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Home My WebLink About02-0611 /' Cj, PA O.C. Rule 5 (b) Form of Certification of Notice. CERTIFICATION OF NOTTCE TlNDRR RULR 5.6(a) Name of Decedent: Barbara Ann Hirn Date of Death: 5/23/2002 Will Number: 2002-00611 Administration Number: To the Register of Wills, Cumberland County: I certify that notice of estate administration required by Rule 5 .6( a) of the Orphan's Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on .Iuly 3. 2002 NAME ADDRESS Haley Him, minor c/o Paul E. Him, Trustee, 27 Longview Drive, Mechanicsburg, P A 17050 Sheldon Blake Anderson, minor c/o Paul E. Him, Trustee, 27 Longview Drive, Mechanicsburg, P A 17050 Notice has now been give to all persons thereto under Rule 5.6(a) except None Signature Date Name (please Print) Harry M. Baturin, Esquire Telephone Number: 717-234-2427 Address City State Zip Code Baturin & Baturin 717 North Second Street Harrisbnrg PA 17102 :-- Capacity: Personal Representative X Counsel for Personal Representative .:::J Register of Wills of CUMBERLAND INVENTORY County, Pennsylvania Estate of Him, Barbara Ann No. ,;{ 1- 6'& - (,1/ I , Deceased Date of Death May 23, 2002 Social Security No. 480802455 also known as 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. l!We verify that the statements made in this inventory are true and correct. J/We understand that false statements herein made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative: Name of Attorney: Baturin. Harry M. I.D. No.: 83006 Paul E. Him, Executor 27 Longview Drive, Mechanicsburg, PA 17055 Address: 717 North Second Street Dated Harrisburg PA 17102 Telephone: 717 234-2427 Description 1991 Toyota automobile (nonoperatable - salvagable for parts only) Value i-', I :~ . . Total (Attach Additional Sheets if necessary) 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 [}/ PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF Of( THE STATUS OF THE ESTATE. IF ESTATE IS NOI COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION STATUS REPORT UNDER RULE 6.12 Name of Decedent: Date of Death: Barbara Ann Hirn 5/23/2002 Estate No.: 2002-00611 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: I. State whether administration of the estate is complete: Yes No X 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: I ;),};31/'~ (date) 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: (Not Applicable in Dauphin County) 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. Date: 0:.f11i/.", ~ jrt. ~ Signature Harry M. Raturinr F:squire Name (Please type or print) 717 North Second Street, Harrishurg, P A 17102 Address 717-234-2427 Telephone No. Capacity: Personal Representative xx Counsel for Personal Representative /?- ?.3-y ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG~ PA 17128-06D1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DF DEDUCTIONS AND ASSESSMENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-14-2003 HIRN 05-23-2002 21 02-0611 CUMBERLAND 101 HARRY M BATURIN ESQ BATURIN & BATURIN 717 N 2ND ST HBG PA 17102 Allount Rellitted *' REV-1547 EX IF' (Ol~as) BARBARA A I CHANGED III 121 131 141 151 161 (7) .00 .00 .00 .00 1.209.85 1.465.62 .00 IBI 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=is4-j-ix-AFi.--rilFoirNOYlci--oF-i:-N'HiRITAN-CE-YAX-A-PPRAIsiifENT-,--AL.LOWANCE-oli----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HIRN BARBARA A FILE NO. 21 02-0611 ACN 101 DATE 04-14-2003 TAX RETURN WAS: I X I ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate {Schedule AJ 2. Stocks and Bonds (Schedule B) 3. Closely Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule OJ S. Cash/Bank Deposits/Hisc. Personal Property (Schedule El 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Ad... Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 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 NOTE: I~ an assessment was issued previously, lines re~lect ~igures that include the total o~ ALL ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of line 14 at Sibling rat. (17) 18. Amount of line 14 taxable at Collat.ral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: 191 nOI 7,363.39 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 2,675.47 9.473 73 6,748.26- .00 6,748.26- 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. .00 .00 .00 .00 .00 ft....., ,+, AMOUNT PAID DATE NUMBER INTEREST/PEN PAID I-I TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 2.060.34 1111 1121 1131 1141 .00 X 00 = .00 X 045= .00 X 12 = .00 X 15 = [191= . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. I IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FDR INSTRUCTIONS. I '1 ,(\., ."(\~ "'\ )",(, This is to certify that the information here given is correctly copied from an original certificate of death dl~ly filed with me as Local ~egistrar. The original certificate will be forwarded to the State Vital Records OHlce for permanent tiling. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~~"~~~, ","\~9" Of Pr.f----_ ""~/ ~1'~~ /~B1 a .9<'" \~\ g:$,:. ~ '. \~~ ~5t (f#,.' I,i;~ ~ \" , ~.. . ,.: ~ ~*'~. ."- -'_'0>""/*;: \* "-".' /~/ \.~ ..//~l "-_~I"'Eir~\ ~~""" '~~~~~#~NNII'IIIIIII t'1AA~~ i/;;J//> Local Re istrar b /J1"7 Fee for this certificate, $2.00 P 8391350 ?!(!-' JS; ,;<OO;l Date H10~ aJH... 2181 COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT Of HEALTH. VITAL RECORDS CERTIFICATE OF DEATH :VPLIP>ll~l '" PlAM...hLNf 8L...CKINK KlNOOl'IIUSlNESSlIN[)USfR... s,"'~ <,,[ """HER u___.__.__~__.____~__~,___~__~" 5EK~1 r:~;;R:"U;8~R -245~ ~BlRTHi'l..AC!:IC,~7.c. PlACEOI'DEIifHICI>ec.""'y.,.,.___,"'""',,"""'...........,,.-) 3la"''''''''e''ll'COOflUYl HOsPITAl ,W.lslip, NY ~~_O ERlOuIpar...... 0 fAC..m.....ME(~""''',..'tul'''''.''''''''"....a<>GIflU<<l(lot' ,=-"",[J NAIoOl::OfO€CEOENTII"......d.... La.., '. Barbara Ann Hirn "GEllasla""",.vl UHOl:R'~EAR VICl(R'Dh:@-O"i{5f-tIIflTH 3 6 v,. -.. O'P HDuo'! .....,;,.. 3 /'2"/66-' . .. COUNTYOfOENH CITY.BOOO, TWPOfOE...Ti1'- . Cumberland OECEDENT'$USUAlOCCllf>liflON I~t:.".~::i,,~':::':t=r custcmer service r k. Silver Spring 27 Longview Drive ...AFUlAl$lMUS_-....:! -.......-. ~..,(SpoICllyl SUIlVIVlNQsPOOSE '0_._......,""""" - IU DECEDENf'SMAIlIHG"'DQIlESS(SI''', Coly/row<l._, LlpCo<>o1 27 r.ongview Drive Mechanicsburg, PA 17050 OECEDENf'S ACTU..... RESIOENCe ~- ""__1 17'.$1... pa ucXJ _,___in Silver Sprinq .. , g o ~ , .. FRHEfI.SN......E(h..,...oO<Q.lasll ". Paul E. Him Jr. w"""1"i1/J'l'~."1ll'l:n Jr_ _. IoIE"IHOOOfOllOPOSlflOH - 0 1IunII..Q es__O __Sl...O ~ oo..~oty' .. $IGNATUflEOfFlINEIlAlSE ~~ . nt..Coo ~ - _... Cumberland --.., "...0 :':"'-:=~OI MOTHER.SN..ME,F...._._sw"...,.) '1. Janis K. Leffhalm INFOAW.NrSMAIUNqAOOAESSIS\<_, C~, SIMa, LlpCodaI ?7 LongvJ.8W Drlve Mechanicsbur PA 17050 PLACEOfOlSPOS/TlON...._oIC........-y,C,.......,.., lOCMlON.C~, s....lil>c..... ._- ,- 21~~estnut Hill Cemetery ~AHD...DOl'lESSOfFACIUTY 22cMal zzi Funeral ll(;ENSE_R .. Upper Allen Twp., PA 8 Mar e P aza ay Hane OIifESlGNE ~.Oay._1 _. IIol€OfOEATH M 21. iT,,,,,",,,.: E"...IM__,itIju'...OI"""'P/1<:.a1__~ca~o.ad'....OIo.111 Do""'""'..lIIa"..,.,.ol""'i"ll,"""~.5C.' l...OAIyONC_....._linoo (1.ew'ccR 24. /d- J-S- '> .J" "".""""orya"Ml, ."""~ "'........1""'. . , ~c.\SEREFERREOTOl.IEOICAl.EXI4oIlNER/COAOHER7 ~O ~ OIifEPRONOlINCEODEAOIMo""'.Dav,Vea'l ~ lj.Il/ a. IAppRl....... :~..= i2'(eJ PART.: OU-~___ingIOOIo"",Du1 ""'......."'llin_"""""""'__..PNlTI Ol.ElOIOFlAS"'CONSEOlIENCEOO I: Ol.ElOlOfI"S..CQNSfOUEtoICEOFj ~- i -,..-. ...u-----.~-_._.-4" l OUElOIOFIA.S..c6NsEOlIENCEOi-\.----~- WERE..UlOPS""INOIf<<)S MAHNEROf OEATH ---...eLEPfllOAlO COMPlETION Of CAUSE __M PI -.- [] N~' -- 0 "''''''''11_''''00'' [J ~O ~ 0 - CJ Could_boo""'.'",,,.." [J OATEOFIN.JUR... l"""""'.Dav,\\oa" lIMEOI'IN.JUFlV IN.JUA"'Af'ftOAK7 DESCRI&Et<<NIlN.JURVClCGUflREO _ 0 NoW .... ~... qRT"hEll<C~"".""y""" .a:RTIfYI~PHVSIC......!I'h""".."c..""""'9.......oI""aon _.....<:01". ""V5oC,.."na.pt"'"""",~~e"'" """.".".,..t~" ".." 2J\ r......._ol...y_no_Il3'...........,........_................I.""m.n...'M...lH " - . PlACE-OflN.iUR....Alhomo,hi,m...'....IOCIOIV."""'. bu"""",,..c<Spec"'l - . '~IIOHOlJWCIHG ANO CERTIFYING ~HV5IC1AH (Ph,",",,~ """ ~'o""""''''''l "".<n .nd ..."Iv"', '" '"y"" 01 .>e,,,,,. To.two _QlmY~""""6g., d..th""c.."..... .......... A'., .ndpIK.. ..........'o_..u..j.I..... m.""e,.. ""ed lOC"'ION(Str_.~,S"'OOI --- ...EOICAL.EX...MINERlCOIlONEIl . On II'HI beI.i. ol..."'in..llon .nd/or in~..Ugalion, In ",y opinion, dUlh O<:c....... a' the Um.. d"., ."d place. and d". ... .h. co"...(_)."" Jl.",."".,.._.a.N.. ,..... .. . ........ ........ ................,.,.... . ............................ REGIlOT '" lICENSE "'BER . OATE StI:j~""::'j};'_1 ~~E .....O~;~::R~ONwtfOCOMPUT~~~~!!lrJ2- ~---~. (11em 27~CANCER CENTER OF CENl1tAL PA.P.C. . FREDERICKSEN 0t11l'T <'ENn:R 202S TmfNOLOGY PARKWAY o ~--~ ll~LULJ u. OATEFI~y,""'r) ". MECJIANICSBUR<l PA 17050 .1111 y' Cf, .-"}9 AC"")O ). , Register of Wills of CUMBERLAND County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Him, Barbara ~ / t'h\~ also known as NO.-2.J .02- tD\\ , Deceased Social Security No. 480802455 Paul E. Him Pelitioner(s), who islare 18 years of age or older, apply)ies) for (COMPLETE "A" OR "B" BELOW:) GJ A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut or Decedent, dated February 9, 2002 and codicil(s) dates N/A named in the Last Wiil of the Slale relevant circumstances. e.g., renunciation, death of executor, ate 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._vic~m of a kjlling and was never adjudicated incapacitated: o B. Grant of Letters of Administration (c,l.a., d.b.n.c.t.a.: pendente lile, durante absentia: durante minoritate) Petitioner(s) after a proper search has/have ascertained the Decedent ieft no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence I (COMPLETE IN ALL CASES:) Attach additional sheets jf necessary. Decedent was domiciled at death in Cumberiand County, Pennsylvania, with his/her last family or principal residence at 27 Longview Drive, Mecbanicsburg, Silver Spring Township, PA 17055 (list street, number and municipality) Decedent, then 36 years of age, died May 23 , 19 2I-, at 27 Longview Dr, Mechanicsburg, Silver Spring Two, PA 17055 (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.............. ........................................................................ ................. $0.00 $0.00 $0.00 $0.00 $0.00 Real Estate situated as follows: N/ A Wherefor, 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 Typed or printed name and residence Paul E. Him 27 Lon view Drive Mechanicsbur PA 17055 RW.1 \\--r~-'( Oath of Personal Representative Commonwealth of Pennsylvania County of CUMBERLAND 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 pre ntative(s) f the Decedent, Petitioner(s) will well and truly administer the estate according to law. N;' Sworn to and affirmed and subscribed day of ~ lJl' -+A 8t41. . J/lUl fL" ~ MARY IS before me this 3rd Estate of Him. Barbara Ann DECREE OF REGISTER Deceased No....2J- 02. - \on also known as Social Security No: 480802455 Date of Death: Mav 23, 2002 AND NOW, ~Y 3, 2002 , 19 _ , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters IZI Testamentary 0 of Administration are hereby granted to Paul E. Him ({c.t.a., d.b.n.c.t.; pendente lite; durante absentia; durante minoriate) in the above estate and that the instrument(s), if any, dated February 2, 2002 ::-; r described in the Petition be admitted to probate and filed of record as the last Will of Deceoenl. FEES Letters .................................... $ Short Certificates(s) ............... Renunciation .......................... Extra Pages ( )............. I.T.R. ..................................... JCP Fee............................... Inventory............................... . Other ...................................... TOTAL .............................$ <.-:! ~ '- c:' r-' 40 00 '......,-' 1 W $ $ $ $ $ $ $ $ 18.00 24.00 5.00 ID.()O 2.00 Attorney: Harry M. Baturin, Esquire I.D. No: 83006 Address: 717 North Second Street Harrisburg PA 17102 97.00 check L.~UU ca~11 Telephone: 717 234-2427 DATE FilED: 7-3-2002 mailed to atty /-J-UL total 99.00 \, PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOI COMPLETED, FILE a 6.12 FORM YRARLY UNTIL COMPLETION STATUS REPORT UNDER RULE 6.12 Name of Decedent: Date of Death: Barbara Ann Hirn 5/23/2002 Estate No.: 2002-00611 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: (date) 3. If the answer to No.1 is yes, state the following: A. Did the personal representative file a final account with the court? Y~ ~ X B. The separate Orphans' Court No. (if any) for the personal representative's account is: (Not Applicable in Dauphin County) 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. Date: ~.~ Signature "" ~':l Harry M. Raturinr Rsquire Name (Please type or print) C- OJ I --' = " 717 North Second Street, Harrishurg, P A 17102 Address 717-234-2427 Telephone No. rr\ P . ~ '",,,.. ~- Capacity: Personal Representative XX Counsel for Personal Representative LAST WILL AND TESTAMENT OF BARBARA HIRN d I - Dd. Ij) II I, BARBARA HIRN, of Mechanicsburg, Cumberland County, Pennsylvania, being of full age and sound and disposing mind, memory and understanding, do hereby make, publish and declare tnis to be my Last Will and Testament, hereby revoking, annulling and making void any and all Wills by me at any time heretofore made. ITEM ONE: I direct that all my legally enforceable debts and funeral expenses be paid as soon after my decease as may be found to be convenient. ITEM TWO: I direct that all estate, inheritance, succession, death or similar taxes (except generation skipping transfer taxes) assessed with respect to my estate herein disposed of or any part thereof, or on any bequest or devise contained in this my Last will (which term when used herein shall include any Codicil hereto), or any insurance upon my life or any property held jointly by me with another or on any transfer made by me during my lifetime or on any other property or interest in property included in my estate for such tax purposes be paid out of my residuary <.Lc.~~ ~' BKRBARA HI RN .-." - 1 estate and shall not be charged to or against any recipient, beneficiary, transferee or owner of any such property or interest in property included in my estate for such tax purposes. ITEM THREE: I give and bequeath all of my personal and household effects of every kind, including but not limited to furniture, appliances, furnishings, pictures, silverware, china, glassware, books, jewelry, wearing apparel, automobiles, and other vehicles, and all policies of fire, burglar, property damage and other insurance on or in connection with the use of this property to my children, SHELDON BLAKE ANDERSON and i-I ql'"'1 ,.,<11- fl'~~ A. HIRN. If any beneficiary hereunder is a minor at the time of distribution, my personal representative may distribute such minor I s share to such minor or for such minor's use to any person with whom such minor is residing or who has the care or custody of such minor without further responsibility and the receipt by the person to whom it is distributed shall serve as the complete discharge of my personal representative. ITEM FOUR: I give, devise and bequeath a.11 the rest, residue and remainder of my property of every kind and description (including lapsed legacies and devises) wherever situate and whenever acquired, whether before or after the execution of this Will, to my children SHELDON BLAKE " \-) ~~ BA RN 2 HQli\~ ANDERSON and HAI A. HIRN in relatively equal shares subject to the restrictions set forth in Item Five of my will. ITEM FIVE: If any share of my estate is to be distributed to a person who has not attained the age of twenty-one (21) years (such person is referred to hereinafter as the "minor"), I direct my personal representative either to (a) distribute such minor's share to the guardian of the minor and such guardian shall hold such share in custody as custodian for the minor under the Uniform Transfer to Minors Act of Pennsylvania or any other state or (b) select a trustee to hold such share in a separate trust for the benefit of the minor, it being my intention by the foregoing provisions to insure maximum flexibility in the administration of any such property, taking into consideration what is in the best interest of such minor, and my personal representative shall not be liable for any decision made in good faith as to whether such property shall be held in custodianship or held in trust for the benefit of any such minor. with respect to any property held in trust pursuant to this section, when any minor under the age of twenty-one (21) attains such age, all remaining income and principal of such trust shall be distributed to such minor and such trust shall terminate. Prior to the termination of such trust, the trustee shall utilize such amounts of trust income and principal as the trustee, in the trustee's absolute and uncontrolled discretion, deem des~~~le\ frQ~ time to time to .-// "'"-- BA RN rovide for 3 the health, education and welfare of such minor directly and without the intraposition of any guardians. If such minor dies before the termination of such trust, the principal and all accumulated income of such trust shall be distributed to such minor's personal representative for administration and distribution as part of his or her estate. For the purposes of this trust, education shall include but not be limited to, private schooling for primary and secondary education, college and post graduate educational and technical or vocational training. Any share so held under the Uniform Transfer to Minors Act shall also be restricted for use in the health, education and welfare of the minor as hereinbefore provided. ITEM SIX: If any beneficiary under my Will, shall die simultaneously wi th me or under such circumstances as to render it difficult or impossible to determine who predeceased the other, then I declare that I shall be deemed to have survived such beneficiary or beneficiaries, taking under my Will, and thus that this Will and all of its provisions shall be construed upon that assumption or basis. ITEM SEVEN: I direct that all legacies and all shares and interests in my estate, whether principal or income, while in the hands of my personal representative, and all principal and income, while being administered by any trustee, shall not be liable to attachment, ~./" ~ t or 4 sequestration for any debts, contracts, obligations, or liabilities of any legatee or beneficiary hereunder, and shall not be subject to pledge, assignment, conveyance, annexation, or anticipation; and the personal receipt by such legatee or beneficiary shall be the sufficient and only discharge of my personal representative or trustee. ITEM EIGHT: I hereby nominate, constitute and appoint as personal representative of my estate, my father, PAUL E. HIRN, and direct that he shall serve without bond in this or any other jurisdiction in which he may be called upon to act. If for any reason PAUL E. HIRN is unable or unwilling to serve as a representative of my estate, then I hereby nominate, constitute and appoint as substitute or successor representative, my sister, LAURA L. MARKIEWICZ, and direct that she shall also serve without bond. ITEM NINE: In the event that my son, SHELDON BLAKE ANDERSON's, father should predecease me or be unable or unwilling to serve as guardian of his person, I hereby nominate, constitute and appoint my parents, PAUL and JANICE HIRN as guardians for my son, SHELDON BLAKE ANDERSON, in this or any other jurisdiction in which he has not reached the age of majority. If for any reason PAUL and JANICE HIRN are unable or unwilling to serve as guardians then I hereby nominate, constitute and appoint LAURA and GREG MARKIEWICZ as substitute or successor guardians. 1~~ &~ -'~ 5 ITEM TEN: In the event that my i~altt/)t'W daughter ~ILEl A. HIRN's, father should predecease me or be unable or unwilling to serve as guardian of her person, I hereby nominate, constitute and appoint, LAURA and GREG MARKIEWICZ as the guardians of my daughter, ~~. HIRN, in this or any other jurisdiction in which she has not reached the age of majority. If for any reason LAURA and GREG MARKIEWICZ are unable or unwilling to serve as guardians then I hereby nominate, constitute and appoint PAUL and JANICE HIRN as substitute or successor guardians. ITEM ELEVEN: Whenever the word personal representative, trustee, or any modifying or substituted pronoun therefore is used in this my Last will and Testament, such words and respective pronouns shall be held and taken to include both the singular and plural, the masculine, feminine and neuter gender thereof, and shall apply equally to the personal representative named herein and to any successor or substitute personal representative acting hereunder, and such successor or substitute personal representative shall possess all the rights, powers and duties, authority and responsibility conferred upon the personal representative originally named herein. ITEM TWELVE: By way of illustration and not of limitation and in addition to any inherent, implied or statutory powers g anted to \,.--,. RN 6 fiduciaries generally, my personal representative is specifically authorized and empowered with respect to any property, real or personal, at any time held hereunder and any provision of this my Last Will and Testament to: allot, allocate between principal and income, assign, borrow, buy, care for, collect, compromise claims, contract with respect to, continue any business of mine, convey, convert, deal with, dispose of, enter into, exchange, hold, improve, incorporate any business of mine, invest, lease, manage, mortgage, grant and exercise options with respect to, take possession of, pledge, receive, release, repair, sell, sue for, to make distributions or divisions in cash or in kind and partly in each without regard to income tax basis of such asset and in general, to exercise all of the powers in management of my estate which any individual could exercise in the management of similar property owned in its own right, upon such terms and conditions as to my personal representative may deem best, and execute and deliver any and all instruments and to do all acts which my personal representative may deem proper and necessary to carry out the purposes of this my Last Will and Testament, without being limited in any way by specific grants of power made and without the necessity of a Court Order. IN WITNESS WHEREOF, I, BARBARA HIRN, the above named, have to this, my Last Will and Testament, typewritten on nine (9) pages, signed my name at the bottom of pages one (1) through seven (7) for the purpose of / \AR~~~ ~, .~-. ../ ---. 7 identification and at the end hereof, on page eight(8), have set my hand and seal this ~ day of '1---eY.:>....."d-- ~~--~_.__. , 2002. ~2~ r Q' BAR HIRN " .,r4r- (Seal) Signed, sealed, published and declared by Barbara Hirn, the above named Testatrix, as and for her Last Will and Testament, in the presence of us, who in her presence and in the presence of each other, have at her request subscribed our names as witnesses hereto. of LLfC' h of ~h 8 COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF YORK We, BARBARA f.mdJQel 8c5i HIRN, ~O\llJn ~ "BeSt and the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare this instrument to be her Last Will and that she has signed willingly (or willingly directed another to sign for her), 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 witnesses and that to the best of their knowledge, the Testatrix was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ,---- - ) ~( ~/ '* \--.-.. lL.." .~ Barb'!E.~)h6: Testatr' --~ ~~~ ~WiM ~ ~itness Sworn and subscribed to before me this q day of Fe1Jruarif 2002. CjfJaJf:&~ My Commission Expires: NOTARIAL SEAl LORRIE A. SHEPPS. Nolary POOIIc Hampton Twp.. Cumberland COunty M Commllllgn I;; Ires J"n. 31 2005 9 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Estate of Barbara Hirn DOCKET NO.: 21-02-611 ORPHANS' COURT DIVISION ORDER AND NOW Oll, ~d'Y of ~ ,2004, "PO' re.i= of the attached petition, Capital Blue Cross is hereby ORDERED to equally divide Decedent's retirement benefit plan between Haley Ann Him and Sheldon Blake Anderson, Jr. Said disbursements are to be made directly to the children's natural parent. No appointment of Guardian is necessary. BY THE COURT . D0 3 ,~} 0" .<J; [' g .s :::t) d, 1':, .b a '. - 0) ~ J. ~ n ~, {', ~/lJ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Estate of Barbara Hirn DOCKET NO.: 21-02-611 ORPHANS' COURT DNISION PETITION FOR DISBURSEMENT OF RETIREMENT BENEFIT PLAN FUNDS I~ a~ . ~ AND NOW, this ~ day of .tin( rJf) , 200i~mes eapitaLj~e (j) 3. '>'-" ('~ Cross, by and through its counsel, REAGER & ADLER, PC, and ~~titions fis COUIti6 , I authorize the release ofthe retirement plan benefits to the minor children ofl)eceden;t, ". ;E:. ,.:;., ~ (j; pursuant to 20 Pa.C.s.A. 95101 as follows: 1. .b: ..... Capital Blue Cross is a Non-profit Hospital Plan Corporation with U ):> a business address at 2500 Elmerton Avenue, Harrisburg, P A 17110. 2. Capital Blue Cross was the employer of Decedent as of her date- of-death on May 23, 2002. 3. During her employment, Decedent accrued retirement plan benefits under retirement plan #001, with a pre-retirement death benefit value of approximately $3,500. 4. Decedent completed the beneficiary designation on this account in equal shares to her children, namely: A. Haley Ann Him, date-of-birth February 5, 1996; and B. Sheldon Blake Anderson, Jr., date-of-birth January 4, 1991. The designation form is attached hereto as Exhibit "A." 5. Both beneficiaries are minor children. /2 . 6. Because both children are minors, Capital Blue Cross is restricted from disbursing these amounts directly to the minors. 7. Counsel for Capital Blue Cross has been in contact with Harry Baturin, Esquire, counsel for the estate and determined that a trust has not been established for the children, nor does the estate intend to create a trust. 8. Therefore, Capital Blue Cross is requesting this Court, under 20 Pa.C.S.A. S5103 to authorize disbursement of approximately $1,750 to the natural parent and custodian of each of the minor children. 9. Haley Ann Him is in the custody of her natural father, Kenneth Adolphus DeLoatch, 106 South White Oak Street, Annville, PA 17003. Said custody was granted by Court Order on June 23, 2003. 10. Sheldon Blake Anderson, Jr. is in the primary custody of his natural father, Sheldon Craig Anderson, 7075 Huntingdon Street, Harrisburg, P A 17111-5237. 11. Pursuant to 20 Pa.C.S.A. S5101, if the value of the estate is less than $25,000, the Court having jurisdiction of Decedent's estate, may authorize disbursement of the estate to the minor or to the parent maintaining the minor, without the appointment of Guardian or entry of security. 12. Without such authority, Capital Blue Cross cannot disburse the balance of this retirement plan to its rightful beneficiaries. WHEREFORE, Petitioner requests this Honorable Court to enter an Order granting its request to pay the custodians of Decedent's minor beneficiaries an equal share of Decedent's retirement plan benefit. Respectfully submitted, DATE:') \~lQt REAGER & ADLER, PC ~D ~ . e r lson antor, EsqUire AttomeyIDNo.: 66378 2331 Market Street Camp Hill, PA 17011 (717) 763-1383 VERIFICATION I, Kieran Hull, verify that the statements made in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: ,;...J,;. S' / () 'I- ~~~.~ Kieran Hull, anager, Employee Benefits '04 ~\:\: :':',2HI"1 CBe E><EC OFFICE::; p.~ '(. ~ Capital BlueCross -r An lndePfndo"t I.JcenHO of l:he 81ue Croaa ~ blUE! Sn1!k1 AasoclAtlon Benefiel' DeSignation Form for the Capital blue Cross Retirement Plan Pre-Retirement Death Benefit (Lao') Hlf" Lj-OO .~O .2-4~ (Please Print) Partlcl';)anr: Soc;al Security Number: Marital Status: --::L. (Fint) D flrR.: f IMI) o Married /Ii( Unmarried .!!.EfQRE COMPLETING THIS FORM. REAnTH~ IMPORTANT INFORMATION ONTHEATl',M;HED COVER lIiEMQ If you are married, complete Section A (and Section C, if electing Option 3). If you are unmarried, complete Sedlon B only. If you wish to namc more beneficiaries than this form provides lines for, .ltach . separate page, and sign and d.te It .150. ation-lIwlarried Partici tion 1 2 OT 3' name beneficiaries' date and s' .-1 Option 1 ; name my spouse, as Primary Beneficiary to receive all death t'le.n~fits. pay~ble by the Plan upon my death. SpO';S~'~ Date of Birth', Spouse's Soe Sec. Number: __'_1- _/_1_ Secondary Bcneficiaries: If I am not man-ied as of my dace of death. my death benefIt, ifan;,-. :ih~J1 be paic to the Secondary Beneficiary(ies) I nave nameQ h.erein, If 1 am married to an :nc:vjdual ocher than the spouse named above as :)f :TIY oate c f death and l have not completed Iii nev,' Beneficiary Designa.tion Form prior to my dcatn. my srouse as of my date of death sha.1l receive the spousal pre-retirement survivor annuity (Spousal Dea.th Benefit) portion of my :otai aealh oenetit. and the Secondary Beneficieryties) naml3d below shall receive the portion of my total death benefit which exceeds the value of the- Spousal Death Benefit. :.. :'\Ierne: Kelationship: ", ~2JJle: Relauonship: :--Jame' RelatIonship' o Option 2 1 name my spouse, as beneficilll)' of the Spousal Death Benefit payablc by the Plan upon my death, r also name the following as the Prjmary Beneficiaiy(ies) to n:ceive any portion of the total death benefit which Is not comprised oflhe Spousa! Death Benefit ("remaining d""th benefif'), Spouse's Date of Birth: Spouse's Sac, Sec, Number: Primary Beneficiaries: a.. Name: Rela.tionship: b, Name; ReladoMhlp; c. Name: Relationship: SecondalY Beneficiaries; If nil of my Primlll)' Beneficiaries. designated l1bove die before 1 die, any remaining death benefit payable upon my death shall be paid to tho following SeeondalY BeneflcialY(ies): a, Name: Relationship: h. Namc: Relationship; c.Name: Relationship: If I am not married as of my dale of death, my dealh benefit, if any. sholl be paid to the Prlmlll)' or SecondalY, as applicable, Bene!icilll)'(ies) I have named herein, If! am m.".ied to an individual other than the spouse named above as of my dale of death and I have no< completed a new Benefielill)' Dt:s{gr.atlon F~!'1'n 'p.!'i~r t~ !T!~' death, my spouse '1S of my date of death shaU recesve the spousal pre~ retirement survivor annuity (Spousal Death Bcnefit) portion of my total death benefit and Ihe Primlll)' or Secondary, as applicable. Beneficilll)'(ies) I have named herein sh~1l receive the- rema.inder of the total death benefir. D Option 3 I elect not to name my spouse as Beneticiary of any part of the death benefit, including ,he Spousal Death Benefit, I deSIgnate the following as my Primary Bcncflciary{ics). I understand that if I elect this option 1 must have my spouse complete the Spousal Consent part (Sectioo C) of this form in which my spouse waives his/her dght to the Spousal DC3.lh Benefit, Prima.ry Beneficiaries: eo, Name: Relationship: b, Name: Relationship: C. Name: Relationship: Secondary Beneflci8J'ies: If ail of my Primary Beneficiaries designated above die before r die, any death benefit payable upon my death sh.l: be paid to the following Secondary Beneticillr)'(ies): a. Name: Relationship; b, Name: Relationship: c. Name: Relationship: If as of my date of death, 1 am married to an individual other ,han the spouse who has provided hislher spousal consent to this beneficiary designation. my spouse as of m~ date of death shall "",eive tho spousal pro- ret~rement survi'\lor annuity (Spousal Death Bcncfit) portion ofmv total death benefit, ano the Primary or Secondary. as applh~Qble. Beneficiary(ies) named he-rein shall rcc~i\l~ the remainder of the total death benefn, I 'Jr.less I have noted otherwise. the death bcnefit will be distributed equally to surviVing Primary Bencficiaries, or ifno Primary BenefiCiaries ,u,..,']Ve me. to surviving Secondary Beneficiaries, If! have indicated a specific percentage of the death benellt be p.id to a Beneficiary who docs not survive me, that portion o[the death benefit will be distributed equally amon~ surviving Bencficiaries. The ~:tt:curjtJn ofthi! Corm lad delivery thertofto th~ Plan AdtDlDllJ~rator revokes.n priO'r deJignatlon. at benel1clAt'Jes tbat I have mlde. I understand chat If I have elected Opdl)a 3 herela lod wish fo change my e1ectiO'l:1l1it .. ~cft!r date I ~ost obt8Jn my spoun', CODscat by buiDg my '1'O'1l"c CODloplek the Sp09Ulllill CODlreIJt parr ($e,rloo q of 8 new BCDeOcl,ry Dellgnaflou Form, unlen tbc cbarlgt. J "Jib to make f. to name my apoulc.., th.e btacftdlu'y of tbe Spousa' Dea1h Benefit. 1 aho ~a.dltnta'Ud that tr 1 have named my spou.e as JOh~ btdeJ1cJary UDdcr Option 1 or bene.Oc:lary orChe SpDusal Death Benefit under Option 2. If I later wish to tbange mr bcaeDdary dec-tJo~,,~1 electibg OJ)dl!~ 3, I must obt.hl my spotllle'l eOQsenL t uodCnt8ou tb.nbe Retirement Plan does-ii~t~DQ8tbute. contract betweea Captbll Blut Cross and tile. DOl' b It to be l!I c:oDsidcrJltton or hldut:emcnt for my ernplo)'men'.- Nothing l:ontaioed in the Piau gjqt me th~ tlllbt to be retained in ,c",'lce or cuar'lItecs my conttnu<<i tmp(otinenr t'C(&l"dlcSl or tbe etrec.t ttrmination of eOJpJoytDeltt WQuld b~ve. Oll me as a partiCipaDt ID tbr: RcUrc:meut'f"I'D. Date: PliIrtidpaul's SI2Qlturei (COllhJluedon 1Ilck) GII: ","_, I) 1.:1{~i~IC''' ~'i: -C:E: ~7 'IJ~ W: 32RI'1 CEC EXEC OFT ICE'::, p. :':', adon ; U..._...arrled Particl ant - Name beDe& ,ies date IlDd si Primary Bene1iclaries: :l, Name: '5 ~Gr"I '7::Ia K<"J .A.rl..~. R~tationship: ~<>..... ~. Name;~ ,. IblaUonl~ ~ ~ :.c.... " NlIII1e: J.e~tin"-~bip~ Secondal'")' :penefilllaries: If all of tny Primary Beneficiarill designated above die before I die, lUl)' d~ath benefit payable upon my dearh shall be paid tc the followjpg: Secondary Beneficiaries: a, Name: ~.c.u\ ~,.n '3"1l.. RelatiorU.hip: -+-A-~ ~-""'" b. Nau:~~~ ~ ~n ReIa .p: ~ c. Name: Relationship: Unlcs< : have noted otherwise, the death benefit will "distrlbuted equa1l)' to swvlvlllf Prim8/)' Beneftoialics, or ifn~ Primary Benefioiaries <lUl'Ii.e me to slU'l'lvillr. Seoontlar)' B<m=fioiaries. In ..e mdiorJacl a spBQlflc ~tI\tIlp of the dealh benefit" paid to a Benetlclary who <doc. not s~ve mo, thai portion of the dealh bene1it will be distrlbuteQ equally amllllll\lnlMlIg Benefi~iaries. - Tbe exe~utloo of this rOflll a!ill lieltvel")' tlIenofCll tile Plan MIIlID15\J'ator revokea all prior IiI&\paUoll' of beDefl.rlOI tllat 1 DIve l:oacie. I ollderltand that If I ahoaJd 11I11'1)' an.r bl"iIlg compJetacl tblI fol'lD II alllllllDllrrlecl partldpallt, thlt III)' spouu Will ",,\omatic8IlY llccome the bellOliQary oUbe Spoll$al Deatll BeueJlt portion oUbe dAtb, benedt end tIIal my detlgJIIllolIllS 10 IOeD!nclJr1" be",lIIll1aU ollly apply a' to the portion ottlle death bellefit wlll~h 's not comprised octbe Spoulal Destll Benellt. I unden;tand that the RetlnmOllt Piau dou Dot QOlIlItltute 8 QOlltract between CapItal Billa CroH Bnd me, nor Ii it to be a conclder- allOD or lnducem....t for III,.. elllplO)'1Dellt. Notlllq COlltalneclln the Plall gllIeS lIle tbe rtlht to be retalneclln IOrvlee or pa1'8llteel 'IDY connnued amplO)'1Dent regardl... ot Ibe "fleet termlaatloll or elllployll\ellt WOlilil bave on me IS a part\dpallt in tbe Rattnm8llt ;PlaD, /\ D'Ite: ~ \ c::, C\~, Partlclplllt'. S;~lal'9: ~,. - I.... ~..- Spousal Conaenl to Plll"tiapant's Bmefit:iary Designation tlnder Opllon ~ of Sedlon A . MUST BE NOOARIZED. t, the ulu;lersigned, [Inlertlllma ofPntkipallt's spouse}, belllg tile iawfulspowe oC [Insert name of hrtlolpant}. do herob)' &0_1 to tho duii/lltioD by my spOIlH ottlle Primlry ud SC6>>lIllary, lfan)'; BeIIe1ldary (..) 08me4ll1ll1er Option 3 oHlle BtocflCiary )~es.gnatlon Form 10 recal". any bellefll becolllllll payable by ruSOD of tbe death of tlle'artldpant.. I allo colIs.nt to lbe pllyml!lll "C death benelits to such Beneficiaries ill all)' Conn provided. bytbe cue Rttlremollt Plan ("Plall"). :; understand that,i! tbl, COlUent ,. ill e!'teet at tha I:IlIIa ot my spouse" dqth, I bavo ..al"" (given up) any rlgbU mlrbt thell bne to nny bellefrt under the Plan payable due to m)' 'poliS'" daatb. I also IIl1dersqlld that, bad I Dot 11l'l11lUd. tbis ~on&ent, I would haye had a right protected by law (subject to the provillon. ot allY appllCllble qUIUfted domotlc relations order ID fa\/or of anOlller Ilarson) t.o the Plan's minlmumSpou181 Death Benefit (payable all bebalf ohuted married plrtl~fpaDts under lbe Plan) pay'bla in i;h" e.cnt oj' the doath of my ,putln It my SPOUIe dies wblle married to me. 'fhli ~on5ent snll walv.r is my free ancl voluntary act. I 11IC8lld tile ~on&Cnt and wllver..t forth herein 10 conlinue to b. .lftctiVe in Ith. ~veut of lilY illcompetOll~. ! bave read my spouse's Detisnllion of Be'llefic:lary alld flllly IIDderatlllld the property subject to tile detlllllltioll illvolves lD)' 'pau.... "..ted accrued bandit ullder the Plall, ill whlcb I JIOUUIa benerlCfal illterert, to. minimum Spousal Death Bene1lt, provided I JUJ"llIVe my,pouu, BtllIl nuJ3isatisfted with the \lrowislolU of tbe deilgnaUOD. I bar.by 80D_t to and aceepllhe b.n.lldary d..lgll8tlon without l'8IIard to wbetller I slInrlve orpreda""..e m)' ,pouse. Tllla COllslat is Irrevocable t1nlellJ my spollse "h."I'"' th~ d...lgp~tl,>n. rr "'l' '1"'"18 .".~:!~~ the d<!lllp.UoIlll, T l1"ri<o~'a\l1! tho' t ~,,!t lite ~ similar r.on$ellt to the IIew deslinaltoQ, or my. 'oll.llent is no lODger effeellve. of SIShlltllre or PartiCipant's Spglls~. !:;Ot:~TY OF l.. . a Not.", Public III aDd for the of , County of . , do banll)' certtt)' t!la, betOre IIUI 01_ , to mil know.. 10 b. the person who.... """'e iJ ."bs<:ribed a~on, alld Cbat _be did III hI1 pru.ence execule the Spollsal Co_t and Waive... bavlllg .clul<>wlodaed t.. In' that _ be did so 8& . tree lIlId \/olulIIII')' a~18IId deed. My C"mmi..ion E~pires~ Slpature of NoC81')' Publie [SEAl.) c;A.~ii)NcWfl9$)~' CERTIFICATE OF SERVICE I hereby certify that on the date set forth below a true and correct copy of the foregoing Petition For Disbursement of Retirement Benefit Plan Funds was served on the following individuals via United States First Class Mail, postage prepaid as follows: Harry Baturin, Esquire Baturio & Baturio 717 North Second Street Harrisburg, P A 17102 Kenneth Adolphus DeLoatch 106 South White Oak Street Annville, PAl 7003 Sheldon Craig Anderson 7075 Huntingdon Street Harrisburg,PA 17111-5237 Dated: J\~\Q~ R'~''''''''.(''",I *' i:QMMONWEAlTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OEPT. 280601 HARRISBURG. PA 17128-0601 DECEDENrS NAME (L.AST, FIRST, At-lOt.4IDDlEIN~) US8ablCWIkbloc:k,\[lsep~ words lI-i3-CZ REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFIClAL USE ONlY '- FlLENUMBER a\ CotlN1Ycoce O~ """ iP'lMB,R I- Z W C W (J W C H i r n Barbara DATE OF DCATH Ann 4 8 0 -8 0 -2 4 5 5 o 5 lz 3 12 0 o 2 DATE OF BIRTH o 3 10 2 11 9 6 6 THIS RETURN MUST BE FILED fN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER (IF APPLICABLE) SURVMNG SPOUSE'S NAME (~, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER N/A .. z w o z o .. '" W 0: 0: o " 00 1.0rtginalRetum 02.SupplementalRetum 0 3. Remainder Retum (dateofdealhpriOfto12-13.a2) o 4. limited Estate 0 4a. Future Interest Compromise (date 01 dealh after 12-12-82) 0 5. Federal Estate Tax Return Required IZ] 6. Decedent Died Testate (AllacheopyofWdI) 0 7. Decedent Maintained a living Trust (Alta::h copy of Trust) Q.. 8. Total Number of Safe Deposit Boxes o 9. Litigation Proceeds Receive<! 0 10. Spousal Poverty Credit I'..of"........' 12.31-91 "" '.1.", 0 11. Election 10 tal< under Sac. 9113(A) f''''"""01 THIS SECTION MUST BlO.eOIl!..I:EtEEJ,Ali.LeORRE$"OJilIilEllleEANI11eoI!lI'IIilE'Ni1'Jll(t'\!~.I!lFORMATI()N:SlfliltlLll. BE DIRECTED TO: NAME COMPLETE MAIUNG ADDRESS H M. Baturin Es uire 717 North Second Street FIRM NAME {If Applicable) BA TURIN & BA TURIN TELEPHONE NUMBER 717 234-2427.' Harrisbur PA 17102 w .. ",:$", ,,0:'" w"" ,,00 ,,0:-' ..Ill .. < 1. Real Estate (Schedule A) (1) OFFICIAL USE ONI. y 0 2. Slocks and Bonds (Schedule B) (2) 0 0 0 3. Closely Held Corporation. Partnership or Sole-Proprietorship (3) 0 0 0 4. Mortgagas & Notes Reallvable (Schedula D) (4) 0 .0 0 5. Cash, Bank Deposi!s & Misceflaneous Persona! Property (5) 2 0 9 . 8 5 Z (Schedule E) 0 6. Join1!y <>One<! Property (Schedule F) (6) 6 5 .6 2 S 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 0 .0 0 :J (Schedule G or L) I- 6. Total Gross Assets (Iotal Unes 1-7) (8) 2 ,,6 7 5 .4 7 ir Cl: 9. Funeral Expensas & Admln~lrative Costs (Sched.ule H) (9) 7 P 6 3 .3 9 (J. , w II:: 10. Debts of Decedent. Mortgage Uabillties. & Uens (Schedule f) (10) 2 .iO 6 0 .3 4 . II. Total Deductions (total Unes9& 10) (11) 9 ,4 2 3 7 3 . 12. Net Value otEstate (Linea minus Unel1) (12) 6 ,7 4 8 2 6 13. Charitabfe and Govemmental Bequests/See 9113 Trusts for which an election 10 tax has not been (13) 0 0 0 made (Schedule J) , 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) . 6 ~7 4 8 .2 6 15. Amount of line 14 taxabra X Z at the spousal tax rate . . .0 (15) . . 0 See Instructions on reverse side for applicable percentaQe i= 16. Amount of line 14 taxable ~~ at 6% rate , X .06 (16) . ....::> 17. Amount of line 14 taxable X .15 (17) 11. at 15% rate . :;; . . 0 0 " 18. Tax Due (18) 0 0 . 19. >>SE-stJRE10:'ANSWEAAtl!/QUESilW/il$,OJiitil2E\!ER$E'Sl'I!)E'A:/ilSREcaEGKMATIl < < Under penalties of pe~ury, I declare that I have examined \his return, including a:companying schedules and s~ts, 3I\d tc \he best of my knowledge and helief, it is lnJe, correct and complete. Declaration of preparer other than the personal representative is based on a111nformatlon of which preparer has any knowledge. SfGNA TURE OF PERSON RESPONSfBLE FOR FILING RETURN ADDRESS DATE SfGNATURE OF PREPARER ADDRESS 717 North Second Street Harrisbur ,PA 17102 DATE 0';;1/ ~I/Q3 Decedent's ComDlete Address: STREET ADDRESS 27 Lonl!View Drive em Mechanicsbur2 I STATE I ZIP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Une 18) 2. Creeits/Payments A. Spousal Poverty Creeit 8. Prior Payments C. Discount (1) 0.00 Total Credits ( A +B +C) (2) 3. InteresUPenalty if applicable D. interest E. Penalty TotallnteresUPenally ( 0 + E) (3) 4. If line 2 Is greater than line 1 + line 3, enter the differenoe. This is the OVERPAYMENT. Check box on Page 1 Une 19 to request a refund (4) 5. If line 1 + line 3 is greater than line 2, enter the differenoe. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the totai of Une S + SA. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WillS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes a. retain the use or Income of the property transferred; ..............................................................0 b. retain the right to designate who shall use the property transferred or its income; ................. 0 c. retain a reversionary intere&t; or ..............................................................................................0 d. receive the promise for life of either payments, benefits or care? ...........................................0 2. If death occurred on or before December 12, 1982. did decedent within two years preceding death transfer property without receiving adequate consideration? If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................................................... 0 3. Did decedent own an "in trust fo~' or payable upon death bank account or security at his or her death? ....................................................................................................................... 0 4. Did decedent own an individual retirement account, annuity, or other non-probate property? .....0 0.00 0.00 0.00 No 00 00 00 00 00 IKl 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN 72 P.S. ~9116 (a) (1.1) (i) provided for the reduction of the tax rate imposed on the net value of transfers to or for the use of the surviving spouse from 6% to 3% for dates of death on or after July 1, 1994 and before January 1, 1995. 72 P.S. ~9116 (a) (1.1) (ii) provided for the reduction of the rate imposed on the net value of transfers to or for the use of the surviving spouse from 3% to 0% for dates of death on or after January 1, 1995. 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 JANUARY 1, 1995 - Please answer the following question by placing an "x" in the appropriate space. Old the decedent create a trust or similar arrangement which is soley for the surviving spouse's benefit for his or her entire lifetime? Yes 0 No lID If you answered yes to the above question, the tax on the trust or similar arrangement is postponed until the death of the second spouse, at which time it will be fully taxable at the rate(s) applicable to the remainder beneficiary(les). Enter the value of the trust on Schedule J, Part II, in order to remove it from the calculation of the tax due in this estate. You may wish to file Schedule 0 in order to make the election available under Section 9113. If the election is made, the trust or similar arrangement is taxed in the estate of the first decedent spouse, the portion of the trust or similar arrangement which benefits the surviving spouse is taxed at the zero tax rate, and the remainder is taxed at the rate(s) applicable to the remainder beneficiary(ies). If you choose to make the election, you must attach Schedule 0 to a timely-filed tax return. along with Schedule(s) K and/or M in order to show the apportionment of the trust or similar arrangement between the surviving spouse and the remainder beneficiary(ies). R"'.'~'''.(WI. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Him Barbara Ann All real property owned solely or as a tenant in common must be reported at fair maRet value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorshio must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. N/A 0.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 ""'500".""'. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN I E NT SCHEDULE B STOCKS & BONDS ESTATE OF Him Barbara Ann All properly joinlly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. FILE NUMBER DESCRIPTION VALUE AT DATE OF DEATH NIA 0.00 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 """150"'."'0",* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN R \ T NT ESTATE OF Him. Barbara Ann Schedule C-1 or C~2 (lncluding all supporting information) must be attached for each cIosely~held corporation/partnership interest of the decedent other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE-PROPRIETORSHIP FILE NUMBER ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH N/A 000 TOTAL (Also enter on line 3. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0,00 "",'0058,""'. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF Him Barbara Ann 1. Name of Corporation Address City 2. Federal Employer 1.0. Number 3. Type of Business FILE NUMBER Zip Code State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year State ProducVService 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting I Non-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 o No If yes, 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 life 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 seli or transfer stock of this company within one year prior to death or within two years if the date of dealh was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Saie Number of Shares Transferee or Purchaser Attach a separate sheet for additional transfers andlor sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. Consideration $ Date DYes o No 10. Was the decedent's stock sold? DYes 0 No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated afterthe decedent's death? 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dales and amounts received. 12. Did the corporation have an interestin 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 s\a1I r tl:il) WIl'H THIS SCHEDULE A. Detailed calculations used in the valualion of the decedent's 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, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies, D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. REV.j506EX~(1.97) '* SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT FILE NUMBER COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF Him Barbara Ann 1. Name of Partnership Address Date Business Commenced Business Reporting Year Slale Zip Code 2. 3. 4. City Federal Employer 1.0. Number Type of Business Decedent was a 0 General 0 Product/Service Limited partner. If decedent was a limited partner, provide initial investment $ 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? If yes, provide amount of indebtedness $ DYes 0 No Was there life insurance payable to the partnership upon the death of the decedent? 0 Yes If yes, Cash Surrender Value $ Net proceeds payable OWner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for addnional transfers and/or sales. o No $ 8. 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. DYes o No 10. Was the decedent's partnership interest sold? If yes, provide a copy of the agreement of sale, etc. 11. Was the partnerShip dissolved or liquidated afterthe decedent's death? 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. DYes o No 12. Was the decedent related to any of the partners? DYes 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 necessary information on a separate sheet. including a Scheduie C-1 or C-2 for each interest THE FOLLOWIJlG fNFO~TlONWIl!f.,e $tlBMmED WfTH THIll SCHEDULE A. Detailed calcuiations used in the valuation of the decedent's partnership Interest. B. Complete copies of financial statements or Federal Partnership Income Tax retums (Form 1065) tor 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 market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX. (1.97) . SCHEDULE D MORTGAGES & NOTES RECEIVABLE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX REl"URN RESIDENT DECEDENT ESTATE OF Him. Barbara Ann All property joinUy-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. FILE NUMBER DESCRIPTION VALUE AT DATE OF DEATH N/A 0.00 TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 ''''.,''''".;,.,,'* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEOENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Him Barbara Ann lndude the proceeds of litlga1ion and 1he date the proceeds were received by the estate. An property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 1991 Toyota (Nonoperatable - salvagable for parts only) VALUE AT DATE OF DEATH 300.00 2. 2002 Pennsylvania State Income Tax Refund 503.94 3. Blue Cross Blue Shield Assn 405.91 TOTAL (Also enteron line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) I 209.85 """"''''.1,.". COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Him Barbara Ann If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. FILE NUMBER SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Paul & Janis Him 27 Longview Drive Mechanicsburg, P A 17055 Parents B c JOINTL Y-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank axoont number or sim~ar identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estale. VALUE OF ASSET INTEREST DECEDENT'S INTEREST I. A. Members 1st Federal Credit Union 4,396.91 33.333 1,465.62 Savings & Checking Account #137250 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL (Also enter on line 6, Recapitulation) $ 1 465.62 (If more space is needed, insert additionai sheets of the same size) ''''''''OEX'I''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC, NON-PROBATE PROPERTY ESTATE OF Him Barbara Ann FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER ATTACH ACOPV OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST PFAPl'LICIIBLEJ 1. N/A 0.00 O. 0.00 0.00 TOTAL (Also enter on line 7, Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) """"CHI''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Him Barbara Ann Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A FUNERAL EXPENSES: L Malpezzi Funeral Home 6,562.20 B. ADMINiSTRATIVE COSTS: 1- Personal Representative's Commissions Name of Personal Representative (s) Paul E. Him Social Security Numberts) I EIN Number of Personal Repre,entative(s) StreetA<l<lress 27 Longview Drive City Mechanicsburg State PA Zip 17055 Yea~s) Commission Paid: 2. Altomey Fee, BA TURIN & BA TURIN 480.00 3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Paul E. Him Street Address 27 Longview Drive City Mechaniscburg State PA Zip 17055 Relationship of Claimant to Decedent Father 4. Probate Fee, Cumberland County Register of Wills Office 79.00 5. Accountanf, Fee, N/ A 0.00 6. Tax Return Prepare~s Fees N/A 000 7. Cumberland County Register of Wills - Short Certificates 18.00 8. Cumberland County Register of Wills - Copies 12.50 9. Cumberland Law Journal - Legal Advertisement 75.00 10. Patriot News - Legal Advertisment 114.19 1L P A Auto License Brokers - Duplicate Title for Car 22.50 TOTAL (Aiso enter on line 9, Recapitulation) $ 7 363.39 .. (If more space IS needed, losert additional sheets of the same Size) ''''''''''','',9''. COMMONWEALTH OF PENNSYLVANIA INHERJTANCETAXRETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF Him. Barbara Ann Include unreimbursed medical expenses. ITEM NUMBER FILE NUMBER DESCRIPTION AMOUNT 1. Penn Credit Corporation - East Pennsboro School District 2000-2001 Occupational & Residential Taxes (Account #TOI01429700) 378.99 2. Penn Credit Corporation - East Pennsboro School District 1999 - 2000 Occupational & Residential Taxes (Account #T0001478099) 371.80 3. Penn Credit Corporation - East Pennsboro School District 1998 - 1999 Occupational & Residential Taxes (Account #263823003) 350.35 4. Penn Credit Corporation - East Pennsboro School District 1997 - 1998 School District Taxes (Account #263823002) 350.35 5. Penn Credit Corporation - East Pennsboro School District 1996 - 1997 Occupational & Residential Taxes (Account #T970296) 307.45 6. Jane E. Biddle, Tax Collector for East Pennsboro School District 2001-2002 Personal Taxes (Bill Number 4372) 301.40 TOTAL (Also enteron line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 2 060.34 ""'."''''''''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER ....,m , Ann RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1. TAXABLE DISTRIBUTIONS (Include outright spousal distributions) 1. Sheldon Blake Anderson Minor Son 112 27 Longview Drive Mechanicsburg. P A 17055 2. Haley Ann Him Minor Daughter 1/2 27 Longview Drive Mechanicsburg. P A 17055 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. N/A 0.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS I. N/A 0.00 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) '''''''''''''.,'. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TI>:X RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on Rev-1500 Cover Sheet FILE NUMBER Him. Barbara Ann This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax retum. o Will 0 Intervivos Deed of Trust 0 Other I.rF!S$tAreJNt'e~Sl'.'~AI.~lill.llffltlN NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANTfS\ DATE OF BIRTH DATE OF DEATH PAYABLE N/A OUleor OTerm 01 Years - OUleor OTerm 01 Years - OUleor o Term 01 Years - OUleor o Term 01 Years - 1. Value of fund from which life estate is payable $ 0.00 2. Actuarial factor per appropriate table Interest table rate - o 3 1/2% 06% 010% o Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) ~ 0.00 ". Al\lN\;/lTYllIt~e~f.e~I.CI lt~l'f'IQN NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANTIS\ DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE N/A OUfeor OTermofYears - OUfeor OTerm 01 Years - OUfeor OTerm 01 Years - OUfeor OTerm 01 Years - 1. Value of fund from which annuity is payable $ 0.00 2. Check appropriate block below and enter conresponding (number) Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12) o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( ) 3. Amount of payout per period $ 0.00 4. Aggregate annual payment, Line 2 multiplied by Line 3 0.00 5. Annuity Factor (see instructions) Interest table rate 0 3 1/2% 06% 010% 0 Variable Rate % 6. Adjustment Factor (see instructions) 7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is : Line 4 x Line 5 x Line 6 $ 0.00 If using variable rate and period payout is at beginning of period, calculation is : (Line 4 x Line 5 x Line 6) + Line 3 $ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax retum. The resutting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16 and 17. (If more space is needed, insert additional sheets 01 the same size) REV-1644 EX + (3-84) '* INHERITANCE TAX SCHEDULE 'L" COMMONWEALTH OF PENNSYlVANIA REMAINDER PREPAYMENT OR INVASION INHERITANCE TAX RETURN RESIDENT DECEDENT OF TRUST PRINCIPAL FILE NUMBER I. Estate of "'Irn Ann (Last Name) {Fint 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 provisio of Section 714 of the Inheritance ond Estate Tax Act of 1961 or to report the invasion of trust principal. II. Remainder Prepayment: A. Election to prepay filed with the Register of Wills on (attach copy of election) (Dote) 8. Nome(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of eledion or annuity is payable NIA C. Assets: Complete Schedule L-l 1. Real Estate $ 0.00 2. Stocks and Bonds $ 0.00 3. Closely Held Stock/Portnership $ 0.00 4. Mortgages and Notes $ 0.00 5. Cash/Misc. Personal Property $ 0.00 6. Total from Schedule L-l $ 0.00 D. Credils: Complete Schedule L-2 1. Unpaid Liabilities $ 0.00 2. Unpaid Bequests $ 0.00 3. Value of Unincludable Assets $ 0.00 4. Total from Schedule L-2 $ 0.00 E. Total value of trust assets (Line C-6 minus Line 0-4) $ 0.00 F. Remainderfactor (see Table I or Table II in Instruction Booklet) 0.00 G. Taxable Remainder value (Line E x Line F) $ 0.00 (Also enter on Line 7, Recanitulationl 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 NIA C. Corpus consumed $ 0.00 D. Remainder factor (see Table I or Tobie II in Instruction booklet) $ 0.00 E. Taxable value of corpus consumed (Line C x Line D) $ 0.00 (Also enter on Line 7, Recapitulation) ns REV- 1645 EX + (3-84) INHERITANCE TAX SCHEDULE L-l COMMONWEALTH Of PENNSYlVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN RESIDENT DECEDENT -ASSETS- FILE NUMBER I. Estate of Him Ann (Last Name) (First Name} {Middle Initial} II. Item No. Description Value A. Real Estate (please describe) 1. N/A 0.00 Tatal value of real eslate $ 0.00 (include on Section II, Line C-l on Schedule L) B. Slacks and Bonds (please lisl) 1. N/A 0.00 Tolal value of slacks and bonds $ 0.00 (include on Section II, Line C-2 on Schedule Ll C. Closely Held Slack/Partnership (attach Schedule C-l and/or C.2) (please lisl) 1. N/A 0.00 Tolal value of Closely Held/Partnership $ 0.00 (include on Section II, Line C.3 on Schedule L) D. Mortgages and Notes (please Iisl) 1. N/A 0.00 Total value of Mortgages and Noles $ 0.00 {include on Section II, Line C-4 on Schedule Ll E. Cash and Miscellaneous Personal Property (please lisl) 1. N/A 0.00 Tolal value of Cash/Misc. Pers. Property $ 0.00 {include on Section II Line C-5 on Schedule II III. TOTAL (Also enler on Section II, Line C-6 on Schedule L) $ 0.00 (If more space is needed, attach addilional 8'/' x 11 sheets.) RfV-l~ EX + {3-84} INHERITANCE TAX '* SCHEDULE l-2 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT elECTION INHERlT"NCE TAA RETURN -CREDITS- FILE NUMBER RESIDENT DECEDENT I. Estate of ....;.n Ann (Last Name) (First Name) (Middle Initiol) II. Item No. Descriotion Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule l-l (please list) 1. N/A 0.00 Total unpaid liabilities $ 0.00 iinclude on Section II, Line 0-1 on Schedule L\ B. Unpaid Bequests payable from assets reported on Schedule l-l (please list) 1. NfA 0.00 Total unpaid bequests $ 0.00 {include on Section II, Line 0-2 on Schedule II C. Value of assets reported on Schedule L-l (other than unpaid bequests listed under "B' above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: 1. NfA 0.00 Total unincludable assets $ 0.00 I;nclude on Section II, Line 0-3 on Schedule II III. TOTAL (Also enter on Section II, Line 0-4 on Schedule L) $ 0.00 (If more space is needed, allach additional 8% x 11 sheets.) "v,'~m.","'. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE ESTATE OF Check Box 4a on Rev-1500 Cover Sheet FILE NUMBER Him Barbara Ann This schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for aU 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 return. 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 decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal righl. 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 Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) $ 3. Value of Line 1 passing to Douse at appc:rate tax rate Check One 6%,03%, 0% (also inciude as part of total shown on Line 15 of Cover Sheet) $ 4. Value of Line 1 Taxable at 6% Rate (also include as part of total shown on Line 16 of Cover Sheet) $ 5. Value of Line 1 Taxable at 15% Rate (also include as part of total shown on Line 17 of Cover Sheet) $ 6. Total value of Future Interest (sum of Lines 2 thru 5 must equal Line 1) $ (If more spaoe is needed, insert additional sheets of the same size) REV-1648 EX (1-92) .. SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX OMSION ESTATE OF (AVAIlABLE FOR DECEDENTS DYING AFTER 12/31/91) FILE NUMBER 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 ................................................ l. 1 765.62 ............."................................. 2. 0.00 ............."................................. 3. 0.00 ................................................ 4. 0.00 ............................."......"......... 5. 0.00 60. 0.00 6b. 6c. 6d. ................................................. 6. 0.00 7. 1 765.62 ................................................ 8. 0.00 ......................................... ....... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. 1,765.62 ; e ere it. If of ntinu to P PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies 01 Federal Individual Income Tax Returns for decedent and spouse) Income; l. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse .... . . . . . . . . . . . . . . . . . . . . 10. 0.00 20. 0.00 30. 0.00 b. Decedent . .... ............... 1 b. 0.00 2b. 0.00 3b. 0.00 c. Joint ........ ......... .......... Ie. 0.00 2c. 0.00 3c. 0.00 d. Tax Exempt Income ........ ld. 0.00 2d. 0.00 3d. 0.00 e. Other Income not listed above ............. Ie. 0.00 2e. 0.00 3e. 0.00 I. Talal............................. lI. 0.00 21. 0.00 3i. 0.00 1. Taxable Assets total from line 8 (cover sheet) ............................ 2. Insurance Proceeds on Life of Decedent ................................... 3. Retirement Benefits ......................."........................................ 4. Joint Assets with Spouse ......................................................... 5. PA lottery Winnings ............................................................... 60. Other Nontaxable Assets: List (Attach schedule if necessary) .. N/A 6. SU8TOTAL (Unes 60, b, c, d) ................................................. 7. Tolal Grass Assets (Add Hnes 1 thru 6) ..................................... 8. Tala I Actual Uabil;t;es ............................................................ 9. Net Value 01 Estate (Subtract I;ne 8 Iram I;ne 7) ........................ If line 9 is greater than $200.000 - STOP. The estate is not eligible to da m th d n I eo e art II. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (In 0.00 + (2n 0.00 + {3n 0.00 = 0.00 (+ 3) 4b. Average Joint Exemption Income ............................................................................................ = II I;ne 4(b) ;s greater than $40,000 - STOP. The estate is not eligible to c1a;m the cred;l. If not, continue 10 Part III. 0.00 PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT ESTATES l. 0.00 2. 0.00 3. 0.00 4. 0.00 s. 0.00 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ................................ 2. Multiply by credit percentage (see instructions) ......................................................."................. 3. This is the amount of the Resident Sp.ousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. ................................................... 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ........................................................................................................... 5. Multiply line 3 by line 4 and enter the total here, This is the amount of the Nonresident Spousal Poverty Credit. In dude this figure in the calculation of total credits on line 18 of the cover sheet. -REV_'''''''''''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX ReTURN RESIDENT DECEDENT SCHEDULE 0 ELECTION UNDER SEC. 9113(A) SPOUSAL DISTRIBUTIONS ESTATE OF FILE NUMBER Him Barbara Ann Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This eiectlon applies to the Trust (marital, residual A, e, ev-pass, Unified Credit, etc.) if 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 0, then the transfero~s personal representative may specifically identify the trust (all or a fractional portion or percentage) \0 be inciuded in the eiection 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 only 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 arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's survivin souse under a Section 9113 A trust or similar arran ement. DESCRIPTION VALUE NIA 0.00 Part A Total $ 0.00 PART 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 NIA 0.00 Part B Total I~ more space Is needed, insert additional sheets of the same size) 0.00