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Home My WebLink About02-0845 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of a/so known as Dean S. Mixell No. To: Deceased. Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania Social Security No. 174-20-6458 The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, apply for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decedent was domiciled at death in Cumberland County, Pennsylvania, with h is last family or principal residence at 301 Walnut Dale Road. Shippensburg. Southampton (list street, number, Twp. or Boro.) Township Decedent, then 73 years of age, died June 9 at Shippensburg Health Care Center. Shippensburg. PA ~ 2002 , 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 situated as follows: 301 Walnut Dale Road, Shippensburg. Southampton Township. Cumberland County 8.300 $ $ $ $ 50.000 Petitioner~ after a proper search ha ve ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name Relationship Residence Gary L. Mixell Son Shippensburg. PA Daniel C. Mixell Son Shiooensburg. PA Diane L. Bauserman Daughter Shipoensburg. PA Gav R. Weaver Daughter Hanover. PA THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. -- '" 8 c " ~- .- '" (I';::' Cll:'" c -g.g ..s': -;;~ ~.... 30 ~ C tlO Vi -i:JSc~~r ~e1 C. ~~ ~ d, 4IA.~..u .n1 /'- 'Diane L. Bauserman 302 Walnut Dale Road, Shippensburg. PA 1725 319 Walnut Dale Road. Shippensburg. PA 1725 8610 Peiper Road, Shippensburg, PA 17257 ........ ~ / OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND } 58 '02 1p .J ;) 50 The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate aCCO.'ding to law. ~ J~ Sworn to or affirmed. and subscribed J ~ . before me this 18th day of ~ / SEPTEMBER Mk~:;1.-t -<' ~i /LijAn.~ l(a.o-J -'?J O"./-> (,Qf> l' ~ /f1<..-J Register ~ ('" ul; - ... '! ::I i en No. 21-02-845 Estate of Dean S. Mixell , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW SEPTEMBER 19 JPJ 2002, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me. IT IS DECREED that Gary L. Mixell. Daniel C. Mixell. and Diane L. Bauserman, ft/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to Gary L. Mixell. Daniel C. Mi xp-ll. ;mt'l _Diane~Bause~..______ in the estate of Dean S. Mixell FEES Letters of Administration ..... $ 115.00 Short Certificates( ).......... $ 9 . 00 Renunciation ................ $ ').00 JCP $ 5.00 TOTAL _ $ 134.00 Filed... ~.-:~~:-.2.QQf....... A.D. 19_ 1101624 )/:;2..". ../~ u.,U ~. p RECElVEO SEP 1 B 2002 RENUNCIATION 21-02-845 In Re Estate of Dean S. Mixell deceased. To the Register of Wills of Cumberland County, Pennsylvania. The undersigned Gay R. Weaver, daughter of the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters of Administration be issued to Gary L. Mixell, Daniel C. Mixell, and Diane L. Bauserman WITNESS my hand this day of ,~:>>X 2002 ~ ~~"~cwW Gay R. Weaver 542~ South Franklin Street Hanover, PA 17331 (Address) (Signature) (Address) (Signature) -::- (Address) '~, '--- HI05.805 REV 9/86 '0;.,"", . . This is to certify that the information here given is correctly copied from an original certificate of ieath duly' filed with Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. me as WARNING: It is illegal to duplicate this copy by photostator photogta~... 8259435 No. Fee for this certificate, $2.00 ., p /u~1 ~~ 21-02-845 . 21fj7 COMMONWEALTH OF PENNSYLVANIA . DI!~~NT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH . . NAME OF DECEOEHTjf",. MicIc:lIe. L_ ,. Dean S Mixell AOE(l_~ UNOEA,YUR -- Doyo SEX I. Male STJl'I'U~ SOCIAL SECURITY ,."UMBER .. 174 - .. 73 COUNTY OF DEArH v... =-"0 Cumberland DECEOENt'S USUAL 0CCtJMl0H ~-=:~C::-:::zI,~ _swus._ SUAIIMNO"""".. ~........ 'MIIDwtld. (If.... QMtmaoen ~ -- ,..Widowed , '70.e9 .....--..._.. Southampton it :..,.. 301 Walnut Dale Road ,.. Shippensburg, PA 17257 FRHEn NAME IF. MidcIe. a.a.) , Frank D. Mixell _s_rr_ Gary L. Mixell 'MElHOO OF II 0 _10 ~O _ 0Iw_ 11 OF .~ ,,... Cumberland 'H.o :-...-:-.::::.. MOTHE"'S NAMI! 1F'.... MiddlI. ~SulNrMI ,.. Hazel M. Holtry . . _"""""T'S_AllIlAE88_00,<-. _.2!p~ 302 Walnut Dal~ Road, Shippensburg, PA 17257 ..~~ l ._.ZIo~ .0Iw~ Cumberland Valley Cumberland County, .... M m W. pennsboro Tw . - .....J4.28""*bt~'" ~...~..... 02.- ____CAf.*(F..... -..- ..... ,"deIIh)___ .. I==- : onMI...".... I I I: .....conIttluttng 10 dIMh. bYI 1IOt.....1fI1M~c:a-.....'" ~ f ',.- -..- If.. .................. ~.e...~ c..-co-.cw.."."., ... .-...s~ '--'~"'ILMT { .. c. d. ~^.; . ...... AN AU10PSY WERE AU10PSY FtNDINGS MANNER OF DEATH PERFORMED? -'-"""""'10 """"""'" OF CAUSE - KI DEArH? - 0 ....0 ...~ ....0 ...0 - 0 DATE OF INJURY C~.Oay.......) TIME OF IHJUAV IN.ftAW'RWDAK? DESCRI8E HCWIfUJRYOCCUAAED. - -- CouId...tJe~ o o o Pl.ACE OfF INJURV . AI t'IcMM, NrIft, ...... fw:toIy. ofIoI ... -....- .... .... 0 ...0 ~ 0'1.' - - CEJI'IWtEJt fCNdl only 0Nt 6CERTFf11<<1PHYSICIAN~~QuMddMlh.......MIOlMf ~...,....pronounc:ecIdMIf\-,o t~rtWfl231 .,............,Il..............................UUM(............................,.,.. .,."........... ... SKI AND -JIIRiONOUNCIMQ AHO ClRTwY1NGPflYSlCL\lllI~ bolt! Pl'oroout'lCIng OMth.-lCl~ IDeade' of dN1rl1 _.....or...,~, ....occurNld................ ....pIece. ...........uueec..........nMf............. -MEDICAL IXAMINIRICORONE" On 1M..... of ..amlMtlon and/or tnvntIgatIoft,ln my opfnion, de. ocCUirMd.. 1M....... dlt., .....,... ..... due to the ClVM(e) and ................ed..................... ........ ........... ..........,......... ............ _....................... 31.. REGlSTRAR'S seGNA1'URE AND NUMBER J.{(~/~ ... u. INRE: ESTATE OF DEAN S. MIXELL, late of the Borough of Shippensburg, Cumberland County, Pennsylvania, deceased : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY : PENNSYLVANIA : ORPHANS' COURT DIVISION : ESTATE NUMBER 21-02-0845 CERTIFICATION OF NOTICE UNDER RULE ~~~(a) Name of Decedent: Dean S. Mixell Date of Death: June 9, 2002 i'\,. Will No. 21-02-0845 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: Gary L. Mixell 302 Walnut Dale Road Shippensburg, P A 17257 Diane L. Bauserman 8610 Peiper Road Shippensburg, P A 17257 Daniel C. Mixell 319 Walnut Dale Road Shippensburg, P A 17257 Gay R. Weaver 542 ~ South Franklin Street Hanover,PA 17331 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except NONE. September 24, 2002 Name: Address: Weigle & Associates, P.C. 126 East King Street Shippensburg, P A 17257 Telephone: (717) 532-7388 Capacity: Personal Representative X Counsel for Personal Representative WEIGLE & ASSOCIATES, RC. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 WELTMAN, WEINBERG & REIS Co., l.P.A. ATTORNEYS AT LAW 323 W. Lakeside Avenue, Suite 200 Cleveland, Ohio 44113-1099 216.685.1000 www.weltman.com COLUMBUS 614.228.7272 CINCINNATI 513.723.2200 PITTSBURGH 412.434,7955 DETROIT 248.362.6100 November 11, 2002 CERTIFIED MAIL Gary L. Mixell, Fiduciary 319 Walnut Dale Road Shippensburg, PA 17257 Re: Estate of Dean Mixell Case No. 21-02-845 Our Client: First USA Bank, N.A. Account No. 4408039996383525 Balance Due: $1,924.92 Our File No. 02744816 Dear Mr. Mixell: This law fIrm represents First USA Bank, N.A. with respect to the claim which we wish to fIle in the estate of Dean MixelI. It is our understanding that you are the Co-Fiduciary of the estate. We are asking that you please accept our client's claim which is based upon its account number 4408039996383525 in the amount of$1,924.92. Please direct all correspondence and disbursements with respect to this estate directly to our offIce. It would also be appreciated if you contact us to advise us when you anticipate making disbursements in this matter so that we may mark our fIle for follow-up at that time. Thanking you in advance f6r your cooperation in this matter. This law fIrm is attempting to collect this debt for our client and any information obtained will be used for that purpose. Lastly, do not hesitate to contact us to further discuss this matter. velAlY urs, . ruat{ D uan . Wilson Legal Assistant (216) 685-1030 t~ ht DEJ:daw cc: Gary L. Mixell, Fiduciary- regular mail Daniel C. Mixell, Co-Fiduciary Jerry A. Weigle, Esquire WWR#02744816 FORM 93-0.C. DIVISION IN THE COURT OF COMMON PLEAS of CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION INRE: ESTATE OF No.2 1-02-845 of Dean Mixell Deceased Goods and services purchased on Visa card First USA Bank. N.A. Account No. 4408039996383525 CLAIM To the Clerk of Orphans' Court Division: Index and make proper entry in your offIcial records of the claim of First USA Bank N.A. c/o Weltman. Weinberg & Reis Co.. L.P.A.. 323 West Lakeside Avenue. Suite #200. Cleveland. Ohio 44113-1099 ( Claimant) in the amount of$I.924.92 against the estate of the above named decedent. This claim is fIled under Section 3532 (b) (2) of the Probate, Estates and Fiduciaries Code. The said decedent, who resided at 301 Walnut Dale Road. Shippensburg. PA 17257, died on (Address) ,20_. Written notice of this claim was given to Daniel C. Mixell and Gary 1. Mixell. Co-Fiduciaries. 319 Walnut Dale Road. Shippensburg. PA 17257 and Jerry A. Weigle. Esquire. 126 East King Street. Shippensburg. PA (Personal representative, if any, or counsel) N{).J8117 J.uy I} ,2002. 17257 on A~L (Claimant) DeJuan 1. Wilson, Agent for the Claimant c/o Weltman, Weinberg, & Reis Co., L.P.A. 323 W. Lakeside Ave., Suite200 Cleveland. Ohio 44113 (Claimant's Address) WELTMAN, WEINBERG & REIS Co., LP.A. ATTORNEYS AT LAW 323 W. Lakeside Avenue, Suite 200 Cleveland, Ohio 44113-1099 216.685.1000 www.weItman.com COLUMBUS 614.228.7272 CINCINNATI 513. 723.2200 PITTSBURGH 412.434.7955 DETROIT 248.362.6100 November 11,2002 Register Of Wills One Courthouse Square Carlisle, PA 17013 Re: Estate of Dean Mixell Case No. 21-02-845 Our Client: First USA Bank, N.A. Account No. 4408039996383525 Balance Due: $1,924.92 Our File No. 02744816 Dear Clerk of Courts: This law firm represents First USA Bank, N.A. in connection with its claim which we wish to file on our client's behalf into the estate of Dean Mixell, deceased. Enclosed is our check in the amount of $5.00 which we understand is the filing fee for this claim. Our client's claim is based upon its account number 4408039996383525 in the amount of $1,924.92. Included with this letter is the claim form which we wish to present to this court and which we are forwarding to the attorney and/or fiduciary of this estate. It would be appreciated if all correspondence and disbursements with respect to this matter be forwarded to our office and to the attention of the undersigned. Additionally, it would be appreciated if any notices of any hearings also be forwarded to the undersigned. Thank you for your cooperation in this matter. veryJf}Y~S' . \ j(Y...(/11111 j J / I-- DeJuan . ~~t;;\ Legal Assistant (216) 685-1030 DEJ:daw Enclosures cc: Daniel C. Mixell, Co-Fiduciary Gary L. Mixell, Co-Fiduciary Jerry A. Weigle, Esquire WELTMAN, WEINBERG & REIS . Co., LP.A. ATTORNEYS AT LAW 323 W. Lakeside Avenue, Suite 200 Cleveland, Ohio 44113-1099 216.685.1000 www.weltman.com COLUMBUS 614.228.7272 CINCINNATI 513.723.2200 PITTSBURGH 412.434.7955 DETROIT 248.362.6100 November 11,2002 Register Of Wills One Courthouse Square Carlisle, P A 17013 Re: Estate of Dean Mixell Case No. 21-02-845 Our Client: First USA Bank, N.A. Account No. 4408039996383525 Balance Due: $1,924.92 Our File No. 02744816 Dear Clerk of Courts: This law fIrm represents First USA Bank, N.A. in connection with its claim which we wish to fIle on our client's behalf into the estate of Dean Mixell, deceased. Enclosed is our check in the amount of$5.00 which we understand is the fIling fee for this claim. Our client's claim is based upon its account number 4408039996383525 in the amount of $1,924.92. Included with this letter is the claim form which we wish to present to this court and which we are forwarding to the attorney and/or fIduciary of this estate. It would be appreciated if all correspondence and disbursements with respect to this matter be forwarded to our office and to the attention of the undersigned. Additionally, it would be appreciated if any notices of any hearings also be forwarded to the undersigned. Thank you for your cooperation in this matter. \Tery~~s, , D.Ilfj!! i ~ t- Legal Assistant (216) 685-1030 .. . DEJ:daw Enclosures cc: Daniel C. Mixell, Co-Fiduciary Gary L. Mixell, Co-Fiduciary Jerry A. Weigle, Esquire WELTMAN, WEINBERG & REIS Co., LP.A. ATIORNEYS AT LAW 323 W. Lakeside Avenue, Suite 200 Cleveland, Ohio 44113-1099 216.685.1000 www.weltman.com COLUMBUS 614.228.7272 CINCINNATI 513.723.2200 PITTSBURGH 412.434.7955 DETROIT 248.362.6100 November 11, 2002 CERTIFIED MAIL Daniel C. Mixell, Fiduciary 319 Walnut Dale Road Shippensburg,PA 17257 Re: Estate of Dean Mixell Case No. 21-02-845 Our Client: First USA Bank, N.A. Account No. 4408039996383525 Balance Due: $1,924.92 Our File No. 02744816 Dear Mr. Mixel1: This law ftnn represents First USA Bank, N.A. with respect to the claim which we wish to ftle in the estate of Dean Mixell. It is our understanding that you are the Co-Fiduciary of the estate. We are asking that you please accept our client's claim which is based upon its account number 4408039996383525 in the amount of$I,924.92. Please direct all correspondence and disbursements with respect to this estate directly to our office. It would also be appreciated if you contact us to advise us when you anticipate making disbursements in this matter so that we may mark our flie for follow-up at that time. Thanking you in advance for your cooperation in this matter. This law ftrm is attempting to collect this debt for our client and any information obtained will be used for that purpose. Lastly, do not hesitate to contact us to further discuss this matter. \Tery rtJ~urs, DelLt~n Legal A sistant (216) 685-1030 1-t.: DEJ:daw cc: Daniel C. Mixell, Fiduciary- regular mail Gary L. Mixell, Co-Fiduciary Jerry A. Weigle, Esquire COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 2B060 1 HARRISBURG, PA 1712B-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT WEIGLE JERRY A ESQUIRE 126 EAST KING STREET SHIPPENSBURG, PA 17257 ---.---- fold ESTATE INFORMATION: SSN: 174-20-6458 FILE NUMBER: 2102-0845 DECEDENT NAME: MIXELL DEAN S DATE OF PAYMENT: 03/10/2003 POSTMARK DATE: 03/07/2003 COUNTY: CUMBERLAND DATE OF DEATH: 06/09/2002 NO. CD 002267 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $1,810.91 I I I I I I I I TOTAL AMOUNT PAID: $1,810.91 REMARKS: JERRY A WEIGLE ESQUIRE CHECK# 240 SEAL INITIALS: AC RECEIVED BY: REGISTER OF WILLS DONNA M. OTTO DEPUTY REGISTER OF WILLS REV-1500 EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 21 2002 0845 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Mixell, Dean S. 174-20-6458 DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 06/09/01 08/30/1928 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 3. Remainder Return CHECK ~ ' 0",.. ~"m ~" '"~_".'_m 8 (date of death prior to 12-13-82) APPRO- 4. Limited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required ~ate of death aHer 12-12-82) PRIATE 6. Decedent Died Testate 7. ecedent MaintalOed a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach copy of Will} (Attachac;opyotTrust) BLOCKS 9. Litigation Proceeds Received 10. Spousal Poverty Credit{date of death between 011. Elect\onto tax under Sec. 9113(A) 12-31-91 and 1-1-95) (Attach Soh 0) ....................."?.........'... ..........................',.,...y., .. ....,......................,n,.....,.,........ q.... ........."','"'".. ..........,.....,............' .'...,............. ... ,,,,,,,,,,,.,,... ..:0:;: "-.' ...:.......':.... .'.'.'. .+,' NAME COMPLETE MAILING ADDRESS COR- Jerrv A. Weiole, Esauire 126 East King Street RE- FIRM NAME (If Applicable) Shippensburg , PA 17257 SPON DENT Weiqle & Associates, P.C. TELEPHONE NUMBER (717) 532-7388 44,500.00 OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) None 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) None 4. Mortgages & Notes Receivable (Schedule D) (4) None 5. Cash, Bank Deposits & MIscellaneous Personal Property (Schedule E) (5) 16,352.83 8. Jointly Owned Property (Schedule F) 0 Separate Billing Requested (6) None RECA- PITULA- 7. Inter-Vivos Transfers & Miscellaneous TION Non-Probate Property (Schedule G or L) (7) 0.00 8. Total Gross Assets (total Lines 1-7) (8) 60,852.83 9. Funera1 Expenses & Administrative Costs (Schedule H)(9) 10,253.75 10. Debts of Decedent, Mortgage !-iabilities, & Liens (Schedule I) (10) 10,356.66 11. Total Deductions (total Lines 9 & 10) (11) 20,610.41 12. Net Value of Estate'(Line 8 minus Line 11) (12) 40,242.42 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax (13) None has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Une 13) (14) 40,242.42 SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Une 14 taxable at the spousal tax rate, or transfers under Sec. 9116(aX1,2) X.O (15) - TAX 16. Amountof Une 14 taxable at lineal rate 40,242.42 X .0 45 (16) 1,810.91 - COMPU- 17. Amount of Line 14taxableatsibling rate 0.00 x.12 (17) 0.00 TATION 18. Amountof Line 14 taxable at coHateral rate 0.00 X ,15 (18) 0.00 19. Tax Due (19) 1,810.91 20. 0 1;l:it\~Qka~R~JI9iQljiMl;jjl(l;j(jiji'1,\ITj!l<<~jj~Nlt\';W#Iil;Q~l'IliA_ijJd I?- R9- b ~ lllllllllWTlONMU$T Il! COM~litm!llllWC COllR!SPONll!liSl!l Ii COHFlllMIAliTAX INIlllI'lMATlON S/fOUU) l'll'lllll'lllllTllllitQ '}";,!!,!,!<"!"i;,<(,4!:f!f'W'iig!~ii:j'Q:iAN$~!Ao;:q!1J;;;$TI9l'!ltP~'RA$iill!Al'!Pll!lIlBl$KMAtB*g, ,."".'""".."............ o PA15001 NTF 29755 Copyright 2000 Greatland/Nelco LP- Forms Software Ol1ly Estate of: Dean S. Mixell SUVlMARY OF ALLOCATIONS 10 BENEFICIARIES Taxable at lineal rate Gary L. Mixell Daniel C. Mixell Diane L. Bauserman Gay R. Weaver 10,060.61 10,060.61 10,060.60 10,060.60 40,242.42 21-2002-0845 PA REV-1500 EX (6-00) Page 2. Decedent's Complete Address: STREET ADDRESS 301 Walnut Dale Road CITY ! STATE I ZIP Sm ,,~ PA 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2., Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 1,810.91 0.00 Total Credits (A + B + C) (2) 0.00 3, Interest/Penalty if applicable D. Interest E. Penalty (3) 0.00 (4) (5) 1,810.91 (5A) 0.00 (5B) 1,810.91 Total Interest/Penalty (D + E) 4. If Une 2. is greater than Line 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 LIne 20 to request a refund 5. If Une 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WillS, AGENT t:~{it{t}t!r!i:i~IW)~{)ii;){:::::::::;i:::;::';':"'" ...........................'..,.......................,..,..,..'.......:..... ................................ ;.......,..:..:".'. ~J~~~~~~~:~:~::~::~:r:~~~Y::,i:;::, :,":':: "":::::::::,:::::,::::::::,:,:::,:",,,:;:::,::~::::,:::,::~:':~:~t):,:::::::::::::";:"':' ..........':.,.:':.,.:.:.:.:.:.~':;,:.:.:...... ..............,...'...'....,';'..;-.'.;,;-,.;.;':.,:,:;;i:::::;;:;:.;.:.... Did decedent make a transfer and: a. retain the use or income of the property transferred; ...".....,.,... . . , , . . . . , , . . . . . , . . b. retain the right to designate who shall use the property transferred or its income; ........... c, retail1 a reversionary interest; or. . .-, . , . . . . . , . . . . . . . . . . .. . . . . . . . . . . . . . . , . . . . . . . , . . . . . . . .. d. receive the promise for Ufe of either payments, bene1its or care? ...,.....,..........,..... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . , .. .. . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . .. . . 3. Did decedent own an "in trust 10r" or payable upon death bank account or security at his or her death? 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . , . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. 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 return, Including accompanying schedules and statements, and to the best of my knowledge and benef, it is true, correct and complete. Declaration of preparer other than the personal representative is based on in10rmation of which preparer has anv knowledQe, L, S~NATURE OF P SON R SPON~ipf.E FOR F1LlN5' RETU~Y.', _ '.~' >' DATE ~Qa-u...v..~ ~ /~ / ~"4' "3/ 0.3 ADDRESS Schedule attached ATURE F PC{f'~ER OH Yes No ~ I ~ @ [!S , PA 17257 00 "" [72 P.S.li 9116(a)(1.1)(i)]. For dates of death on or after January 1, 1995, the tax ra.te is imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. Jj 9116 (al (1.1)(ii)]. The statute rilles nnt P-lCP-mllt 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 sUfviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: Tha tax rata imposed on tha net value of transfars from a daceased child twenty-one years of age or younger at death to or for the use of a natural pan,,"i., an adoptIve parent. ora stepparent of the child is 0% [72 P.S.li9116(a}(1.2)J, The tax rate Imposed on the net value oftransfers to or for the use of the decedent's lineal benefic;iaries is 4.5%, except as noted in 72.P.S.li 9116(1.2) [72 P.S.li 911fi(a}(1l1. The taJl;rate impcsed on the net \Ialue tlf transfers to or fOf the use of the dec;edent'$ siblings is 12% 172 P.S. li 9116(a}(1.3)]. A sibling is defined. under Section 9102. as an individual who hasat leilstone parent in common with the decedent, whether by biood oradoption. o PA15002 NTF 29756 Copyright 2000 GreatlandlNelco LP ~ FormS Software Only Estate of: Dean S. Mixell 21-2002-0845 The following person (s) are signing the retUlll as representative (s) of the estate: Gary L. Mixell 302 Walnut Dale Road Shippensburg, PA 17257 Daniel C. Mixell 319 Walnut Dale Road Shippensburg, PA 17257 Diane L. Bauserman 8610 Peiper Road Shippensburg, PA 17257 REV-~502 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dean S. Mixell SCHEDULE A REAL ESTATE FILE NUMBER 21-2002-0845 All real property owned solely or as a tenant In common must be reported at faIr market 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 01 survivorshIp must be disclosed on Schedule F. ITEM NO. DESCRIPTION VALUE AT DATE OF DEATH 1 Real Estate located at 301 Walnut Dale Road, Shippensburg, PA - sold 12/23/02 44,500.00 TOTAL (Also enter on line 1, Recaoitulat\on) $ (If more space is needed, insert additional sheets of the same size) 44,500.00 7 CPA21 NTF 10904 Copyright Forms Software Only, 1997 Nelco, Inc. REV-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAA RETURN RESIDENT DECEDENT ESTATE OF Dean S. Mixell SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-2002-0845 Include proceeds of litigation & date proceeds were received by the estate. All prOD. lolntlv-owned with right of survlvorshlD must be disclosed on Sch. F. ITEM NO. DESCRIPTION VALUE AT DATE OF DEATH 1 Cash on hand at date of death 2,000.00 2 Orrstown Bank Checking Account #625094 201.48 3 Orrstown Bank Savings AcCOilllt #34992 1,699.61 Interest on above item accIUed as of decedent's death 2.44 4 Orrstown Bank Irrevocable Burial Certificate of DefOsit #5030058169 3,743.30 Interest on above item accIUed as of decedent's death 4.36 5 Receivable from Gay R. Weaver for payments and payoff on her installment loan 3,482.72 6 Pr=eeds of public sale of personal property 11/09/02 4,479.60 7 Adams Electric Cooperative - patronage refund received 12/26/02 8 Proration of County taxes at real estate settlement 12/23/02 9 Proration of School taxes at real estate settlement 12/23/02 604.97 1.66 132.69 TOTAL (Also enter on line 5, Recaoitulatjon) $ (If more space is needed, insert additional sheets of the sarna size) 16,352.83 7 CPA81 NTF 1090l'. Copyright Forms Software Only, 1997 Neice, Inc. REV-1511EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dean S. Mixell SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-2002-0845 Debts of decedent must be recorted on Schedule I. ITEM NO. DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Fogelsanger-Bricker Funeral Home 5,672.80 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 0.00 Name of Personal Representative(s) Social Security Number(s}/EIN No. of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees Name: Weigle & Associates, P.C. 3,792.64 3. Family Exemption: (If decedent's address Is not the same as claimant's, attach explanation) 0.00 Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 146.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 See Schedule attached Total frc:rn continuation page(s) 642.31 TOTAL fAlso enter on line 9, Recapitulation) $ 10,253.75 7 CPA.11 Nir 10S11 Copyright Forms Software Only, 1997 Nelco, Ino. (If more space is needed, insert additional sheets of the same size) Estate of: Dean S. Mixell SCHEDULE H, PART B -- Administrative Costs Item No. Description 7 CUmberland Law Journal - advertising Letters Testamentary 8 News Chronicle - advertising Letters Testamentary 9 Shippensburg Post Office - certified letter to Department of Public Welfare 10 South Central Hare Settlements - copy of deed 11 earl Bert & Associates - 12/03/02 statement regarding deed research 12 Sailhamer Real Estate - market analysis dated 09/20/01 13 Register of Wills, Cumberland County - filing PA Inheritance Tax Return 14 Register of wills, CUmberland County - filing Family Settlement Agreement 15 Weigle & Associates, P.C. - reimbursement for postage, xerox capies, and long distance telephone calls 16 Linda K. Klein - notary fee TOTAL. (Cany forward to main schedule) . . . . . . Page 2 21-2002-0845 Arrount 75.00 109.64 4.42 1.50 210.00 100.00 15.00 85.00 28.75 13.00 642.31 REV-1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF I:ean S. Mixell Include unreimbursed medical eXpenses. ITEM NO. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-2002-0845 DESCRIPTION AMOUNT 1,506.95 432.70 1,543.07 54.82 1,018.10 10.12 97.22 61. 00 7.00 49.81 107.35 190.00 14.45 25.50 119.49 20.70 25.00 1,487.33 77.31 25.00 3,483.74 $ 10,356.66 L 1 Gary". Mixell - reimbursement for payments on loan obligation for Gay R. Weaver (January to June 2002) 2 O=stown Bank - payment on loan obligation for Gay R. Weaver 3 O=stown Bank - payoff of loan obligation for Gay R. Weaver 4 O=stown Bank Checking Account #625094 - checks clearing after date of death 5 Fogelsanger-Bricker Funeral Home - unpaid balance of Daisy Mixell (spouse of deceased) funeral 6 Chambersburg Hospital - 09/13/02 staterrent 7 Sprint - 06/24/02 statement 8 Huckleberry Land Water Association - 08/01/02 statement 9 Shippensburg Health Care Center - 06/21/02 statement 10 Adams Electric Oooperative - 09/19/02 statement 11 Chambersburg ALS - West Shere EMS - 06/07/02 and 06/08/02 ambulance calls 12 Huckleberry Land Water Association - 09/01/02 statement 13 Nationwide Insurance - auto insurance premium 14 Huckleberry Land Water Association - 10/01/02 statement 15 Sprint - final billing 10/04/02 16 Adams Electric Oooperative - 09/25/02 statement 17 Huckleberry Land Water Association - 11/03/02 statement 18 shippensburg Health Care Center - final statement 19 Consolidated Collection Services, Inc. - 3 oustanding balances owed to Chambersburg Hospital 20 Huckleberry Land Water Association - 12/01/02 statement Total from continuation rlrlcre (s) 7 CPA12 NTF 10912 TOTAL (Also enter on line 10, Recapitulation) (If more space is needed, insert additional sheets of the same sIze) Copyright Forms Software Only, 1997 Nelco, Inc. Estate of: Dean S. Mixell SCHEDULE I -- Debts of Decedent, l'brtgage Liabilities and Liens Item No. Description 21 Timmons Oil, Inc. - 12/16/02 delivery 22 Consolidated Collection Services, Inc. - outstanding balance owed to Charnbersburg Hospital 23 Adams Electric Cooperative - 12/19/02 statement 24 Gary L. Mixell - reimbursement for payment of Adams Electric Cooperative service fee 10/28/02 25 Gay R. Weaver - reimbursement for payment of 09/14/02 Adams Electric Cooperative statement 26 Pharmacare - 11.30/02 statement 27 Yogindra S. Balhara, MD - 11/27/02 statement 28 First USA Bank - credit card balance 29 Hucklebery Land Water Association - 01/02/03 statement 30 Adams Electric Cooperative - 12/31/02 statement 31 Real Estate settlement expense - 1% realty transfer tax 32 Real Estate settlement expense - 2002 sch=l taxes TOTAL. (Carry fo:rward to main schedule) . . . . . . Page 2 21-2002-0845 Amount 102.00 51. 40 109.98 12.00 115.01 35.68 44.20 1,924.92 25.00 25.18 445.00 593.37 3,483.74 REV-1513 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES Dean S. Mixell . No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 Gary L. Mixell 302 Walnut Dale Road Shippensburg, PA 17257 2 Daniel C. Mixell 319 Walnut Dale Road Shippensburg, PA 17257 3 Diane L. Bauserman 8610 peiper Road Shippensburg, PA 17257 4 Gay R. Weaver 542 1/2 Scuth Franklin Street Hanover, PA 17331 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustaa(s) Son Scn Daughter Daughter 21-2002-0845 AMOUNT OR SHARE OF ESTATE 10,060.61 10,060.61 10,060.60 10,060.60 ENTER DOLLAR AMTS. FOR DISTRIBS. 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 None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS None 7 CPA13 NTF 10913 TOTAL OF PART II -- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 Copyright Forms Software Only, 1997 Nelco, Inc. (If more space is needed, insert additional sheets of the same size) A, Settlement Statement L an 2. OFmHA 3. DConv. Voins. '6. File Number 5 0 0 10 02GONTZ This form 'IS furnished 10 give you a statement of actual settlement costs. Amounts paid 10 and by the settlement agent ara shown. Items marked "(p,o.c.)" were paid outside the closing; they are shown here for information purposes end are not inclUded in the totals. WA~N!NG: II j~ a crime to knowi~gly r:nake false slstema,nts 10!h~ United Slalas on thls?f tinY other simila~ form. Penalties upon OM N.202-2 8. Mortgage Insurance Case Number Note: D. NAME OF BORROWER: OOR SS' E. NAME OF SELLER: OD'S '. r. NAME OF LENDER: ADDR'SS: G. PROPERTY ADDRESS: Clifford G. Gontz and Connie D. Gontz 334 Strohm Road Shi en bur P A 17257 Estate of Dean S. Mixell 301 Walnut Dale Road, Shippensburg, PA 17257 H. SETTLEMENT AGENT: South Central Home Settlements, Inc., Telephone: 717-532-7387 Fax: 717-532-6552 LA" "IT ME T 126 E st Kin S eet Shi ensbur PA 1 257 TTLE T DAT 12/23/2002 J. SUMMARY OF BORROWER' TRANSACTION: R M EFOMB WE 4 K. SUMMARY OF ELLER'S TRANSACTION: A NTDE LE' 44 500.00 44 500.00 809.50 1. 66 Ad' 12 I r i dva 2002 1.66 dv n 12 132.69 12 200 132.69 o 12 200 R 45 443.85 420. F BORR WER 500. 4 450.00 ER T ELL 44 634.35 4 450.00 445.00 SETT EMENT TATEMENT PAr.~? iLE"ENT r.HAR"~S PAID FROM PAID FROM 'TAL SALES/BRI1KER'S COMMISS.I1N bORerl nn nri'"' 44 500.00 @ 0.000 - BORROWER'S SELLER'S Oivi.inn . .". .......... FUNDS AT FUNDS AT . In SETTLEMENT SETTLEMENT n? . ." 7n3 . n,irl,t: 800. IT~M" PAYABL~ IN r.ONN~r.TION WITH L"AN Rnl. ,. ". Rn? I n,n . " on, .. . ., ... RnA RM I .nd.(, .. RnA MnrloRO. . Rn? ,... RnB. Rno Rln RI' 900. ITEMS REI1"IR~D RY LE",nER TO RE PAin IN AD"H""E on1 'nl.M,1 .mm .. ~, 1_." on? ~ .. gn' ' In. .. 004. on' 1000. R~SERV~S DEPn';;T~D WITH LIONnER F"" 10"' .. ~, Imn 1 nn? ,,"-" -- Imn Inn, .T. _n ~, 5.64 Imn Innd -. ~, '_n Inn' -. -, 21.24 Imn 1nno 1100. TITI E CHAR"E" Hn' .,.. 11n? In South Central Home Settlements Inc. 125.00 Hm nl., Hnd nl.i 1105. IlnR NnlRN .... 11n7 I. Wei......le & Assooiates 200.00 ...,. \ 110B Ti ... ..... . 'ARTMENT or !lOUSING AND URBAN DEVELOPMENT L S File Number: 02GONTZ ~~ ORRSTOWN BANK TO: Weigle & Associates PC Attorneys-at-Law 126 East King Street Shippensburg, PA 17257 FROM: ORRSTOWN BANK P.O. BOX 250 SHIPPENSBURG PA 17257-0250 RE: ESTATE OF Dean S Mixell DECEASED DATE OF DEATH: June 9,2002 IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD, ON THE ABOVE DATE, THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK: (1) CHECKING ACCOUNTS DATE OF DEATH ACCOUNT NO. TiTLE OF ACCOUNT DATE OPENED PRINCIPLE & ACCRUED INTEREST 625094 Dean S Mixell 4/1/86 201.48 (2) SAVINGS ACCOUNT DATE OF DEATH ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPLE & ACCRUED INTEREST 34992 Dean S Mixell 6/30/97 1,699.61 2.44 (3) CERTIFICATES OF DEPOSIT DATE OF DEATH ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPLE & ACCRUED INTEREST 5030058169 Dean S Mixell 6/30/97 3,743.30 4.36 Date: 09/16/02 By: Timothea Customer Service Operator P.O. BOX 250 SHIPPENSBURG, PA 17257 TEL. (717) 532-6114 \lA.R-03-2003 MOil 094S 41,' !IRDiiK'ffJ3: March 3. 2003 i: 1) 53C9304 P. CU : ~ ORRSTOWN BANK GARY MIXELL 302 WALNUT DALE ROAD SHIPPENSBURG. P A. 17257 RE: ACCOUNT #120027161 FOR GAY WEAVER. To Whom It May Concern: The following is the payments that Gary paid on Gay's account. 1/21102 2/26/02 3J14J02 4J8/02 6/26/02 8/15/02 8/22/02 Total $ 430.20 $ 216.35 $ 213.85 $ 213.85 $ 432.70 $ 432.70 $ 1.539.09 I- 5. H r'''./;"i'.., t S3t478.74 1- ).0;..';-:: 3yliL,7"l.. If you have any questions, pleases call me at 530-2661. Sincerely, ~'~'r(f.~~ Betsy 1. Smith Collection Departtnent l'd 682S?:S6 : 01 6~~ _ r"l 7 ~ ;E: :..~ -:on./. ll3.\(IW /-Il:I9:WO~;/ d~s:m ~C'02-t>-0't:I~ - ~-r.;- - ~' ORRSTOWN BANK N ~&.~~ . :..--- Teller #rrransaction # Time/Dale Amount Account # 306110099 LF' DUF' 030B01:58F'M08/22/02 $1,543.07 11120027761 BR-J6A ...." I'h'.hl' l',' ...\lIL' [" ,'nl<'r thi... Ir,ln...,ldlol1 in vour H'(\,rd... t R~\\ i: DO? 000 "', \ - 1',-" ~,; t " " . -,' " .',. 'Zs4^J~e~'~'fllil'eI/ c;r7i; ~()~ 7&1 " '10U J'I fJ/'ifJ) 61((" rltJ,d(pf65,j """ " ,DATE O(~ ~" CUtJl(~~.J JwJ(5 ~ DEPOSITS MAY NOT BE AVAILABLE FOR IMMEDIATE WITHDRAWAL I' r, . 't1, 'fwI" (QRTOTALFOIOM0l>El1!l1Oe1 . " w sue TOTAl ... SIGN I-lEflE FOFlCASH AECEIVEO IIFREQUIREOI * ..,.,,'; GJ;79~ ;J SOH,I: 1.O:l OO:lI,'HII' o ,,00 * 500.00+ 420.0U+ 110.0 (l + 1 "\" "no" 59.00+ '7 "" 1 0 + 1 , 2"j 'I 'j U 0 3,i~6ae5CJ+ '+,479060 * .. :-':.,e-j + ,:';:'O'l) -I- ii 0(1 -I- 1 (:: l~' 0 ::'~-I + /;<>1 'I -I- - <', ," + '" ~: /?-Rr-6 ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRIS8URG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-15~7 EX AFP 101-051 Clerk.. Cc,urt Oumbenand Co., PA 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 ~ REV =is4j-i3f-AFP-coY:03Y-NoTici--oF-YNHiifiTANcE-TA;rjfppRA-isiiiENT~--AL1-oWAifcE-oR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MIXELL DEAN S FILE NO. 21 02-0845 ACN 101 DATE 04-21-2003 JERRY A WEIGLE ESQ WEIGLE & ASSOCS 126 EKING ST SHIPPENSBURG PA 17257 RR~~i~~;~. CHi\~;I~~ TE OF DATE OF DEATH .03 APR 28 ~~UMBER ACN 04-21-2003 MIXELL 06-09-2002 21 02-0845 CUMBERLAND 101 DEAN S Allount Rellitted TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets U) (2) (3) (4) (5) (6) (7) 44.500.00 .00 .00 .00 16.352.83 .00 .00 (8) NOTE: To insure proper credit to your account. subllit the upper portion of this forll with your tax paYllent. 60.852.83 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) UO) 10.253.75 10.356.66 (11) (2) (3) (4) 20.610 41 40.242.42 .00 40.242.42 If an assessment was issued previouslY6 lines 146 15 and/or 166 176 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due NOTE: (9)= .00 1.810.91 .00 .00 1.810.91 .00 X 40.242.42 X .00 X .00 X 00 = 045 = 12 = 15 = TAX ~REDITS: . n. ..~-~.. l+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 03-07-2003 CD002267 .00 1.810.91 TOTAL TAX CREDIT 1.810.91 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 $1. 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.) 0;1 oK REGISTER OF WILLS, CUMBERLAND COUNTY STATUS REPORT UNDER RULE 6.12 Name of Decedent: Dean S. Mixell Date of Death: June 9, 2002 Will No. Admin. No. 21-02-0845 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 X b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes X No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with t Cerk of the Orphans' Court and may e attached to this por. Date: :s /tlt13 - Qr N N J ry A. Weigle, Esquire Name (Please type or WEIGLE & ASSOCIA~ES,_P.C. 126 East King Street Address Shippensburg, PA 17257 ( 717) 532-7388 Tel. No. -- 0... -<.J ,~ -.:13 ";:;::: .' ,., (t) i~~ \I):; uc:i (MAH:rmf/AM3) 7'~' 0,1~ c. OJ gcu a:: a:: -=;:r -- >- ~ Capacity: Personal Representative p X Counsel for personal representative E --- ESTATE OF DEAN S. MIXELL File No. 21-02-0845 FAMILY SETTLEMENT AGREEMENT THIS AGREEMENT made this _foG day of ~ ' 2003, BETWEEN: GARY L. MIXELL, DANIEL C. kIXELL, DIANE L. BAUSERMAN, and GAY R. WEAVER, being the heirs-at-Iaw of Dean S. Mixell, late of the Township of Southampton, Cumberland County, Pennsylvania, AND GARY L. MIXELL, DANIEL C. MIXELL, and DIANE L. BAUSERMAN, Co- Administrators of the Estate of Dean S. Mixell, deceased, WHEREAS, Dean S. Mixell died June 9, 2002, intestate; and WHEREAS, Letters of Administration were granted to Gary L. Mixell, Daniel C. Mixell, and Diane L. Bauserman on September 19, 2002, by the Register of Wills of Cumberland County, Pennsylvania; and WHEREAS, all assets of the late Dean S. Mixell have been liquidated or distributed and all his debts paid in full, and further the period of four months having been terminated since the first advertisement of the issuance of Letters to the said Co-Administrators, the said parties hereto desire to waive the duty of the Co- Adminstrators to file a First and Final Account with Proposed Schedule of Distribution for purposes of confirmation by the Court of Common Pleas of Cumberland County, Orphan's Court Division, AND FURTHER desire that a Family Settlement Agreement be executed, which Family Settlement will be duly recorded among the deed records in and for Cumberland County. WEIGLE & ASSOCIATES, P.c. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 NOW, THEREFORE, WITNESSETH, that the parties hereto, in consideration of the premises above stated, and of the Accounting and Proposed Schedule of Distribution attached hereto and made a part hereof, and the receipt of their distributive shares as therein shown, do mutually bind themselves to the said Distribution and Accounting as set forth and further mutually release each other and in particular Gary L. Mixell, Daniel C. Mixell, and Diane L. Bauserman, Co-Administrators, from all claims and demands whatsoever arising out of settlement of the Estate of Dean S. Mixell. The parties hereto do further agree that should any liability come due to the estate of the said decedent after the signing of this agreement, we and each of us do hereby covenant and agree with each other and the aforesaid personal representatives that we will contribute pro rata our share of the estate to satisfy any and all claims, demands, suits, or causes of action which may be successfully prosecuted against the said estate or the aforesaid personal representatives after the signing, sealing and delivery of this family settlement agreement and final release. IN WITNESS WHEREOF, the parties have hereunto set their hands and seals the day and year first above written. ~~~ (SEAL) -(a,n~~ ~~ (SEAL) Daniel C. Mixell ' -11,;( (l~. cI /!Jaa.u--- (SEAL) Diane L. Bauserman ~av~JOJJ.(}\. (SEAL) WEIGLE & ASSOCIATES, P.c. - AT RNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND On this, the ~ day of ~ ' 2003, before me, the undersigned officer, personally appeare GARY L. MIXELL, DANIEL C. MIXELL, DIANE L. BAUSERMAN, and GAY R. WEAVER, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official se 1. Notarial Seal Roorda R. Wolford, Notary Public hippensburg Sere, Cumberland Cou M Commission Expires Jan. 20, 2005 WEIGLE & ASSOCIATES. P.C - ATTORNEVS AT LAW - 126 EAST KING STREET - SHIPPENSBURG. PA 17257-1397 CO-ADMINISTRATORS' ACCOUNT FIRST AND FINAL ACCOUNT OF GARY L. MIXELL, DANIEL C. MIXELL, AND DIANE L. BAUSERMAN, CO-ADMINISTRATORS FOR ESTATE OF DEAN S. MIXELL, DECEASED Date of Death: Date of Co-Administrators' Appointment: Dates of Advertisement of Letters: News Chronicle Cumberland Law Journal Accounting for the Period: June 9, 2002 September 19, 2002 September 27, October 4, 11,2002 October 4, 11, 18, 2002 September 19,2002, to April 30, 2003 Purpose of Account: Gary L. Mixell, Daniel C. Mixell, and Diane L. Bauserman, Co- Administrators, offer this account to acquaint interested parties with the transactions that have occurred during their 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: Jerry A. Weigle, Esquire Weigle & Associates, P.C. 126 East King Street Shippensburg, P A 17257 717-532-7388 WEIGLE & ASSOCIATES, P.c. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG. PA 17257-1397 SlM-1ARY OF ACCOUNT Estate of Dean S. Mixell For Period 06/09/01 Through 4/30/03 Page Proposed Distribution to Beneficiaries 8 Principal Receipts Net Ga.in (or lDss) on Sales or Other Dispositions Other Receipts 1-2 less Disburserrents: Administration Expenses (Prin) Fees and Ccmnissions (Prin) FUneral Expenses (Prin) Other Expenses (Prin) 3 3 3 4-5 $ 2,599.22 3,792.64 5,672.80 10,356.66 Balance before Distributions Distributions to Beneficiaries Principal Balance on Hand 6 Incare Receipts less Disbu:rserrents 7 Balance before Distributions Distributions to Beneficiaries Incare Balance on Hand Chnbined Balance on Hand Fiduciary Acquisition Value $41,681.46 ---------- ---------- $64,052.83 0.00 0.00 $64,052.83 22,421. 32 $41,631.51 0.00 $41,631.51 $ 49.95 0.00 $ 49.95 0.00 $ 49.95 $41,681.46 ---------- ---------- RECEIPI'S OF PRINCIPAL Estate of Dean S. Mixell As of 4/30/03 Assets Listed in Inventory (Valued as of date of death) Cash on Hand Cash on hand at date of death Checking Accounts Orrstown Bank Checking Account #625094 Savings Accounts Orrstown Bank Savings Account #34992 $2.44 Accrued Interest certificates of Deposit Orrstown Bank Irrevocable Burial certificate of Deposit #5030058169 $4 .36 Accrued Interest Debt Inst:rurrents Recei vahle fran Gay R. Weaver for payrrents and payoff on her installIlEIlt loan Residences Real Estate located at 301 Walnut Dale Road, Shippensburg, PA - sold 12/23/02 Household Goods & Fu:mishings Proceeds of public sale of personal property 11/09/02 Refunds Adams Electric Coaperati ve - patronage refund received 12/26/02 Proration of County taxes at real estate settlerrent 12/23/02 Proration of School taxes at real estate settlerrent 12/23/02 $ 604.97 1.66 132 .69 Page 1 Fiduciary Acquisition Value $ 2,000.00 201.48 1,702.05 3,747.66 3,482.72 44,500.00 4,479.60 RECEIPI'S OF PRINCIPAL Estate of Dean S. Mixell As of 4/30/03 Assets Listed in Inventory (Valued as of date of death) Miscellaneous Property lV.bn'\.lITeIltal Life Insurance - proceeds of policy paid towards fnneral billing VFW Post 6070, Newville, PA - death benefit received 01/20/03 'IOI'AL INVEN'IORY $ 3,000.00 200.00 Page 2 Fiduciary Acquisition Value $ 739.32 3,200.00 $ 64,052.83 ----------- ----------- DISBURSEMENTS OF PRINCIPAL Estate of Dean S. Mixell For Period 06/09/01 Through 4/30/03 Administration Expenses (Prin) 09/19/02 Register of Wills, cumberland Oaunty - letters Testarrentary and Short Certificates 09/19/02 Shi~ Post Office - certified letter to DePartrrent of Public Welfare 09/19/02 South Central Hare Settlerrents - copy of deed 09/24/02 OJrnberland law Joumal - advertising letters Testarrentary 11/04/02 News Chronicle - advertising letters Testarrentary 11/19/02 Register of Wills, OJrnberland County - 4 Short Certificates 12/05/02 Carl Bert & Associates - 12/03/02 staterrent regarding deed research 12/26/02 Sailh.arrer Real Estate - market analysis dated 09/20/01 03/06/03 Register of Wills, OJrnberland Oaunty - filing PA Inheritance Tax Return 03/06/03 Register of wills, OJrnberland Oaunty - PA Inheritance Tax 04/30/03 Register of Wills, OJrnberland Oaunty - filing Family Settlerrent Agreerrent 04/30/03 Weigle & Associates, P.C. - reimburserrent for postage, xerox copies, and long distance telephone calls 04/30/03 Linda K. Klein - notary fee Fees and Carmissions (Prin) 03/06/03 Weigle & Associates, P.C. - attomey fee Funeral Expenses (Prin) 09/19/02 Fogelsanger-Bricker Funeral Heme $ 134.00 4.42 1.50 75.00 109.64 12.00 210.00 100.00 15.00 1,810.91 85.00 28.75 13.00 Page 3 $ 2,599.22 3,792.64 5,672.80 DISBURSEMENTS OF PRINCIPAL Estate of Dean S. Mixell For Period 06/09/01 Through 4/30/03 Other Expenses (Prin) 09/19/02 Orrstawn Bank - payment on obligation for Gay R. Weaver (advanced on 08/15/02) 09/19/02 Ol::rstawn Bank - payoff of loan obligation for Gay R. Weaver (advanced on 08/22/02) 09/19/02 Orrstawn Bank Checking Account #625094 - checks clearing after date of death 09/19/02 Fogelsanger-Bricker Funeral Hare - unpaid balance of Daisy Mixell (spouse of deceased) f'lll1eral 09/24/02 Chambersbuvg Hospital - 09/13/02 staterrent 09/24/02 Adams Electric Cooperative - 09/19/02 staterrent 09/25/02 Sprint - 06/24/02 staterrent 09/25/02 Hucklebeny land Water Association - 08/01/02 staterrent 09/25/02 Shi~ Health Care Center - 06/21/02 staterrent 10/01/02 Chambersburg ALS - West Shore EMS - 06/07/02 and 06/08/02 ambulance calls 10/03/02 Huckleberry land Water Association - 09/01/02 staterrent 10/03/02 Nationwide Insurance - auto insurance premium 10/08/02 Huckleberry land Water Association - 10/01/02 staterrent 10/16/02 Sprint - final billing 10/04/02 10/18/02 Adams Electric Cboperative - 09/25/02 staterrent 11/12/02 Hucklebeny land Water Association - 11/03/02 staterrent 11/25/02 Shi~ Health Care Center - final staterrent Page 4 $ 432.70 1,543.07 54.82 1,018.10 10.12 49.81 97.22 61.00 7.00 107.35 190.00 14.45 25.50 119.49 20.70 25.00 1,487.33 DISBURSEMENTS OF PRINCIPAL Estate of Dean S. Mixell For Period 06/09/01 Through 4/30/03 11/25/02 Consolidated Collection Services, Inc. - 3 oustanding balances owed to Chambersbuvg Hospital 12/05/02 Hucklebeny land Water Association - 12/01/02 statement 12/18/02 Timmons Oil, Inc. - 12/16/02 delivery 12/23/02 Consolidated Collection Services, Inc. - outstanding balance owed to Chambersburg Hospital 12/23/02 Real Estate settlement expense - 1% realty transfer tax 12/23/02 Real Estate settlement expense - 2002 school taxes 12/31/02 Adams Electric Cbaperative - 12/19/02 statement 12/31/02 Gary L. Mixell - reimbursem:mt for payment of Adams Electric Cbaperati ve service fee 10/28/02 12/31/02 Gay R. Weaver - reimbursement for payment of 09/14/02 Adams Electric Cbaperative statement 12/31/02 Pharmacare - 11.30/02 statement 12/31/02 Yogindra S. Balhara, MD - 11/27/02 statement 01/08/03 First USA Bank - credit card balance 01/08/03 Hucklebery land Water Association - 01/02/03 statement 01/10/03 Adams Electric Cbaperative - 12/31/02 statement 03/06/03 Gary L. Mixell - reimbursement for loan payments made for Gay Weaver frcm January to June, 2002 'IDI1\L DISBURSEMENTS OF PRINCIPAL $ 77.31 25.00 102.00 51.40 445.00 593.37 109.98 12.00 115.01 35.68 44.20 1,924.92 25.00 25.18 1,506.95 Page 5 $ 10,356.66 $ 22,421.32 ----------- ----------- PRINCIPAL BAI..1!.NCE CN HAND Estate of Dean S. Mixell As of 4/30/03 Checking Accounts Orrstown Bank Estate Checking Account #103-003491 Debt Inst:rurrents Recei vahle fran Gay R. Weaver for payrrents and payoff on her installrren.t loan less: Inccme balance on hand PRINCIPAL BALANCE CN HAND Page 6 CUrrent Value Carrying Value $ 38,198.74 $ 38,198.74 3,482.72 3,482.72 $ 41,681.46 49.95 $ 41,681.46 49.95 $ 41,631. 51 $ 41,631.51 ----------- ----------- ----------- ----------- RECEIPI'S OF INcn.1E Estate of Dean S. Mixell For Period 06/09/01 Through 4/30/03 Interest Orrstown Bank Estate Checking 12/15/02 interest 01/15/03 interest 02/17/03 interest 03/16/03 interest 04/15/03 interest Orrstown Bank Savings Account 09/19/02 Interest date of death to closing Orrstown Bank Irrevocable Burial 09/19/02 Interest date of death to closing Total Interest 'IOTIU.. RECEIPI'S OF INcn.1E $ 0.68 9.45 14.34 11. 37 11.02 46.86 $ 0.91 2.18 Page 7 $ 49.95 ----------- $ 49.95 ----------- ,. ----------- PROrosED DISIRIBurIONS 'ill BENEFICIARIES Estate of Dean S. Mixell For Period 06/09/01 Through 4/30/03 Page 8 To: Ga1:y L. Mixell 1/4 Residuary Share of Estate - Cash Cash $ 10,420.37 Total $ 10,420.37 To: Daniel C. Mixell 1/4 Residuary Share of Estate - Cash Cash 10,420.37 Total $ 10,420.37 To: Diane L. Bauserman 1/4 Residuary Share of Estate - Cash Cash 10,420.36 Total $ 10,420.36 To: Gay R. Weaver Receivable owed to Estate 4/30/03 Receivable frcm Gay R. Weaver Olrrent balance 3,482.72 $3,482.72 Total $ 3,482.72 To: Gay R. Weaver 1/4 Residuary Share of Estate (less debt owed to estate) - Cash Cash 6,937.64 Total $ 6,937.64 'IOTIU.. PROrosED DISIRIBurION'S 'ill BENEFICIARIES $ 41,681.46 ----------- ----------- GARY L. MIXELL, DANIEL C. MIXELL, and DIANE L. BAUSERMAN, Co- Administrators of the Estate of Dean S. Mixell, deceased, hereby declare under oath (penalties of perjury) that they have fully and faithfully discharged the duties of their office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the estate have been paid in full; that, to their knowledge, there are no claims now outstanding against the estate; and that all taxes presently due from the estate have been paid. ~~7?;1~ Daniel C. Mixell, Co':"Administrator ftt CL~;{ tlJ~ Diane L. Bauserman, Co-Administrator ea Rhonda R. Wolford, Notary Public hippensburg Bore, Curnbarfand Cou Commission Extlir<J5 Jan. 20, 2005 WEIGLE & ASSOCIATES. P.c. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG. PA 17257-1397