The URL can be used to link to this page

Home My WebLink About02-0725PETITION FOR PROBATE Estate of ,~ ~,: ~ F.~ ~ %~ ~ -~~ ~) also known as '`. eceased. Social Security No. or older an The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of in the last will of the above decedent, dated _ and codicil(s) dated Register of ills forte County of ~ in the Commonwealth of Pennsylvania _ na ed_ 19~ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ~ ~ Cou{~tx, Pgnns~lv~s-ja, with F-'-~'-'~- last fSa'~i1i}' or rincipal r sidence at ' G" - ~?[? ~ I ~t~~ K-~. `:~ . ~~(list street, number and(m~uncipality) 1 `, ( years pf age,,.died 6 ~~ 1'~ (~ ~ ~i ~1~R'~'~ , and GRANT OF LETTERS To: Except. as follows, decedent di not marry, was not di reed and did not have a child born or adopted after execution of,tpg,will offered for probate; was not the victim of a killing and was never adjudicated incompetent: ( ) P P P Y (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in P~psylvania $ situated as follows: I~tt-'nN~ IIf domic led inePa owned proPVly ersonaltimoateedtvalues as fallows: $ ~,~j(1`~) ,e .-. ~ v , 1 °' ~ ~~ 1~G1. _ ~o - ~~.r ca •... i ., - r ~a 4, ~ o c ' 00 WHEREFORE, petitioner(s) respectfully~eq est(s) the probate of the last will and codicil(s) presented herewith and the grant of letters ~ (testamentary; ad istration e.t.a.; administration d.b.n.c.t.a.) theron. OATH OF PERSONAL REPRESENTATIVE COMMONWEA TH OF EN SYLVANIA 1 COUNTY OF u,n\ ss n ~ (` L'I,tiIC? 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 represen- tative(s) of the above decedent petitioner(s) will well truly ad inister the tate according to law. Sworn to or affirmed and subscribed ~ ~~ ~~~'~-~`:~ ~~c'~'-'~ ~~~'_~~ rte,(, ~ ~ v, before me this 12th day of «+~ ~~ - /.1 Au st ,~ ~ 2002 A /~~ 1 / (~p rk~nna M _ nttc~ . 1 ~t r~rn ~ v egister ~7 ~/'~~ No. 21-zoo2-725 Estate of MI~rE H. JEFFERSON Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW August 13th 1~ 2002 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 August 25th, 1975 described therein be admitted to probate and filed of record as the last will of MIGI~TONNE H. JEFFERSON ; and Letters TESTAMENTARY ____ are hereby granted to SARA ANN AHRENS FEES Probate, Letters, Etc. ......... ~ 40.00 Short Certificates( .......... ~ 6.00 Renunciation ................ ~ x-Pages(1) ~ 3.00 JCP 5.0~ TOTAL ~ Filed August .13ths 2002 , . 554.00 Register of Wills ,~~'7l/-~~~C.U~'~~ Donna M. Otto,lst~Dpty. ATTORNEY (Sup. Ct. LD. No.) ADDRESS PHONE MAILED LE'I't`ERS TO EXECU'T'RIX ON 8/13/2002 - d f ~ Tina! certificate of death duly filed with me as This is to certih~ that the inbrmauon here given is correct y c.opie torn an orig local R~egistrar.~ The original certificate will be forwarded to the State Vital Records Office for permanent fiVing. WARNING: It is illegal to duplicate this copy by photostat or photograph. • Fec for this certificate, x2.00 ~ local Registrar P 7685597 ~;,>. TYPE/PRINT W PERMANENT BLACK INK "~ 1 M705.10.7 Rev. x187 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH rate NAME OF DELEDENT(fva. Midae.la91 SE% SOCIAL SECURItt NUMBER GATE OF OEATM,Menm. Oay.'rearl OCTOBER 16, 2001 FEMALE 183 - 44 - 7710 ,. ,. 1. MIGNONNE H . ,JEFFERSON ,. AGE ILap anndayi UNDER 1 YFaR UNDER 1 DAY DATE OF BIRTH B87THPLACE iC,ry ono PLACE OF DEATH (CIVCM avy «b - sea ~natruclms an aver noel MMNS . Days !laws . MinaM Monm. Oay.'bml SIMea FCr Cawuryl „OSp1~: OTHER: MAY 26 , HAGERSTO~IN, IrlpalwK ^ ERIOMppi•M ^ ~A ^ Nwn~. ~ Rrndsnc• ^ (s~d» ^ 89 Yrs. ~ s 1912 T. w. ~ . _ s. COUNtt OF DEATH CRY. BOIlO. TWP OF DEATH FACKITY NAME III rot xrngW,an.9~w wep and rv%nbpi VWS DECEDENT OF HISPANIC ORIGIN? RACE-Ammican Indian. 8lscK. WKS•, Nc. MANOR CARE HEALTH SERVICES- "•7~ °'~^%Y"~aea""~"a" Is~wi WHITE Maxrin, PusRO Rion. pe. CAMP HILL CAMP HILL a, le. CUMBERLAND • ,~. a. ,w DECEDEM'S USUAL OCCUPiVpN KWOOF BUSINESS/INWSTRY YIAS DECEDENT EYERW DECEDENT'S EDUCATION MARITAL STATUS-Wniad SURVTVING SPOUSE yYldpWd. IM de. pvma0an neural ARMEDFORCEST tom ad N•vN NSrriW, U. S . (GivIUM «auamna WrngmoK TpT q wwkin9 p•;mn«us•refredl V•s ^ NoI q E4rwn 1ut21 1 It~~ 1 WIDOW~L hl „w „w RESIDENCE „ „- ,.. ,.. DECEDENT'S MUTING ADDRESS (SKeal. Ciry/ro.n, Slaas. ZpCodel ~uKNTS ^n ..anw.am 1•w~ d ,T PENNSYLVANIA ..- e. .. a __ OM ,Ta. SMM 21 SOUTH 26TH STREET RESH)ENGE ~iein1 ,CAMP HILL, PA 17011 1 °`""~ „b_L CUMBERLAND '°""p'PT d~"°'0iC0o"`°nd CAMP HILL if . vaNnrl«up !:roue anA+ao. HB/1ER'S NAME (Frp. MiOde. Lauri MOTHER'S NAME IF p. Midde. Maiden Sanxui THURSTON CORA M ,.. JOB NEWTON HOCKERSMITH . ,,. WFORMANT'S NAME ITyP•IPrnll WFOHMANT'S MAM.S/G ADDRESS IStrap.Cry/TpM, SIW. Lp Coda) 21 SOUTH 26TH STREET CAMP HILL, PA 17011-4612 :e.. S LLY AHRENS METHOD OF pSPOSITKNa DRE OF DISPOSITION ,,,. PLACE OF DISPOSRION-Nam•d CsnWSry, Crwnatay LOCA710N-CAyyTavn, Slalw ZlpCoa BuriN^ G•rrrslion® Rmrwalk«n Sla1•^ (MmN. DaY rip! 2001 ^ OCTOBER 17 ^ «OUwr PMC• YORKTOWNE CREMATORY YORK, PA 17404 , o„rr( oartpiort 21w 2tE. t/c. xld. ITY F FA CIL SIG RILL SERV PER^MI ACTWD. N LICENSE MBER NAME ANDAOORESS O x2wr •-Qi~~/7'L. ,~'~ZWEILER F.H., 1111 E. MARKET ST. YORK, PA 17403 ~w iami' `. wMn ng 8ls o•p a . Maul ou«red a1 tlw time, dale and Plsc• Rated. LICENSE NUMBER DATE SIGNED (MOMt. Day. Yexl s nal a ~ u 4rrr• of rYaM b (S,pwwro d•i ear..aa 27h. xx. n. . (MOnN, Day.rixi YvAS CASE REFERREDTO MEOIAIg7CK E]UMWEPoCORONER7 21-28 b•c«ripl•l•d Oy ME OF DEATH OATEP CE ^ ~ 4NA. .e risay No 2e. J M. 2S. N. 27. MRT 1: Entu 1M oia•san, irgmia«cmgacMiarwNCn rA ed tM aalA. DO rla MIm lfta npds al dying, such as Cardiac «respiralory a s1, 5A¢Ck or M IaiMn•. I ApproAimM• PART K: ONw si9nl8cux coriAliorM co«ribrlMq W d•W, bid n«nsuOiMnON UnOYlyirp cWN 9iv^in R1f1T I. Y r. ;«~~~~ Lip ortlY ens cause on •a«r SYSEDUTE CAUSE IFwr t daeasa«°^ LI~~G craN<~1Z n o•aatl-- a r..r q OItE W IDA AS A CONSEOl1ENCE DF7 S•Wrs'dUlY asl rorldaiorn b Dl1E W(OfI AS ACONSEOUENCE DFk 1 iany, 4tl6rtpmm~aQMS psN. East ISIOERLYIIID ~ ~ c CAUSE IDUeaw «m,.ry _ 2Nl sdiaYd eveNa DUE W TOR AS ACONSEWENCE OFT: rarirp in daM) LAST 0. VNS AN AIROPSY WERE AUTOPSY FINOS1CaS YANNEROFf~ATH DATE OFINJURY TIME OFINJURY INJURYR WORK'! OESCfOBE NOW INIURY OCCURRED. PERFORMED? A1aULABIE PRIOR W IMmm. DaY Year) IONKCAUSE +.'~ ^ OF DERH ~%~ NYap L J Yw ^ Na ^ Psndinp lnvssllgaK«1 ^ AccA•nl ^ (Yqq ri ^ No ld Y'w ^ Ns ^ SurM• ^ CaAd nq G dsprmmW ^ PLACE OF INJURY. Al-hour,, ~ st, roM. factory, ol8c• M. 70¢. LOCQgN IStreN. Gry/TOan, 5Wy s Lw 2Sb. 2f. ouibro, Ne. ISpauM 70•. 701. CE11Tff1Elllp+etl~oray arwl alham com lebdltem x71 n h n nced d h d ' SIGNATURE ANO EOf CERTIFIER r p oe po ou e dealt, xTa~anane. o vsca CERTIFYING PHYSICIAM(Myerran cena,vng ouae GaaUt escrrrred dwbM•causNsl and manner assMW ..................................................... ^ HSr•hwf Wrnysmr4dt,• 710. ~-1 . DATE SKNED IMarsn. Day. riot! LICENSE N R •IRONOUNUNG M10 CEtiTWY1NG PHYSICIAN(PhystWnhodtaorouncvt9 deaf? Ono cenayvptocauudOealN /may 161 [c' ~(~ D\d{'~ S S i 71e. 71d. To N• 0••101 mY Ynowledge, death occurred at do Sm., dots, and plats, and OW to IM wY•eIN •~ manner as alatsd .......................... (\ E OF DRATH`K `(N ~ A Ll, A US NAME AND ADDRESSOF PERSON WHO COMPLETED C ~ {~ . ~ (11¢m 27i Type or Prinl ~ o ~j G o w 1 ^a^ ,„,JJ GFL •YEDN:AL EAAYINER/CORONER On IM Basis 91 naminalbn andlw investigalbn, hl my opinion, deNh oocurted at the lima, date, ono plat., arw due to the cause(q aM ^ w.A2 r ~ h 1 •'t o L{ '; L~ Y"~ ~7`j annar Y alatad .................................................................................................. 71a. 72. REGI RAR'S SIG ATURE N BER .~ i 1I J I I 4] I~ I ~ DATE FILED (MOnM. Day Year! . l ~,» ~. ~.~~~t dill ~rth tZestMrrcertt nr ,::~Z/ Cf~' 7~~ 5 r'.QIrr'.'10rITdE I? . JFnr, r??e~rl -[~ r"in•nOnnP. JefferSOn, ?. rP_S-d_('rlt Of '^~Or~r 7'O'VnSI'liC~, VO]"'r (.-ounty , PPnnsvlVania, bPi n~ Of SOUnd Hind anc'. *nE~~:Ory , ~.O *~a>>e , nUblishl ?n~? declare thi^; ~,~,~ I~a.st ''-i.7.1 and "'est.a,ment, hereby re~TO,c;_nm and r~~l,.-i Y?r" V01 d c`3n~~ ?r1C~, x9.11_ ?'71115 Ii t1 ?'?E.' ',r1E'?'E_'t0~'Or'.' 1"!~.~e . ^TRC,m; T nrdP-r"' a.nd d;.rect th,~.t a1.7_ of my jtzGt de'~ts ~.nd funeral expenses shall ':,e raid as soon after. m,:T decease a.s ,!a.~T ?~e found convenient. ^FCOND: All the rest, resl.due and .remainder of my estate, real, personal a.nd mixed, of. 1lha.tever nature and ~,rheresoever situate, ?--~rhich I ma,`I O''?n Cr 'tiaVE' t~7P, ri. f'''--"?t t0 d.J.SpO°~E' O`~ at t:I"1P t11"1.E' Of m`T dP.Ce<'~.SE', T cr-i VE', deViSE' an~~ ':)eCille~,t'rl t0 mTr d-aUs?;'1tE'r, "ark. Ann ~:tilr'E'rZS, a};sOlutel~r, Or ~ -! n ~ f' 1 ~r d!'CFS<9.Se t0 Her C't1~_ldren In E~nl.zal Stil%'..rC'S, Y)Pr stlr~°>, to ~e t'~lezrs ~.~solutely. '-"`T'~'~ • T_n the event that my s~:; ~' d~.lzmhter, ".ara r'•.nn ~',hrens , ShOUld DredeCE'~S~? i'?E', Or ShOUld di_e ',^I 1.tiZOUt lE'<9.Vln~'' iSSUe SUr'ViVj.nt-'', then T ~~.Ve, deVl_Se and benUF?~.t''1 ?"'''I rEs~_dUar~' E'StatE` 9.c a.fOrF'S?1~" (a) 'she sum of 'y'en ~")ousand (~1_C , OCn . CO) nollars to Ct . ~,n~~re~~?s ::niscopal ~;~urc'z, Yorl~, Pennsylvania. (b} `~:ze sum. of rive ~'~>.ousand ("~~,~C0.0~) Dollars to "t. Johns :niscor>a.l Church, Yorl., Pennsylvan ia.. (c) `~L1~>e balance of mfr residuary estate to my daurnhter's husband., Christian Tloss P.hrens, absolutely. In the event that Christi~.n joss ~`:'.~ras doe~:~ not survive me then the balance of my residuary estate to the "hrinerst Cr.ipnled Children's zTospitals. EOTJRT'I: I order and. direct m-;i .Executrix, hereinafter named, to pay all transfer inher~ta.nce, estate, succession, death, and le>Tacy taxes , to •:rhich m~,~ estate or the transfer of any pronerttT hereunder ma; be subject, and to cha.rme such taxes as part of the expense of admin- R istration, and to pa,y the same from my residuary estate. rInTFI: I Izereby nominate, constitute and appoint m:y dau~-hter, Sara Ann ,?hrens, t'rie Executrix of this, m,y Fast ?'_11 and Testament, and T_ do direct that no bond. shall be rewired of such Executrix hereunder. r~~y said Executrix shall nave full. po~ve_r, a.t ?per discretio to do anv and all thin~r,s necessar~r for. the complete administration of my estate, includi.r.~ tl~e po~.,rer to sell, at nu.blic or private sale and a1i tho~;.zt ordor of Court , an,y .real or ne.rsonal property relonmin~- to 1~~~ estate , a.nd t.o cor!round, comnromi se or other,~r ise to settle or adjust an~r and all claims , char~-es , debts and demands ~~iha.tsoever a~ai.nst or ...n favor of m;4~ estate, a.s fu11v a.s T_ could do i f living. In tl~e event that my said daughter, Sara Ann Ahrens, should predecease rye, or in the event that ire should both perish in a common disaster, then I nominate, constitute and ap~?oint my daughter's husband, Christian `Toss Ahrens, as the alternate Executor. "aid ~.~.lternate :executor shall ;•ia.ve all of the po?~~ers, nrivilet~es, duties, and immunities as hereinbefore more fully set forth for my ori_~inal executrix. I order and direct that m~~ Executrix or 'Executor, herein named, shall emnl.o?a m.y attorney, Donald T. Puc;'~ett, as counsel for my said estate. IIv ?aITl~vrz~ ~S ?~IHEnEOF, T Have he?~eunto set my hand and seal to this, m~, east ''~ 11 and mestament, this 2 ~ da~r of ~ " "`'~ `"`''~ , 1~?7~ . _ SEAL) ~nonne FF ,.- son `?i~.ned, sealed, published and declared, by the above named Testatrix, as and for her Last ?1i 11 and Testament, in the presence of us , ~~rho a.t her rec?uest and i n her presence , and i n the presence of e~~.ch ot'zer. , have hereunto subscribed our names as ?~aitnesses. _. -mil JCJIn ~~wC~-~ _ 4 '`'~~~ C `~ ~ L ~<. off ~~( .._7~ ~°~~ REGISTER OF WILLS OF COUNTY OATH OF SUBSCRIBING WITNESS (each) a subscribing witness to the will presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that ~' `~ present and saw the testat ,sign the same and that '~ request of testat in l~_ presence and (in the pres other subscribing witness(es)). Sworn to or affirmed and subscribed before me this ~ day of _ signed as a witness at the each other) (in the presence of the 19 Register 21-2002-725 (Name) (Address) (Name) (Address) REGISTER OF WILLS OF Ctitmberlana COUNTY OATH OF NON-SUBSCRIBING WITNESS ~~ ~ , ~ r ~ U.c u_ l~l f l ~l 11'~ ~ ~~~ ~~ k 1 y i _) r\ ~~ ~~ ~1~ k. ~ l~' ~ (each) a subscriber hereto, (each) being duly qualified according~vto law, depose(s) ar~d s .y )that s"TIA~~ ~ ~1fRcA9S familiar with the signature of L ~ ~~ ~~ ~ ~~5~)1!~ ~{~~-' (~'(1%~ codi testate r of (one of the subscribing witnesses to) the will presented herewith and that - believe the signature on the , wil is in the handwriting of '{rn~ ~ r 1w! 1 Y'.ntJ 1~11~Y/ ~ - ~c~ l~~F~!~~~. 11 to the bes'~of ~~~. knowledge and belief. /~ ) // Sworn to or affirmed and subscribed before ~ CZ.~~' (~l,~n--nJ l~/t~i.~~„q~ me this _. 1 nth day of !N ~ne) n ~ z _• A-ui`~"st~~-~T , 1'~x 200 j _~; ~ `ter: ~cl"~ ~ 1~~'' ~~17 ivr~r> ~ 111 ~~J~ ~i L l,Ci~) ~~ ~~~' 1( Donna M. Otto,lst (Name) ~ =1 c, _ c; , (Address) 1 h ~ ~ ) REV-15UOEX (IJ.-OO) w "' ::ll::::!;(I) ,,0:>: w"" :rOO ,,0:-' ..<II .. '" COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT 280601 HARRISBURG, PA 17128-0601 I- Z W C W (,) W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) :t't. 0 DATE OF DEATH (MM-DD-YEAR) I ItH(;-() I REV-1500 OFFICIAL USE ONLY ~ All ~I FilE NUMBER ~L - 0 2- COUNTY CODE YEAR (g 1 j s-__ ~ER INHERITANCE TAX RETURN RESIDENT DECEDENT - ")')/ a a$ -1.<;'-/;1. THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) [X] 1. Original Return D 4. Limited Estate I.RJ 6. Decedent Died Testate (Attach capy of Will) D 9. litigation Proceeds Received "' z w o z o .. '" w 0: 0: o " D 2. Supplemental Return D 3. Remainder Return (date a/death prior to 12-13-82) D 4a. Future Interest Compromise (date of death alter 12-12-82) D 5, Federal Estate Tax Return Required D 7. Decedent Maintained a Living Trust (Attach copyo/Trust) ~ 8. Total Number of Safe Deposit Boxes D 10. Spousal Poverty Credit (date a/death between 12-31-91 and 1-1-95) D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property Z (Schedule E) 0 6. Jointly Owned Property (Schedule F) ~ D Separate Billing Requested :J 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property !::: (Schedule G or L) l1. <( 8. Total Gross Assets (total Lines 1-7) (,) 9. Funeral Expenses & Administrative Costs (Schedule H) W D:: 10. Debts of Decedent, Mortgage liabilities, & liens (Schedule I) 11. Total Deductions (total lines 9 & 10) 12. Net Value of Estate (Line 8 minus line 11) 1.1 .sOlTTli :l. (;,1' H c:...Alrl~ I1IlL..J P A . S-r I')f;J/I -'-/(;,/;1. (1) (2) (3) (4) (5) I I , I I ! i L;j OFFICIAL USE ONLY s:. LJ I? .'-1 B Y,1J:J.. .9Y (8) (7) (9) (10) (8) ~.IIC[l,.()O :31.1);2.<6 .3<;' . <t <D-3 0, 41J... (11) (12) (13) LjtJ. ~q~ - 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES (14) z o !ci: I-' :J l1. :i! o (,) ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1 .2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT x.O_ (15) x.O_ (16) x .12 (17) x .15 (18) (19) 'S.TR'l.~ Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + 8 + C ) (2) 3. InteresVPenalty if applicable D. Interest E. Penalty TotallnteresVPenalty ( D + E ) (3) 4. If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) 8. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS ......0 ...0 No ~ I&J [>(J IKJ ~ 00 .......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. 1. 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. retain a reversionary interest; or.. d. receive the promise for life of either payments, benefits or care? . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...... 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.. .. 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . Yes ............0 o ....0 .....0 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete Declaration of preparer other than the personal representative is based on all information of which preparerhas any knowledge SIGNATU ~O~8LE F ADDRESS ...lJ StlOT).\ 1tn1"1-j ST SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~ > AIfIP I:l Jl.1 - ? A. " I ')tlll -'-1 (" d. DATE ADDRESS 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 PS 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)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116(a)(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)J. 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. ...."",,.."". COMMONWEAL"'" Of peNNSYLVANIA INHE~TANce TAX RETlJRN RESIO!_ SCHEDULE B STOCKS & BONDS ESTATE OF :s ~ 'f.f-u.st\AJ M""Lc,lIJr1 AlIJ'V ~ AI property jolnlly-ownod wiIIl right of .._;p..... be dloclo.iId Oft _... ~. ITEM NUMBER Fn.E NUMBeR ~C)();1.. - a m :L~ 1. DESCRIPTION /lIt, SHMt5. k.lJ ll'INT1 I\l, l-II\JA'V\.JAL (c:.a hl-'\()0 ~u.s.lf '" 1<<.t~3^O -/0-;)... 'V...oInI'#..lIJy W(,1\rf POt-CI t AFTt~ fJltrl.> Of D'i.ATI-{ (SoU.. An A.~'''H.i;) VALUE AT DATE OF DEATH . S;YI~,i8 TOTAL (AI'" enter on line Z. Recopltulilllon) . $.1 tt I '\ . y. 8 (W mo~ SIl8CE Is needed. IMen oddl1lonill sheets 0I111e s.rne size) RETAIN THIS INFORMATION FOR YOUR RECORDS. I Prudential ~ Financial - Transaction Statement 0001366070 MIGNONNE H JEFFERSON 21 S 26TH ST CAMP HILL PA 17011 NUMBER OF SHARES CREDITED 172.0000 . TRANSFER AGENT ACCOUNT NUMBER 11097446R 1IIIIIIIIIIIIillllllllllllil CUSIP NUMBER 744320 10 2 010110974468 PIU/PASSWORD. PLEASE HEP CDNFIDElmAl . 6777 2R6S January 2002 W c'rc plcascd to I\'olwmc )'OU as a UCI\' stockholdcr of Prudcntial Financial. Inc. On December 1 R. 2001. Prudential completed its conversionli'om a mutual company tl' a stl'ck company. As part of l'ur conversion. we are issuing stock to eligible omlers of the company. This includes anYl'n~ whl' owned an eligible policy or annuity contract as ofD~cember 15. 2000, You have received the number of shares listed abl've. Compensatil'n fl'r all of your policies eligible for stock is included in this statement. This does not affect your insurance policy or annuity in any way. Stl'ck l'''1lership is a benefit ofhl'lding an eligible policy or contract. It does nl't replace Yl'ur pl'licy l'r contract. or change your benefits, c~sh values, eligibility for policy dividends or guarantees. You ell' nl't have tl' give any1hing up to receive stock. I10w \',"II' allotment of shares was determined. Company actuaries and external advisors developed a plan for dividing the value of Pm de ntia I among its owners. Factors such as the type of life, annuity or health policy or contract you owned, the lace value, and how tl'ng you owned it determ ined how many shares you received. Your shan.'s arc rt..'gistl'l"cU 011 the books of J'rudenlial Financial, Inc. Prudential has engaged EquiSer\'c Trust Company, N.A.: a provider of sharehold.er ser\'icesJ to hotd yom shar~3 at no eost to you. A stock certificate is not required to continue holding your sbarc$ in book-entry l"lmn. The cnclosed broc1nu.e explains how to hold shares~ transfer or sell shares, or obtain a stock certincate~ thrOllgh EqulS~lYe. Nok: If you would like EquiScfvC to continue holding your shares at no co~t~ no action is required. A commissiun-free salt,s and pllrchast's program will bt' availahle fur Ct'rlain shareholdl'rS in till' future. To pal1icipate. YOll must own 99 shares or fewer and hold yom shares in book-entry forn1 as they an.: now. Se.,;- bal.:k for more in1ormation. "'hat nlll should do no\\'. 1) Keep this statement fl'r your records. 2) Read the enclosed brochure fl'r infonnation on how you can bold, transfer or sell YOlU' shares through EquiSer\'e's Sales Facility, or obtain a stl'ck cettilicate. SEE BACK FOR ADDITlONAL lNFORMA TION. Questions? Call 1-800-305-9404 weekdays from 8:00 a.m. to 7:00 p.m. (ET). For hearing impaired. call 1-800-619-2837. Or visit prudential.equiserve.com DEPARTMENT OF THE TREASURY . INTERNAL REVENUE SERVICE OMS No. 1545.0715 1a Dateo!sale 1b CUSI? No. 2 Stock, bonds, etc. Reported to IRS } ~ Gross proceeds Proceeds From 2002 02/12/02 44320 10 2 5 . 41 7. 48 Gross proceeds less commi~ Broker and S and option premiums Barter Exchange Form 1099-B Transactions 4 Federal Income luwllllheld Account number 5 Description $ SALE OF S TDCK Copy B K2 300110 97-4468 COMMON For Recipient 0.00 PRUDENTIAL This is important tax RECIPIENrs name, street address, city, stale and ZIP code PAYER'S name, address, cily,slale, ZIP code andlelephone no information and is being furnished to the I1IGNCNNE H JEFFERSON EQUISERVE. INC. Internal Revenue Service. If you are 21 S 26TH ST PRUDENT! AL FINANCIAL. II'. required to file a return, a negligence CAMP HILL PA 17011-4612 P.O. 80X 43033 penalty or other PRUVIOENCE. RI. 02940-303 sanction may be imposed OnYOu~fthlS 1-800-305-9404 income is taxab e and the IRS determines that it has not been reported. RECIPIENT'S identification number PAYERS Federalidentificalion number Form 1 099~B 183-44-7710 43-1912740 INSTRUCTIONS FOR RECIPIENT ON REVERSE SIDE DETACH BEFORE CASHING CHECK "v.'~m'I"971. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF "3 ~fHAS4:JN ft'll (.I\.IMJN't, H FILE NUMBER ~ C)t\~ - C)~ ') t.S Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH I\LLf IRS) ~ANK .6..\L-TJ/M^'l" frlfJ 1.I:('9{ <:'liH~IN(y A~tt;)\J1IJI (:)OOC)S---t..$::S~-~ 6 A L^NQ.'v (St.& A:,.rA.~'r1'i.-0 Acc:.A.v'EL) '"I1\l'JtA~.>T 19Q'7, ~I '1.'t? " '3- f. T-c w E.JL'i.~ r-UN~A.l.. HOM'iJ Utf.f>I\Ji) I" I t. As.- T )'f\-1^)(i. T s,'j '1oj.,J< PA 1'>~03 r~\)1Yt,f'J/ fA'- "X N.>\I~f\"'Ci.. ~oJnP~NY a,.. ~tJk)tA :2.;'(%0,00 1S,~~ TOTAL (Also enter on line 5, Recapitulation) $ If.! 'l/:2.. ' ~ Lf (If more space is needed, Insert additional sheets of the same size) iii allflrst MIGNONNE H JEFFERSON 21 S 26TH ST CAMP HILL PA 17011.4612 1".111,"11111I,"11..,11.1"1.11",,.11,,1.1..1.1,.,11,1,,11 Page T of 3 Relationship With Interest September 25, 2001 thru October 25, 2001 M'gn0nn8 t1 ..8'I,.SOO Acta NO ul)uuS..~5Jti-3 ,..... ~ V Oillitlrst.com V ;t4-hour CUstomer Service 1-800-533-4630 ActivIty Summary Annual percentage yield earned Avg. daily ledger balance Avg. daily collected balance Interest earned this statement Interest paid this statement Interest paid this year Days covered by this statement 0.45:< $2,132.84 $2,13D.37 .81 .81 $14.33 31 Balance on 09/24 Deposits and additions Checks Balance on 10125 $1,922.16 974.42 -988.77 $1,907.81 Deposits and addnlons DlIff!!! Description Amount 10/03 10/12 ACH CREDIT PRU ANNTY PYMT 021020183447710 1221211670JEFFERSON, MIGNONNE 20012705491960 ACH CREDIT US TREASURY 303 sac SEC 187109090D SSA 3031036030MIGNONNF H .IFFFF~!;ON20n12741'275~81 DEPOSIT ACH CREDIT PRUDENTIAL GLDI PAYMENT 183447710 9066232404JEFFERSON, MIGNONNE 20012850918627 INTEREST PAID $172.65 10/01 10/03 682.00 75.90 43.06 10/25 .81 $974.42 000352 0014-98317901781 050 Belandng your checkbook Be sure you have recorded rNefY account transaction--whether it was by ATM, teller, internet banking, merchant purchase, automated telephone system, electronic transfer or pre-authorized payment-as well as aIT fees and interest payments in your checkbook register. Compare your checkbook to the list of transactions on your statement. and put a check mark: in your register beside each one. Enter all transactions that remain unchecked in the appropriate column below. Additions Withdrawals . Write your current statement balance on the line directly below. . Under "Additions, . fist a/l deposits, transfer5 and other additions to your account that you have not checked off in your register. Total the additions and add this amount to your current statement balance. Enter this on line 2. . Under "Withdrawals, . list any checks, payments, transfers or other withdrawals that you have not checked off in your register Total the withdrawals and enter this amount on line 3. . Subtract the total 'Withdrawals' from "Additions" and enter that figure on line 4 below. This amount should match YOur checkbook. $ o S....ment balanco + $ . Additions $ = $ o To..1 " Withdrawals Errors or questions about your electronic transactions Telephone us at l-8OCJ...533-4630 or write to us at Allfirst _ Error Resolution, Mail Code 101-825, P.O. Box 17033, Baltimore, MD 21297-0529 as soon as you can, if you think your statement or receipt is wrong or if you need more information about a transfer listed on the statement or receipt. We must hear from you no later than 60 days after we sent you the ARST statement on which the problem or error appeared. When you call or write, please provide: your name and account number, a description of the suspected error, and the dollar amount of the suspected error. We will investigate your complaint and correct any error promptly. If we take more than 10 business days to do this, we will credit your account for the amount you think is in ern'Jr, so that you will have the use of the money during the time it takes us to complete our investigation. Questions about your statement Call us, Alllirst Bank or Allfirst Financial Center N.A., at 410-244-4300 or 1-800-533- 4630 (TOO 1-800-225-8359) concerning questions or suspected errors on your statement, or to report a lostIstolen ATMNisa" Check Card or to request a reminder of your existing personal id~ntification nlJmber (PIN), or for other matters relating to your account. You may also write to us at the addresses shown below. Depending on the type of problem, calling may not preserve your rights. When you call or write, please provide: your name and account number, a description of the SUSpecl:ed error, and the dollar amount of the suspected error. Errors Dr questions about your non-electronic transactions Call us at the number above. You must report suspected errors on non-electronic transactions within 14 days. All items are credited subject to final payment. TO request an ATMMsa Check card or PIN Please visit your nearest branch location. Visit our website at alltirstcorn to locate the branch nearest you. Automated telephone service For balance and transaction information or to verlfy a direct deposit or electronic transaction, or to transfer funds between related checking, money mark.et, savings and line of credit accounts call 410-244-4300 or 1-800-533-4630. Internet Banking For account balances, transaction information, to verify a direct deposit or electronic transaction, or to transfer funds between r@lated accounts, visit our website at allfirstcom Change of addNss Cut off the top of page 1 of your statement,. cross out the incorrect infonnation, and write the correct information and the date on which it became effective, and sign it. You may drop the slip off at any branch, include it with your next: AN deposit or mail it to: Customer Infonnation services, Mail Code 501-120, P.O. Box 1596, Baltimore MD 21203. Written Inquiries For ATMMsa Check Card or ATMlMerchant Purchase inquiries or Internet inquiries, write to: Debit Card Services - Error Resolution, Mail Code 101-825, P.O. Box 17033, Baltimore, MQ 21297-0529. ForACH transactions, write to: ACHlEDI 5OMces, Mail Code 501-181, P.O. Box 17039, Saltimor1l, MD 21297-1039. P_ge 2 of 3 REV-1511EX+(1-971 '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FilE NUMBER 1-~ C J.. - CJ:J 'M.~ ESTATE OF -S ~ f Ff,~5o(\ 1J ft\-z. (, f\J 0 /oJ AH... Debts of decedent must be reported on Schedule I. H ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~T-c. 1.\)(,/ L'i.R f\)1V~Ml- HOJ\)u '3()()~. cro III ( t, ).>) Jt\ ^~y'<j,.-r s., 'J OJ?. K.., PA. )') lf00 (s.'t.{' ~-rTA<::'I\t.1)) B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City Slate Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees G'f.OO 5. Accoun1ant's Fees 6. Tax Re1urn Preparer's Fees 7. 1tI, s..> h. '0> ft\}L~I\{,t P~..s.""f A. C, L P -\e.)l..1 N (J- SO.~ PI-t';)~O ~ oPy TOTAL (Also enteron line 9, Recapitulation) $ -:!>IJ 8,crt> (If more space Is needed, insert additional sheets of the same size) Et/weiler r~~ 1111 EAST MARKET STREET YORK, PENNSYLVANIA 17403 7171843-0216 M. ROBERT ETZWEILER Mrs. Sally Ahrens 21 South 26th Street Camp Hill, PA 17011 The Funeral Service for Mrs. Mignonne H. Jefferson Account Number- 2001-11348 PROFESSIONAL SERVICES, FACILITIES, EQUIPMENT AND AUTOS Cremation with Memorial Service $1940.00 -~--------------- 51940.00 $1940.00 =====:=======.,,== SELECTED MERCHANDISE: Standard concrete urn vault Cultured Marble Urn Engraved acknowledgment cards Veterans Register Book Laminated Obituary 5225.00 5260.00 56.00 $28.00 $9.00 .----._---------- 5528.00 $2468.00 ====...,========>1.... CASH ADVANCES ., 5445.00 575.00 $16.00 --------~._------ 5536.00 $3004.00 Opening Grave ClergylMass Offering Certified Copies of the Death Certificate =============0...==== Total 53004.00 HISTORY 1211212GO 1 payment from Monumental Life Total Interest! Amount Received: $-2220.00 -------------- 5-2220.00 ==============,,=== S784.00 TOTAL OUTSTANDING BALANCE AS OF 01103/2002 5784.00 ~':':' ~SM ""<ONA< ~ $ElECTfD """""'"' Terms: Net 30 days. A service charge of 1.5% per month or an annual percentage of 18% will be added to the unpaid balance beginning 60 days from the date of the Funeral Purchase Agreement. "People you can count on" RECEIPT FOR PAYMENT ------------------- ------------------- Cumberland County - Register Of wills Hanover and High Street Carlisle, PA 17013 ' JEFFERSON MIGNONNE H File Number 2002-00725 Remarks AHRENS SARA ANN SK tHv1\'G ~YtJ-:::".:JLjO Recetpt Date Rece~pt Time Receipt No. 8/13/2002 11:44:34 1030213 ------------------------ Distribution Of Receipt ------------------------ Transaction Description PETITION FOR PROBA SHORT CERTIFICATE EXTRA PAGES JCP FEE Payment Amount 40.00 6.00 3,00 5.00 Check# 10327 Total Received. ... ..... $54.00 $54.00 f.)Lll\ltr fCi. If;:} ~ , ----- ';'(i,~~ Payee Name CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M,D REV.1S12EX+(1-97) _.'.~" - -_.~ ~~ SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS f'ih <"I\IMNf. FILE NUMBER ~~()~ - 00 1.1-'(' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT OECEDENT ESTATE OF -:r ~f-F(,~ <Jl N Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT ~\:)"''''\:ll\l w(.<\LTI1 Of P A (StE.. A'1JA.C1H-D) 31., "90. ~Gl ~ Qvt..N/lJ.I'l\ (S(~ 1\ S,,> ClCo , A, t 5 A"'/A.~H'l.0 3(.,.13""0 TOTAL (Also enteron line 10, Recapitulation) $ :3').../):/.(,. 3<:;, (If more space is needed, insert additional sheets of the same size) *' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 January 25, 2002 SALLY AHRENS 21 S 26TH STREET CAMP HILL PA 17011-4612 Re: MIGNONNE JEFFERSON CIS #: 370149835 SSN: 183-44-7710 Date of Death: 10/16/2001 Dear Ms Ahrens: Please be advised that the Department of Public Welfare is attempting to recover the mone~ary value of any and all eligible assets in the subject estate. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Your responsibilities, as the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to insure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public Welfare maintains a claim in the amount of $37,690.36 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 491 62 P.S. 14121 effective August 15, 1994, as amended by Act 20-951 effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $16,464.18, was incurred during the last six months of the decedent's life; therefore 1 it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estatesl and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $21,226.18, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estatel please provide copies of the deedl the latest tax assessment and a current appraisal, if available. Sincerely, CaJ. Jj. ~ Carl G. Rinkevich TPL Program Investigator 717-772-6258 717-772-6553 FAX Enclosure . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPl SECTION. CASUALTY UNIT PO BOX 8466 HARRISBURG PA 17105-8486 January 24, 2002 STATEMENT OF CLAIM SUMMARY Estate of JEFFERSON, MIGNONNE ID 370 149 835 MEDICAL. CLASS 3 CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 15,524.93 20,125.72 35,650.65 DRUG 939.25 1,100.46 2,039.71 . REIMBURSEMENT TO DPW 16,464.16 21,226.16 37,690.36 ., I . COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 ~ STATEMENT *** QUANTUM IMAGING & THERAPEUTIC ASSOCIATES, INC. BILLING OFFICE 1 A97 FOR SERVICES RENDERED AT: 2527 CRANBERRY HIGHWAY MXI MOBILE WAREHAM, MA 02571-5010 5120 LANCASTER STREET 800 299 9770 1 508 295 5556 HARRISBURG PA 17112 PLEASE KEEP THIS PORTION FOR YOUR RECORDS. . EIN: 25-1792806 *****FIRST-CLASS AUTO***5-DIGIT 17011 MIGNONNE JEFFERSON A97*737822*724*00 21 S 26TH ST CAMP HILL, PA 17011-4612 1...111...111......11...11.1..1.11.....11..1,1..1,1...11,1.,11 PA YMENTS RECEIVED AFTER BILLING DA TE WILL NOT APPEAR ON THIS STA TEMENT. PATIENT MIGNONNE JEFFERSON ACCOUNT NUMBER BilLING DATE BALANCE NOW 737822A97 05/27/02 . 36.0: DATE OF I PROCEOURE I ICD9-eM I DESCRIPTION OF SERVICE I AMOUNT' SERVICE CODE CODE , 05/21/01 7101026 t1EDICAR SERVICE 162.9 HAS D NEED CHEST SINGLE VIEW NIED CLAIM AS A NON-COVERED ROUTINE OCTORS LETTER OF NECESSITY FOR PROCE~ 36. o~ ING. . *1F 1NSUR '.t.ICE INF RMATIDr. BELO~J IS HICORRECT, PLEP,SE PRO\!IDE REV.1513 EX+ 11.97) *' SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESJDENT DECEDENT FILE NUMBER ." <:l o:z. - Co RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) NUMBER I. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. fuCNt. ~s AMOUNT OR SHARE OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. AJoN'V 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1'00rvv TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, Insert additional sheets 01 the same size) CERTIFICATION OF NOTICE UNDER RULE 5.6(al Name of Decedent: ~ ~F F~ 1~5~_ ~ ~b ~ N ~ Date of Death: ~G'T I ~^ ®, Will No. ~.00~ ~ n0~ d ~ Admin. No. ~,f' ~ o~ 1 ~~ To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the O hans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on _ 0~- I ~~ o+ Name d P ~i~R~~A~, of ~iivAryc~aL O~~AA~rlu~ts 1~1DS-g~l~~ Notice has now been given to all persons entitled thereto under Rule 5.6(a) except mow, ~~~ Date: Address Signature Name SARA ~ ~t.+i ~ ~~ N ~ Address ~_~`~~~-y ~ ~~'~ ~.. Ain ~ H r ~~. ! q..,, 1 ~ O) )- y 6) ~ Telephone (~(~) ~ "~ ~ .- Q~ Capacity: X Personal Representative Counsel for personal representative ~~-~~~ 6 COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 NOTICE OF INHERITANCE TAX HARRISBURG, PA 17128-0601 APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 E% ~FP (01-02) DATE 11-04-2002 ESTATE OF JEFFERSON MIGNONNE H DATE OF DEATH 10-16-2001 FILE NUMBER 21 02-0725 COUNTY CUMBERLAND SARA ANN AHRENS ACN 101 21 S 26TH ST Amount Remitted CAMP HILL PA 17011 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT H OUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ----------------------------- -------------------- --------------------------------------------------------------- REV-1547 EX AFP (01-02) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF JEFFERSON MIGNONNE H FILE N0. 21 02-0725 ACN 101 DATE 11-04-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) 5,417.48 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (47 .00 of this fora with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 4,212.94 tax payment. 6. Jointly Owned Property (Schedule F) (6) .0 0 7. Transfers (Schedule G) (7l .00 8. Total Assets (g) 9,630.42 APPROVED DEDUCTIONS AND EXEMPTIONS: 3,118.00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 37,726.36 11. Total Deductions (11) 40.844.36 12 . Net Value of Tax Return (12 ) 31, 213.94 - 13. Charitable/Governmental Bequests; Nonelected 9113 Trus ts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 31,213.94- NOTE: If an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 00 00 .00 15. Amount of Line 14 at Spousal rate (15) • = X 16. Amount of Line 14 taxable at Lineal/Class A rate (16) • 00 X 045 = . 00 17. Amount of Line 14 at Sibling rate (17) .00 X 12 = .00 18. Anount of Line 14 taxable at Collateral/Class B rate (18) •0 0 X 15 = .00 19. Principal Tax Due (19)= .00 Twv rnrnrr~. rnrncn) I nL{.Glr ~ I ~~~~~~~~~ • • , I AMOUNT PAID _-~ DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RESERVATION: Estates of decedents dying on ar before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class 8 (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. PURPOSE OF NOTICE: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.S. Section 91407. PAYMENT: Detach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side. --Make check or money order payable to: REGISTER OF HILLS, AGENT REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application far Refund of Pennsylvania Inheritance and Estate Tax^ CREV-13137. Applications are available at the Office of the Register of Wills, any of the 23 Revenue District Offices, or by calling the special 24-hour answering service far forms ordering: 1-800-362-2050; services for taxpayers with special hearing and / or speaking needs: 1-800-447-3020 (TT only). OBJECTIONS: Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount ar interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: Factual errors discovered on this assessment should be addressed in writing ta: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (7171 787-6505. See page 5 of the booklet ^Instructions far Inheritance Tax Return for a Resident Deceden Y' (REV-1501) for an explanation of administratively correctable errors. DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%) discount of the tax paid is allowed. PENALTY: The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6%) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are: Year Interest Rate Daily Interest Factor Vear Interest Rate Daily Interest Factor 1982 20% .000548 1992 9% .000247 1983 16% .000438 1993-1994 7% .000192 1984 11% .000301 1995-1998 9% .000247 1985 13% .000356 1999 7% .000192 1986 10% .000274 2000 8% .000219 1987 9% .000247 2001 9% .000247 1988-1991 11% .000301 2002 6% .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (157 days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. STATUS REPORT UNDER RULE 6.12 Name of Decedent: J C,~f~J2Shnl ~=C oNN Date of Death: OG"T Will No. ~0~~ -~ Ot1'7~5 Admin. No. ~,~- Q~- Q~ 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 J( 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 ~ No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. Date ~~_..~~o ~ ~~GC/ ignature s~~A AN~r A~R~~~ Name (Please type or print) '~, ~ S o u7N ~ ~o H S~' CA~r, P H r ~~. ~ A 1 ~ti-a- y Address Tel. No. Capacity: ~ Personal Representative Counsel for personal representative (MAH:rmf/AM3)