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Home My WebLink About02-0118 PETITION FOR PROBATE and GRANT OF LETTERS \-Ielen m Smith No. 2/ - ~2. - 1/ Y To: . Estate of also known as Register of Wills for the I- Deceased. County of in the Social Security No. l:if 1- I (". ") 5-3 cj Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut r 1)( RS iu the last will of the above decedent, dated mO,U c.j and codicil(s) dated ' named , w-Eiooo, (state relevant circumstances, e.g. renunciation, death of executor, etc.) h(2(" (list street, number and muncipality) Decel}d,ent, then 1 Cj.:r- ears of age( die fl Uu . ,;/ j , wr.~DO;;!. , at MO(~ .5..p\ I 05, Q C>t n I~ A nOil . Except as fo lows, decedent dId not marry, was not dIvorced and dId not have a chIld born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent 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 situated as follows: $ L15ooo,oO . $ $ $ ,30) OQJ,OO WHEREFORE, petitioner(s) respectfully presented herewith and the grant of letters theron. req~) the probate of the last will and codicil(s) .to MP{).fo r'l I (testamentary; administration c.t.a.~ administration d.b.fl.c.t.a.) "" u . " :g3 "" "," . ". c';:: 'II";:: -;;-~ ""~ 50 ,. o '" in Be Q , ~~~(~~~~ '2,0:>; ChOrleS 51" mQ~nQ(\1(5 'oulj (J~\ il055 10 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 1 ss COUNTY OF rflMRRRr liNn J Sworn to or affirmed and SUbscribedJ before me this 1 S T day of '> 1~~(~~~/~/:~'u~~.;, ' M RY LEWIS RegISter I 7 -~q - Lf 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 represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. !JCAJY\QJ,. ~~ ~(~dMU ( riO, (' . uO{ I~' - " ~ ~ No. ?10?_11A Estate of HELEN M SMITH . Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW FEBRUARY 1 ST _.__.JWl<? 00 2 in consideration (.: '.,~e petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated MI>.Y 4 ?OOO described therein be admitted to probate and filed of record as the last will of HELEN 1\ CI\ITn and Letters 'T'R"'T'IIMRN'l1I>.RY are hereby granted to LINDA C SHAMBAUGH AND'iIDIANE L HENRY,'! A. K. A. fH Al\lR t, ~or,n~N ~;x~=.,~ ~nj -tJ/ ) ;':J~ MA CLEW ISter of W,Us FEES Probate, Letters, Etc. ......... S 1 1 5 . 00 Shon Certificates( 6) . . . . . . . . .. S 1 il 00 xx,~~~x. 'EXTRA' PAGEs5 9.00 ,Ie? S ~ 00 TOTAL _ S 14 7 . 00 Filed FEBRUAR.Y. .1.,. 20.Q2............ MAIL TO EXECUTOR CALL DIANE OR LINDA ATTORNEY (Sup. Ct. LD. No.) ADDRESS PHONE co q N 1"- ," ::') (,) a:. ~ ..:> ~>= "iJ :::::: ;". - ....,)0 ~ I CD w.J w... .r.;, '1:l ~.f 4.,> _..... Y ". . REG~TER OF WILLS OF CO ~ . pATH OF SUBSCRIBING WITNESS N c: .(j\ h, (each) being duly qualified according to present and saw ~ I a:J U-J (,*~la sub~ribing::"il!'ess to the l~ ,OQepose~ and ~@ that 0u the testat , sign the same and that request of testat_ in h other subscribing witness(es)). / Sworn to or affirmed and subscy.ii:d before me this / day of , 19_ signed as a witness at the e presence of each other) (in the presence of the (Name) 0' Register (Name) (Address) REGISTER OF WILLS OF CUM8ERLAN COUNTY OATH OF NON-SUBSCRIBING WITNESS .;[)\~\-.. \\.Y\'\',,\ t:l~l'\ "b\Q'f\.Q.., kc:;~::k~n , h\l~Q..,c.... S\to..~h (each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that <-t-Y\s1 A A "i\O , familiar with the signature of ll.. Q.r'> l"Y\. mi ~ c~ testa~ of (one of the subscribing witnesses to) the will that ~'^<. W.Q.\\ l'Y\. Smt+~ to the best of ry;.:r- presented herewith and codicil believes the signature on the will is in the handwriting of knowledge and belief. ~V'{\dC).J ~ ~VlCtmbQll~JJJ me this 1 S'l' day of ~ l'L _ IIYf'!,!e) (> \ ~ARY 2002 x~ '6D~ UUf\XJ!l) ~, ~C}\,).pA \1055 ///;K::~;:;~~dN'~~Z~Y ~JQ;Y1Q cK (S~QlaYteJ(.1J()(IcWYJ . (Name) j) 30\ :) Chrs-\-o1vtSly11f?c,hClnl<sburq r'A (Address) 1,055' Sworn to or affirmed and subscribed before HlO'),~()'i I,EV ()l~() T~jis is to certify that the information here given is correctly copied from an originaJ certificate of death d1,J-ly filed with me as Local ~:gistraL The original cerriflcate will be f()rwarded w the State Vital Records Office tor permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~%I/I', 11\I,,"~~\1H OF PEi,....____ l#~~.r;,"'~ l~_V- ~.\<;;;-., ,~!. . .... .1"''' ~QI'" ~',' ~i ~w , yn' />~ ~*"'.' ,'-, '. ,~i*~ "4\~~~ . /;:.:,i \.~~, ,//~/ "":.?lMfN'-\\{~"""'" -""'''//#HII~JfIJIJI'' f~ f(~A ~ Local Registrar Fel..' for this cerril'lcate, $2.00 P 8065946 9 ,? AAA-Ul7r ,j?; d.:1" "- /, Date. H"j~ :4JA~. 2/&1 COMMONWEALTH OF PENNSYl.VANIA . DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH TYPE;P"'INT '" PEAIIlANUH B'ACI(INK AGr(l...8."~vJ UNDERt YEAR -- - <.II4OtR't>>II' ......... 1M....'.. Sf:~Female , N......EOfOECEPfNT,f,''',M_,"...) 79 .. alRfHPl.ACE'C"'.nd s..,."'I'"'"",,'C""""vJ Shiremanslown, Pa. CClUNTV Of Df,(fH Cumberland East Pennsboro White . ~. DECEDENT'SUSUAt. OCCuP>ll1Of,j (Gi""......d_k_d.,o::2r~ ol_k"'ll~upervisot'J ". 1~. DECfiOENl'Sr.lAIL1OO...PDRfSS/Sl'_,CIyIklwn,_,Z",eo.:..l DECf'DENT'S 617 Apple Drive ~~NCE Mechanicsburg, Pennsyt\lania 17055 ~.::~ ". '-- ((H~ 11 , ennsy v nra 2\'~\ ~STA1US._ ~--~~ "\ml~ SlIRVIY'fllGSPQUSE ,1_,'lI"'I-'__ State Government .. fIl1HER.S.......MI: If...,_, ""'l Cumberland ~ - --, --.., IN.t] :...~::OI MOlHEA'S_lf...,,,,_.-,5uI~_ Emma Jacobs .. _OA"'AN"'~trf~h"'fflR'eh~tl'itlrStre-e~hanicsburg, Pa 17055 _. PlACEOf'OISPOS1fIOf,j."""'",~~ LOCNlOH.~.s....Z",,~ Ofou..."- St. John's Cemetery Camp Hill, Pennsylvania 17011 .. 17C.O....,__'" - 17..51... ,~. Mechanicsburg -. Charles Erb , o u . o o l ... INfOf'llL.lHT'S_(l~,""l - METMOOOf'OISPOS1lI(l/\l O _ro c_O ~_Sl",.O - ""- ". S1GNAlURE'Of' Diane L. Golden 21c. 11.. ? AC'fll4loASSOCtl UCENSENUMB,ERFD_014316_L ~.\NDAODfIESS~fAClllTY Myers Funeral Home, Inc, 37 East Main Street Mechanicsburg, Pa 17055 ""_ol"'l'k OCC_al,...,....,__~.."'O<l UCENSENUt.lllEA D,I\\"E~D o.~,_, ~. 2k Wl\.SCASEAEffRAEDlOloCEDIC.....ElUlMINERlCCJJll)Nt:R1 ~O ~lil. '.Sfl"a'f'I."...._gt....."....... .. 'App1Iar...... :inI__~ :--- ,""nl: OIhw~QolfIClIIionoo_oIIo.WIglO_,DoII nIIII......inlI.._~__..1WIT1 J,.--.~ d.;>. ~ OUElOjOAASACCY<$El)UENCEOFj ~~. ~ o P""EOf' 'NJURY (Mto,"",O.av,,,"arl Tlr.lfOf' INJUAY DESCRIBE HOW INJURV OCCURHfO _EAQFOEATH ~'b6 _ 0 [\2.... _. -- P.ndooII"'''"'__ o o [) pu..cTQF,,.:iuRY-....ho_,......._.''''''''''''_. ~.,c,,~..1 - M. ~JZ _u CO<JldOOlt..""..",,,,,o<I lOCAf'IOH(9I_,C~,Slal.,j ~. G("'''''~RIC~oo._,''''l .CIUITIfYINClPHY5IC1...N'pr.V""'....""'''''_~'''.........._''''ao''''''''''''.'"''',''''I1.o.po<V>Ou,><:e<l''''.,,,.'''}c"'n''''',,,''',"0231 T._......,...'k"""'............"'occ"mod_.......U"04(.I.f14"'."""'....._ 'PI'lOffOUNCINQANOc.E"T'fYlHG"""SIdAN(pt,.......,""""'<V>Ou""'ng""a"'.'od<."~"'~."..."'''''.,h, T......_.."'.k""..'-'Iq.,..._oe<:"'......__.......ndpl.....ndd...,.......u04(.I....."'.on.,.....," OIl1ESlGNEDI.......,~,_1 - 2...]- 02- "~H'~---- 'M€OICAL t:XAMllllEflICORDNIEIl Onllllt>oo.l.ol..."wn.tlon.ndlorln...II\l.llon.inm,oplnlon.du,lloccu".d.11...11rn.,d.t.._l"ac..__Iol,,"-C"'''I.j.nd .....nn.......1U.-d ". R~G' Afl'SSlGNATURE ","DNUMB~R (11.0 ;l.d "1' ~ 1.,1"').,1,;11 ~" ~J U 10-1 (2.. V ..l# :;?I'J{) OJ- I I .)1 .;.. " "~J i~ c. :,:;~ ',,,to G>CC CC ';,' !Xl 9- N n: ~ \ ffi '..... Fl :h ,~-~ :1) :: <..~ - DU 21-02-117 LAST WILL AND TESTAMENT OF HELEN M. SMITH I, HELEN M. SMITH, of Mechanicsburg, Cumberland County, Pennsylvania, make, publish and declare this as and for my Last will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FIRST: I give and bequeath the sum of One Thousand and NO/lOO ($1,000.00) Dollars to certain of my grandchildren, same specifically being as follows: JAMES HENRY; JEFFREY HENRY; JASON HENRY and BRANDON SHAMBAUGH. SECOND: I give and bequeath the sum of One Thousand and NO/lOO ($1,000.00) Dollars to my great-granddaughter, AIMEE HENRY. THIRD: I give and bequeath the sum of Five Hundred and NO/lOO ($500.00) Dollars to my great-granddaughter, SHELBY HENRY. FOURTH: I give and bequeath the sum of Five Hundred and No/lOO ($500.00) Dollars to my great-grandson, KEVIN HENRY. FIFTH: Should any of the individuals named in Clauses FIRST through and including FOURTH above predecease me, I direct that their share or shares under this, my Last Will and Testa- ment, be and become a part of my residuary estate to be distrib- uted as set forth hereinbelow. SIXTH: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, to my daughters, DIANE L. HENRY and LINDA C. SHAMBAUGH, in equal shares, provided that should any of my children predecease me, I give and bequeath such child's share unto her issue per stirpes by representation, and if there be a failure of same, then I give and bequeath such deceased child's share to my surviving children as provided herein. SEVENTH: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all proper- ty, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivi- sion, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to abandon any property which is of little or no value. (0) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given by the Federal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named beneficiaries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order 2 to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. ErGHTH: I direct that all inheritance, estate, trans- fer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with respect to property passing under this Will, shall be paid out of the principal of my residuary estate. NrNTH: All interests hereunder, whether principal or income, which are undistributed and in the possession of the fiduciaries acting hereunder, even though vested or distribut- able, shall not be subject to attachment, execution or sequestra- tion for any debt, contract, obligation or liability of any beneficiary, and furthermore, shall not be subject to pledge, assignment, conveyance or anticipation. TENTH: I nominate and appoint my daughters, DIANE L. HENRY and LINDA C. SHAMBAUGH, Co-Executrixes of this, my Last Will and Testament. I direct that my cO-Executrixes, and their successors, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last will and Testament, this 4'*-day of ..:2b<>'" '"ma..;;- , 2000. ..;1 Ii! /170 L~ 7;1 . ;L.;.i;:tr- HELEN M. SMITH (SEAL) 3 Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. Address Address 4 Ul J: i tn :;:: )> ~ 0 '- 6'*'~~ ::< " --I rn z m ~ {f} . --I Z 11 ~ '" 0 rn "" -< . Z l: " Ul Z Z --I 0 ~ '!\ ~- Q r' ~ < ):- <~ ';0 ~ :;; - ... ~ - "6 '.'," ,. 'i:,') ( ~'l;:: t) (j.) llCI:. ~ ~ :s: . ~- \ cP W u- N P ~ r~, ~ ~"' ~ @ E - IN RE: Estate of Helen M. Smith, late of the Borough of Mechanicsburg, Cumberland County, pennsylvania IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION File No. 21-2002-118 PROOF OF CLAIM To Mary C. Lewis, Register of Wills and Clerk of Orphans' Court please index and make proper entry into your official records and docket concerning the Estate of Helen M. Smith the claim of James D. Bogar, Esquire, in the amount of $332.50. The claim is for legal services rendered to the Estate of Mary M. Smith and to Linda C. Shambaugh and Diane L. Golden, formerly Diane L. Henry, Co-Executrixes of the Estate of Helen M. Smith. This Proof of Claim is filed pursuant to 20 Pa.C.S.A. ~ 3384 and ~ 3532, of the Probate, Estates and Fiduciary Code. Written notice of this claim was given to Linda C. Shambaugh and Diane L. Golden, formerly Diane L. Henry, Co-Executrixes of the Estate of Helen M. Smith, by letter dated February 20, 2002. Dated: March 12, 2002 \..c ~~ co (/ J es D. B r, Esquire One West Ma Street Shiremanstown, PA 17011 (717) 737-8761 ,-" ~ ~ f::5 ,,'k '- -;= .~I,! :; .....1'... ~~ April 14, 2002 REGISTRAR OF WILLS CUMBERLAND COUNTY COURTHOUSE CARLISLE, PENNSYLVANIA 17013 ESTATE OF: HELEN M. SMITH S.8.#187-16-5534 Date ofDeatb -1/23/02 FILE #21-02-0118 (3 MONTH FILING OF ESTATE TAX) To Whom It May Concern: Attached is Cbeck #17 in the amount of$6,000.00 for estimated taxes of the Estate of Helen M. Smith, submitted in a timely fashion to take advantage of the early filing discount. If you should have any questions or need additional information, please contact Linda Shambaugh between the hours of8:30 and 4:30 at (717) 787-6200. The co-executrixes of the Estate are presenting this check: Linda C. Shambaugh 803 Charles Street Mechanicsburg, PA 17055 and Diane L. Golden 301 S. Chestnut Street Mechanicsburg, PA 17055 C''.j :-:~ ~~~ro.~ [', '" ~ Linda C. Shambaugh 1.-,.- 0: '-'C N . >= PJ5 "'I''' ~~ ........ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES' DEPT. 280601 HARRISBURG, PA 17128-0601 AEV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SHAMBAUGH LINDA C 803 CHARLES ST MECHANICSBURG, PA 17055 .Uhu_ fold ESTATE INFORMATION: SSN: 187-16-5534 FILE NUMBER: 2102-0118 DECEDENT NAME: SMITH HELEN M DATE OF PAYMENT: 04/16/2002 POSTMARK DATE: 04/15/2002 COUNTY: CUMBERLAND DATE OF DEATH: 01/23/2002 NO. CD 001073 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $6,000.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: LINDA C SHAMBAUGH & DIANE L GOLDEN CHECK#17 SEAL INITIALS: CW RECEIVED BY: TAXPAYER $6,000.00 ' MARY C. LEWIS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEP,.280601 HARRISBURG, PA 1712$-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SHAMBAUGH LINDA C 803 CHARLES ST MECHANICSBURG, PA 17055 --------l\lld ESTATE INFORMATION: SSN: 187-16-5534 FILE NUMBER: 2102-0118 DECEDENT NAME: SMITH HELEN M DATE OF PAYMENT: 04/16/2002 POSTMARK DATE: 04/15/2002 COUNTY: CUMBERLAND DATE OF DEATH: 01/23/2002 NO. CD 001073 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $6,000.00 I I I I I I I t TOTAL AMOUNT PAID: $6,000.00 REMARKS: LINDA C SHAMBAUGH & DIANE L GOLDEN CHECK#17 SEAL INITIALS: CW RECEIVED BY: REGISTER OF WILLS MARY C. LEWIS REGISTER OF WILLS . f' Ms. Linda shambaugh:<l~:,'J 803 Chari"" Street \> Mechanicsburg, PA 17055-394t "',; I v 1.'- i . "'\" . ,J :: ,.' ".." .- ~-.\_ _,J ') : .,/< ~~.~:,.'(,-~,~~~,\~:j/ ';~~ -->,~-~-,.;J"; .,.' (' ",~ .. \,..,V' -. (',' p -- ....,.,-.c._~"o -"~',:""","~~"....~._.~/;rr.;.,,'~~ ~ 7001 1940 0006 2850 3680 ~~ ~ ~~U W~~ Ov'N1 ~ \ iA-h A ~~ ~a' ~_'-'V~<3 C~ Gf\ ~lOlj CERTIFICATION OF NOTICE UNDER RULE 5.6Ia) Date of Death: ~QQJYl, 111 ~~~ O,\JJf\\AD.l\ ~ ~~J ~("C);; , ;)()() ~ -lX) II '8' Name of Decedent: Will No. Admin. No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the ~"ans' C~ Rules was served on or mailed to the following beneficiaries of the above-captioned estate on .;J - ! l -0 : Name ~'...Jr ~ddress (n 9) c~b (~5) ,{t~~) ~,,-QqL ~I~ S rn bQ.L a\~ ~~\\lU ~ ~ Q dQu.q~ ~. r<\D~I~ 1'D~S ~~\,,~y d.91d.~~. ~QY)~d~,PA IqyL.\lo ~ tU. ~y a I J{)cuV\., c.c:vxt, ~( rn n0'55 ~~cw~.~~~J1) ?:06CtruQQj~. (jlQd(~S Notice has now been given to all persons entitled thereto under Rule 5.6(a) except 'N \ A Date: s-g..o~ Signature8~ c.%~h Name \--\~dCL C r SromVn.u.qh Address ~ ~ ~, ~, {)A 1'1055 " C". tr) ~ ~ ',: p ,- Telephone fill wk. (I (/) lJiQj-C04l4- 0'l!? - (J; ;)..00 ,"'"' ~'--- Capacity: _ Personal Representative _Counsel for personal representative April 14, 2002 REGISTRAR OF WILLS CUMBERLAND COUNTY COURTHOUSE CARLISLE, PENNSYL V ANlA 17013 ESTATE OF: HELEN M. SMITH S.8.#187-16-5534 Date of Death -1123/02 FILE ##21-02-0118 (3 MONTH FILING OF E8TATE TAX) To Whom It May Concern: Attached is Check #17 in the amount of$6,000.00 for estimated taxes of the Estate of Helen M. Smith, submitted in a timely fashion to take advantage ofthe early filing discount. If you should have any questions or need additional information, please contact Linda Shambaugh between the hours of 8:30 and 4:30 at (717) 787-6200. The co-executrixes of the Estate are presenting this check: Linda C. Shambaugh 803 Charles Street Mechanicsburg, PA 17055 and Diane L. Golden 301 S. Chestnut Street Mechanicsburg, PA 17055 Sincerely, Linda C. Shambaugh ~ S;-o ~ CERTIFICATION OF NOTICE UNDER RULE 5.6(a\ Date of Death: ~QgNL 111 ~orn\lo.l\ ~ f!).no~ -rnll 'g Name of Decedent: ;' ~ Will No. To the Register: ~~~ g)..j J {:)IY);; , Admin. No. I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the o~lans' C~ Rules was served on or mailed to the following beneficiaries of the above-captioned estate on ~ - --0 : Date: s-q-O~ Signaturedvrdcu c'8~h Name \--\~dcu ('~. S~\rnllq,h Address ~ ~ ~, ~, {)A \"10<05 Telephone n 11 Viq ') - <:Q4l 4- wI<'. (, t I) '7'(57 - (J) ;)..00 Capacity: ~ Personal Representative _Counsel for personal representative RECEIPT FOR PAYMENT ------------------- ------------------- Cumberland County - Register Of Wills Hanover and High StreeE Carlisle, PA 17013 Rece~pt Date Rece:J.pt Time Recelpt No. 7/15/2002 14:01:45 1029928 SMITH HELEN M File Number 2002-00118 Remarks LINDA C SHAMBAUGH JA ------------------------ Distribution Of Receipt ------------------------ Transaction Description Payment Amount Payee Name INH TAX RETURN 15.00 CUMBERLAND COUNTY GENERAL FUN Check# 2671 Total Received......... $15.00 $15.00 . ' 'Pt1lCL RECEIPT FOR PAYMENT ------~------------ ------------------- Cumberland County - Register Of Wills Hanover and High StreeE Carlisle, PA 17013 Receipt Date Receipt Time Receipt No. 2/01/2002 14:07:50 1028215 SMITH HELEN M File Number 2002-00118 Remarks DIANE L GOLDEN JA ________________________ Distribution Of Receipt ---.--------------------- Transaction Description Payment Amount Payee Name PETITION FOR PROBA EXTRA PAGES SHORT CERTIFICATE JCP FEE 11.5.00 9.00 18.00 5.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D Check# 3595 Total Received......... $147.00 $147.00 , i w (,) w a w .. ,,"l.. u&" w"'g xi.... u~.. z o j:: j ~ ..... ii: ~ w It: z o !i S~ :E o o .~ COMMONWEALTH OF PENNSYlVANIA DEPARTMENT OF REVENUE DEPT 280601 RRISBURG, PA 17128-0601 DECEDENr5 NAME {lAST, FIRST, AND MIDDlE INrrw-) USIl a btri block 10 sepaate words 39 if < n.-=Y-I~UU ~ INHERITANCE TAX RETURN FIlENUMBER RESIDENT DECEDENT ~;,.,. S m i h H e e n SOCW.SfCURITYNUMBER DATE OF DEATH 1 8 7 -1 6 -5 5 3 4 o 2 o 1 1 8 - ..- M DATE OF BIRTH o 1 /2 3 /2 0 0 2 o 2 /2 0 /1 9 2 2 (IF APPlICABlE) SURVMNG SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITlAl) SOClAL SECURllY WlM!.ER THIS RETURN MUST BE FILED IN DUPlICATE WITH THE REGISTER OF WILLS .. Z w I o 1. Original Return o 4. Limited Estate o 6. Decedent Died Testate (Attach copy of WI) o 9. Liligalion Proceeds Received THIS SECTION MUST BE COMPLETED. ALL NAME Linda C. Shambau h FIRM NAME (If AppicwB) T8.EPHONE NUMBER 71 697-5414 1. Real Estale (Schedule A) 2. Slocks and Bonds (Schedule S) o 2. Supplemental Return 0 3. Remainder Return (daIeofdeahlriJrlo12-13-82) o 4a. Future Interest Compromise (dale ofdealh alter 12-12-82) 0 5 Federal Estate Tax Return Required o 7. Decedent Maintained a Living Trust (AltachCOVtofTrust) _ 8. Total Number of Safe Oeposi\ Boxes o 10. Spousal Poverty Credit (lkte of death between 12-31-91:n:1 1-1-95) 0 11. Election to tax under Sec. 9113{A) (Altach Seh 0) SPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: COMPLETE MAIUNG ADDRESS 803 Charles Street Mechanicsburg, Pennsylvania 17055 (1) (2) OFFI9AL USE ONLY , ..., d f',.' 20,457.60 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 12. Net Value of Estate (line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 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) 4. Mort9"9es & Noles Recewatte (Schedule D) 5. Cash, Bank. Deposits & Miscellaneous Personal Property (Schedule E) 6 JOIntly Owned Property (Schedule F) 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G 01 l) 6. To131 Gra... Assets (Iolal lmes 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage liabilities, & liens (Schedule t) 11. Total Deductions (tota! Lines 9 & 10) 15. Amount of hne 14 taxable at the spousal tax rate , See instructions on reverse side for applicable percentaQe 16. Amount of line 14 taxable at 6% rate 17. Amount of line 14 taxable at 15% rate ,1 3 18 Tax Due (4) (5) (6) (7) o .0 0 31,833.58 92,395,00 0' (8) , 1 44,686.18 .-..,. (9) (10) 1 0 ,2 8 9 .6 0 1,670.83 (11) (12) (13) 1 1 ,9 6 0 4 3 1 3 2 ,7 2 5 7 5 1 ,0 7 6 .6 5 ,1 3 1 ,6 4 9 .1 0 (14) x .0 (15) 1 x)(@ 5, 9 2 7 e ^ 4 2 1 A ^ ) . 6 4 , 9 1 o x 15 o .0 0 (H) (18) 7: :J'" Q f'L i S 19. DATE PI> ''1055 7/15/02 DATE '1 hsloJ, 5,924.21 > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Underpenalies ofpeljury, I declare that I h8Y8examined this return, incUding acoompanying scheduk::s and statements, and to the best of myknowl::ldge ll'\d beief, it is true, correct aru:l oo~. 0ec'<<aIi0n of JnlPl:ferother 1han1he a\ a\iveisbasedorralinformationofoMlich hasan krlowed SI TURE OF PERSON RE ISLE FOR F.ILlNG RETURN ADDRESS Linda Shambaugh 803 Charles Street Mechanicsbu PA 17055 ADDRESS (l\().('te L. 0 [clen 301 5 ChQ5tf1vlS'i.0IE'C'hCln'( bur ! , '(Sal)AlBI~~auaq JapUlBWaJ a'll pUB asnods 6UI^ll\JnS a'll uaaMlaq luawa6uBJJe JeIIWIS JO IsnJI a'll jO IUaWUOIl.loddB a'll MO'lS 01 JapJo UI ~ JO/PUB)f (s)a(npa~s 'II!M 6uole 'UJOlaJ XBI pely-Af9w!1 B OJ 0 a/npe~S 'I~ellB Isnw noA 'uolpela a'll a~Bw 01 asoo'l~ noA jl '(sel)AlBp~auaq JapUIBWaJ a'll 01 alq~!lddB (s)aleJ a'lllB peXBI Sl JapUIBWaJ a'll pue 'aIBJ XBI OJaz a'llle peXBI SI asnods 6UI^ll\JnS a'll sl~auaq 'I~I'IM luawa6ueJJB Jellwls JO IsnJI a'll jO uO!l.lod a'll 'asnods lua~p jSJY a'll jO alBlsa a'll UI paxBI Sl luawa6ueJJB JBI'WIS JO ISnJI a'll 'apBw sl uOlpela a'll jl 'f: ~ ~6 uOlpeS Japun alqBI!B^B uOlpela a'll a~ew 01 JapJO UI 0 alnpa'l~S am 01 'IS!M ABW no). 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'c .UII + ~ .UII UBllIJ.IB0J6 S! l aull jl (C) (3 + a) ,\jIBuadAsOl.IUlllljOl 00'0 00'0 00'0 oO'GLe 'S 'p 00'0 ,\jleU.d '3 IS"'.IUI '0 .IQeO!ldde ~ ,\jfllu.dAsOlalul 'C 00'0 00'0 ~Z'96Z'9 TZ''7Z6', gR'RAS'j (l) (:) + a + '0') SI!pOl:) lelol ~Z'96Z 00 000 9 lunOOSIO ':) SIU.W,\ed JO~d '8 liPOl:) ,\jJ"^Od IBSnodS ''0' S1U.W,\ed/SliPOl:) 'l (8~ .U!l ~ aBed) .no xel .~ :Sl!paJO pue SluawJ\ed xe.1 (~) 9S0H dlZ I 'v'd I 6Jnqs~lue4~all'J 31V1S Am aAIJQ a/dd'v' n9 . SS3t10aV 13-::JH1S .- -.- . # --_. on_ _ _ ..._ --- .'. COMMONWEALTH OF PENNSYLVANIA IN""RITANCE TAX RETURN RESID NT 0 NT ESTATE OF FILE NUMBER Smith Helen M. 21 02 0118 All real property owned solely or al a tenant in common mUlt be reported at fair market valu.. Fair martet value is defined as the price at which property woutd be exchanged between a wilir11 buyer and a wiDing seller, neither being compelled 10 buy or sell, both having reasonable knowledge of the relevant facIs. Reot p_rty which II jolnUy-ownod with right of survivorshiD must be disclosed on Schedule F. ITEM NUMBER 1. SCHEDULE A REAL ESTATE DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enteron line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ,.,. COMMONWEALTH OF PENNSYLVANIA INI;lERlT ANCE TAX RETURN I SCHEDULE B STOCKS & BONDS E ATE OF Smith Helen M All property jolll\ly-owned wilIl right of survivorship musl bs disclosed on Schedule F. ITEM NUMBER 1. FILE NUMBER 21 02 0118 DESCRIPTION eMS Energy Corp Series F General Term Note (Purchased 2/21/01/Matures 1/15/2004) Accl. #044-335026-28 (with Prudential Financial-Lemoyne, PAl 20,000 quantity/RO MP 7.000 VALUE AT DATE OF DEATH 20,457.60 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 20457.60 .- COMMONWEALTH OF PENNSYlVANIA INH~RJT ANCE TAX RETURN SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE-PROPRIETORSHIP ESTATE OF Smith Helen M FILE NUMBER 21 02 0118 ~ C.1 or C.2 (Including all supportil'll infonnation) must be _ for each closely-held corporation/partnership interest of the decedent. other than a soIa-proprietorship. See instructions for the supporting information to be submitted for sole--proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 3. Recapitulation) $ (If more space Is needed, insert additional sheets of the same size) ~~'1"7: '* COMMoNWEAlTH OF PENNSYLVANIA INHERITANCE TAX RElURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF Smith Helen M FILE NUMBER 21 02 0118 1. Name of Corporation Address city 2. Fedetal Employer 1.0. Number 3. Type of Business State Zip Code State of InCOljlOllltion Date of Incorporation Total Number of Shareholders Business Reporting Year Product/Service 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting I NotJ..Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? 0 Yes ONe ffyes, Position Annual Salary $ TIme Devoted to Business 6. Was the Corporation indebted to the decedent? 0 Yes o No If yes, provide amount of indebtedness $ 7. Was there I~e insurance payable to the corporation upon the death of the decedent? 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years ~ the date of death was prior to 12-31.$2? o Yes 0 No If yes, 0 Transfer 0 Sale Number of Shares Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. g. Was there a written shareholde(s agreement in effect at the time of the decedent's death? ff yes, provide a copy of the agreement. Consideration $ Date o Yes 0 No 10. Was the decedenfs stock sold? 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedenfs death? 0 Yes 0 No ff yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-l or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedenrs stock. B. Complete copies of financial statements or Federal Corporate Income Tax retums (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submn a list showing the cornpiete address/es and estimated fair market value/s. If real estate appraisalS have been secured, attach copies. D. Ust of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. Ust of officers, their salaries, bonuses and aIYf other benefits received from the corporation. F. Statement of dividends paid each year. Ust those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. ." SCHEDULE C.2 PARTNERSHIP INFORMATION REPORT COMMONWEALTH OF PENNSYLVANIA INlllERIT ANCE T 1\1... RETURN I T FILE NUMBER 21 02 0118 ESTATE OF Smith Helen M 1. Name of PartnelShip Address City Date Business Commenced Business Reporting Year State Zip Code 2. Federal Employer !.D. Number 3. Type of Business ProductlSelVice 4. Oecedent was a 0 General 0 limited partner. If decedent was a limited partner, provide initial invesbnent $ 5. PERCENT OF PERCENT OF BALANCE OF PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? K yes, provide amount of indebtedness $ o Yes 0 No 8. Was there IWe insurance payable to the partnership upon the death of the decedent? 0 Yes if yes, Cash SUllllnder Value $ Net proceeds payable Owner of the policy g. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years W the date of death was prior to 12-31-821 DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. o No $ 10. Was there a written partnership agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. o Yes 0 No 10. Was the decedenfs partnership interest sold? If yes, provide a copy of the agreement of sale, etc. 11. Was the partnership dissolved or liquidated after the decedenfs death? 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. o Yes 0 No 12. Was the decedent related to any of the partners? o Yes 0 No If yes, explain 13. Did the partnership have an interest in other corporations or partnerships? 0 Yes 0 No If yes, report the necessal}l intonnation on a separate sheet, including a Schedule C-l or C-2 for each interest THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedenfs partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Fonn 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair mar1<et value/s. If real estate appraisals have been secured, attach copies. D. Any other infonnation relating to the valuation of the decedenfs partnership interest. .,. SCHEDULE D MORTGAGES & NOTES RECEIVABLE COMMflNWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Smith. Helen M. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. FILE NUMBER 21 02 0118 ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 4. Recapitulation $ (If more space is needed, insert additional sheets of the same size) 0.00 .~ COMMONWEALTH OF PENNSYlVp.,NlA INI<ERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Smith Helen M. FILE NUMBER 21 02 0118 This schedule must be completed and fled W the answer to any of que5lions 1 through 4 on the ....... side of the REV-I500 COVER SHEET is yes. DESCRIPTION Of PROPERTY %OF ITEM \NO_IX'E1lElWiECf'rnET1WtSFEJlEE. lHBlRB.ATlONSI-FTOl:EEDENT NCJTIE~TeOFTIW4SFER DATE Of DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER ATlAaiArxPfCl'TI-EIHDFORREN.. ESTATE VALUE Of ASSET INTEREST "''''''''''-'' 1. TOTAL (Also enter on line 7, Recapitulation) S (If more space is needed, insert additional sheets of the same size) .. COMMONWEALTH OF PENNSYLVANIA 'INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Smith. Helen M. Debts of decedent must be reported on Schedule I. FILE NUMBER 21 02 0118 ITEM NUMBER OESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Funeral Home 7,775.00 2. Food after Funeral (Home of Linda Shambaugh 803 Charles Streets, Mech.) 350.00 3. Memorial Stone - Gingrich Memorial 375.00 4. Memorial Flowers 249.10 5. Additional Short Certificates 90.00 6. Minister (Rev. Seifried) SI. John's Lutheran Churc, Shiremanstown, PA 45.00 7. SI. John's Cemetary, Camp Hill, PA 500.00 8. Clothes (Bon Ton" Camp Hill) 76.00 B. ADMINISTRATIVE COSTS: 1. PefSOnal Representative's Commissions Nane of Personal Representative (s) Social Security Number{s) / EIN NlII1ber of Personal Represenlalive(s) Street Address City Slate Zip Yealjs) Commission Paid: 2. Attomey Fees James Bogar Attorney At Law, Shiremanstown, PA 17011 682.50 3. Famly Exemption: (If deoedenrs address is 00\ the same as c1aimanrs. attach explanation) Claimant SlIeet Address City , Slate Zip R_hip of Claimant to Deoedent 4. Probate Fees Registar of Wills 147.00 5. Accounlanrs Fees 6. Tax Return Preparer's Fees 7. Inheritance Tax Filing Fee TOTAL (Also enter on "no 9, Recapitulation) $ 10 289.60 (If more space is needed, insert additional sheets of the same size) ._....__.,._.,~ ..~.. ESTATE OF Smith Helen M COM~NlNEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21 02 0118 Includ. unr.imbur.ed medical .xpen.... ITEM NUMBER OESCRIPTION AMOUNT 1. 47.53 2. 3, 4, 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. United Water of PA Mechanicsburg, PA 17055 PPL Company Harrisburg, P A 123.57 Verizon Telephone Harrisburg, P A 29.78 AT&T Long Distance Telephone Harrisburg, P A 2.01 Comeast Cable Company Trindle Road, Camp Hill, PA 17011 46.19 Lakeview Home Health Care Boiling Springs, PA 168.00 Sears (Credit Card) Camp Hill Department Store 244.02 Stamps (U.S. Postal Service-Mech.) 13.96 Health South Rehab Hospital Mechanicsburg,PA 13.96 David Cordier (Appraisal of belongings) Camp Hill, PA 25.00 State Retirement System - return portion of check to Commonwealth of PA 49.91 Registered Letter to Lawyer (James Bogar) Cost Shiremanstown, PA 17011 3.94 Holy Spirit Hospital Camp Hill, PA 17011 108.01 Physicians Rehab Mechanicsburg, PA 390.41 Quantum Imaging Trindle Road, Camp Hill, PA 18.21 TOTAL (Also .nteron line 10, Recapitulation) $ (If more space is needed, in..rt additional sheets of th. same size) 1 670.83 Smith, f:lelen M. 21 02 0118 \ Schedule I - Debts or Decedent, Mortgage Liabilities, & Liens PaQe 1 ITEM NUMBER DESCRIPTION AMOUNT 16. Winding Hill Vel. Hospital 110.00 Mechanicsburg, PA 17. Moffitt Heart & Vascular Group 13.92 1000 North Front Street Wormleysburg, PA 17043 18. Lawn & Grounds Maintenance 125.00 Harry Poff, Apple Drive, Mechanicsburg, Pa Brandon Shambaugh, Charles Street, Mechanicsburg, PA 19. West Shore EMS 44.57 20. Borough of Mechanicsburg (Sewer/Refuse) 92.84 Mechanicsburg, PA 17055 SUBTOTAl SCHEDULE I 386.33 GRAND TOTAL SCHEDULE I $ 1,670.83 .Q)lr COMMpNWEALTH OF PENNSYLVANIA INl<ERlTANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER !':mith H >!"n M. 21 0' 011R RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY 00 Not List Trustee(s) OF ESTATE 1. TAXABLE DISTRIBUTIONS (include oullight spousal distributions) 1. Unda C. Shambaugh (SS#194-42-8667) Daughter One Half of Residue 803 Charles Street Mechanicsburg, PA 17055 2. Diane L. Golden (SS#193-36-4969) Daughter One Half of Residue 301 E. Chestnut Street Mechanicsburg, PA 17055 3. James B. Henry (SS#199-aO-o537) Grandson 1,000.00 413 E. Marble Street Mechanicsburg, PA 17055 4. Jeffrey T. Henry (SS#199-a0-0536) Grandson 1,000.00 2272 Locust Drive Lansdale, PA 19446 5. Jason W. Henry (SS#199-a0-2133) Grandson 1,000.00 21 Kower Court Mechanicsburg, PA 17055 6. Brandon F. Shambaugh (S5#204-70-3016) Grandson 1,000.00 803 Charles Street (12 yrs. old) Mechanicsburg, PA 17055 7. Aimee Henry (SS#176-74-2036) Great Grand-daughter 1,000.00 413 E. Marble Street (9 yrs. old) Mechanicsburg, PA 17055 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET ll. NON- TAXABLE DISTRIBUTIONS; A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. Donations to Church 736.65 Church of the Brethren Mechanicsburg, PA 17055 2. Good Will Industries of America 340.00 Simpson Road Mechanicsburg, PA 17055 TOTAl OF PART n - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 1 076.65 (If more space is needed, insert additional sheets of the same size) Smith, Helen M, 21 02 0118 PaQe2 Schedule J - Beneficiaries - 1 . RELATIONSHIP TO OECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(Sl RECEIVING PROPERTY Do Not List Trustee/s) OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 8. Shelby Henry (55#192-76-2070) Great Grand-daughter 500.00 413 E. Marble Street (5 yrs. old) Mechanicsburg, PA 17055 9. Kevin Henry (55#176-78-6804) Great Grand-son 500.00 413 E. Marble Street (3 yrs. old) Mechanicsburg, PA 17055 REV-16M ~X + (J...84) INHERITANCE TAX *' .' SCHEDULE "L" COr..f1.1C\NWEAL TH OF PENNSYLVANIA REMAINDER PREPAYMENT OR INVASION " INHERITANCE TAX RETURN RESIDENT DECEDENT OF TRUST PRINCIPAL FILE NUMBER 21 02 0118 I. Estate of !':mith H"I"n M (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule Is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the Invasion of trust orincipaL II. Remainder Prepayment: A. Election to prepay filed with the Register of Wills on (attach copy of election) (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate $ 2. Stocks and Bonds $ 3. Closely Held Stock/Partnership $ 4. Mortgages and Notes $ 5. Cash/Misc. Personal Property $ 6. Total from Schedule L-1 $ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities $ 2. Unpaid Bequests $ 3. Value of Un includable Assets $ 4. Total from Schedule L-2 $ E. Total value of trust assets (Line C-6 minus Line D-4) $ F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (Line E x Line F) $ (Also enter on Line 7, Recapitulation) III. Invasion of Corpus: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus consumed or annuity is payable C. Corpus consumed $ D. Remainder factor (see Table I or Table II in Instruction booklet) $ E. Taxable value of corpus consumed (Line C x Line D) $ (Also enter on Line 7, Recapitulation) INHt:KII ANl,;t: I AA. SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION iNHERITANCE TAX RETURN 21020118 '. RESIDENT DECEDENT -ASSETS- FILE NUMBER I. Estate of Smith Hplen M. (Last Name) (First Name) (Middle Inilial) II. Item No. Descriotion Value A. Real Eslate (please describe) T olal value of real estate $ (include on Section II, Line G-1 on Schedule L) B. Stocks and Bonds (please list) Total value of stocks and bonds $ (include on Section II, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or G-2) (please list) Total value of Closely Held/Partnership $ (include on Section II, Line G-3 on Schedule L) D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ (include on Section II, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property $ (include on Section II Line G-S on Schedule L\ III. TOTAL(Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, attach additional BY.< x 11 sheets.) REV-1fj46 EX + (3-M) INHERITANCE TAX .. . SCHEDULE L-2 CO~NWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION " INHERITANCE TAX RETURN -CREDITS- FILE NUMBER 21020118 RESIDENT DECEDENT I. Estate of Smith H"I"n M. (Last Name) (First Name) (Middle Initial) /I. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) Total unpaid liabilities $ (include on Section II, Line 0-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) Total unpaid bequests $ (include on Section II, Une 0-2 on Schedule L) C. Value of assets reported on Schedule L-1 (other than unpaid bequests list d under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL(Also enter on Section II, Une D-4 on Schedule L) $ (If more space is needed, attach additional 8% x 11 sheets.) - COMMONW~THOFPENNSYLVAN~ '. \ INHERlTANCETAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE ESTATE OF Check Box 4a on ReY.1500 COYer Sheet FILE NUMBER Smith. Helen M. 21 02 0118 This schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax retum. o Will 0 Trust 0 Other I. Beneficiaries NAME OF AGE TO BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedenrs death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. o Limited right of withdrawal o Unlimited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest $ 2. Value of Une 1 exempt from tax as amount passing to charities, etc. (also indude as part of total shown on Line 13 of Cover Sheet) $ 3. Value of Line 1 passing to spouse at app[)cate tax rate Check One 06%,03%, 0% (also indude as part of tolal shown on Line 15 of Cover Sheet) $ 4. Value of Line 1 Taxable at 6% Rate (also indude as part of total shown on Line 16 of Cover Sheet) $ 5. Value of Une 1 Taxable at 15% Rate (also indude as part of total shown on Une 17 of Cover Sheet) $ 6. Total value of Future Interest (sum of Lines 2 thru 5 must equal Line 1) $ (n more space is needed, insert additional sheets of the same size) ~ SPOUSAL POVERTY CREDIT -COMMONWEALTH OF PENNSYLVANIA . INHERITANCE TAX DMSION (AVAILABLE FOR DATES OF DEATH 1/1/92 to 12/31194) ESTATE Of FILE NUMBER 8mi h' Helen M. 21 2 0118 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. PART I - CALCULATION OF GROSS ESTATE ...................... ........................... J. 144686.18 ..................... ........ ................... 2. ............................. ................--.. 3. .................................................. 4. ........................... ...................... 5. 6a. 6b. 6e. 6d. .................................................. 6. 7. 144 686.18 ............... ..............-................... B. .................................................. ..-....,.......................................... .~ 144,686.18 aim the credit. If not continue to Part II PART " - CALCULATION OF JOINT EXEMPTION INCOME - (Attach caples of Federal IndiVidual Income Tax Returns for decedent and spouse.) Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse ......................... la. 2a. 3a. b. Decedent ...................... lb. 2b. 3b. c. Joint............................. Ie. 2e. 30. d. Tax Exempt Income ..... ld. 2d. 3d. e. other Income not listed above ............ le. 20. 30. f. Total............................. If. 21. 3f. 1. Taxable Assets total from line B (cover sheet) .....,................ 2. Insurance Proceeds on Life of Decedent .............................. 3. Retirement Benefits .............................................................. 4. Joint Assets with Spouse ............................................... 5. PA Lottery Winnings ............................................................ Sa. other Nontaxable Assets: List (Attach schedule if necessary) 6. SUBTOTAL (Lines 6a, b, c, d) ............................................. 7. Total Gross Assets (Add lines 1 thru 6) ................................ 8. Total Actual Liabilities .......................................................... 9. Net Value of Estate (Subtract line B from line 7) ................... /fine 9 is greater than $200,000- STOP. The estate is not eligible to cl 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (11) + (21) + (31) = (+ 3) 4b. Average Joint Exemption Income ............................................................................................ = If line 4(b) is greater than $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part 1/1. PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT ESTATES 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ....................... ... 1. 2. ... ... 3. ... 4. .~~. 2. 3. Multiply by credit percentage (see instructions) ................................................................... This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 1B of the cover sheet. ............................................ For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate............... ....................................................................................... Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spou Poverty Credit. Include this figure in the calculation of total credits on line lB of the cover sh 4. 5. :~ SCHEDULE 0 ELECTION UNDER SEC. 9113(A) SPOUSAL DISTRIBUTIONS COMMONWEALlH OF PENNSYlVANIA. 4NHERrTANCE TAX RE11JRN RESIDENT DECEDENT ESTATE OF FILE NUMBER Smith. Helen M. 21 02 0118 Do not complete this schedule unless the estate is making the election to tax .ssets under Section 9113(A) of the Inheritance & Estate Tax Act. ff the election applies to more than one trust or similar arrangement, a separate fonn must be filed for each trust. This election applies to the Trust (marital. residual A. B. Bv-pass. Unified Credit. etc.t ff a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule O. then the transferor's personai representative may specifically identify the trust (ali or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election oniy as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arranQllment included as a taxable asset on Schedule O. The denominator is eQual to the total value of the trust or similar ananoemenl. PART A: Enter the description and value of an interests, both taxable and non-taxable, regardless of location, which pass to the decedenfs survivin souse under a Section 9113 A trust or similar arran ement. DESCRIPTION VAlUE Part A Total $ F'ART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made. DESCRIPTION VALUE Part B Total $ ilf more space is needed, insert additional sheets of the same size) 1/-",,'39- ~/ \. BUREAU OF INDIVIDUAL TAXES ~ INHERITANCE TAK DIVISION DEPT. 280601 HARRI~aURG~ PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX LINDA C SHAMBAUGH 803 CHARLES ST MECHANICSBURG PA 17055 DATE ESTATE OF DATE OF DEATH FILE NUMBER , . COUNTY ACN 09-02-2002 SMITH 01-23-2002 21 02-0118 CUMBERLAND 101 Alsount R8IIitt.d *' REV-l&47Ell'AFPI01-0U HELEN M MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ~ REy=gW-Ex--AFP"foFozrNoYicE-oF-YriHEifii'ANcE-TAx"APpiiiiisEHENT~--AL:rOWAi-jCE-CjR---"--"---------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SMITH HELEN M FILE NO. 21 02-0118 ACN 101 DATE 09-02-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Est.t. (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held stock/Partnership Interest (Schedule C) 4. "ortgages/Notes Receivable {Schedule DJ 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule f) 7. Transfers (Schedule G) 8. Total Assets (1) 12) (3) (4) (5) (6) (7) .00 20,"57.60 .00 .00 31.833.58 92.395.00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule IJ 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J] 14. Net Value of Estate Subject to Tax (9) (10) 10,289.60 1.670.83 (11) (12) (13) (14) NOTE: To insure proper credit to your account~ submit the upper portion of this forn with your tax payatent. 1"",686.18 11.960 43 132,125.75 1,076.65 131,6"9.10 NOTE: I~ an assessment was issued previOUSlY, lines 14, 15 and,or 16, 17, 18 and 19 will reTlect Tigures that include the total of Abh returns assessed to date. ASSESSMENT OF TAX: IS. Amount of Line 14 at Spousal rate 16. Anount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due T X C D TS: (15) .00 X 00 = .00 (16) 131,6<t9.10 X 0"5 = 5,92".21 (17) .00 X 12 = .00 (18) .00 X 15 = .00 (19)= 5,92".21 AHOUNT PAID 6,000.00 + DATE 0"-15-2002 HUH8ER CDOOI073 INTEREST/PEN PAID (-) 296.21 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 6,296.21 312.00CR .00 312.00CR . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. 1 IF TDTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE OUE A REFUND. SEE REVERSE SlOE OF THIS FORH FOR INSTRUCTIONS.) ; RESERVATION: Estates of decedents dying on or before December Il, 198Z -- if any future interest in the 8state is transfarred in possession or enjoy.ent to Class B (collateral) beneficiaries of ths decedent after the expiration of any estate for life or for years, the Co..anwealth hereby axprBssly reserves the right to appraise and 8558S5 transfer Inheritance Taxes at the IBWful Class B (collateral) rata on any such future interest. PURPOSE OF NOTICE: To fulfill the requiregants of Section 214D of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.5. Section 9140). PAYMENT: Detach the top portion of this Notice and sub.it with your paYMent to the Register of Wills printed on the reverse side. --Make check or .oney order payabb to: REGISTER OF KILLS, AGENT REFUND (eM): A refund of a tax credit~ which was not requested on thtl Tax Return~ lIay be requested by cOllpletlng an "I\pplication for Refund of PennSYlvania Inheritance and Estate Tax" lREY-1313J. Applications are available at the Office of the Register of Wills~ any of the 23 Revenue District Offices~ or by calling the special 2~-hour answering service for forms ordering: 1-800-362-2050} services for taxpayers with special hearing and I or speaking needs: 1-800-~~7-3020 (TT only). OBJECTIONS: Any party in interest not satisfied with the appraistlment~ allowance~ or disallowance of deductions~ or asseSSMent of tax (inclUding discount or interest) as shown on this Notice lIust object within sixty (60) days of rsceJpt of this Notice by: --written prottlst to the PA Deparbent of Revenue~ Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the Matter determined at audit af the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: Factual errors discovered on this assessllent should be addressed in writing to: PA Department of RevanU&~ Bureau of Individual Taxes, ATTN: Post Assessment Review Unit~ Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of tho booklet "Instructions for Inheritance Tax Return for a Resident Decadent" (REV-ISO!) for an explanation of administratively correctable errors. DISCOUNT: If any tax due is paid within three (3) calendar 1Il0nths after the decedent's death; a five percent (57-) discount of the tax paid is allowed. PENALTV: The 15~ tax allnesty nan-partIcipation penalty is co.puted on the total of the tax and interest assesssd; and not paid before January 18; 1996; the first day after the end of the tax amnesty periOd. This non-participation penal ty Is appealable in the san .annar- and in the the salle tille periOd as YOU would appeal the tax l!lnd interest that has been assessed as indicated on this notice. INTEREST: Interest is Charged beginning with first day of delinquency; or nine {9) .anths and one (1) day frOIl the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interast at the rate of six (6~) percent per annuli Calculated at a daily rate of .000164. All taxes which beca~e delinquent on and after January 1; 1982 will bear interest at a rate which will vary frail calendar year to calendar year NJth that rate announced by the PA Departllent of Revenue. The applicable interest rates for 1982 through 2002 are: Vear Interest Rata Daily Interest Factor Vear Interest Rate Daily Interest Factor 1982 207- .000548 1992 OX .0002~7 1983 167- .000438 1993-1994 n .000192 ,... 11:': .000301 1995-1998 'X .000247 1985 13:': .000356 1999 n .000192 1986 10~ .000274 2000 OX .000219 1987 97- .000247 2001 'X .000247 1988-1991 117- .000301 2002 6X .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAIO X NUKBER OF OAYS OELINQUENT X OAILY INTEREST FACTOR --Any Notice issued after the tax beco.es delinquent will reflect an inter-est calculation to fifteen (15) days beyond the date of the assass.ent. If pay.ent is made after the interest computation date shown on the Notice, additional interest must be Calculated. /7-.3'f>- ~ "- BUREAU Of INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRr.lBURG~ PA 17128-06Dl COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT '*' REW.liD7 EX AFP (Dl~02) LINDA C SHAMBAUGH 803 CHARLES ST MECHANICSBURG PA 17055 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 09-30-2002 SMITH 01-23-2002 21 02-0118 CUMBERLAND 101 HELEN M Amount Rellitt.d MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER Df WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account I submit the upper portion of this for.. with your tax pay.ent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV: ii;orEx--Aiip--fiiFo2y------..ii-iNHERI1:ANcE""iAx--s'i"iifEME-N"T"i:iF-Ac-couiff--iiif.------------------ --- THIS STATEHENT IS PROVIOED TO ADVISE Of THE CURRENT STATUS Of THE STATED ACN IN THE NANED ESTATE. SHOWN BELOH IS A SUHHARY Of THE PRINCIPAL TAX DUE, APPLICATION Of ALL PAYHENTS, THE CURRENT BALANCE, ANO, If APPLICABLE, A PROJECTED INTEREST fIGURE. ESTATE OF SMITH HELEN M FILE NO.21 02-0118 ACN 101 DATE 09-30-2002 DATE Of LAST ASSESSMENT OR RECORD ADJUSTMENT: 08-26-2002 PRINCIPAL TAX DUE: ....... . 5,924.21 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-15-2002 CDOOI073 296.21 6,000.00 09-13-2002 REfUND .00 372.00- TOTAL TAX CREDIT 5,924.21 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 PAYMENT IS REquIRED. If TOTAL DUE IS REfLECTED AS A "CREDIT" (CRJ, YOU HAY BE DUE A REfUND. SEE REVERSE SIDE Of THIS fORH fOR INSTRUCTIONS. J , PAYMENT: Datach the top portion of this Notice and submit ~ith your payment mads payable to the nams and address printed on the reverse sids. If RESIDENT DECEDENT make check or money order payable to: REGISTER OF WILLS" AGENT. If NON-RESIDENT DECEDENT maka chack or .cney order plIyabla to: COMMONWEALTH OF PENNSYLVANIA. REFUND (CRl: A refund of a tax crBdit~ which was not requested on the Tax RBturn~ .ay be requested by co_plating an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313l. Applications arB evailabla at the Office of the Ragister of Wills~ any of the 23 Revenue District Offices or fro. the Department's Z4-hour answering service for forms ordaring: 1.SOO-36Z-ZaSD; services for taxpayers with special hearing and I or speaking needs: 1-800-447-3020 (TT only). REPlV TO: Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue~ Bureau of Individual Taxes~ ATTN: Post Assessment Review Unit~ Dept. 2806o1~ Harrisburg~ PA 17l28-0601~ phone (717) 787-6505. DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death~ a five percent (5~) discount of the tax paid is allowed. PENAL TV: The 15Z tax a~nesty 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. INTEREST: Interest is chargad beginning with first day of delinquency~ or nine (9) .onths and one (1) day fro. the date of death~ to the date of payment. Taxes which became delinquent before January 1~ 1982 bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .000164. All taxes which becaMe delinquent on and after January I, 1982 will bear interest at a rate which will vary fro. calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are: Vear Interest Rate Daily Interest Factor Vear Interest Rate Dai ly Interest Factor 1982 ZO~ .000548 1992 9. .000247 1983 167- .OOD43a 1993-1994 1Z .000192 1984 llZ .000301 1995-1998 9. .000247 1985 13Z .000356 1999 n .000192 1986 loZ .000274 2000 .. .000219 1987 9Z .000247 2001 9. .000247 1988-1991 llZ .000301 2002 6. .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAVS DELINQUENT X DAILV INTEREST FACTOR * --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (IS) days beyond the date of the assess.ent. If paymant is made after the interest eo.putation date shown on the Notice~ additional interest must be calculated. STATUS REPORT UNDER RULE 6.12 Name of Decedent: He Ie n (\01. SrYll~ h Date of Death: JANUA~'t' 2?, J.DOL Will No.: ~\ -Od--(')Il~ Admin.No.:~coJ013 01/ 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 0 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 0 b. The separate Orphans' Court No. (if any) for the personal representative's account is: _ c. Did the personal !9')fesentative state an account informally to the parties in interest? Yes IKl No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk ofthe. Orphans' Court and may be attached to this report. Date:--L:.L~-Oll dlf\~Q) 0).~ Signatur~6.JN ci'. ~ o...vru \.-Indw c,. S\rQYl\~nlJ..q ~ Name DIOdle. L Golden. 6'03~ ~,,~,PA 116?5 Address --PI S C h<?stn ut S,\-(<>e t jYWch!:i()?nw1 (,ll) ~ql-5~14 11~55 Telephone Nc() (1) lo Ci'1- 011110 Capacity: ~ Personal Representative o Counsel for personal representative *