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Home My WebLink About02-0566Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of M. FERN BAIR No. ~ ~'~2"5~1y Also known as MARION F. BAIR ,Deceased Social Security No. 172-01-8927 CARLA HACKMAN POTTS Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE "A" OR "B" BELOW:) A. Probate and Grant of Letters and aver that Petitioner is the executor named in the Last Will of the Decedent, dated SEPTEMBER 10. 1996. Alexander Bair Hershfield, stepdaughter, was named co-executrix but she renounced (Renunciation is attached) and requests Letters be issued to Carla Hackman Potts, your Petitioner State relevant circumstances, e.g. renunciation, death of Executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not to victim of a killing and was never adjudicated incompetent: ^ B. Grant of Letters of Administration (d.b.n.c.t.a.: pendente life; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Relationshi Residence COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania, with her last family or principal residence at Claremont Nursing & Rehabilitation. Carlisle, Pennsylvania (List street, number and municipality) ~ ~~~ Decedent, then 86 years of age, died May 15, 2002, at Clarement Nursing & Rehabilitation Center f &~ (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property .....................................................................$ 2,000.00 (If not domiciled in PA) Personal property in Pennsylvania .....................................$ (If not domiciled in PA) Personal property in County ....................................................$ Value of real estate in Pennsylvania ......................................................................................................................$ Total ......................................................................................................... $ 2.000.00 Real Estate situated as follows: Wherefore, Petitioners respectfully request the probate of the last Will presented with this Petition and the grant of letters in the appropriate form to the undersigned: Si nature T ed or rinted name and residence L'c~~, yK~-ter- crafts ~y~~,s~,~ ~,~~~ , 1i ~~ ~ ~ .~i CARLA HACKMAN POTTS ~/~~ ~~du~~ ~~ 204 Edwards Avenue Mt. Gretna, PA 17064 ~A~'~ ~' /y~~~~'`~~~ ~~1-~0- z Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner above-named swears and affirms that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioners and that, as personal representative of the Decedent, Petitioner will well and truly administer the estate according to law, Sworn to and affirmed and subscribed C,.~c.~~~/ZCi2y~ ~~- '~~~ ~ ~s~~~ Carla Hackman Potts ~~4~ it;~oc:~~1 cts ; Before me this 17th day of C'~~,-~~ ~, //~c~c~vr~yc JUNE , 20 02 MARY LEWI No. ~ I ' 02 -51010 Estate of M. FERN BAIR a/k/a MARION F. BAIR Social Security No: 172-01-8927 Date of Death: May 15, 2002 AND NOW, J[7~1E 17- , 2002, in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters Testamentary are hereby granted to CARLA HACKMAN POTTS a~ ~o~ yes in the above estate and that the instrument dated September 10. 1996 r'~~- x ~ ~ ~ described in the Petition be admitted to probate and filed of record as the last Will of the Decedent FEES Letters ........................... Short Certificate(s) Renunciation ............. Affidavit ( ) ................. Extra Pages ( )....... Codicil ............................ JCP Fee ....................... Inventory ...................... Other .............................. $ 25.00 $ 3.00 $ s nn $ig_oo $ 5.00 TOTAL......... $ 56.00 FILED; 6-1~i-02 mailed to atty 6-17-02 ~~ Register f Wills ~- I,Ef9IS Attorney: HORACE A. JOHNSON I.D. No: 06340 Address: Johnson. Duffie. Stewart 8~ Weidner. 301 Market Street. P.O. Box 109. Lemoyne PA 17043- Telephone: 717-761-4540 _ This is to certify that the information here given is correctly copied from an• original eertifieat~p•of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 8207392 No. i. i N Rer. ?!B7 Local Registrar MAY 18 2002 Date COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH r•nme ur ue,.eVenlLerli Mdo,e, UOI SE% SOCIAL SECURITY NUMBER DATE OF DEA7H.MWI, Oar.'hp) , Marion Fern Bair . :Female >.172 - 01 - 8927 ~• Ma 15 2002 AGE ILap BiMdy) UNOERTYEAA UNDERiD/Of DATE OF BIRTH BWTIIRACEIC•Y and PLACE OF OEQH(CMrA aky my-fee •Ipr~ceonaa~anp soy MDalu ) Days Horne ) MNaee IMari. Oa~L yferl SIaM«FOregn C«any) HOSPRAL OTlIER: 86 Y~• ep22,1915 TUpper Swatar Dgpi.n^ ERIOIapMwn ^ Dw^ ,~ 14si,~„u^ ^ COUNTY Of DERH CRY, 8080.1WPOF DEATH FACRRY NAVE na aW~•Agn.prve talep and nwnoarl YLNS DECEDENT OF laSPANIC Biz RACE•ArnpignDllfen, Black While. aa. No ® hr. ^ B ys ap.clly Caw. (sParfrl Cumberland Be{~liddlesex Tw Claremont Nursin & Rehab TMuloen.PxerloRiean.elG White ,B. DECEDENT'S USUAL OCCl1PATgN IGNOOF BUSINESSANDUSTRY WAS DECEDENT EVER NI DECEDENT'S EDUCATION MARIUL STA7U8-MpriW SlIRV11ANG SPOUSE •mda.«a ao~. wnnpp nw„ U.S. ARMEOfOTICE31 Nevp M lAlid 4 pr g oa•d, la wa•, pr•nwden rlrn•1 d rr•~EUa: mrra wrefred.) ENrnerlMr,ttSecorldary CaMSa DN«ced lSpeclq TeacherPublic Schools ""^ "°~ (~+~I (~~« ~I idowed : ,~ ~ • . . , ,s. OFCEDEM'B LEAKING ADDRESS (SDeal Citylbwn. S,pw ZgCodel DECEDENT'S PA ~ ,Te.® r...d.e.dpray.d" Mi r1 c11 PRPX 375 Cl t i 'T'-~'"' ,,,P. aremon Dr ve RESIDENCE d•c•daa Carlisle, PA 17013 «IO ""'"' ~~ Cumberland "wnfup7 "°•0aC0M1Mvi0 ,TD. ,Ta^ •el:n.cxwamoa a e FElIER'S NAME IFiaL Mddl•. Leal) yi oo. MOTHER'S NAME IFap. Mdde. Madan Swnamy ,., Lawrence L. Hackman ,~. EfoaLLANT•S NAME(IyppPr:y) WFORMANT'S MULUIG ISswLCtyJt«.rL SIw,Zq Ceoal Barbara Fowler ,BD.317 Carol S re LIETnoo aF DISPOSITION DATE CF DISPOSITION PLACE aF aSPOSIT10N- Name a Camppy, GemMOry LOCQION - cilyrro••L Suu. zo Coo BvW ® Gerrlubn ^ Nanwva nom Sw• ^ .Day. Year1 or OBwr PMCe DR,aaen^ olnpLSp.c,I~,L ^=May 21, 2002 =~Mt. Olivet Cemetery ,. dew Cumberland PA 17070 = , OF LICENSEE OR ACiWLi AS LICENSE NUMBER NAPE ANO ADDRESS OF FACY.I7V D 012 42-L 7 0 acne 27a<oayarn c•rII~+Iq Yo .aepn oc«aradallle ume.OUe era qaa pal W. LICENSE 8ER DAIS SIGNED i. ea www M l•n. aa.m Io ar,rywwaaMD. pA«pI. O•y, Y•pl F ~ ~ v DD-S - OU1 Zl.STp + L- J / /S"I p~ SwM Et-4S mu,a t•^'PT•~Dy T ATH DATE PRONOUNCED DEAD pACM,Day.riM) v ~ WAS CASE REFERRED TO MEDICAL E%AMINERICORDNER7 ,_., / Doreen •Aa p•rlowlws dean. 0 ' ,e. No L~ _~. ~ ~-~ M. xe. S ~ IS(a ~ ». E). PARF 1: Eaa BIe Qlfeafea, injlaiee a mmpaca"rn.NOD plYed BIa OeeD,. Oo rot enp TIN rtpW a dyYlp, fucD as Caaao p napralory ureN, slwc• «MN laiwa. ~ Appro:enat• PART E: OBw Lip oayerr Caw on ern Yr ' b . ~YeerYY DawNn na ~ qpW Pr•n "PAIR 1. pWl arld Gen MEDIATE GUSE 6•+al I I Oarracaw«r ~ '_h1q' ~ I ,aAigneaan)-~ a. I IIti1 A- ~ TO TOR AS A CONSEQUENCE OF): I + DUE c ~ EailrereiaayMmr10eioru D `_ uF i E an,i laadq b inalledlaTe TO (OR AS A CONSEQUENCE OF): ~ tape. Enpr IIIIDEIILYEIO I CAIEE(Oiaeaee«ry'uy - e ~ . Bu! imaNd averet DUE lO (OR AS A CONSEQUENCE 0F1: 1 ~q+I Weal) IAET 4 _ 1Ae13 AN AUTOPSY PEA+ORMED7 WERE AUTOPSY FTNpNG3 AMLEABLE IR101110 MANNER OF OEATN DATE OFIWURY TIME OFIWURY NaJURY AT WORK7 DESCRIBE HOWIWURY OCCURRED. OYPLETION OFCAUSE ~ (Moon. Dal'. vYar) Of OERH7 ~~~ ^ Naawa AeeiWn ^ PpIdMIpDMpiQallerl ^ Va• ^ Ne^ TDe ^ No Yea ^ No SuicWa ^ Could ror M d•larm"W ^ M. Oe. PLACE OF IWURY • AI Mme qrm pnN hao elkc• LOCIQION S R tw. „. , , , ry, l •a•I. CAY o+m. SWq Duildfllp, eIC.15pK+n aa•. ~, CEIRIFIERICNOa«fyu„al - - 'O181TIFYEID MIYSICIAN IPnyawn cpMyg CauE• a 4ial vdyn snoop ohvscun Ms PrnMIlnCed peon ana [omplNb nem 231 iti M Owt o/ my a,gvrl•ASa Wm xcunW due a IM sla//N~N1~7~ITLE OF CERTIFIER ~ ,L / ~ . caua•(f) and manner a• a,a,•A ..................................... ^ ................ - '/` J\ G 1U• Q ~. 'PRONOUNCING AND CERTIFYBHI-NYSICIANIPDyscan non yonouncrp aeon and cps/ynp acwa•d deau.l le d1 D t a ENSE NUMBER DIJE SIGNED IMann. Osy. Nar1 I O a •• ap anordado•, Wam xeuned at UI• Bm•, dart. and PMCe, and dw b N• csua•!y and mamer as ataT•d .......................... S ~~ V ~ ~~-» ~ ],e. ~ td. NAME ANO ADDRESS OF PERSON WHO COMPLETED GUSE OF DEATH 'MEDICAL E)(AMINER/CORONER (nem 27) Typo or Print OR N,e baUe of eaaminalbn endlor ImesUgalion, in my opinion, death occurred at IAe Time, dale, and place, and du. tone eeuse(a) and manner as fiatad n 1 & 3 Gv r a N+aa. '~ . ........................................................................................ ^ ~,.. .......... I~oaS' REGISTRAR'S SIGNATURE AND NUMBER /l ~, / GATE flLEDIMOnn. pay rpa~l a. 099999-00005/September S, 1996/HAI/PAR/56244 ~~z~t mill ~n~ C~TP~~~mPnt OF M. FERN BAIR ~t-o2.- ~~~. I, M. FERN BAIR, of Hampden Township, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any Will previously made by me. ARTICLE I. I direct that all my debts and funeral expenses, including my gravemarker, and all expenses of my last illness, that my estate is obligated to pay, shall be paid from my residuary estate as a part of the expense of the administration of my estate. ARTICLE II. I give and bequeath to ALEXANDRA BAIR YOUNG HERSHFIELD, the following tangible personal property: A. Corner cupboard. B. Wing chair upholstered in red and gold pattern. i 099999-00005/September 5, 1996/HAJ/PAR/56244 C. End table with burnt orange the top. D. Maple bedroom furniture (guest room), consisting of two chests of drawers with matching mirrors, small round end table with drop leaf, and hanging curio shelf. E. Brass table lamp in guest room (gift of Alexandra Young to Irene Bair). F. Leather-top coffee table with drop-leaf sides. G. Occasional chair given to Irene Bair by Helen Lindenburger. H. Clark Bair sheet music. I. Small Italian inlay table, a gift from Alexandra Young to Fern and Clark Bair. ARTICLE III. I give and bequeath the following tangible personal property to BARBARA BAIR FOWLER: A. Paintings and other art works by Barbara Fowler. B. Windsor-style dining room chairs. -2- ~ __ __ 099999-00005/September 5, 1996/HAJ/PAR/56244 C. Wrought-iron floor lamp with glass table attached. D. Popular sheet music. E. Small mahogany telephone table with shelf and drawer. F. Hand-crafted decoupage jewelry box, a gift from Barbara Fowler to Fern and Clark Bair. ARTICLE IV. I give, devise and bequeath all the rest, residue and remainder of my tangible personal property, excepting cash, to my niece, CARLA HACKMAN POTTS. ARTICLE V. I give and bequeath to my greatnephew, DAVID H. POTTS, one-half (1/2) of my CCNB Stock and PNC Stock. ARTICLE VI. I give and bequeath to my greatniece, REBECCA LEIGH POTTS, one-half (1/2) of my CCNB and PNC Stock. -3- 099999-00005/September 5, 1996/HAJ/PAR/56244 ARTICLE VII. I give, devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, as follows: A. 66 % to my niece, CARLA HACKMAN POTTS. B. 17 % to my stepdaughter, ALEXANDRA BAIR YOUNG HERSHFIELD. C. 17% to my stepdaughter, BARBARA BAIR FOWLER. D. Should any of the persons named in this Article VII predecease me, the share of said deceased person shall go to her issue living at the time of my death, per stirpes. E. In the event that CARLA HACKMAN POTTS predeceases me and at the time of my death has no living issue, then her gift lapses and it shall be added to the gifts to the stepdaughters. F. In the event that a stepdaughter predeceases me and at the time of my death has no living issue, then her gift shall lapse and be added to that of the other stepdaughter. G. In the event that both stepdaughters predecease me and at the time of my death have no living issue, then their gifts shall lapse and be added to that of CARLA HACKMAN POTTS. -4- 099999-00005/September 5, 1996/HAJ/PAR/56244 Should any of the named persons in this Article VII predecease me, the share of said deceased person shall go to her issue living at the time of my death, per stirpes. ARTICLE VIII. I direct that all taxes that may be assessed in consequence of my death of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as part of the expense of the administration of my estate. ARTICLE IX. I nominate and appoint my niece, CARLA HACKMAN POTTS, and my stepdaughter, ALEXANDRA BAIR YOUNG HERSHFIELD, or the survivor thereof, Executrices of this my Last Will and Testament. If all of the aforementioned shall fail to qualify or cease to act, I nominate and appoint PNC Bank, Executor of this my Last Will and Testament. ARTICLE X. I direct that my Executrices shall not be required to give bond for the faithful performance of their duties in any jurisdiction. -5- 099999-OOOOS/september S, 1996/HAJ/PAR/56244 IN WITNESS WHEREOF, I hereunto set my hand and seal this ~ day of v , 1996. M. FERN BAIR (SEAL) Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other have hereunto subscribed our names as witnesses. -6- 099999-00005/September 5, 1996/HAJ/PAR/56244 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. We, M. FERN BAIR, \~1-a~....~`,._. ~ . ~ and ,the Testatri and the witnesses, respectively, whose names are signed to the attac ed or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she had signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and that to the best of his/her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. Sworn to or affirmed to and subscribed to before me by M. FERN BAIR, Testatrix, and ~_ ~ . ~~~, and ~,~ ~(~...,~-~ witne s, this 1 p ~ day of , 1996. Notary Public My Commission Expires: NOTARIAL SEAL DlAhINE I F~t~O. vnk~r~r p~atiicr ~v1y Gorrirniss~on~ftxpiFes Dec. 11, 1597 Register of Wills of RENUNCIATION The undersigned. 5 County, Pennsylvania -~uPcr,~1'Y of the above- (Capacity) named decedent, hereby renounces the right to administer the estate an~~d~~r~~espectfuliy requests that Letters Testamentary be issued to ~~~,~gz ~~~'_t~ WITNESS my hand this _~ day of , 2002. j Name ADDRESS ~~- ,-- ~.._ CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: M. FERN BAIR Date of Death: Will No.: May 15, 2002 2002-00566 Admin. No.: To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on July 15, 2002. Name Address CARLA HACKMAN POTTS 204 Edwards Avenue Mt. Gretna, PA 17064 ALEXANDRA BAIR YOUNG HERSHFIELD 69 Dennis Drive Amherst, MA 01002 BARBARA BAIR FOWLER 317 Carol Street New Cumberland, PA 17070 Notice has now been given to all persons entitled thereto under Rule 5.6(~cept: Date: July 1,5, 2002 ;`_ =. ~ _. 1~1' H CE A. JOHNSON s ,Duffle, Stewart & Weidner d ss 301 Market St. P. O. Box 109 Lemoyne, PA 17043-0109 Telephone (717) 761-4540 Capacity: Counsel for personal representative /7- 7(J- z.. REV-1500 EX + (6-00) CAPB HpRL EplO CRAC KOTK ES C P o 0 R N R 0 E E S N T C o M P T U A T X A T I o N REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER o E C E o E N T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) C! OFFICIAL USE ONLY 21-02-0566 BAIR MARION FERN DATE OF DEATH (MM-DD-YEAR) COUNTY CODE YEAR SOCIAL SECURITY NUMBER 172-01-8927 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE DATE OF BIRTH (MM DO YEAR) 05/15/2002 09/22/1915 (IF APPLICABLE SURVIVING SPOUSE'S NAME LAST, FIRST, AND MIDDLE INITIAL NUMBER REGISTER OF WILLS SOCIAL SECURITY NUMBER X 1. Original Return 4. Limited Estate X 6. Decedent Died Testate 2. Supplemental Return 40. Future Interest Compromise (date of death after 12 7. Decedent Maintained a LIving Trust (Attach copy of Trust) 12-82) 1 (Attach copy of Will) D 9. Litigation Proceeds Received D 10. Spousal Poverty Credit (date of death between 12-31 91 and 1-1-95) THIS SEC:rION'MU$nlill9MPUH~.:f<Ii'~Q.RESll:ONDIll~gFi,~tlAL TAX I NAME COMPLETE MAILING ADDRESS o Horace A. JOHNSON FIRM NAME (If Applicable) Johnson, Duffie, Stewart & Weidner TELEPHONE NUMBER 3. date of death . Remainder Return prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes ". Election to tax under Sec. 9113(A) (Attach Sch 0) .~AjlIIPN SliDIIIlD E. IiIl!<lm,!'I'~!; P. O. Box 109 301 Market Street Lemoyne, PA 17043-0109 R E C A P I T U L A T I o N 61-4540 Real Estate (Schedule A) Stocks and Bonds (Schedule B) Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly OWned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (1) (2) (3) None None None (4) (5) None 2,927.58 (6) 2,965.50 None 4,841. 50 105,538.91 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) 16. Amount of Line 14 taxable at lineal rate 0.00 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate (105,163.82) 19. Tax Due 20. x X X X .0 0 o 45 .12 .15 Copyright (c) 2000 form software only The Lackner Group, Inc. OFFICIAL USE ONLY (8) 5,893.08 (11) 110,380.41 (12) (104,487.33) (13) (14) (104,487.33) (15) (16) (17) (18) (19) 0.00 0.00 0.00 0.00 0.00 Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 375 Claremont Drive CITY I STATE I ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 Total Credits ( A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WillS, AGENT PI.EASEi:~~~!~~::y:~:~::i~6[[6!i~di~~~~Y:16i~~i~~:i~[~2:1:~:d::~N "X" :~~iy~:~~~~i~i6~:~:I~y~ii~[62:R:~:iii": 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ~ ~xxx b. retain the right to designate who shall use the property transferred or its income; . c. retain a reversionary interest; or. d. receive the promise for life of either payments, benefits or care? 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN. 0.00 (4) (5) (5A) 0.00 0.00 0.00 0.00 D D D []J []J []J Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all Information of which preparer has any knowledge. S~=ZPONS'BLE:;'&J ER THAN REPRESENTATIVE Carla HACKMAN-POTTS 204 Edwards Avenue ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - ~ ~ - - - - - - - - - - - - - - - - - - - - - -- Mount Gretna, PA 17064 Johnson, Duffie, Stewart & Weidner P.O. Box 109 - - - -~~ - --- - - --- ---- - --- - -- - - -- ~ - -- - -- - - -- ~-- - -- - -- --~ Lemo PA DATE 1,,1'1/03 DA E For dates of death n or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 9116 (a) (1.1) (in For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 9116 (a) (1.1) (ii)J. 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 twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2) [72 P.S. 9116(a)(11] The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) RE~-1508 EX t (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MARION FERN BAIR SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY SS# 172-01-8927 05/15/2002 FILE NUMBER 21-02-0566 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION PNC Bank Checking Account No. 51-4000-2246 - Cash received after date fo death VALUE AT DATE OF DEATH 53.69 2 Claremont Nursing Home Guest Fund Account Refund 1,849.44 3 PNC Bank Checking Account No. 51-4000-2246 810.45 4 Proceeds from sale of Jewelry and Coins by Brickers Auction. See attached Inventory/Sale Sheet from Brickers Auction 214.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space IS needed, Insert addItional sheets of the same sIze) Copyright (c) 1996 form software only CPSystems, Inc. 2,927.58 Form REV-150B EX (Rev. 1-97) REV-1509 EX .. (1~97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MARION FERN BAIR SCHEDULE F JOINTLY-OWNED PROPERTY SS1! 172-01-8927 05/15/2002 FILE NUMBER 21-02-0566 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. A. SURVIVING JOINT TENANT(S) NAME Stone & Murray Funeral Home ADDRESS RELATIONSHIP TO DECEDENT None New Cumberland, PA 17070 B. c. JOINTLY-OWNED PROPERTY, LETTER ITEM FOR JOINT NUMBER TENANT 1 A DATE MADE JOINT 03/17/99 DESCRIPTION OF PROPERTY Include name of financial institutIon and bank account number or similar Identifying number. Attach deed for Jointly-held real estate. PNC Bank Checking Account No. 5000900773 This Account was held as a joint account with the Funeral Home. Decedent never received money from the Account. Entire proceeds from the account went to the payment of the Funeral Expenses. DATE OF DEATH VALUE OF ASSET 5,931. 00 % OF DATE OF DEATH DECO'S VALUE OF INTEREST DECEDENT'S INTEREST 50.00% 2,965.50 TOTAL (Also enter on line 6, Recapitulation) $ (If more space IS needed insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. 2,965.50 Form REV-1509 EX (Rev. 1-97) RE~-lS11 EX + (1~97) COMMONWEALTH OF PENNSYLVANIA INHERITANCET/1\)( RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF MARION FERN BAIR SSII 172-01-8927 05/15/2002 FILE NUMBER 21-02-0566 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES, 1 Stone & Murray Funeral Home 2,965.50 B. ADMINISTRATIVE COSTS, 1. Personal Representative's Commissions 900.00 Name of Personal Representative(s) Carla HACKMAN-POTTS Social Security Numbens) I EIN Number of Personal Representative(s) Street Address 204 Edwards Avenue City Mount Gretna State PA Zip 17064 - Year(s) Commission Paid: 2. Attorney's Fees Johnson, Duffie, Stewart & Weidner 900.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip - Relationship of Claimant to Decedent 4. Probate Fees Register of Wills 56.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 Cumberland County Register of Wills - Inheritance Tax Return 20.00 Filing Fee $10.00 Inventory Filing Fee $10.00 TOTAL (Also enter on line 9, Recapitulation) $ 4,841. 50 (If more space IS needed, Insert additional sheets of the same size) Copyright (c;) 1996 form software only CPSyslems, Inc;. Form REV-1511 EX (Rev. 1-97) REV.1512 EX +(1-97) COMMONWEAL'TH OF PENNSYLVI\NIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MARION FERN BAIR SCHEDULE I DEBTS OF DECEDENT. MORTGAGE LIABILITIES, AND LIENS SStI 172-01-8927 05/15/2002 FILE NUMBER 21-02-0566 Include un reimbursed medical expenses. ITEM NUMBER 1 DESCRIPTION Brickers Auction - Commission for sale of Personal Property AMOUNT 34.00 2 Commonwealth of Pennsylvania Department of Public Welfare claim against the Estate 105,504.91 TOTAL (Also enter on line 10, Recapitulation) $ (\i mote space IS needed, Insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. 105,538.91 Form REV-1512 EX (Rev. 1-97) REV-1513 EX +(9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF MARION FERN BAIR SSifr 172-01-8927 05/1512002 FILE NUMBER 21-02-0566 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE 1 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERlY TAXABLE DISTRIBUTIONS [Include outright spousal dlstrlbutrons, and transfers under Sec. 9116(a)(1.211 Barbara Bair Fowler 317 Carol Street New Cumberland, PA 17070 Stepchild Seventeen (17%) Percent NUMBER I. 2 Carla Hackman Potts 204 Edwards Avenue Mount Gretna, PA 17064 Niece Sixty-Six (66%) Percent 3 Alexandra Bair Young-Hershfield 69 Dennis Drive Amherst, MA 01002 Stepchild Seventeen (17%) Percent ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS, A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space \s needed, insert additional sheets of the same size) Copyright (c) 2000 form software only The Lackner Group, Inc. 0.00 Farm REV-1513 EX (Rev. 9-00) LISTING OF EXIBITS ATTACHED TO THE INHERITANCE TAX RETURN FOR THE ESTATE OF MARION FERN BAIR EXHIBIT A Last Will and Testament for M FERN BAIR dated September 10, 1996 '--o-c-_-, J1Last 3It11 aub Wtstamtm OF M. FERN BAIR I, M. FERN HAIR, of Hampden Township, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any Will previously made by me. ARTICLE 1. I direct that all my debts and funeral expenses, including my gravemarker, and all expenses of my last illness, that my estate is obligated to pay, shall be paid from my residuary estate as a part of the expense of the administration of my estate. ARTICLE II. I give and bequeath to ALEXANDRA HAIR YOUNG HERSHFIELD, the following tangible personal property: A. Corner cupboard. B. Wing chair upholstered in red and gold pattern. j 4 I I "I ! C. End table with burnt orange tile top. D. Maple bedroom furniture (guest room), consisting of two chests of drawers with matching mirrors, small round end table with drop leaf, and hanging curio shelf. E. Brass table lamp in guest room (gift of Alexandra Young to Irene Bair). F. Leather-top coffee table with drop-leaf sides. G. Occasional chair given to Irene Bair by Helen Lindenburger. H. Clark Bair sheet music. I. Small Italian inlay table, a gift from Alexandra Young to Fern and Clark Bair. ARTICLE III. I give and bequeath the following tangible personal property to BARBARA BAIR FOWLER: A. Paintings and other art works by Barbara Fowler. B. Windsor-style dining room chairs. - 2 - , l C. Wrought-iron floor lamp with glass table attached. D. Popular sheet music. ".'; E. Small mahogany telephone table with shelf and drawer. F. Hand-crafted decoupage jewelry box, a gift from Barbara Fowler to Fern and Clark Bair. ARTICLE IV. I give, devise and bequeath all the rest, residue and remainder of my tangible personal property, excepting cash, to my niece, CARLA HACKMAN POTTS. ARTICLE V. I give and bequeath to my greatnephew , DAVID H. POTTS, one-half (1/2) of my CCNB Stock and PNC Stock. ARTICLE VI. I give and bequeath to my greatniece, REBECCA LEIGH POTTS, one-half (1/2) of my CCNB and PNC Stock. - 3 - 1 I ! ARTICLE VII. I ! I give, devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, as follows: A. 66% to my niece, CARLA HACKMAN POTTS. B. 17 % to my stepdaughter, ALEXANDRA BAIR YOUNG HERSHFlELD. C. 17% to my stepdaughter, BARBARA BAIR FOWLER. D. Should any of the persons named in this Article VII predecease me, the share of said deceased person shall go to her issue Jiving at the time of my death, per stirpes. " I i E. In the event that CARLA HACKMAN POTTS predeceases me and at the time of my death has no Jiving issue, then her gift lapses and it shall be added to the gifts to the stepdaughters. , '1 ' F. In the event that a stepdaughter predeceases me and at the time of my death has no Jiving issue, then her gift shaH lapse and be added to that of the other stepdaughter. G. In the event that both stepdaughters predecease me and at the time of my death have no living issue, then their gifts shall lapse and be added to that of CARLA HACKMAN POTTS. - 4 - .....;J Should any of the named persons in this Article VII predecease me, the share of said deceased person shall go to her issue living at the time of my death, per stirpes. i I "'j ARTICLE VIII. I direct that all taxes that may be assessed in consequence of my death of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as part of the expense of the administration of my estate. ARTICLE IX. I nominate and appoint my niece, CARLA HACKMAN POTTS, and my stepdaughter, ALEXANDRA BAIR YOUNG HERSHFIELD, or the survivor thereof, Executrices of this my Last Will and Testament. If all of the aforementioned shall fail to qualify or cease to act, I nominate and appoint PNC Bank, Executor of this my Last . Will and Testament. ARTICLE X. I direct that my Executrices shall not be required to give bond for the faithful performance of their duties in any jurisdiction. . . - 5 - i , 'j ...J IN WITNESS WHEREOF, I hereunto set my hand and seal this /0 day of ~~ ,1996. '--In. f~ Ii.~..,) (SEAL) M. FERN BArR Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament. in the presence of us, who, at her request, in her presence and in the presence of each other have hereunto subscribed our names as witnesses. - 6 - .1 ~ "~'I ,~ . AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA 55. COUNTY OF CUMBERLAND We, M. FERN BAIR, ~ -A. ~ and ~~~ ~ . .{l... ~ ~'" , the Testatri and the witnesses, respectively, whose names are signed to the atta~ed or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she had signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and that to the best of his/her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. Sworn to or affirmed to and subscribed to before me by M. FERN BAIR, Testatrix, and \~ A.~ and ~ 1i ~ ,witne s, this '\~ ~day of "fI ; , 1996. ';:)k~~ ~~, Notary Public My Commission Expires: NOTARIAL SEAL DIANNF I.JN!G. "Infar\' Public Lerno';l;:-. ".;~' :-'d~,;l' ,:>}';;.l)I_'.';~\li\1 CD. My CommissIon Explles Dec. 21, 1997 Register of Wills of CUMBERLAND County, Pennsylvania INVENTORY Estate of MARION FERN BAIR No. 21- 02 - 0566 also known as Date of Death 05/15/2002 Deceased Social Security No. 172 - O1- 8927 Carla HACKMAN-POTTS, Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I /We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Horace A. JOHNSON Attorney: I.D. No.: 06340 Address: P. 0. Box 109 Lemoyne, PA 17043-0109 Telephone: 717/761- 4540 Description (See continuation page(s) attached) Personal Represents/ti//vI'~~ ~ ~ /~ ~ ~~,Q~~ _ l Signature: l'~C~"q/ ~~' "_`'"-' "- "v ~~ Carla HAC:[~IAN- POTTS Signature: Address: 204 Edwards Avenue Mount G\rJetna, PA 17064 Telephone: 717 ~ 7 j ~ J ~ l~? 1-~ Dated: ~ '-} [,~ ~j Value (Attach additional sheets if necessary) I Total: 2 , 927.58 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form #RW-7 (1992) INVENTORY Estate of: MARION FERN BAIR Date of Death: 05/15/2002 County: Cumberland CASH: Claremont Nursing Home Guest 1,849.44 Fund Account Refund PNC Bank Checking Account No. 810.45 51-4000-2246 PNC Bank Checking Account No. 53..69 51-4000-2246 - Cash received after date fo death PERSONAL PROPERTY: Proceeds from sale of Jewelry 214..00 and Coins by Brickers Auction. See attached Inventory/Sale Sheet from Brickers Auction TOTAL RECEIPTS OF PRINCIPAL ............... 2,713.58 214.00 2,927.58 -1- JERRY R. DUFFIE RICHARD W. STEWART C. ROY WEIDNER, JR. EDMUND G. MYERS DAVID W. DELUGE RALPH H. WRIGHT, JR. DAVID J. LANZA MARK C. DUFFIE MELISSA PEEL GREEVY MICHAEL J. CASSIDY ROBERT M. WALKER LAW OFFICES JOHNSON, DUFFIE, STEWART ~ WEIDNER A Professional Corporation 301 MARKET STREET P. O. BOX 109 LEMOYNE, PENNSYLVANIA 17043-0109 WEBSITE: www.jdsw.com TELEPHONE 717-761-4540 FACSIMILE 717-761-3015 E-MA[L mail®jdaw.com February 7, 2003 Register of Wills Office Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Dear Register: HORACE A. JOHNSON COUNSEL TO THE FIRM KEIRSTEN WALSH DAVIDSON OF COUNSEL E-MAIL dlw@jdsw.com Re: Estate of M. Fern Bair SSN: 172-O1-8927 Date of Death: May 15, 2002 Your File No. 21-02-0566 Enclosed for filing please find the following documents for the above referenced decedent: 1. 2 Original PA Inheritance Tax Returns. There is no tax due. This is an Insolvent Estate. 2. Check No. 8532 in the amount of $20.00 representing the filing fees for an Insolvent Estate and Inventory. 3. 1 copy of Pages 1 & 2 of the Pa Inheritance tax return, which we ask that you time-stamp and return to us in the enclosed envelope. 4. Inventory 5. Page one of the Inventory, which we ask that you time stamp and return to us in the enclosed envelope. Should you have any questions, please do not hesitate to contac;t our office. Thank you for you assistance in this matter. Very truly yours, ana L. ieseman Legal Assistant ;.~ 7 ~~:: W Z O .. yW ? ~ a ~ o ~ 3 ~ a Q~~~,z a ~ ° > N ~ w o N W Y m Z W ~ Q D W li O~aa ~ a o z p `" ~ 0 z ~ O ~ N Z O J Q ~I NI N V ~" L1. 0 v M r-I O v~ ~~ a ~ ~ v U ~ ~ c`~ ~ ~?-~o~~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX -IVISIDN -EPT. 2806D1 HARRISBURG, PA 17128-0601 HORACE A JOHNSON JOHNSON ETAL PO BOX 109 LEMOYNE COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REY-1547 EX AFP (O1-OS7 DATE 03-31-2003 ESTATE OF BAIR FERN M DATE OF DEATH 05-15-2002 FILE NUMBER 21 02-0566 ' - - C(?l~IVTY CUMBERLAND ACN 101 Amount Remitted PA 17043 ~~~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BAIR FERN M FILE N0. 21 02-0566 ACN 101 DATE 03-31-2003 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this form with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 2,927.58 tax payment. 6. Jointly Owned Property (Schedule F) (6) 2,965.50 7. Transfers (Schedule G) (7) .00 8. Total assets (g) 5,893.08 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 4,841.50 (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 105 , 538.91 11. Total Deductions (11) 1 1 D .;80 .41 12. Net Value of Tax Return (12) 104, 487.33- 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (l4) 104,487.33- NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) •00 X 00 _ .00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) .00 X 045 . .00 17. Amount of Line 14 at Sibling rate (17) .00 X 12 = .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 - .00 19. Principal Tax Due (1q)= .00 DATE _ ~ NUMBER I INTEREST/PEN PAID (-) I AMOUNT PAID TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ~ IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) STATUS REPORT UNDER RULE 6.12 Name of Decedent: M. FERN BAIIZ a/k/a MARION F. BAIR Date of Death: MAY 15, 2002 Will No.: 2002-00566 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rule, 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 X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No X b. The separate Orphans' Court No. (if any) for the personal representative's Account is: c. Did the personal representative state an account informally to the parties of interest? Yes X No d. Copies of receipts, releases, joinde~s'and approvals of formal or informal accounts maybe filed with the Clerk of the Owns' Court and~nay be at~d to this report. ~ - / / Date: April 22, 2003 ~r ~, .. - ~ co N i2 ...... Q ~. :. Y ~~ M ~~~ ~ ~~ .f,... Q ' ' '.k) r ~~-: ~';: ..., 301 P.O OX 1 STEWAEZT & WEIDNER a!PA 17043 1-4540 Personal Representative (x) Counsel for Personal Representative G oh COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISIDN DEPT. 280601 INHERITANCE TAX HARRISBURG, PA 17128-0601 STATEMENT OF ACCOUNT REY-1607 E% AFP (O1-YS7 DATE 06-01-2004 ESTATE OF WORMAN HELEN A DATE OF DEATH 07-06-2003 FILE NUMBER 21 03-0566 COUNTY CUMBERLAND DAVID H STONE ACN 101 STONE ETAL Amount Remitted 414 BRIDGE ST NEW CUMBERLAND PA 17070 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this fora with your tax payment. CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS 1 ---------------------------------------------------------------------------------------------------------------- REV-1607 EX AFP (O1-03) ~~~( INHERITANCE TAX STATEMENT OF ACCOUNT ~(~(~ ESTATE OF WORMAN HELEN A FILE N0. 21 03-0566 ACN 101 DATE 06-01-2004 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 04-26-2004 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): 8,452.93 PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID C-) AMOUNT PAID 10-06-2003 CD003088 422.65 9,000.00 05-10-2004 REFUND .00 964.72- - ~. ~. ,, TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. * IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( ( IF TOTAL DUE IS LESS THAN S1, /~ NO PAYMENT IS REQUIRED. `~ ~ IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) 8,452.93 .00 .00 .00 ~~