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HomeMy WebLinkAbout12-18-13 (2) REV-1737-1 EX+(6-08) pennsylvania NONRESIDENT DECEDENT DEPARTMENT OF REVENUE AFFIDAVIT OF DOMICILE PO BOX 28o6o1 HARRISBURG,PA 17128-o6oi This affidavit must be completed and sworn to by a person having personal knowledge of these facts, preferably by a surviving spouse or member of the decedent's family. Name of Decedent Date of Death MARILYN J.ABEL 04/05/2103 Legal Address at Time of Death: Street Address City/Borough State ZIP Code 38 FLOYD STREET EAST HAMPTON NY 11937 The following information is submitted in support of the statement that the above individual was not domiciled in the Commonwealth of Pennsylvania at the date of death. 1. Names and addresses of the decedent's surviving spouse and members of his/her immediate family: Name and Relationship to Decedent ANNE M. SEARER, SISTER Street Address City/Borough State ZIP Code 2125 CAREY WAY HUMMELSTOWN PA 17036 Name and Relationship to Decedent Street Address City/Borough State ZIP Code Name and Relationship to Decedent Street Address City/Borough State ZIP Code 2. Did the decedent ever live in Pennsylvania? ❑ Yes PC No w rrt If yes,during what periods? - _ o 4 3. Did the decedent spend time in Pennsylvania during the five years preceding death? Off Yes If yes,during what periods and at what address(es)? CO . YES, FOR SHORT, OCCASIONAL VISITS AT 866 SAND HILL RD., HERSHEY PA 17033 �-' c QD c; `� = ' n c7 0 -yj 4. What was the nature of decedent's place(s)of residence during the five years immediately preceding death? Indicate whether decedent resided in a house or apartment and whether it was rented or owned by the decedent, j/40r whether Ore edensided in a hotel or the home of relatives or friends. C_n `r1 DECEDENT LIVED IN A CO-OWNED HOME IN NEW YORK STATE 5. Was the decedent employed during the five years preceding death? I8[ Yes O No If yes,list the name(s)and address(es)of employer(s). EAST HAMPTON HISTORICAL SOCIETY, 101 MAIN STREET, EAST HAMPTON, NY 11937 METROPOLITAN MUSEUM OF ART, 15 W 49th STREET,NEW YORK, NEW YORK 10020 6. Did the decedent leave a will? 19 Yes ❑ No If yes,state the court that admitted the will to probate and the date admitted,and attach a copy(including all codicils)and a certificate of issuance of letters testamentary. SUFFOLK COUNTY SURROGATES COURT, 320 CENTER DRIVE, RIVERHEAD, NY 11901 CERTIFICATE OF APPOINTMENT DATED JULY 12, 2013 7. If the decedent did not leave a will,has an administrator of the estate been appointed? ❑ Yes ❑ No If yes,state the court that appointed the administrator and the date of appointment,and attach a certificate of the issuance of letters of administration. N/A 8. At any time during the last five years did the decedent execute a will,codicil,trust indenture,deed,mortgage,lease or any other document in which the decedent was described as a resident of Pennsylvania? ❑ Yes X No If yes,describe such document. _. NONRESIDENT DECEDENT AFFIDAVIT OF DOMICILE (continued) Page 2 9. Did the decedent pay a tax on income or on intangible property to any state,county or municipality during the last five years? If yes,where and when was it paid? RJ Yes ❑ No STATE PROCESSING CENTER, P O BOX 61000,ALBANY, NY 12261-0001 10. To what regional office of the Internal Revenue Service did the decedent forward his federal income tax returns during the last five years preceding death? DEPARTMENT OF THE TREASURY INTERNAL REVENUE SERVICE CENTER KANSAS CITY, MO 64999-0002 11. At the time of death,did the decedent own,individually or jointly,any interest in real property,including lease-holds,or tangible personal property located in Pennsylvania? K Yes ❑ No If yes,describe the property in detail. CUMBERLAND COUNTY ASSESS NO 44000545,MAP NO 44-060041-065, DEED 0025 L/92 12.17 ACRES - VACANT LAND 12. In what business activities was the decedent engaged during the last five years preceding death? Indicate whether decedent was employed or otherwise engaged in the business,and state the names and the addresses of the persons,firms or corpora- tions with which the decedent had such business effi!iations(Except for employer listed in#5). EXECUTIVE DIRECTOR OF EDUCATIONAL BOOK AND MEDIA ASSOCIATION GENE BAHLMAN, PRESIDENT, PO BOX 3363,WARRINGTON, VA 20188 13. What is the estimated gross value of the decedent's estate,exclusive of real property and tangible property located outside of Pennsylvania? $736,077.00 14. At the time of death,did the decedent own or operate an automobile? ICI Yes ❑ No If yes,in which state was it registered? NEW YORK 15. At the time of death,was the decedent a member of a church or any other organization? It Yes ❑ No If yes,provide the name and address of the church or any other organization. MOST HOLY TRINITY CATHOLIC CHURCH, 79 BUELL LANE, EAST HAMPTON NY 11937 16. State the purpose or reason the decedent owned real property in Pennsylvania. LIKED OWNING THE LAND 17. Include any other information you wish to submit in support of the contention that the individual was not domiciled in Pennsylvania at the time of death.If more space is needed,use additional sheets of paper of same size. SHE LIKED LIVING IN NEW YORK. Name of Person Completing Affidavit Relationship to Decedent ANNE M. SEARER SISTER Street Address City State ZIP Code 2125 CAREY WAY HUMMELSTOWN PA 17036 Under penalties of perjury, I declare that based on my personal knowledge of the decedent, the information provided on this form is true, correct and complete. Signature Person Com I ing Affidav' Date 11/15/2013