71�249-3188 Fax:(71�249-2883
Aprii 5, 2013
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the o�cial legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Bruce J. Warshawsky, Esquire
RE: Jonathan D. Faircloth Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payabte to: Cumberland Law Journal.
Adve�tisement inserted on the following dates:
March 22, March 29, and April 5, 2013
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 0 .00
Total Amount Due $ 75.00
Payment received by
N . r
CUNNIN�3HAM�CHERNICOFF,P.C. 051196
Date: April OS,2013 CHE� 51196
Amount: �75.00
Paid To: Cumberland Law Journal
Matter# 602013
Ctient Name Estate of]onathan D.Faircloth
Proof of Publication/Estate of Jonathan Fourcloth
CUNNINGHAM d� CHERNICOFF, P.C. CI71ZEN8 BANK �-�e��so �ECK NO. 051196
. OENERAI.ACCOUNT . Pennaylvania
2320 N.2nd 3Tf�EET
� '' HAHRISBUR(3,PA 17110 S 1196
s••Seventy Five •i*#****+'*'"rs*sss**�tr*v�ss++s���s+s��ss�ia�sastit* and 00/100 Dollars
DATE AMOUt�R�
` PAY ro�u onoen oF
� Apr 08,2013 �75.00
Cumberland Law Journal C M i CHERNICOFF,P.C.
, . - 32 South Bedfotd Street ENERA UNT
Carlisle,PA 17013
� _____P�QfsCP�bl�c�iooL����?�Qf�Oiia_th_aQFQU�IQth_.__ _ _�
i�'05 L L96i�• �:03607615D�: 6 20 L684593��'
� � I N V O I C E
1500 Paxton Street
J OU R NAL Harrisburg,PA 17104 4/8/2013
T. 717-236-4300
M U LT I M E D I A F. 717-236-6803 ORDER�l: 89175
www.journalmultimedia.com TERM3: Net 30 Days
INVOICE TO ----- ADVERTISER
Cunningham &Chernicoff, P.C. Cunningham 8 Chernicoff, P.C.
Accounts Payable
P. 0. Box 60457
Hamsburg, PA 17106
INVOICING:Advertiser
DESCRIPTION OF CHARGES COST � CRE01T � BALANCE
PUBLICATION: CLASSIFIED/CENTRAL PENN BUS.JRNL
COVER DATE: 4/5/2013 THEME: CLASSIFIED AD/CENTRAL PENN BUSINESS JOUR
RATE CARD:
DESCRIPTION OF AD:
Legal listing:Estate of Jonnthnn D.Fnircloth
REP(S):
MARK SUNDAY
SIZE: LEGAL LISTING, PAGE: 150.00
COLOR: B8W 0.00
SPACE SUB-TOTAL: 150.
• BALANCE DUE: 150.00
� �
� ' .
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH Receipt Date: 2/O1/2013
Cumberland County - Register Of Wills Receipt Time : 14: 05 : 08
One Courthouse Square Receipt No. : 1072924
Carlisle, PA 17Q13
FAIRCLOTH JONATHAN DEAN
Estate File No. : 2013-00130
Paid By Remarks : CUNNINGHAM & CHERNICOFF PC
DMB
- -- ------------- -------- Receipt Distribution -- ----------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 20 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENER.AL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 050988 $93 . 50
Total Received. . . . . . . . . $93 . 50
RECEIPT FOR PAYMENT
GLENDA FP.RNER STRASBAUGH Receipt Date : 3/06/2013
Cumberland County - Register Of Wills Receipt Time: 14 : 10 : 34
One Courthouse Square Receipt No. : 1073320
Carlisle, PA 17Q13
FAIRCLOTH JONATHAN DEAN
Estate File No. : 2013-00130
Paid By Remarks : DMB INGHAM & CHERNICOFF PC
_ ___-------------------- Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
BOND 15 . 00 CUMBERLAND COUNTY GENER.AL FUN
----------------
Check# 014399 $15 . 00
Total Received. . . . . . . . $15 . 00
CUNNINOHAM 8 CHERNICOFF,P.C. 014365
DATE : February 07, 2013
Ck�1 : 19365
AMOUNT: $100.00
Matter: 602013 Matter Description: Estate Administration
Client: Estate of Jonathan D. Faircloth
Paid To: Reilly Insurance
EXPLANATION : Rdministrator's bond
C�`'' �` " � _CUNNINGiHAM d�CHERNICOFF P.C. CfTiZENS BANK 3-7815/360
•�. � ' ,, cu�rs�rRUST�ccouKr;.' ' Pennsylvania CNEdC NO. �-014 36 5 .
�_�, ?�. f{ � . , 2320 N.2nd BTREET ` j �
� '� �' � '- HARR188URO,PA 17110
14365
�?= ':, , . � � �
>f''•��F"� . . , . . . . . .
t :� . �� � � � , . . . . , , . , . .
:�, . .� . . . � : . ,. ... . . . - . , . .. . .
:< ***One Hundred 00/100Dollars
:: . • - DATE AMOUNT'' ,
;�PA�:ro�e o�oa�of . .
,;, }.. .
,. , "�; : , Feb 07,2013 $100.00
" .` Reilly Insurance
,
;: .
,,,,;.,
CUNNIN(�HAM�CHEANICOFF,P.C.
CUENTS TRUBT ACCOUNT
4N'�� • l
Ar�minia�gtnr'a b�nd — — � —
��'014365��' �:036076 i50�: 6 2 �4 i70690��'
� � ,
. .-- ------------ ---------------- .
: �
. �
: �DI ;
: Bond No. 61588765 �
. �
: Western Sure Com an :
� p Y �
. ,
. ,
; Know all Persona by theae Preaenta: '
.
. �
.
: THAT VVE, Alicia D Faircloth aH PrinCi Sl �
.
. � P , �
; and WESTERN SURETY COMPANY, a corporation duly licenaed to do �
; buainesa in the Commonwealth of Penneylvania, are held and ;
% firmly bound unto the Commonwealth of Pennaylvania in the aum of .
. �
� �
' Five Thousand and 00/100 Dollara( S5,000.00 � �
.
to be paid to the eaid Commonwealth, or ita certain Attorney or Asaigna, to which
payment well and truly to be made, we bind ourselvea jointly and severally, for
and in the whole, our heira, executora and adminiatratora, firmly by theae
preaenta.
Sealed With Our Seale-Dated the 7th day of February ,
in the year of our Lord 2013 ,
The Condition of This Obligation Is Such, That If The Above Bounden Principal, aa Adminiatrator of all
and eingular the Gooda, Chattels, and Credita of_1Qnathan Dean Faircioth ,
deceased, dcea make or cauae to be made, a true and perfect inventory of all and singular the Gooda,
Chattela and Credite of the aaid deceased, which have come or ahall come to the hande, posaeeaion or
knowledge of the Principal or into the handa or poaseaeion of any other peraon or peraona, for the said
deceased and the same ao made, do exhibit, or cause to be exhibited, into the Rsgiater'e Offce in the County
of_ Cumberland Countv ,within thirty daye from the date hereof;and the same Gooda,
Chattels and Credite, and all other the Gooda, Chattela and Credita of the said deceaeed, at the time of
his/her death, which at any time ehall come to the hande or poaaeasion of the Principal, or into the handa and
poseesaion of any other peraon or peraone, for the said deceaeed do well and truly administer according to
law, and further do make or cause to be made, a juat and true account of said Adminietration, within six
months from the date hereo� or when thereunto required by the Orphans'Court, and all the rest and reaidue
of the said Goods, Chattele and Credits which ahall be found remaining upon the said Adminiatrator's
account, the aame being firat examined and allowed by the Orphans' Court of the county having juriadiction,
ahall deliver and pay unto auch peraon or peraona at the eaid Orphana' Court, by their decree or aentence,
purauant to law, ahall limit and appoint, and shall well and truly comply with the lawa of this
Commonwealth relating to collateral inheritancea; and if it ahall hereafter appear that any laet will and
� testament was made by the deceased, and the same ahall be proved according to law, if the said Principal .
; being thereunto required, do aurrender the said Letters of Adminiatration into the Regiater's Office ;
' aforesaid,then this obligation to be void, otherwiee to remain in full force. ;
.
i i�tt�tNlnirn,,,� �
�
�� �4 red in the preaence of �
� .,.. ..,, , � .
:
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' ''� 0''•r.......•��p .��' WESTE SURE TY COMPANY %
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' Paul T.Bruflat, or Vice President �
; Form 1149-M12-2002
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VVestern Sure Com an
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POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENT3:
That WESTERN SURETY COMPANY, a corporation organized and existing under the laws of the State of South Dakota, and
authorized and licensed to do business in the Statea of Alabama, Alaska, Ari2ona, Arkansas, Califomia, Colorado, Connectic�t.
Delaware, Distrid of Columbia, Florida, Georgla, Hawaii, Idaho, Illinois, Indiana, lowa, Kansea, KentuGry, Louisiana, Maine,
Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraske, Nevada, New Hampshire, New Jersey,
New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina,
South Dakota, Tennessee, Texas, Utah, Vermont, vrginia, Washington, West Virginia, Wisconsin, Wyoming, and the United
States of America,does hereby make,constitute and appoint
Paul T. Bruflat of Sioux Falls
State of South Dakota , ib regularly elected Vice President �
as Attomey-in-Fact, with full power and authority hereby conferred upon him to sign, execute, adcnowledge and deliver for and on
ib behalf as Surety and as its ad and deed,the following bond:
One Administrator Jonathan Dean Faircloth
bond with bond number 615 8 8 7 B 5
fOf Alicia D_Fairclnth
as Principal in the penalty amount not to exceed: a 5,000.00 ,
Weatem Surety Comparry turther certiflas that the following is a Uue and exact copy of Sectlon 7 ot the by-laws of Weatem Surely Company
duly adopted and now In foroe,to-wit:
Secdon 7. All bonds, polidas, undertakings, Powers of Attomey, or other obligatlons of the corporatlon ahall be exacuted In the corporata
�ame of tha Company by the Proaident, Secretary, any AasistaM Sec:retary,Treasurer,or arry Vice President, or by such other ofice►a as the
Board oi Directors may euthorize. The Prosident, any Vloe Proaident, Secretary, eny Aasiatant Secretary, or the Treasurer may appoiM
Attomeya-in-Fact or ageMs who shall have authorfty to Isaue bonda,polides,or undertakings In the name ot the Company. The corporate seal Is
not neoeaaary for the valk►ihr of any borMa,polidea,undertakinga,Powers of Attomey o�ofher obligations of the corporadon. The algnature of any
auch oMcar and the corporate seal may be p►inted by facaimlle.
In Witness Whereof, the said WESTERN SUREN COMPANY has caused these presents to be executed by its
Vice President with the corporate seal affixed this 7th day of February
2013 '
ATTEST WESTE N URET COMPANY
- V By � �
L.Nelson,Aasistarrt Secxetary Paul at,Vice Preaident
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��pORATE ;�``w4.'��Qp pRq'�o�,"''.
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STATE OF SOUTH DAKOTA ga , �, , �:, y��y.;�-�;
COUNTY OF MINNEHAHA } ��y S�'•�.. ,.•��+.�=
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On this 7th da of Februarv 2013 ''`�„f����i"��L►+�
Y , , before me,a Notary Public,personally appeared
Paul T. Bruflat and L. Nelson
who,being by me duly swom,adcnowledged that they signed the above Power of Attomey as Vice President
and Assiatant Secretary, respectively, of the said WESTERN SURETY COMPANY, and edcnowiedged said instrument to be the
voluntary act and deed of said Corporation.
ititi��titi�ti�ti��tirrti�.�ti�ti t
; S. PETRIK ;
;�NOTARY PUBLIC e/��i ���,I� ./�
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My Commisalon Expires August 11,2018 Notary Public
Fortn F197S1-2012 �
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: BEFORE THE REGISTER OF WILLS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
ESTATE OF JONATHAN DEAN
FAIRCLOTH, ;
DECEASED •
: NO 21-13-0130
DECREE OF THE REGISTER OF WILLS
AND NOW,this 1 st day of February,2013, upon consideration of the Petition for
Probate and Grant of Letters filed by Alicia D. Faircloth, dated and filed on February 2,
2013, for the estate of Jonathan Dean Faircloth, IT IS HEREBY DECREED that the
Petitioner shall post surety bond in the amount of$5,000.00 in the name of the
Commonwealth. Pursuant to Cumberland County Local Rule 359, any corporation
acting as surety shall have filed in the office of the Prothonotary, a copy of its last
annual statement to the Insurance Commissioner of the Commonwealth of
Pennsylvania.
IT IS FURTHER DECREED that upon proper filing the Bond of Personal
Representative, Letters of Adminstration shall be granted to Alicia D. Faircloth.
,
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. 'Glenda Farner Strasbaugh, Register of Wil
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