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HomeMy WebLinkAbout02-0671 .'~ PETITION FOR PROBATE and GRANT OF LETTERS No. 2\ -02 -lD1J To: Estate of Mary Ann Barrows also known as Register of Wills for the Deceased. County of Cumberland in the Social Security No. ? 14-09-19 1 S Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who islare 18 years of age or older an the executor in the last will of the above decedent, dated Mav 16 and codicil(s) dated NONE named . 19~ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumberland h fer last family or principal residence at ?S Stephen Rrl Camo Hill. PA 17011 County, Pennsylvania, with r F.~~t ppnn~horn Town~nip, (list street, number and muncipality) Decendent, then 84 years of age, died .June 29 ,~ 2002 at M::Innr r::lrp, SQ,u.thJ:li nil1 pt-nn Tm.mc:hi r Except as follows, decedent djd not marry. was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: NONE Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: 125,000.00 $ $ $ $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters testamentary theron. (testamentary; administration c.t.a.; administration d.h.n.c.t.a.) " .". u c u ~3 U" "'u C -00 c"':::: tIS"= 3d:: U~ 50 " c "" iii [' II ,- (Xc"';" D I L )(tfVL1'L~0' David O. Barrows 25 Steohen Road r.::Imp Hill, FA 17011 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 1 ss COUNTY OF CTlMBF:RLAND 1 The petitioner(s) above-n'UIJed swear(s) or affirm(s) that the statements in the foregoing petition are true and c",{rect to th~ be~t of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. <f' . I (, Sworn to or affirmed and subscribed I~{{,.,-t (). I.:..,C>1/L-r'-<-,-L before me tlds 25th day of 02 '" Qq' '" " :: ~ ~ Register 11-11-10 -'. No. ,21-0.2-L,'1 Estate of Mary Ann Barrows , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW JULY 25, 2002 19_. in consideration of the petition on the reverse side hereof. satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated May 16. 1983 described therein be admitted to probate and filed of record as the last will of Mary Ann Barrows and Letters Te~tamentary are hereby granted to David O. Barrows Probate, Letters, Etc. ., , . . . . .. $ Short Certificates( )..,....... $ ~.ld.I:q.pag.,~ $ jcp $ TOTAL _ $ Filed 7-25-2002 . , . . oo'iiea.' to ' atty' ?:-2'S-':20C)2 . , 235.00 9.00 3.00 5.00 252.00 ~~.Cf'>dJ gister of Wills 1oD.cw.. t.~ Debra K. Wallet (23989) ATIORNEY (Sup. Ct. LD, No,) FEES 24 N. 32nd St.. Camp Hill, PA 17011 ADDRESS (717) 737-1300 PHONE II . , 21-02-671 IN THE NAME OF GOD, AMEN: [I !, Marry Ann Barrows, a citizen and resident of the district of Center, county II of Calhoun, state of West Virginia, being of sound mind and disposing memory, but ever II mindful of the uncertainty of life, do hereby make, publish, and declare the foregoing II to be my last true will and testament, hereby revoking and annulling any and all wills II which may have been heretofore made by me as follows, to-wit: I! FIRST: It is my will that all of my just debts and funeral and burial expenses II be paid as soon after my death as may be practical by my Executor hereinafter named. I' '! SECOND: All the rest, residue, and remainder of the property that I may own i I at the time of my death, including real, personal, and mixed, and regardless of where 'I the same is situate, I hereby will, devise, and bequeath unto my son, David O. Barrows; I however, In the event my said son should predecease me, then I hereby will, devise, and i. grand-"La.~, II bequeath all of my said property to my daughter, Elizabeth Grace Barrows. Ii THIRD: I hereby name, constitute, and appoint my said son, David O. Barrows, , I to be the Executor of this, my last true will and testament, and I direct that no bond i , I or security on bond be required of him as such. I, >I IN TESTIMONY WHEREOF, I do hereunto set my hand at the law office of II Victor Hamilton, in the town of Grantsville, county of Calhoun, state of West Virginia, !I on this / [" -bJday of May, 1983, and I do, at the place and on the day and date last " I i aforesaid, publish and declare the foregoing writing to be my last true will and testamer t. , Ij !I I, Ii " Ii i U) 7 "in""f ./ "" '/,~")?1./\/L '''-lV-~ i/ ,t "_1_' <---L._ ~'- Y.....- (/,: (? MARY ANN BARROWS II Signed, published and declared by the above named Testatrix, Mary Ann II Barrows, to be her last true will and testament, at the law office of Victor Hamilton, I' in the town of Grantsville, county of Ca Ihoun, state of West Virginia, on this L b t/. I day of May, 1983, and the undersigned, at the request of the said Testatrix, in her II presence and in the presence of each other, at the place and on the day and date last II aforesaid, do hereunto sign our II VICTOR HAMILTON I ATTORNEY AT LAW P. O. BOX 236 ;UNTSVlLLE, WEST VIRGINIA I, 'I' 304-354.8727 i I " !I names as subscribing witnesses to said 4-tf' /J? t2i4fl.'fZ< Ir~-{)J~Q~ will. VICTOR HAMILTON ATTORNEY AT LAW P. O. BOX 236 ;RANTSYILLE, WEST VIRGINIA 304-3154-6727 II . , . STATE OF WEST VIRGINIA, COUNTY OF CALHOUN, TO-WIT: ~ m,f/~~ and ife ~AMIl.1 A )~CJ ^ ) each being duly sworn upon their oaths, say that they make and subscribe this affidavit at the request of Mary Ann Barrows, the Testatrix named in the foregoing will bearing I, date on the "ct, day of May, 1983; affiants further say that said will was so made and ,I , i executed by the said Testatrix at the law office of Victor Hamilton, in the town of I :' Grantsville, county of Calhoun, state of West Virginia, on the day and date last aforesai1, :1 and that they, at the request of the said Testatrix, in her presence and in the presence i of each other, at the place and on the day and date last aforesaid, signed their names I i' as subscribing witnesses to said will, and that at the time of the execution of said will I' , by said Testatrix, she was of sound mind and disposing memory and fully capable of making a will. ~ 7?;//ZU'~ ~ ' }/ ~^ '---GJ(~ Taken, subscribed and sworn to before the undersigned, a Notary Public in and for the county of Calhoun, state of West Virginia, on this k~ day of May, 1983. I ! a r ~5/~-z- ~ NOTARY PUBLIC My commission expires: ~ I <-t l \. T 'f / ii ., " 3:r' -l 3: ):>):> 0 ):> " i'iVl i'i " -<-l -< ,. ):>~ z <. ):> " ~ ." ~ Zr' Z S 0 ,. Zr' " " " Z r !!\ " r .; 0 cP):> .. 0 0 cP ~ " " ;ll ):>Z ):> " ;: 'Pel i'i .. (; .. :t ~ ~ -< i'i-l i'i .; .. )> $ .. ~ ~ om - 0 0 ~Vl r' ~ " )< ~ ~ " " Vl-l r' Vl Z '" ):> ;; '" 0 3: " ;Z m '" z :;: -l " 0 '11 - .:..::: ? r.. BEFORE THE REGISTER OF WILLS, CUMBERLAND COUNTY, PENNSYLVANIA CERTIFICATION OF NOTICE UNDER RULE S.6(a) Name of Decedent: Mary Ann Barrows Date of Death: June 29, 2002 Will No. 2002-00671 To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on September 24,2002. Name Address David O. Barrows 25 Stephen Road Camp Hill, PA 17011 Elizabeth Grace Barrows 25 Stephen Road Camp Hill, PA 17011 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Date: September 24, 2002 WUt.- t ~ Debra K. Wallet, Esquire 24 N. 32nd Street Camp Hill, PA 17011 (717) 737-1300 Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARAISBURG,?A 11128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BARROWS DAVID 0 25 STEPHEN ROAD CAMP Hill, PA 17011-1159 nnu__ fold ESTATE INFORMATION: SSN: 234-09-3915 FILE NUMBER: 2102-0671 DECEDENT NAME: BARROWS MARY ANN DATE OF PAYMENT: 09/30/2002 POSTMARK DATE: 09/27/2002 COUNTY: CUMBERLAND DATE OF DEATH: 06/29/2002 NO. CD 001671 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $10,000.00 I I I I I I I I TOTAL AMOUNT PAID: $10,000.00 REMARKS: DAVID 0 BARROWS CHECK# 324 SEAL INITIALS: CW RECEIVED BY: REGISTER OF WILLS MARY C. lEWIS REGISTER OF WillS OJ/-c J2.~ Ce.7/ Do..v ~ ci O. 134. rOJ Uf <; I J2]C..,-/(,"c"cG';"\, ~ tJ;Z;7J'C.tttr (;!>~,k cF ~'Q A-n" &rf?t.<-/s, . d- <) 5+e.~),el1.. P../2 Cq v"v\P H,') I Pir no ( J !<e(j (S -fey crf LJ: Us CC/ HI l::,ey IK..J C"'It'\?J LPvr+ h.tlv.s <2- I LOv ,,-t-4r;>iJse ~U<1 r~ C4J-/,'s(e Pit /7015> i 7(:1 j. :::::"/'-::;:::.::::;:;::::: ".' "'.' ,,'f"I!' f' II., /1,. ,If,!, II, .',/. ", ",/,', ~.I! I..' 1.1 "~I REV. \500 EX + (6-l10) *' I"J- 7')~ /CJ REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT ,/ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) t 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES , 15.Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) ~ z w o w U w o COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT_2B0601 _ _ __ HARR~BURG, PA 171~8-060~__ I _____ ----------- DECEDENTS NAME (LAST. FIRST. AND MIDDLE INITIAL) Barrows, Mary Ann DATE b-j: DEA"TH(MM-DD-YEARj---- i I 21 00671 ~ Original Ret~- D 2. Suppl~-;:;:;ental Re~m D 4. Limited Estate D 4a. Future Interest Compromise (date of death after 12-12-82) ~ 6. Decedent Died Testate (Attach copy D 7. Decedent Maintained a Living Trust (Attach of Will) copy of Trust) D 9. Litigation Proceeds Received D 10. Spousal Poverty Credit (date of death between D 11. Election to tax under Sec. 9113(A) (Attach Sch O) --~ S-~CTION MUST SeeoMPLE~~Oi!RE;:~~~~~~~-~~O COIlFIDEIfl1IAC Ti\i!IIN~ORMATION SHOUI::D BE DlllEC~D TO: --- NAME COMPLETE MAILING ADDRESS Debra K. Wallet ~ ---- ---- --- -- ~iRM NAME (If applicable) ~\\,Offices ofDebra K. Wallet__ _ __ ~~~~'ii1l2;i ~~~g ElEPHONE NUMBER 1 2l7/~37-1300 ___m__ 06/29/2002 I DATE OF BIRTHtMM-DD~YEAR)--- I 12/07/1917 02 COUNTY <;;.QDE YEAR_ NUMBER ----- ----- SOCIAL SECURITY NUMBER 234-09-3915 ,(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST AND MIDDLE INITIAL) w ~ :.:::$(1] u.~ w~U ~OO u.~ ~~ ~ << ,~ "'z Ww .0 .z 00 U. 1_ Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship z o ~ ~ ~ ~ << U W . 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6_ Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) THIS RETURN MUST BE FilED IN DUPLICATE WITH THE I __B_EGISTER OF WILLS SOCIAL SECURITY NUMBER ----os:- o o Remainder Return (dateofdealh prior 10 12-13-82} 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes -'----- 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (line 8 minus Line 11) z o ~ ~ ~ ~ . o u S 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 (1) None (2) 125,157_58 -- (3) None (4) None --- (5) 6,198,80 (6) 157,552_71 ------- (7) None (8) (9) 8,170.43 ------ (10) 10,660,10 U-TiClAL USE ONi.'"r J 288,909,09 19, Tax Due (11) 18,830.53 (12) 270,078,56 (13) (14) 270,078.56 x .00 (15) 270,078_56 x .045 (16) 12,153_54 ------------- x .12 (17) x .15 (18) (19) 12,153_54 20, 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT_ >>BE'SURE TO AlfSWeJlli\LL I:lUEs'TiOllS O~ IIEVERSE''SIOE IINO RECHECK MilT'" << Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev_ 6-00) Decedent's Complete Address: STREET ADDRESS 25 Stephen Road CITY r STATE PA- . --- Camp Hill i ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 12,153.54 10,000.00 526.32 Total Credits (A + 8 + C) (2) 10,526.32 3. InteresVPenalty if applicable D. Interest E. Penalty A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (3) (4) (5) (SA) (58) 0.00 TotallnIeresVPenalty (D + E) 4. If line 2 is greater than line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. 1,627.22 1,627.22 Make Check 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 No a. retain the use or income of the property transferred;...... ................................................ . . ....0 ~ ~: ~:~::~ :h;e~~~;i~~~~s:~~~:es~~~.~~~~~.~.~.~..t~~.:.~~:.~~.~~~~~~~~~~~.~~.~~.~~.~.~.~~~:~::...............:: :: .. :. .. ..~ ~ d. receive the promise for life of either payments, benefits or care?........................................... . 0 ~ 2. 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 for" 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 nonMprobate 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. Under penalties of perjury, I declare that I have examined this retum, including accompanying schedules and statements, and 10 the best of my knowledge and beiief, it is true, correct and complete. Declaration E!"~2~~er othe:~_!h.an the personal ~~prese_ntative is based on _<:ill) _infon:nation of which preparer hasanx ~owledge. _ _ ________ SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE Dart:r~:jJ{!c~,/t~~~1fl'Jaxabll ____ 3-26-!.~'~';; SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE Debra K. Wallet \.Q ""'- ~ . W.....c:- ADDRESS' DATE- Street 17011 3 -:Lr - .1(0) 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 or for the use of the surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)]. 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)J. The statute does not exemoa 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 twentYMone 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) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 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 at least one parent in common with the decedent, whether by blood or adoption. *' L SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I FILE NUMBER _21 -02_~0671 _ ESTATE OF Barrows, Mary Ann All property jointly..owned with right of survivorship must be disclosed on Schedule F. N~~E~ER I --- 1 t Salomon Bros. Investors Fund . #9061472719 DESCRIPTION UNIT VALUE ,VALUE AT DATE OF , DEATH 125,157.58 _1__ 1___ TOTAL (Also enter on line 2, Recapitulation) 125,157.58 '* SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ____..1 I FILE NUMBER u~~_2 - 0067~__ ESTATE OF Barrows, Mary Ann 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 I DESCRIPTION VALUE AT DATE OF DEATH 2,102.10 Blue Cross/Blue Shield refunds 2 HCR Manor Care refund 233.70 3 2002 Federal Income Tax refund 3,863.00 TOTAL (Also enter on Line 5, Recapitulation) 6,198.80 *' SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA ~ INHERITANCE TAX RETURN RESIDENT DECEDENT -- ----.. -- -...-...- -- ESTATE OF FILE NUMBER I 21-02-00671 Barrows, Mary Ann If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A David O. Barrows 25 Stephen Road CampHill,PA 17011 Son JOINTLY OWNED PROPERTY: LETTE~DATE' DESCRIPTION OF PROPERTY % OF DATE OF DEATH- ITEM FOR JOINT MADE Includ~ n~me of fmanClalmstltutlon and bank .account number DATE OF DEATH DECO'S VALUE OF NUMS-E-:- TENANT JOINT~s~mllar Identifying number At~Ch deed for JOintly-held re~l- VALUE OF ASSET INTEREST DECEDENT'S INTEREST estate. --- - - - A , Nov. 2000 Commerce Bank Checkmg Acc!. 10,891.14 50% 5,445.57 #0513140574 2 A approx. Vanguard Investment Acct. 1999 #09936801976 247,127.19 50%' 123,563.60 3 A approx. Vanguard Brokerage Acc!. 1999 #45V347659 57,087.08 50% 28,543.54 j TOTAL (Also enter on line 6, Recapitulation) 157,552.71 *' SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I I I FILE NUMBER 2l.~02-0067~__ ESTATE OF Barrows, Mary Ann Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 2 FUNERAL EXPENSES: Myers Funeral Home I 37 E. Main St., Mechanicsburg, PA 17055 Stump Funeral Home P.O. Box 648, Grantsville, WV 26147 Superior Service Monuments 2,117.00 1,226.82 3 495.01 4 Minnich Florists 63.60 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Social Security Number(s) I EIN Number of Personal Representative(s): Street Address City Year(s) Commission paid Attorney's Fees Debra K. Wallet, Esq. State Zip 2. 2,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent State Zip 4. Probate Fees 287.00 5. Accountant's Fees 6. Tax Return Preparer's Fees Barbush and Hoffman 425.00 7. ! Other Administrative Costs 1 Forensic Pathology Assoc. (cranial autopsy) 1,500.00 2 Photocopies, postage, mileage, notary, etc. 50.00 _J Total of Continuation SChedule{s) 6.00 TOTAL (Also enter on line 9, Recapitulation) 8,170.43 *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Schedule H Funeral Expenses & Administrative Costs continued ESTATE OF Barrows, Mary Ann 3 Vital Records (death certificates) I FILE NUMBER 21 - 02 - 00671 6.00 __L_ Page 2 of Schedule H . SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I_ I FILE -N-UMBER----- 21 - 02 :~0671 ESTATE OF Barrows, Mary Ann Include unreimbursed medical expenses. ITEM NUMBER I DESCRIPTION AMOUNT Neighbor Care Pharmacy 466.78 2 West Shore Health & Rehab 3 Associated Cardiologists 4 Lower Allen EMS 5 Penosylvania Neurology 6 West Shore Family Practice 7 Mobile X-Ray Imaging 8 HCR Manor Care 9 Holy Spirit Hospital 10 PA Department of Revenue (estimated taxes) II US Treasury (estimated taxes) 12 Quantum Imaging 13 McCuen and Associates 14 Heritage Medical Group 15 West Shore EMS 16 Pathology Assoc. of Central P A 1,421.00 1.74 36.87 41.24 9.64 53.54 1,372.69 18.78 833.00 6,000.00 27.81 240.93 88.30 39.22 8.56 TOTAL (Also enter on Line 10, Recapitulation) 10,660.10 REV.1513 EX+ (9-00) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT L_ SCHEDULE J BENEFICIARIES ___l I FILE NUMBER 21 - 02 - 00671 ESTATE OF Barrows, Mary Ann N~ME AND ADDRESS OF PERSON(S) RECEIVING PROPERT~J TAXABLE DISTRIBUTIONS (include outright spousal distributions) NUMBER RELATIONSHIP TO DECEDENT DQ..N.otI 1st Trlll!.tAAtS) AMOUNT OR SHARE OF ESTATE I. David O. Barrows 25 Stephen Road, Camp Hill, PA 17011 Son '100% Enter dollar amounts for distributions shown above on lines 15 through 18, 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-~AXABLE DIST~BUT~O_NS ON L1N~ 13 OF REV-1500 COVER SHE=T1 ... VICTOR HAMILTON AllORN!."t AT LAW P. O. BOX 238 GIl-'''''tSV1\.U.. WEST VIRG1H1Jo. 304-3154-6727 \ Ii I I, Marry Ann Barrows, a citizen and resident of the district of Center, county of Calhoun, state of West Virginia, being of sound mind and disposing memory, but ever mindful of the uncertainty of life, do hereby make, publish, and declare the foregoing to be my last true will and testament, hereby revoking and annulling any and all wills which may have been heretofore made by me as foUows, to-wit: FIRST: It is my will that aU of my just debts and funeral and burial expenses be paid as soon after my death as may be practical by my Executor hereinafter named. SECOND: All the rest, residue, and remainder of the property that I may own at the time of my death, including real, personal, and mixed, and regardless of where the same is situate, I hereby wiU, devise, and bequeath unto my son, David O. Barrows; however, in the event my said son should predecease me, then I hereby wi11, devise, and grand- }\L..~. bequeath aU of my said property to my daughter; Elizabeth Grace Barrows. THIRD: I hereby name, constitute, and appoint my said son, David o. Barrows, to be the Executor of this, my last true wiU and testament, and I direct that no bond or security on bond be required of him as such. IN TESTIMONY WHEREOF, I do hereunto set my hand at the law office of Victor Hamilton, in the town of Grantsvi11e, county of Calhoun, state of West Virginia, on this 1(" -+tday of May, 1983, and I db, at the place and on the day and date last aforesaid, publish and declare the foregoing writing to be my last true wi11 and testame t. ~}//tU''-''L-1 t2u.Pt-- 6Ct/'v'L~ tI MARY ANN BARROWS Signed, published and declared by the above named Testatrix, Mary Ann Barrows, to be her last true wi11 and testament, at the law office of Victor Hamilton, in the town of GrantsviUe, county of Ca Ihoun, state of West Virginia, on this LIP tI. day of May, 1983, and the undersigned, at the request of the said Testatrix, in her presence and in the presence of each other, at the place and on the day and date last aforesaid, do hereunto sign our names as subscribing witnesses to said will. ~d /77 /)~r/#/ 1y~ 'iA)~O~ ... ~. . ! i II I' II :1 !\ i STATE OF WEST VIRGINIA, COUNTY OF. CALHOUN, TO-WIT: II &-d ml?~~ and ~U~,;,t1~1A)OJ'r^) II each being duly sworn upon their oaths, say that they make and subscribe this affidavit \. at the request of Mary Ann Barrows, the Testatrix named in the foregoing will bearing I date on the "ct;; day of May, 1983; affiants further say that said will was so made and ", I executed by the said Testatrix at the law oIfice of Victor Hamilton, in the town of jI Grantsville, county of Calhoun, state of West Virginia, on the day and date last aforesai , III and that they, at the request of the said Testatrix, in her presence and in the presence ,I of each other, at the place and on the day and date last aforesaid, signed their names I' I! as subscribing witnesses to said wilI, and that at the time of the execution of said will ! by said Testatrix, she was of sound mind and disposing memory and fulIy capable of i II making a wilI. 1,1 !I I I I I \ ~ 7?/.6k~ , ~/ Taken, subscribed and sworn to before the undersigned, a Notary Public in and for the county of Calhoun, state of West Virginia, on this /ba?;- day of May, 1983. :1 " I I I Ii il , ~,-~ ~~ NOT ARY PUBLIC My commission expires: (~ I '-+l \. T '1 J '. VICTOR HAMILTON ATlORHEl A.l' LAW P. O. BOX 236 GRAI'ITSVILL!. WEst Vl\l:Q,IMIA 304-384.8727 Register of Wills of Cumberland County, Pennsylvania INVENTORY , Deceased No. 21 - 02 - 00671 Date of Death 6/2912002 Social Security No. 234-09-3915 Estate of Barwws,_Mary i\.nn also known as David O. Barrows - .,__ __ __ ___ ...__ __ - __ ___ __._ ._ ___ __ _n .__ __ ____ __ ___ __ ___ - ~ The Personal Representative(s} of the above Estate, deceased, verify that the items appearing in the foilowing Inventory include ail of the personal assets wherever situate and all of the real estate located In the Commonwealth of Pennsylvania of said Decedenl, that the valuation piaced opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of 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. l!We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities. Attorney: Debra K. Wallet Personal Representative ~ C('{J Signature:_ //['~:,- ----z/' _ _ ' David O. Barrows ) I_){ ~., Ll{'L:l I.D, No.: 23989 Signature: Signature: Address: 24 North 32nd Street Camp Hill, PA 17011 Address: 25 Stephen Road Camp Hill, PA 17011 Telephone: 717/737-1300 Telephone: 717-732-0692 Dated: c3):0BJ-,.''S Personal Property Salomon Bros. Investors Fund #9061472719 125,157.58 Blue CrosslBlue Shield refunds 2,102.10 HCR Manor Care refund 233.70 2002 Federal Income Tax refund 3,863.00 Total Personal Property $131,356.38 (Attach additional sheets if necessary) Total Personal Property and Real Estate $131,356.38 T ~ To: P;-;-;-'" ~ . , ' ',' " ,-,.' \ (1 \ / \ / ..... (, '" ...............-.::..:.-./ F:IRST CLASS III. I I .Law e..Yfico of DEBRA K. WALLET 24 N. 32nd STREIT CAMP HILL, PA 17011 Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 _~~.". U.S Pf.,STA,G( t!I' ~~~J~ Ii '1 ::) , ~ "/,'.{. ~ .,JL. . - ~-~ * *\ :-; HE,[,;:-:I~ 1/r:;~j6d *1 MAIL ( c 0) STATUS REPORT UNDER RULE 6.12 Name of Decedent: Mary Ann Barrows Date of Death: June 29, 2002 Will No. 2002-00671 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 No X 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: July 1, 2003 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 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 d. Copies of receipts, releases, joinders an6 approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. Da te: 3/28/03 ~l!..tJ~ Signa Lure Debra K. Wallet, Esq. Name (Please type or print) 24 N. 32nd St., Camp Hill, PA 17011 Address (717) 737-1300 Tel. No. Capacity: Personal Representative (MAH:rmf/AM3) X Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT WALLET DEBRA K ESQUIRE 24 N 32ND STREET CAMP HILL, PA 17011 -nnn-fold EST A TE INFORMATION: SSNo 234-09-3915 FILE NUMBER: 2102-0671 DECEDENT NAME: BARROWS MARY ANN DATE OF PAYMENT: 03/31/2003 POSTMARK DATE: 03/28/2003 COUNTY: CUMBERLAND DATE OF DEATH: 06/29/2002 NO. CD 002362 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $1,627.22 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: DAVID 0 BARROWS C/O DEBRA K WALLET ESQUIRE CHECK# 114 INITIALS: AC SEAL RECEIVED BY: REGISTER OF WILLS $1,627.22 DONNA M. OTTO DEPUTY REGISTER OF WILLS I / / / COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE , BUREAU OF INOIVIDUAL TAXES \I INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG~ PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF OEDUCTIONS AND ASSESSMENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER :49 COUNTY ACN 06-03-2003 BARROWS 06-29-2002 21 02-0671 CUMBERLAND 101 R€Jc':'c: Hc',.;' DEBRA K WALLET 24 N 32ND ST CAMP HILL '03 JUN-6 Fl11 PA 17U;~i CLirnb~ '*' REV-15UEXAFP (01-031 MARY A Allount Remitted I CHANGEO III (21 (31 (41 (51 (61 (71 .00 125,157.58 .00 .00 6.198.80 157,552.71 .00 (BI 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 ~ RE-Ij=is4i-EiCAf:P--[oFoiY-NOi'"iCE--OF-i-NHEifiTAtjcPfA"x-XppRimiEHENT:--ALi-oWANCE-C.-Ii----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BARROWS MARY A FILE NO. 21 02-0671 ACN 101 DATE 06-03-2003 TAX RETURN WAS: (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 BJ 3. Closely Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule DJ 5. Cash/Bank Deposits/Misc. Personal Property {Schedule EJ 6. Jointly Owned Property (Schedule f) 7. Transfers (Schedule GJ 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. 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 (91 (101 8,170.43 NOTE: To insure proper credit to your account~ submit the upper portion of this form with your tax payment. 288,909.09 18.830 ~3 270,078.56 .00 270,078.56 NOTE: If an assessment was issued previOUSly, lines 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 (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS' .00 X 00 = .00 270,078.56 X 045 = 12,153.54 .00 X 12 = .00 .00 X 15 = .00 (191= 12,153.54 10.660.10 Ill1 (121 1131 1141 . eATN"N' ,+j AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-I 09-27-2002 CDOO1671 526.32 10,000.00 03-28-2003 CD002362 .00 1,627.22 TOTAL TAX CREDIT 12,153.54 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 . IF PAID AFTER DATE INDICATED~ SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $l~ NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)~ YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. I c STATUS REPORT UNDER RULE 6.12 Name of Decedent: Mary Ann Barrows Date of Death: June 29, 2002 Will No. 2002-00671 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.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No 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 X No d. Copies of receipts, releases, joinders an~ approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. Date: 6/16/03 "=' " ~JJiK.. l{. y.~ Signature ~',~" ~ Debra K. Wallet, Esq. Name (Please type or print) 24 N. 32nd St., Camp Hill, PA 17011 Address I~ "" p -,,.>, ~~- ( 717) 737-1300 Tel. No. Capacity: Personal Representative (MAH:rmf/AM3) X Counsel for personal representative IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF MARY ANN BARROWS, DECEASED No. 2002-00671 APPROVAL OF ACCOUNT, WAIVER, RECEIPT, RELEASE, AND AGREEMENT OF INDEMNITY The circumstances leading up to the execution of this instrument are as follows: 1. Mary Ann Barrows died on June 29,2002, leaving a Will dated May 16, 1983, naming David O. Barrows as Executor. 2. Letters Testamentary were granted to David O. Barrows by the Register of Wills of Cumberland County on July 25, 2002. 3. It is the desire of the Barrows heirs that the Estate be distributed without the formality of a court proceeding in order to save the expense, publicity, and delay incident to such court proceeding, and the Executor is willing to make such distribution upon the execution of this instrument. 4. An account of the administration of the Estate of Mary Ann Barrows has been prepared by the Executor. A copy is attached hereto as Exhibit A. 5. In consideration of the foregoing, the undersigned hereby: A. Represents and warrants that he has read and understands this instrument and that the facts set forth above are true and correct to the best of his knowledge, information and belief; -1- B. Declares that he has examined the attached account of the administration of the Estate and the attached schedule of distribution; that he finds them to be true and correct in all particulars; that he accepts and approves them as if they had been duly filed, audited, adjudicated and confirmed absolutely by the Orphans' Court Division of the Court of Common Pleas of Cumberland County, and as if the amounts shown as distributable had been duly awarded to him; C. Waives the filing and auditing of the account of the administration of the Estate in the Orphans' Court Division of the Court of Common Pleas of Cumberland County, and agrees that the Orphans' Court Division of the Court of Common Pleas of Cumberland County may by its decree confirm the account and approve the schedule of distribution; D. Requests the Executor to make distribution of the principal and income in accordance with the schedule of distribution, and effective upon delivery to him of the amounts shown as respectively distributable, acknowledges receipt of such property; E. Agrees to refund to the Executor any amount which may at any time be determined to have been an erroneous distribution to him, regardless of the cause of such erroneous distribution, even if attributable to negligence, and agrees that any period for the limitation of actions for the collection of any erroneous distribution shall commence only at such time as the Executor shall have obtained actual knowledge of such erroneous distribution and that in no event shall the period for collection of any erroneous distribution be less than two years after the actual discovery thereof; F. Absolutely and irrevocably remises, releases, quitclaims and forever discharges David O. Barrows, individually and in his capacity as Executor, from any and all -2- actions, suits, payments, accounts, reckonings, liabilities, claims and demands relating in any way to the administration of the Barrows Estate; G. Agrees to indemnify and hold harmless, to the extent of the funds received by him hereunder, David O. Barrows, individually and in his capacity as Executor, from and against any and all claims, loss, liability or damage (including legal fees and costs in connection therewith) which he may suffer or to which he may be subjected by reason of his administration of the Estate, the settlement of his Executor's account and the distribution of the assets of the Estate without having the formal approval of the Orphans' Court Division of the Court of Common Pleas of Cumberland County, including, but not limited to, any liability for any federal estate tax, Pennsylvania inheritance tax or any other death taxes, together with interest and costs incidental thereto, relating in any way to the Estate; and H. Declares it to be his intention that this instrument, consisting of three pages, shall be governed by the law of Pennsylvania and shall be legally binding as an agreement under seal upon him and upon his heirs, executors, administrators and assigns. Executed on ",.\\ , 2003. DAVID O. BARROWS , /1,,1../">.--) 1 (' Ll '~_;/.- \_(\. (Seal) -3- BEFORE THE REGISTER OF WILLS, CUMBERLAND COUNTY, PENNSYLVANIA No. 2002-00671 FIRST AND FINAL ACCOUNT OF DAVID O. BARROWS, Executor For ESTATE OF MARY ANN BARROWS, Deceased Date of Death: June 29,2002 Date of Executor's Appointment: July 25, 2002 Accounting for the Period: July 25,2002 to June 11, 2003 PURPOSE OF ACCOUNT: David O. Barrows, Executor, offers this Account to acquaint interested parties with the transactions that have occurred during her administration. The Account also indicates the proposed distribution of the Estate. It is important that the Account be carefully examined. Requests for additional information or questions or objections can be discussed with: Debra K. Wallet, Esquire 24 N. 32nd Street Camp Hill, PA 17011 I. D. #23989 (717) 737-1300 Exhibit A Proposed Distribution to Beneficiaries PRINCIPAL Receipts Less Disbursements Debts of Decedent Funeral Expenses Administration Expenses Federal and State Taxes Fees and Commissions Principal Balance on Hand SUMMARY OF ACCOUNT Page Current Value Fiduciary Acquisition Value 5 $100,898.63 2 $131,356.38 3 3 4 4 4 $10,660.10 3,902.43 1,843.00 11,627.22 2,425.00 $30,457.75 $100,898.63 RECEIPTS OF PRINCIPAL Assets Listed in Inventory: (Value as of Date of Death) Stocks: Salomon Bros. Investors Fund Refunds: Blue Cross/Blue Shield Refunds $2,I02.IO HCR Manor Care Refund 233.70 2002 Federal Income Tax Refund 3,863.00 TOTAL ASSETS LISTED IN INVENTORY: 2 $125,157.58 $6,198.80 $131,356.38 DISBURSEMENTS OF PRINCIPAL Debts of Decedent: Neighbor Care Pharmacy West Shore Health & Rehab Associated Cardiologists Lower Allen EMS Pennsylvania Neurology West Shore Family Practice Mobile X-Ray Imaging HCR Manor Care Holy Spirit Hospital PA Dept. of Revenue (estimated taxes) US Treasury (estimated taxes) Quantum Imaging McCuen and Associates Heritage Medical Group West Shore EMS Pathology Assoc. of Central PA Funeral Expenses: Myers Funeral Home 37 E. Main St. Mechanicsburg, PA 17055 Stump Funeral Home P.O. Box 648 Grantsville, WV 26147 Superior Service Monuments Minnich Florists $466.78 1,421.00 1.74 36.87 41.24 9.64 53.54 1,372.69 18.78 833.00 6,000.00 27.81 240.93 88.30 39.22 8.56 $2,117.00 1,226.82 495.01 63.60 3 $10,660.10 $3,902.43 Administration Expenses: Probate Fees Forensic Pathology Assoc. Photocopies, postage, mileage, etc. Vital Records (death certificates) Reserve for Filing of Account Federal and State Taxes: PA Inheritance Tax Fees and Commissions: Debra K. Wallet, Esq. - Atty. Fees Barbush & Hoffman (tax prep) $277.00 1,500.00 50.00 6.00 10.00 $2,000.00 425.00 4 $1,843.00 $11,627.22 $2,425.00 PROPOSED DISTRIBUTION TO BENEFICIARIES TO: David O. Barrows 25 Stephen Road Camp Hill, PA 17011 $100,898.63 TOTAL PROPOSED DISTRIBUTION TO BENEFICIARIES: $100,898.63 5 :'1 ",." 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