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HomeMy WebLinkAbout02-0588PETITION FOR GRANT OF LETTERS Estate of also known as No. 21- ~2- y a~ ,Deceased Social Security No. 1 ~~~ - 3~ ~~~`-~~ Petitioner(s), who is/are 1 S years of age or older, apply)ies) for (COMPLETE "A" OR "B" BELOW:) A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut Decedent, dated and codicil(s) dated 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 the victim of a killing and was never adjudicated incapacitated: f~l B. Grant of Letters of Administration ~y (c.t.a., d.b.n.c.t.a.: pendente lite, durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Relationship Residence - ~ ~ C' ~«, l ~~ -~E~lti~-t'~' ~v ~,~ iz' ~ ~. ~ - (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in ~C.c_-t~-t-~-~~(C<.~<~~...- County, Pennsylvania, with his/her last family or principal residence at (list street, number and municipality) Decedent, then -~ y years of age, died ~~''~ ~ ~, (Location) Decedent 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 ........................................................................................ Total .................................................................................................................... f`~~)t :fzr,, 7~ i1v Z_ L°-Q. r~7C $ 5 ; ~~~ $ ~i OCk7 Real Estate situated as follows: Wherefore, Petitioner(s) respectfully request(s) the probate of the Last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: Signature named in the Last Will of the Typed or printed name and residence ~C P., ~ a-~.. 1.= . 3 L ~~~ -7 7 ~~ r/~c~ i ~--~ _ --, , ~ ~ Oath of Personal Representative Commonwealth of Pennsylvania County of The Petitioner(s) above-named swear(s) and 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 representative(s) of the Decedent, Petitioner(s) will well and truly administe~e~s~ acco ~dyrtg to law. Sworn to and affirmed and subscribed before me this 24th day of JUNE 2002 MARY C LEWIS ~e :d1~• k . Nu ~,w, DECREE OF REGISTER Estate of l ' ~~ ~ ~ (~~ S l ~ ~-~~~n f~t~ ~?~ ~r7 Deceased No. ? ~ -~~-ERR - also known as Social Security No: ° ~ `~ - ~~~ ~' ~~'~ ~ Date of Death: ~~~ ~ ~ I ~{ ~ ;L ~c~ AND NOW, JUt~ 25, 2002 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters ^ Testamentary of Administration ((c.t.a., d.b.n.c.t.; pendente Iite; durante absentia; durante minoriate) are hereby granted to ~~ ~ t ~~ ~ ~~ ~ in the above estate and that the instrument(s), if any, dated described in the Petition be admitted to probate and filed of record as the Last Will of Decedent. FEES Letters .................................... $ 25.00 MARY C LEWIS Register of Wills Short Certificates(s) ............... $ 18.00 Renunciation .......................... $ 10.00 ? Extra Pages ( ) ............ • ~. $ / _..~~~._ Signature .T.R ....................................... $ JCP Fee ................................. $ 5.00 Attorney: I.D. No: ~70 ~, ~-f Inventory ................................ $ Other .......BOND ...................... $ 15.00 Address: ..2 3 ~ ~ 6~ ~~-~c~~= .~5:t . TOTAL .............................$ ~~ - 00 Telephone: DATE FILED: 6-25-2002 called admin 6-25-2002 lO~,tiU~ k 1 kNl. Z his is to certih that the information here given is correctlti~ copied from an original certificate of death duly filed with me as Local Registrar. I~he 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 ~3200~ ~o. ~T INNS ~ !C? ~ ~' 1~ St'~u,W R~'gr~ : W MITE ~ ~E~V"E12. M~4-QED O'er, ~~~t ~ o~ N 105- , aJ Rev. 2rB7 TINT ENT NK ~ ~~ A ~ L-ft' _ If>cal kZegistrar `~IUN 21 2Q02 v.,re COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT Of HEALTH • VITAL RECORDS CERTIFICATE OF DEATH NAME OF DECEDENT IFan. Marne, Lan) ~ -~ SEX SOCUI SECURITY NUMBER GATE OF DEATN.MGM. Day, barl ~ 184 - 38 - 6008 June 19.2002 Male , . Hamm ,. ~~ Charles Wa ne _ AGE Ilan Bamoay) UNDER I YEM UNDER 1 DID' DATE OF BIRTH BDRHPIJICE !C.ry ana PLACE OF DEATN ICnecA ary dre- see malrhdwn to odrN soul MOMM Deya /ldraa , M'amlae ~MOntn Y.'Axrl aFCragn ComhYl HOSPITAL: OTHER: Wi~~iamsport may ~0 ^ ~~ ~ ^ " ~ , [ OM , I IWN^ ERIOMpaINm npa en,. Raamanca ^ Ml ^ 54 Ym. 48 7. ea. e . 5 COUNTY OF DEAfN T~ P~OE~IEA1~ FACILT'NAME PI~d msAWan, give area? and numbNi VMS DECEDEM OF HISPANIC ORIGIN? RACE-Amencan moan, BOCk, Wnae. NC. Ea S~ROS "eIlli`J Uor Na~. y..^Ky... ,p.tM CuE.n. ISpeCay) West Shore Rehabilitation KJn.PwrlpRirJn,Nt. Male ante ,e Tw d b l • j p. ,,, ,. . an er ,~ Cum k. DECEDEM'S USUAL OCCVPATKNI KIND Of BUSINESS/INOVSTRV MMS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS-MartNd SURVIVING SPOVSE Wbo.aa. In we. qna maaen naval M a rt~ U 5. ARMED FgiCESi S n aw com NsvN r ~ C rs (CH.re krm d work dory dA rros ~ P~~~^°'1'~~rlq)a Naval Supply Dep tYe,~ N,^ EIN^•^~,/~ °^°•ry ,,.;«;°,2 Divorce"c'~ - ns, u, u, la. n. ,,. DECEDENT'SMAILINC ADDRESS ISIreN.CMrtown.Sma.ZpCodel DECEDENT'S pennsylvania ,Tt.^ Ma,wtwNemra~ ~- ~ 213 Walnut Street , ACTUAL /7a. SMI d eCadNK RESIDENCE Penna. 17013 lisle C Mvama '~•° ~'; Cumberland ,py„p,yp ,,~~ap aacse.mar.e Carlisle e ^^ ? ,Te ai m d la d K le tfJ , ar ~~ ,,, . rr t . w m . t y de. FRNER'S NAMEIFwn, MmdN. Lan) MOTHER'S NAME IFKn,M a Y•y Surgap)ejsa Legros lYl Y t~~• Theodore E. Hamm 1r1 ,~. ,,. INFORMANT'S NAME (Typd~a'll 1~7 3 5T'S MAILING ADDRESS (Strea4 Cay/fin. SWS. Zq Cod! 3 02 Texas 77 I~ouston wn Street wl d M Keith E. Hamm , , , o a ea METi/00 OF DISPOSITK)N DATE OF DISPOSITION PUCE OF OISPOSRKXe • Nona W Cemetery, Crematory LOCQION -Ciry/Twn, Slm, Zq Cow Pl D IMr ata Bwin ^ Cremation (~I a.nlorr hdn $IW ^ IMmm, ay, Marl d ry.Harrisburg,Penna. East Harrisburg Cremat • =~ Dameen^ ahN(spetarl ^„Tune 24,2002 = :,. . . ' SIGNArVRE FUNERALSERVICELN:ENSEEOFtPERSQNACTINGASSVCH LICENSEN008~19-L n}iwln RE Brothers: ~r1Y~~ ,P ~~yg~a egg 1 xze. c~ • m. pna es t7a-c onM v.Wn um irg Tot my anowNdge. wale oceuned allW hma. Dale antl plan salad. LICENSE NUMBER DATE SIGNED (MtAh. DW. Marl ~ pnysicwr arailade at nma tI warn I Tent, 65' ~ g - ~ earuty olw~n. r7e. t7e. 77a. nsm. pa-26 must W mrrlpnad M TIME Of DEATH D E PRONOUNCED DEADI .Day. Year, wA5 CASE REFER RED TO MED AL XAMINERICORONER? ~~*! Ma N J parxm ..MO pmrmturtn warn. ((~~ O J ~ M N © ~ ~ ~ M ZS R l. MRT I: EntN tM diseaaaa, mryrias d eompeCatgrN 37 . . enich caused Ina warn. Do m1 emN m . a maw of dying, soon as urdiaC or respiratory arreal, sMCR d Man IaduN. I Approaimab PART K: dnN sgniecarK condniorr rmnlrMdirg m warn, twl r tlla IArdarl M^ n PART I n t res ldl Cause ^ . Lin dM/ Orr Gorge M aarJr lino. I imerrn hanraen I onaat arm wad, aWEDIATE CAUSE (Fort y lI~ (~}-~-- . o u q N 9 9 dsenededaemn ftr.t 4 /+-< tir y~/~~ -. , ~~Gr7/}i7 ~e5 . rasuarq r dealM Du roroRASncoNSEOUENCecFr ~ ~ ~ /~ < P!f rr a ~Z .~-, seQa.muay Its oonwiom h. DUE TOIOR AS A CON E it arN, kednq m.nmedau eauM. EMN UNDERLYING I ~ t GAl1SE ID~suss d nArry , ,uK ewialea avNas DUE ro lOR AS A CONSEQUENCE OF1: I renArq n daaml LA37 e. r ViaS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH GATE OFINJURY TIME OFINJURY INUURY AT WORK? DESCRIBE MOW INJURY OCCURRED. PERFORMED? AVIVUBLE PRKXI ro (Mmm. Oay, Mar) COMPLETION a CAUSE s~ NnurN Izl Hom~eida ^ OF DEATN? Accmem ^ PeMinglrnsstigatihn ^ 70e 7pC. M. rba ^ No ^ 7lle. ]Od. r' a ^ No ~ ~~7(I Yea ^ No ~! SrAeida ^ Coum not W wrrmmed ^ . PUCE OF IW URY - AI soma, term, nren, ladory, olhce LOCRK)N ($heN. GIyR . Smlal - a Wildlrp, Ne. ISpeCdvl xe.. ase. r. 7w. Tln. CEIRIHER ICt`acA CrYy' oval $IGNIQURE TITLE OF CERTIFI 'CERTIFYING PNYSICIAMIPnrscrn cwlayaq caused wam vnen arwlnN OnYSK~an vas ddauncrm deals ana comdelad llem 271 want oceuned Due b be eause(al and meow/ se ftalad ..................................................... ^ Te dr Wet of my RnowNdga / • L/l ,te, 4 , _ DATE SIGNED,IMd+m, Dar. Marl UCEN UMBER •PRONOVNGNG ANO CERTIFYING PHYSICIAN(Pnysican hdn prorld,ncaq Deem ant CMAymg,a cause of deaml ...... arm dw to the causela) and manner ea orated ................... la wl m M Y / 71C G 714 ~ Zv 2-- e, ar p ce, l na, To IM Wet of my knowledge, death attwre0 al t NAM ADDRESS OF PERSON WHO COMP E ATN ~~ ~ ~ (Item 27)Typea Print Thomas I u • - 'MEDICAL EXAMINER/CORONER On the basis of naminatlonand/or investigation, in my opinion, death occurred al the Ilme. date, and place, and due to the cause(s) and ^ 50 ~ Brandt Avenue. mannaFa,,,n.d .................................................................................................. berland Penna. 17070 ~~ ~,.. . REGIS AR'S SIGNATURE AND / UMBER DATE FILEDIMOntn. Day. Marl ~ RENUNCIATION Estate of ~~`L~~--(c J: ~tl~ --~`.~n~ No. r~/-C?o2 - SSt~' also known as The undersigned, ~ d~ ~C~r (Signature) the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters ~-~~c~ ~-: ~ t; ~E~. (t .~ ~ be issued to K~-L.~ Zti ~ • ~ ~Zu~~~ i~ Witness hand this ~ ~~ { t° day of . ~-~- - c•~ ~ -~ t (f (Signature) - ~ " (Address) (Signature) (Address) (Address) Deceased (Relationship) of Sworn to or affirmed and subscribed before me this ~ r~~ day of ~-D~?'- l~t~~~ ~ ° /~-R-+~Q~~C ~~c~C-C.~1~1 ~-- Notary Public My Commission Expires: f '~/ ~~~n~}-- (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTARIAL 8EAL CASSANDRA T. ROSENBAUM, Notary Public Camp Hill Boro, Cumberland County My Commission Expires December 4, 2004 NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 RENUNCIATION Estate of ~~11~~~-~, ~ 6~~~cc ~~~-~~~o,-~ No. ~~ ° C1o? - 5'~}35l also known as The undersig ,Deceased 5 ~~"' ( ~ ~ ~ 1~.-- ~ of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters ~~~->_,,,~ ~, L. ~,,k ,-~u ~ ~ ~-~ be issued to _ i~ -~.~ ~--h ~"~ . ~--f~.~.-~-. wt ~l rc,, Witness hand this day of ~~=~~ ~~i~ ~~ ~ ~~~s~ ~~~GC~~c~.ms~~~~~7>0 / (Signature) (Address) (Signature) (Address) Sworn to or affirmed and subscribed before me this ~j^ day of a --- ' . Notary Public My Commission Expires: ~ ~ly!~~ (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) N01`ARIAL BEAL CASSANDRA T. ROSENBAUM, Notary Public Camp Hill Boro, Cumberland County My Commission Expires December 4, 2004 NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 THE CINCINNATI INSURANCE COMPANY BOND NO. B80- .~ -~ Bond of Administrator, Executor, Conservator, Guardian or Trustee Court Case No.: o`~ ~ - G'~ -~~~ In the matter of the Estate of Charles Wayne Hamm State/Commonwealth of _Pennsvlvania KNOW ALL MEN BY THESE PRESENTS, that I/we, Keith E . Hamm 6735 Meadowlawn Houston TX 77023 , as Principal(s), and The Cincinnati Insurance Company as Surety, are held and firmly bound unto the Probate Judge of the aforesaid County, and his/her successors in office, in the sum of Five Thousand (S 5 , 000 _- Dollars, conditioned that the above-bounden Principal who has been appointed Executor (Administrator, Executor, Conservator, Guardian or Trustee) of the Estate of Charles Wayne Hamm who is Deceased (Deceased, a Minor or an Incompetent) required of him/her under said appointment. shall well and truly, faithfully perform all of the duties Dated this 24th day of June 200 Principal(s): Surety: THE,CyKI¢"INNATI.INSr(Ji~AI~E COMPANY Ho craft Hockle & 0' Donnell ~ v (At~orr{y-in-~ Agent/Agency: p Y /~ PO BOx 116 Carlisle,PA 17013 ~ (name and address) The above bond approved the ~~>(~ ..~ day of ~ 10 ~'m r~~ By ~ ~ of aforesaid County ATTACH THE POA AND SEAL WHERE APPLICABLE In the Court of Cumberland County S-2800 (8/99) (COURT COPY) THE CINCINNATI INSURANCE COMPANY Fairfield, Ohio POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That THE CINCINNATI INSURANCE COMPANY, a corporation organized under the laws of the State of Ohio, and having its principal office in the City of Fairfield, Ohio, does hereby constitute and appoint David W. Hopcraft; Jeffrey L. Scott and/or Patricia K. Arbegast of Carlisle, Pennsylvania its true and lawful Attorney(s)-in-Fact to sign, execute, seal and deliver on its behalf as Surety, and as its act and deed, any and all bonds, policies, undertakings, or other like instruments, as follows: Any such obligations in the United States, up to Five Million and No/100 Dollars ($5,000;000.00). This appointment is made under and by authority of the following resolution passed by the Board of Directors of said Company at a meeting held in the principal office of the Company, a quorum being present and voting, on the 6th day of December, 1958, which resolution is still in effect: "RESOLVED, that the President or any Vice President be hereby authorized, and empowered to appoint Attorneys-in- Fact of the Company to execute any and all bonds, policies, undertakings, or other like instruments on behalf of the Corporation, and may authorize any officer or any such Attorney-in-Fact to affix the corporate seal; and may with or without cause modify or revoke any such appointment or authority. Any such writings so executed by such Attorneys-in- Fact shall be binding upon the Company as if they had been duly executed and acknowledged by the regularly elected officers of the Company." This Power of Attorney is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of the Company at a meeting duly called and held on the 7th day of December, 1973. "RESOLVED, that the signature of the President or a Vice President and the seal of the Company may be affixed by facsimile on any power of attorney granted, and the signature of the Secretary. or Assistant Secretary and the seal of the Company may be affixed by facsimile to any certificate of any such power and any such power of certificate bearing such facsimile signature and seal shall be valid and binding on the Company. Any such power so executed and sealed and certified by certificate so executed and sealed shall, with respect to any bond or undertaking to which it is attached, continue to be valid and binding on the Company." IN WITNESS WHEREOF, THE CINCINNATI INSURANCE COMPANY has caused these presents to be sealed with its corporate seal, duly attested by its Senior Vice President this 28th day of April, 1999. `~+"10'°'•~~~,~ THE INNATI INSURANCE COMPANY CORPORATE ° SEAL ~ ~~~c o x i o Senior Vice President STATE OF OHIO ) ss: COUNTY OF BUTLER ) On this 28th day of April, 1999, before me came the above-named Senior Vice President of THE CINCINNATI INSURANCE COMPANY, to me personally known to be the officer described herein, and acknowledged that the seal affixed to the preceding instrument is the corporate seal of said Company and the corporate seal and the signature of the officer were duly affixed and subscribed to said instrument by the authority and direction of said corporation. 1~ ,a+ hS 9 ~ 1' ~ k L / V N: W (~d~r h5k~ ', a ~,.. ~ i ,G.. . , r .w, t ,~~ ~' ,~ ~ MARK J. LLER, Attorney at Lew • NOTARY PUBLIC -STATE OF OHIO ~ , + .oiT;4 ~ ' My eemerleelen kee ~w eeplvAtlen y,~~`' ~; ~ ~_` "~.,~ ;;.: t';'~' date. Ssctlon 147.03 O.R.C. I, the undersigned Secretary or Assistant Secretary of THE CINCINNATI INSURANCE COMPANY, hereby certify that the above is a true and correct copy of the Original Power of Attorney issued by said Company, and do hereby further certify that the said Power of Attorney is still in full force and effect. GIVEN and r my hand and seal of said Company at Fairfield, Ohio. this ~ ~/ ~ day of _ /~~~, ~~~ - ~~ ~j - 1 y CORPORATE 3 g SEAL Assistant Secretary oH~o ' BN-1005 (4/99) S ~ ~t CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: Charles Wavne Hamm Date of Death: June 19 2002 Will No. 21-02-588 of 2002 To the Register: Admin. No. 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 Logan T. Hamm 122 E. Willow Street Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6 (a) except N/A Date: July 15, 2002 _ /1!. Susan H. Confair, Esquire Reager & Adler, PC 2331 Market Street Camp Hill, PA 17011 (717) 763-1383 Counsel for Personal Representative Cumberland County INVENTORY Estate of HAMM, CHARLES WAYNE also known as Deceased No. 21 02 0588 Date of Death 6/19/02 Social Security No. 184386008 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 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 made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Attorney: SUSAN H. CONFAIR I.D. No.: 70241 Address: 2331 MARKET STREET CAMP HILL PA 17011 Telephone: 717-763-1383 Stocks & Bonds Description Closely-Held Corporation, Partnership or Sole-Proprietorship Mortgages & Notes Receivable Cash, Bank Deposits, & Misc. Personal Property MEMBERS FIRST FEDERAL CREDIT UNION 1997 GEO METRO (Attach Additional Sheets if necessary) P nal Representativ Dated 4/10/03 Value 0 Total 2,896.72 2,625.00 5,521.72 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. r' RW-4 Cumberland County f ftiV~~ J I ORY Estate of HAMM, CHARLES WAYNE also known as Deceased No. 21 02 0588 Date of Death 6/19/02 Social Security No. 184386008 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 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. iil/Ve understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section ~1~,Od rela(inry 1n uns.~/o~ i f-i sific~fion to ~uthorilics, Name of Attorney: SUSAN H. CONFAIR I.D. No.: 70241 Address: 2331 MARKET STREET CAMP HILL PA 17011 eleohone: 7 i 7-76:'-138 Stocks & Bonds Description Closely-Hclc Corporation, Partnership or Sole-Proprietorship Mortgages & Notes Receivable Cash, Bank Deposits, & Misc. Personal Property f~~EMBERS FIRST FEDERraL CREDIT UNION 1997 GEO METRO (Attach Additional Sheets if necessary) Person I Representative: Dated ~=-~--?~ ~ tl 3 Value Total 2,896.72 2,625.00 5,521.72 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. RW-4 RE'I-150. O:X ~ \!5-OO1 . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 /1-7/- /~ REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) I- Z W C W U w c HAMM, CHARLES WAYNE DATE OF DEATH (MM-DD- Year) DATE OF BIRTH (MM.DD-Year) 06/19/2002 05/10/1948 {IF APPUCABLE} SURVIVING SPOUSE'S NAME (LAS1, F1RS1, AND MIDDLE INITIAL) w >-- :x::$cn u"''' w15g :>:",... U~QJ <: [R] 1. Original Return o 4. Limited Estate 06, Decedent Died Testate (Allacl1copyofWill) o 9. Litigation Proceeds Received o 2, Supplemental Return o 4a. Future Interest Compromise (date of death after 12.12-82) o 7. Decedent Maintained a Living Trust (AttaCl1 copyofTrust) o 10. Spousal Poverty Credit (dateofdeall1between 12-31.91 and 1-1-95) OFFICIAL USE ONLY C/ FILE NUMBER 21-020588 ""'C5'UN1v"'C5'DE~A~--"Nli'MBER-- SOCIAL SECURJ1Y NUMBER 84-38-6008 THIS RETURN MUST BE FilED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Return (date ofdealh pnor to 12-13-B2) o 5. Federal Estate Tax Return Requtred _ 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (AttacI1SchO) .',( COMPLETE MAILING ADDRESS 2331 MARKET STREET >- z w c z o "- '" w '" '" o u NAME SUSAN H. CONFAIR FIRM NAME (If Applicable) REAGER & ADLER, P.C. TELEPHONE NUMBER 717-763-1383 CAMP HILL z o i= :3 ~ l- ii: <C U w 0:: 1. Real Estate (Schedule A) (1) 2. Stocl<s and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule 0) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) o Separate Billing Requested 7.lnterNivos TransfefS & 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/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) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLiCABLE RATES z o i= ~ ~ a. :!E o u ~ I- 15, Amount 01 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 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0.00 X _ (15) X_(16} X .12 (17) X .15 (18) (19) PA 17011 OFFICIAL USE ONLY I I 5,521.72 \ (8) 5,521.72 1,965.39 6,958.71 (11) (12) (13) 8,924.10 -3,402.38 (14) -3,402.38 o 'd t" C I t Add ece en s ampl e e ress: STREET ADDRESS 213 Walnut Street CITY C I' 1 -I STATE PA I ZIP arise 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. Interest/Penalty it applicable D. Interest E. Penalty 4. TotallnteresUPenalty (0 + E) 11 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 If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE, (3) (4) (5) (5A) (5B) to: REGISTER OF WILLS, AGENT 5. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE, Make Check 0.00 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ........................................................................... D 129 b. retain the right to designate who shall use the property transterred or its income; ........................................ D 129 c, retain a reversionary interest; or .........................,.......................................................................,.... 0 ~ d. receive the promise tor life at either payments, benefits or care? ............................................................. D 129 2. If death occurred after December 12, 1982, did decedent transfer property within one year at death without receiving adequate consideration?................. ............... .............. ............................., .... .............. 0 ~ 3 Did decedent own an 'in trust for" or payable upon death bank account or security at his or her death? ................. D 129 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .' .......,.................. ......,.................... ....,........................................... 0 ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, 3/ 2Cb,j /1N/ For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to orfor the use of the surviving spouse is 3% [72 PS 99116 (a) (1.1) (ill. 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. 99116 (a) (1.1) (ii)]. The statute does not exemot 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. 99116(a)(I.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. 99116(1.2) [72 P.S. 99116(a)(1)]. 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. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has alleasl one parent in common with the decedent, whether by blood or adoption. ",v.,W"".'''''( *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEOENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF HAMM CHARLES WAYNE FILE NUMBER 21 02 0588 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 MEMBERS FIRST FEDERAL CREDIT UNION VALUE AT DATE OF DEATH 2,896.72 2. 1997 GEO METRO 2,625.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets at the same size) 5,521.72 """"1'."'971'.. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESlDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF HAMM CHARLES WAYNE FILE NUMBER 21 02 0588 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. EWING BROTHERS FUNERAL HOME 775.00 urn for remains B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) I EIN Number of Personal Representative{s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees REAGER & ADLER, P.C. 850.00 3. Family Exemption: (It decedenfs address is not the same as claimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 91.00 5. .Accounlanfs Fees 6. Tax Return Prepare~s Fees 7. CUMBERLAND LAW JOURNAL - legal advertising 75.00 8. THE SENTINEL - legal advertising 74.39 9. FIDUCIARY BOND - Cineinatti Insurance Company 100.00 TOTAL (Also enter on line 9, Recapitulation) $ 1,965.39 (If more space IS needed, insert additional sheets of the same size) "",,,;,,,;,,,;* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEr DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF HAMM CHARLES WAYNE FILE NUMBER 21 02 0588 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 224.73 1. CARLISLE REGIONAL MEDICAL CENTER 2. CENTRAL PENN MEDICAL GROUP 656.00 3. JOSEPH A. GENSBIGLER. DDS. 2,002.00 4. HOLY SPIRIT HOSPITAL 63.80 5. VISA CREDIT Account No. 4287 5900 0037 4864 2,552.18 6. MEMBERS FIRST FEDERAL CREDIT UNION - CAR LOAN 1,460.00 TOTAL (Also enter online 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 6,958.71 ~ ~- ~J--~O~ COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE v INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 E%AFP (01-037 DATE 05-12-2003 ~~ ~`~` r - `"~ ESTATE OF HAMM CHARLES W ~a " DATE OF DEATH 06-19-2002 FILE NUMBER 21 02-0588 SUSAN H CONFAIR ~O3 f'!AY 15 ~~d :~,CCNNTY lO1BERLAND REAGER 8~ ADLER t'~A Amount Remitted 2331 MARKET ST , CAMP HILL PA 170~~ ,l}tTiL 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 CO1-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HAMM CHARLES W FILE N0. 21 02-0588 ACN 101 DATE 05-12-2003 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) 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) .0 0 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) C3) .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) 5,521.72 tax payment. 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .0 0 8. Total Assets Ig) 5,521.72 APPROVED DEDUCTIONS AND EXEMPTIONS: 1,965.39 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) C10) 6,9 58.71 11. Total Deductions C11) 8.924.10 12. Net Value of Tax Return C12) 3,402.38- 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 3,402.38- NOTE: If an assessment was issued previously, l ines 14, 15 and/or 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 C15) • 00 X 00 = . 00 16. Amount of Line 14 taxable at Lineal/Class A rate I16) .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 nernrrn_ X19)= .00 PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID C-) 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" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 INHERITANCE TAX HARRISBURG, PA I7I2s-obol STATEMENT O F A C C O U N T REV-1607 E% ~FV (01-03) DATE 06-01-2004 ESTATE OF OBRIEN JANET M DATE OF DEATH 07-03-2003 FILE NUMBER 21 03-0588 COUNTY CUMBERLAND HERSHEY TRUST CO ACN 101 100 MANSION RD EAST Amount Remitted PO BOX 445 HERSHEY PA 17033 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 form with your tax payment. CUT ALONG THIS LINE - RETAIN LOWER-PORTION-FOR-YOUR RECORDS ---~- ------ --------------------- ---------------------------------------------- REV-1607 EX AFP (01-03) *** INHERITANCE TAX STATEMENT OF ACCOU *** ESTATE OF OBRIEN JANET M FILE N0. 21 03-0588 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: 05-17-2004 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): 8,341.52 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 10-02-2003 CD003078 417.08 8,000.00 05-17-2004 REFUND .00 75.56- TOTAL TAX CREDIT 8,341.52 SALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. (`IF TOTAL DUE IS LESS THAN S1, /"~ NO PAYMENT IS REQUIRED. C--. L' IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOIU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) ~~~ ~.% PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION. STATUS REPORT UNDER RULE 6.12 Name of Decedent: Charles Wame Hamm Date of Death: June 19, 2002 Will No.: 21-02-0588 Admin. No.: 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 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.l 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 in interest? Yes No X D. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. .~.~'~;', '1 - '~ Date: ~ ~ ~~ " ~ 6 t~ 9 L ,ltf ~3 ~0. `~ -~~~ ~~ ~_,~a~ ,, ~, , Susan H. Confair, Esquire Reager & Adler, P.C. 2331 Market Street Camp Hill, PA 17011 (717) 763-1383 Counsel for Personal Representative