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Home My WebLink About02-0846 Eswreof RUSSELL L. BREAM also known as PETITION FOR PROBATE and GRANT OF LETTERS No. :; J .. O;J. Cj4 UJ To: Register of Wills for the , Deceased. County of GUMBERLAND in the Social Security No. I ~ 7 - 22. - () i./ lJ. oS Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitionerCS), who isXat]{ 18 years of age or older an the execut R T X in the last will of the above decedent, dated NOVEMBER 20, 2001 and codicil(s} dated NONE named ,Jfgc_ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Qecendent was domiciled at death in CUMBERLAND h 1 S last family or principal residence at 89 BAL TMORE CUMBERLAND COUNTY PENNSYLVANIA Decendent,then 82 yearsofage,died SEPTEMBER 14, 2002 ,219.: at CARLISLE REGIONAL MEDICAL CENTER, CARLISLE, PENNSYLVANIA . Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: WO Nli' Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ (If not domiciled in Pa.) Personal property in Pennsylvania $ '715'. ,C)~. Db (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ 1 50 , 000 . 00 situated as follows: 89 BALTIMORE PIKE GAHUN~H~, P~NNSYLVANIA I/jl4 WHEREFORE, petitioner{q respectfully requesttslJ the probate of the last will and codiciI{9} presented herewith and the grant of letters TESTAMENTARY (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. ~. -~ \I) .., u c: '" ,,~ i~ REY : g~~~~;€, --~~- ~-. -~ a:~ Mr. 11-" Lt. Y SPAiN(;'$ J f>A '''(JIgS" 3~ r "''- =:;0 t;j c: 01) Vi ~~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA } ss COUNTY OF CUMBERLAND The petitioncr(&) above-named swear(B:) or affirm(~ that the statements in the foregoing petition are true and correct t6 th€ best of the knowledge and belief of petitioner{1$} and that as personal represen- tative(s) of the above decedent petitioner(ij will well and truly administer the tate according to law. ~ c>i)' :It t:l ~ ~ ~ No. 21-02-846 Estate of RUSSELL L. BREAM , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW SEPTEMBER 19, 2002 )djjx ,in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(~ dated NOVEMBER 20, 2001 described therein be admitted to probate and filed of record as the last will of RUSSELL L. BREAM and Letters TESTAMENTARY are hereby granted to JOYCE A. CAREY ~ ... FEES Probate, Letters; Etc. ......... $ Short Certificates( ).......... $ :bnllmliXl:i<<xl. extra. .page..s $ jcp $ TOTAL _ $ Filed 9 - 1 9 - 200 2 .... oatie'd' atty' '9~'i 9'-':2'00'2' and put in atty proth box 270.00 1~.00 12.00 5.00 302.00 DAVID A~ BARIC, ESQUIRE 44853 o I Bm~s~lfiEt. t?~~tlERER 17 WEST SOUTH STREET CARLISLEADDRESS PA 17013 (717) 249-6873 PHONE 9-19-2002 .....-~""" .:"...c t1JU).,'H!) Kt.,V 1)/86 This is to certifY that the information here given is correctly copied fro~ an original certificate of death dul~ filed with me as Local Registrar. The original certificate will be forwarded to the State VItal Records Office for permanent filIng. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~~.~~~L~ Local Registrar Fee for this certificate, $2.00 p 8608152 SEP 1 7 2002 Date H105. 143Rtw. 2187 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH 'IHT AGE (l"'_ 82 UNQER , YEAR - Ooys UHDfAfOll!f Hours ! M..,.".. sex l. Ma..ee SWI FIlf MJM8EA SOCIAl.. SECURITY NUM8ER .. 197 ---' 22 _ 0443 DA.TE Of OEATH IMonlh. 0.", ...) 9/14/2002 ~I Cumbelt.eand .. CaJtU-6.ee Calt.eio.ee Regiona.e Medica.e^ Cent~1t ""5 DECEDENT EYEA IN Il€CEDENT'S EDUCATION u.s, ARMEO FORCES? ...0 "'KK PA PLACEI7DEIJH~O"yQ1"8 ~onsl'UClIOntonoeMl"'" HOSl'tTAL ,-Q: ~o ENT >lK NAME Of DECEDENT If It". Midc:lte. Las, ,. RU.6.6e.t..e L. Blteam v... COUNTYOFOERH DECEDENT'S USUAl. OC:CUAOlOOOl (GNo....... _.............__ 1~XU....-'-) Canning FactOlttj . ".. 111t. DEC€DENT'S "'-'"'INGACOAESSlSO.... c..--. -. zo,~) OECEOENT'S 889 BaU.i.molte Pik.e ~=NCE GMdnelt.6 PA 17324 on~ MAArTAt. STATUS - Mamed ,...., MwriId. WidDwId. w'tdOrltd:" ~'~~Bli.ck.Whlt..eIC. '--'1 ,o. White SUAVMNG~ (It...... QMl"*'*' """* ,o. FRttEA'S NAME (F'.... Mickle. YtlJ 111.. CumbeJc.land ... - ...... -' "..0 ::... -==,:;::.. MOTHE.A"S NAME (Fit.. Mickle. Ma.den s..,.,.".) <:lluth Mirlrllr>tllYl ...... ,10._ _. ... M. 25. 27. """ 1: Encer Iftt diMII.... itliUritN or compicatioN wtlich ~ tM _ath. 00 not.... IN mode of dying, such I. eatdiK 01 rtsPitatOfy ",.. thaet Q( hUrt.....,.. ... oNIf ON cauN on HCh line. ORE SIGNED 111 L. -.Day.-. ..... ,.,{I/-3i7t;9S- . 9-/1./..;10();J" VMS CASE REFERRED TO MEOtCAL EXAMINERl'COROHEA? ....0 ...~ E ... I~. 'int.wI~ : onM ___...,. :.2 ciA Ho.tfT., 00ll0t___1O_.... ... rMufting in the ~,....... in PARt t. DUE 10 lOA AS .CONsEQUENCE Oft. WERE AU10PSY FIHOING$ -....n.E PAIOR 10 ~OF~ CJI: DERH? MAHNER OF DEAT11 ...0 - -.. - ~ o DArE OF lHJUFlY ,-, Cloy,-, TIME. OF INJURY INJURY R W()AK? OESCRMSE HOW' W4J\.IRY OCCURRED. - o o o Pl..AC1E OF INJURY. AI hcJrM. famt....... tldory. otf'QI M. -....- .... .... 0 ...0 ....0 -- Co\lId _ be deUrnwned 'MEDICAL EXAMIHEAICOftOHEA Oft the M.. of namlnetlon and/or Inyestlg.tion,ln my opinion. d.ath occurr" at the "me, date, and pI.u. anet due to the c....{.) and tnafU'teru.tatM..,.,.....,.......,...........,.................................................................. . ".. REGtSTRAA'S SIGNATURE AND N ~.~~~ 1~1 \~ \101 ... dCP~ - .... CIIn'....,~ ontor onet .cunlFYlMO"",SlCIAN(Ph'(SIC.-neenl)olngCllUNt:JdnIh -'*'~ Df\WC,*,heSpl'~dealha/'lOC:~ n8'ft23) ,..........fftYknoWliIdglt.*athOCCUrTecl,........c.UM{.).nd"'........,.....ted.,.................,. ........................,....... 39. "fttIIOHOUHCfHQ AND eEJtT""'tNQ 'HYStCIAM t~ boItl pranounong 0Mth Mw:J~ IOcauw Ol' de8lhl Tolhe bMlof "" 1Ilno..... ..... occurred.... _, date. and pIKe, and d.-e to ....caVM(.).nG1 manne,.. .,.tltd.........., ................ ~ LAST WILL AND TESTAMENT OF RUSSELL L. BREAM 21-02-846 I, Russell L. Bream, of Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking all other wills and codicils heretofore made by me. FIRST I direct the payment of my debts and the expenses of my last illness and funeral from my estate as soon after my death as conveniently may be done. If there be no cemetery lot available for my interment, owned by me at the time of my death, I authorize my personal representative to purchase such cemetery lot with a contract for perpetual care, using therefor funds from my estate, and I authorize my personal representative to cause title to or ownership of such lot so purchased to be vested in such person as my personal representative shall designate. Further, in this connection, I authorize my personal representative to expend funds from my estate, in such amount as my personal representative shall consider necessary and desirable, for the purchase, erection and inscription of a suitable marker for my grave. SECOND I give, devise and bequeath my entire estate of whatever nature and wherever situate to Joyce Arlene Carey, if she shall survive me by thirty (30) days. In the event she predeceases me or fails to survive me by thirty (30) days, then I give, devise and bequeath my entire estate to Larry Ray Carey if he shall survive me by thirty (30) days. In the event he predeceases me or fails to survive me by thirty (30) days, then I give, devise and bequeath my entire estate to Dawn Lynn Jumper. THIRD I direct that no executrix or other fiduciary named, nominated, or appointed by this my Last Will and Testament shall be required to post any bond or give any security of any type for any purpose whatsoever, any law or rule of the court of the Commonwealth of Pennsylvania or any other jurisdiction to the contrary notwithstanding. I direct that the law of the Commonwealth of Pennsylvania shall apply to any interpretation or application of the validity of this instrument. FOURTH My executrix and trustee shall have the following powers in addition to those vested in them by law and by other provisions of this Will, applicable to all property, real, personal or mixed and wheresoever situate, including property held for minors, whether principal or income, exercisable without court approval, and effective, with respect to each item of said property until actual distribution thereof. A) To retain, as investments of my estate or trust, any or all assets of my estate, real, personal, or mixed, without regard to any principal of diversification, and to purchase and acquire real or personal property and to hold any or all of such real and personal property retained or acquired without making the same productive of income. B) To permit the children, or any of them, to occupy any real estate retained or acquired upon such terms and conditions as my executor or trustee shall deem proper. C) To pay all taxes, charges and expenses of maintenance, upkeep, improvements, development, protection, preservation and investment of any retained or acquired real or personal property, such payments to be made from either principal or income as my executor or trustee shall determine. D) To retain or invest any and all funds, whether principal or income, in any real or personal property without restriction to legal investments; to purchase investments at premiums; to exercise all rights of a security holder or share holder in any corporation; and to lease, mortgage, pledge, give options upon or sell at public or private sale and without approval of any court, any real or personal property, or portion or portions thereof, irrespective of the manner or the means by which the same was acquired by my said executor or trustee. E) To make payment or distribution herein provided for in cash, kind or partly in cash and partly in kind, at valuations fixed by my executor or trustee at the time of distribution. FIFTH Any and all payment or payments of any sum or sums, whether in cash or in kind and whether for principal or income, payable to an heir, or any of them, shall be made upon the sole receipt of the respective individual to whom the payment is made, and free from anticipation, alienation, assignment, attachment, and pledge, and free from control by the creditors of any such beneficiary. SIXTH I appoint Joyce Arlene Carey, Executrix of this my Last Will and Testament. Should my said Executrix fail to survive me or for any reason fail to qualify as Executrix, then I appoint Larry Ray Carey, Executor of this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of four (4) typewritten pages, the first three (3) of which bear my signature in the margin for the purpose of identification, this 20th day of November, 2001. ~ a-~ ~A/YYL; Russell L. Bream (SEAL) Signed, sealed, published and declared by the above named testator, Russell L. Bream, as and for his Last Will and Testament, in the presence of us, who, at his request, in his sight and presence, and in the sight and presence of each other, have hereunto subscribed our names as witnesses. /.y;{ ADDRESS /1#. ~.v~ alt03 ~ ~. c$~i\.f)/G ADDRESs6/7 N. Walnut }'t., "-'it. H-o{ly Spgs; PA (70<06 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND We, Russell L. Bream, ~ d. ~ and ~~~ the testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument of his Last Will and Testament, and that he signed willingly and that he executed as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the Will as witnesses, and that to the best of their knowledge, the testator was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. Sworn to and subscribed before me this 20th day of November, 2001. %~Pd Notarial Seal Jennifer S. Linds2Y, i\iotary Public Carlisle 80'0, Cumberland COU;ltv I My Comrnisslon ExpirE'::~ ['.4G\f, 29. 260:3 ) ;V7fATItJer, p;;~;Y!iJ2~;;;;t~r;~'.;_~;:~'>_~ . CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Russell L. Bream Date of Death: September 14,2002 02/ - O~ - fs-LJIo 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 Name Address Joyce A. Carey One Tee Jay Drive, Mt. Holly Springs, Pennsylvania 17065 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except NONE Date: September 25, 2002 David A. Baric, Esquire O'Brien, Baric & Scherer 1 7 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Capacity: Personal Representative x Counsel for Personal Representative ~ Law Offices O'BRIEN, BARIC & SCHERER 17 West South Street Carlisle, Pennsylvania 17013 Robert L. O'Brien David A. Baric Michael A. Scherer (717) 249-6873 Fax (717) 249-5755 E-mail: obs@obslaw.com direct: dbaric@obslaw.com November 22, 2002 Register of Wills Cumberland County 1 Courthouse Sq. Carlisle, P A 17013 RE: Estate of Russell L. Bream File No. 21-02-0846 Dear Register: Enclosed find a check payable to Register of Wills, Agent in the amount of $10,000.00 paid as estimated inheritance tax for the above estate. Thank you for your attention to this matter. Very truly yours, ?J:::Ji ?J:RER David A. Baric, Esquire cc: J. Carey ,,--!.-: COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BARIC DAVID A ESQ 17 WEST SOUTH ST CARLISLE, PA 17013 ------~- fold ESTATE INFORMATION: SSN: 197-22-0443 FILE NUMBER: 2102-0846 DECEDENT NAME: BREAM RUSSELL L DATE OF PAYMENT: 11/22/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 09/14/2002 NO. CD 001878 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $10,000.00 I I I I I I I I TOTAL AMOUNT PAID: $10,000.00 REMARKS: DAVID A BARIC ESQUIRE CHECK# 119 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS MARY C. LEWIS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BARIC DAVID A ESQ 1 7 WEST SO UTH ST CARLISLE, PA 17013 ---.---- fold ESTATE INFORMATION: SSN: 197-22-0443 FILE NUMBER: 2102-0846 DECEDENT NAME: BREAM RUSSELL L DATE OF PAYMENT: 04/15/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 09/14/2002 NO. CD 002450 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $515.00 I I I I I I I I TOTAL AMOUNT PAID: $515.00 REMARKS: DAVID A BARIC ESQUIRE CHECK# 141 SEAL INITIALS: AC RECEIVED BY: REGISTER OF WILLS DONNA M. OTTO DEPUTY REGISTER OF WILLS ~'i-'500 EX ie-D"I 1'7- .?9- ? / ()FFi::~_\i.. -.;St C,'-J~"f REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT W" COMMONWEALTH OF PENNSYLVANIA ,~ . DEPARTMENT OF REVENUE . DEPT 2B0601 HARRISBURG, PA 1712B-0601 ...." - FILE NUMBER 2 1 _ 0 2 o 8 4 6 COUNTYCQDE YEAR NUMBER I- Z W C W U W C DECEDENTS NAME (LAST, FIRST AND MIDDLE INITIAL) Bream, Russell L. 0443 SOCIAL SECURITY NUMBER 197 ~ 22 DATE OF DEATH (MM-DD-YEAR) September 14, 2002 DATE OF BIRTH (MM-DD.YEAR) October 6, 1919 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) None w >- ::.:~IJ') :.Jtt::::.: wo.u ",00 u"'~ 0."' 0. " ~ 1. Original Return o 4. Limited Eslate o 6. Decedent Died Testate (Artach copy of WOII) o 9. Litigation Proceeds Received o 3. Remainder Return ;dale of deatn prior to 12.t3-82i o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) {AltachSchO) D 2. Supplemental Return D 4a, Future Interest Compromise (date 01 death after 12.12.82) D 7, Decedent Maintained a Living Trust (Atlacr copy of Trust) D 10. Spousal Poverty Credit (dateordeath~etween 12.31.91 and 1-1-95) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENt: '~ ,t:otIFIDEN1'IATAX INFORMA110NSHOULD BE DIRECTED TO: NAME David A. Baric, Esquire COMPLETE MAILING ADDRESS >- z w C z o 0. '" W '" '" o U 17 West South Street Carlisle, Pennsylvania FIRM NAME (II Applicablei O'Brien, Baric & Scherer TELEPHONE NUMBER ( 717) 249-6873 17013 O~-f:l( i.:..L 'Gs~ o~L.y" 1. Real Estate (Schedule A) 2. Slacks and Bonds (Schedule B) (1) 131,370.00 (2) 0.00 (3) 0.00 (4) 0.00 (5) 59,921.87 (6) 13,774.24 (7) 54,128.49 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) z o < ..J ::::l l- e:: <( u w 0:: 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property (Schedule G or L) 259,194.60 8, Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (B) 21,276.68 0.00 (9) (10) 11. Total Deductions (total Lines 9 & 10) 21,276.68 237,917.92 0.00 (11) (12) (13) 12. Net Value of Estate (Line 8 minus Line 11) 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) 237,917.92 (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ I-' ::::l a.. :::E o U ~ 15. Amount of Line 14 taxable at the spousal lax rate, or transfers under See, 9116 (a)(1.2) x.O_ (15) x .045- (16) 10.574.00 x .12 (17) x ,15 (IB) 441 00 (19) 11.015.00 234.977.g;> 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 2,940.00 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 > > BE SURE TO ANSWER ALL QlIl!l!l1QtllI, SESIDEAADRECIfl!CK MATH < < Decedent's Complete Address: STREET ADDRESS 889 Baltimore Pike .,. ~, CITY Gardners I STATE PA I ZIP 17324 Tax Payments and Credits: 1. Tax Due (Page 1 Une 1 g) 2. Credils/Paymenls A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 11,015.00 10,000.00 500.00 Tolal Credils (A + B . C ) (2) 10, 500 . 00 3. InleresUPenally if applicable D. Interest E. Penally TolallnleresUPenally ( D . I (3) 4. If Une 2 is greater Ihan Une 1 + Une 3, enter Ihe difference. This is Ihe OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Une 1 + Une 3 is grealer Ihan Une 2, enter Ihe difference. This is Ihe TAX DUE. 515.00 A. Enter the interest on the tax due. (5) (5A) B. Enler Ihe lolal of Une 5 + 5A. This is Ihe BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. relain Ihe use or income of Ihe property transferred; .......................... ..................................... . ... ............... 0 ~ b. retain the right to designate who shal! use the property transferred or its income; .......... ......... .....,................ 0 ~ c. retain a reversionary interest; or ............... ............................................................................. ...... .................... 0 IX) d. receive the promise for life of either payments, benefits or care? ................................................ ... ..............,. D ~ 2. If death occurred after December 12. 1982, did decedent transfer property within one year of death without receiving adequate consideration? . ...........,.... 0 ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ............. D ~ 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 pel1alties of perjury. I declare that I ha~e examil1ed this re!um. il1c1uding accompal1ying schedules and slatemer.ts. al1d to the best of my knowledge and belief. it is true, correct and complete Declaration of pre parer other than the persol1al representati~e is based 011 all il1formation of which preparer has al1y knowledge olly Springs, PA 17065 DATE D4 15 fJ3 ADDRESS 17 West South Street, Carlisle, PA 17013 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii) 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 the surviving spouse is the only beneficiary. For dales of dealh 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 paren or a stepparent of Ihe child is 0% [72 P.S. 99116(a)(1.2)]. The tax rale imposed on Ihe nel value of Iransfers 10 or for Ihe use of the decedent's lineal beneficiaries is 4.5%, excepl as noled in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (72 P.S. 99116(a)(1.3)]. A Sibling is defined, under Section 9102, as a individual who has at least one parent in common with the decedent, whether by blood or adoption. REV.1502 EX+ (12.85) . SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Russell L. Bream FilE NUMBER 02-0846 (Property iointly~owned with Right of Survivorship must be disclosed on Schedule F) All real estate should be reported at fcrir market value which is defined as the price at which property would be exchanged between a willing buyer and a willing ,.n.r, neiiher being compelled to buy or sell, both having reasonable knowledge of the relevant fads. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 889 Baltimore Pike Gardners, Pennsylvania $131,370.00 17324 ASSESSMENT RECORD ATTACHED " TOTAllAlso enter on line 1, Recapitulation) (If more space is needed, insert additional sheets of same size.) S 131,370.00 REV-ISllEX.CI.f7) '* SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COM/.tONWEAI.Tli OF PENNSYLVANIA INHERITANCE T~ RET\lRH RESIDENT DEe DENT ESTATE OF Russell L. Bream FILE NUMBER 02-0846 Include the. proceed. of itigation and the date the proceeds were received by 1M estate. All property jolntly-owned with tII. rillhl of sUlYivo..hlp must be disclosed on Schedul. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. All America Financial Life Insurance & $ 34,406.16 Annuity Company Contract No. GN00133104 Beneficiary: Estate of Russell L. Bream 3. Adams County National Bank Checking Acct. No. 1360345 $ 2,000.00 $ 22,846.03 2. Miscellaneous Personalty 4. United States Savings Bonds (4) $50.00 each Series E, Issued March, 1979 Nos. L21613556665E, L2161355666E, S2161355669E and L2161355668E $ 669.68 TOTAL (Also enteron line 5, Recapitulation) $ 59,921.87 (If more scace is needed, insert addit\onal sheets of the same size) F<:,:"s':oS E~. (,.9., ,._ It ~~ 1f~~'ifii1.i~ ~~- CQI/,I,':!N'A'EA.L TH OF PEr.;rJSYlVANIA \f~HERI1 ,t.'\CE 1M. RETURN RESIDa.;T DECEDEt;r SCHEDULE F JOfNTL Y.OWNED PROPERTY ESTATE OF Russell L. Bream 02-0846 FILE NUMBER If an asset was made joint within one year of the decedent's date of death, It must be reported on Schedule G. SURVIVING JOINT TENA'H(S) t~AME RELATlO~jSHIP TO DECEDEt:r A Joyce A. Carey B. Larry Carey c. ADDRESS One Tee Jay Drive Mt. Holly Springs, PA 17065 One Tee Jay Drive Mt. Holly Springs, PA 17065 daughter son-in-law JOINTLY-OWNED PROPERTY: lEnEt<, O:.TE DSS:RIPTION OF PROPERTY ~OF DATE OF DEATH ITEM FC=<:.IOINT II...;;:JE Include name of financial instiliJtio': a.1d bank account number or similar identifying number_ Atta::h DATE OF DEATH DECO'S VAlUE Of NUMBER TENA~T JOINT deeCfof joinlty-he-\dreal estate VAlUE OF ASSET I~TERESr DECEDENT'S INTEREST 1. A PNC Bank Checking Account 9,634.21 50 4,817.05 No. 5140181176 2. A PNC Bank Savings Account 12,034.38 50 6,017.19 No. 5130331173 3. B 1995 Chevrolet PiCkUp 5,880.00 50 2,940.00 TOTAL (Also e,ter 0' line 6, Reoa?;lula:ion) $ 13,774.24 (17 rTlO'& S:.::;:;e is needed, insect adi\t;oila! she€.ts of the S3'T1e s\ze) REV"""~"""'*. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DEceDENT SCHEDULE G INTER.vIVOS TRANSFERS & MISC. NON.PROBATE PROPERTY ESTATE OF Russell L. Bream FILE NUMBER 02-0846 This schedule must be completed and fried W the answer to any of questions I through 4 on the lOve"" side of the REY.I500 COYER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME Of THE TlWWeRa nE.lR.P.EV.~$HlPTO~tlElfT HiDT'riC DAn Cf lfWlSFCR. DATE OF DEATH DECO'S EXCLUSION TAXABLE VALU ATT~HACOP't'OFTHEOEeOFORF/ElI.ESTAn:. VALUE OF AS"ET INTEREST IlFAF'PI.lCASLe\ NUMBER 1. Transferee: Joyce A. Carey 54,122.49 100 n/a 54,128.4 daughter Transfer: September 14, 2002 Allmerica Financial Life Insurance & Annuity Company Contract No. GNl30529 TOTAL (Also enter on line 7, Recapitulation) $ 54,128.49 .. 9 (If more spaoe lS needed, Insert additional sheets of the same size) ."""""",..n. ~THOfPEHHSY\.~"",,, INHERITANCE T~ RETURN RE IIlENTIlECE NT ESTATE OF Russell L. Bream SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 02-0846 DeblI of decedent mult be reported on Schedule l ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOllinger Funeral Home $ 7,848.80 501 North Baltimore Avenue Mt. Holly Springs, PA 17065 B. ADMINISTRATIVE COSTS: 1- Personal R.p....ntative'. CommisSions Name of PO/SO!1al R.presentative (.) Joyce A. Carey Social SeaJrtty Numbe~.) I EIN Number 01 PO/SO!1a' Representalive(.) StmetAddress One Tee Jay Drive City Mt. Holly ~pringc::: State PA Zip 17065 Yea~.) Commission Paid: 2, Attomey Fees O'Brien, Baric & Scherer $11,723.36 3. Family Exemption: (II decedenr. address is not the same as c1aimanr., attach explanation) Claimant None Street Address City Slate Zip R.latlon$l\ip of Claimant \D Dece<lont 4. Probate Fees $ 302.00 5, Accountanfs Fees 6. Tax R.tum Preparer. Fees 7. 2002-03 Personal Tax ( school) $ 10.00 South Middleton School District 8. 2002-03 Real Estate Tax (school) $ 1,392.52 South Middleton School District 9. Title Transfer Costs, 1995 Chevrolet S-10 pickup $ 121.00 TOTAL (Also enter on line 9, Recapitulation) $ 21,397.68 " <If more spa::e IS needed, IOsert addItIOnal sheets of \he same sIze} REV-151J EX. (1-91) '* SCHEDULE J BENEFICIARIES ESTATE OF NUMBER L COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Russell L. Bream NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distnbutions) 1. Joyce A. Carey One Tee Jay Drive Nt. Holly Springs, PA 17065 FILE NUMBER 02-0846 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) daughter AMOUNT OR SHARE OF ESTATE all of the rest, residue and remainder 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. 8. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. 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 of the same size) ~ LAST WILL AND TESTAMENT OF RUSSELL L. BREAM 21-02-846 I, Russell L. Bream, of Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking all other wills and codicils heretofore made by me. FIRST I direct the payment of my debts and the expenses of my last illness and funeral from my estate as soon after my death as conveniently may be done. If there be no cemetery lot available for my interment, owned by me at the time of my death, I authorize my personal representative to purchase such cemetery lot with a contract for perpetual care, using therefor ~ funds from my estate, and I authorize my personal representative to cause title to or ownership of such lot so purchased to be vested in such person as my personal representative shall designate. Further, in this connection, I authorize my personal representative to expend funds from my estate, in such amount as my personal representative shall consider necessary and desirable, for the purchase, erection and inscription of a suitable.marker.for my grave. SECOND I give, devise and bequeath my entire estate of whatever nature and wherever situate to Joyce Arlene Carey, if she shall survive me by thirty (30) days. In the event she predeceases me or fails to survive me by thirty (30) days, then I give, devise and bequeath my entire estate to Larry Ray Carey if he shall survive me by thirty (30) days. In the event he predeceases me or fails to survive me by thirty (30) days, then I give, devise and bequeath my entire estate to Dawn Lynn Jumper. THIRD """:!"-''''.:~r;:~~,~1t!! , I direct that no executrix or other fiduciary named, nominated, or appointed by this my Last Will and Testament shall be required to post any bond or give any security of any type for any purpose whatsoever, any law or rule of the court of the Commonwealth of Pennsylvania or any other jurisdiction to the contrary notwithstanding. I direct that the law of the Commonwealth of Pennsylvania shall apply to any interpretation or application of the validity of this instrument. FOURTH My executrix and trustee shall have the following powers in addition to those vested in them by law and by other provisions of this Will, applicable to all property, real, personal or mixed and wheresoever situate, including property held for minors, whether principal I( ,. or income, exercisable without court approval, and effective, with respect to each item of said property until actual distribution thereof. A) To retain, as investments of my estate or trust, any or all assets of my estate, real, personal, or mixed, without regard to any principal of diversification, and to purchase and .-acquire real or personal property and to hold any or all of such real and personal property-retained or acquired without making the same productive of income. B) To permit the children, or any of them, to occupy any real estate retained or acquired upon such terms and conditions as my executor or trustee shall deem proper. C) To pay all taxes, charges and expenses of maintenance, upkeep, improvements, development, protection, preservation and investment of any retained or acquired real or personal property, such payments to be made from either principal or income as my executor or trustee shall determine. D) To retain or invest any and all funds, whether principal or income, in any real or personal property without restriction to legal investments; to purchase investments at premiums; to exercise all rights of a security holder or share holder in any corporation; and to lease, mortgage, pledge, give options upon or sell at public or private sale and without approval of any court, any real or personal property, or portion or portions thereof, irrespective of the manner or the means by which the same was acquired by my said executor or trustee. I. E) To make payment or distribution herein provided for in cash, kind or partly in cash and partly in kind, at valuations fixed by my executor or trustee at the time of distribution. FIFTH Any and all payment or payments of any sum or sums, whether in cash or in kind and whether for principal or income, payable to an heir, or any of them, shall be made upon the .~ sole receipt of the respective individual to whom the payment is made, and free from anticipation, alienation, assignment, attachment, and pledge, and free from control by the creditors of any such beneficiary. SIXTH I appoint Joyce Arlene Carey, Executrixo!thismy Last Will and Testament. Should my said Executrix fail to survive me or for any reason fail to qualify as Executrix, then I appoint Larry Ray Carey, Executor of this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of four (4) typewritten pages, the first three (3) of which bear my signature in the margin for the purpose of identification, this 20th day of November, 2001. ~ ct ~,vYYt, Russell L. Bream (SEAL) Signed, sealed, published and declared by the above named testator, Russell L. Bream, as and for his Last Will and Testament, in the presence of us, who, at his request, in his sight and presence, and in the sight and presence of each other, have hereunto subscribed our .t( ,. names as witnesses. ADDRESS /1 It. ~.Y~alm ~ ';f(1l'~;i~ADD~~~517 N, VII al mil <;r" (vlt. H-oI!y Spgsi Pit 170105. - COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND We, Russell L. Bream, liJmli d. ~ and ~~~ the testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator .d;n~c1 :::..-:d executed theinstrurnent of his Last Wi!! and Testame!!t, llnd th~( 11e si~~ed willingly and that he executed as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the Will as witnesses, and that to the best of their knowledge, the testator was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. Sworn to and subscribed before me this 20th day of November, 2001. 'i , ~~~ Notarial Seal Jen~ifer S. Lindsay, Notary P~b!i9 . Carlisle .Boro, Cuml5ertand C6unfy My Comrrnsslon Exp:rer; Nev, 29. 200.3 Mt;;mber, PBrnSY~'1aniaA.s$.:x.:i3tI0n 0: N(~:;:"~ . Form-View - public tax file 2-4-2003.fp5 Page I of I Form View public tax file 2-4-2003.fp5 Home Help Search Ta~le View Viewing: 1 of 1 District_Number 40 ParceUdentlfier 40-15-0201-002 Map_Sufflx_Number House_Number 889 St",.. BALTIMORE PIKE Ow".'.Name.' BREAM, RUSSELL Owner_Nam8_2 Land_US8_Code R Property_Description & SR 0094 Living_Area 1405 Current_Land_Value 33140 Current_improvement_Value 98230 CUl'Tent_Total_Value 131370 Current_Preferred_ Value Acreage 6.00 CleanGreen_Status Taxable_OT_Exempt Sale_Amount Sale_Month Sale_Day Sale_Century Sale_Year Deed_Book_and_Page Year_Built 1958 http://205.247.227. 59: 591/FMResIFMPro?-db=public%20tax%20file%202-4-2003 .fp5&-op=bw&House%5... 2/12/03 . /?-c?9- J ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX Recoraed Rec..st.....,. '03 (jA TE ESTATE OF DATE OF DEATH FILE NUMBER JUN -6 1\11 :4IUNTY ACN 06-03-2003 BREAM 09-14-2002 21 02-0846 CUMBERLAND 101 DAVID A BARIC OBRIEN ETAL 17 W SOUTH ST CARLISLE ESQ '* REV-15~7 EX AFP lDI-D5) RUSSELL L Cis~rk."r Allount R_itted PA 1701Fumbe:t,3 .,,.....v. 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=iS4'-EXAFP--nff=oiY-NOYiCE-OF-YNHEififANCi-YAX-APP;firisEHENT~--Ai.U)WAiici-('-R----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BREAM RUSSELL L FILE NO. 21 02-0846 ACN 101 DATE 06-03-2003 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE 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 I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will r~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. A.ount 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 TAX C TS: (1) (2) (3) (4) (5) (6) (7) 131. 370.00 .00 .00 .00 59,921. 87 13.774.24 54.128.49 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/Governmental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) UO) 21.276.68 .00 Ul) (2) (3) (4) NOTE: .00 237,917.92 .00 .00 X 00 = X 045 = X 12 = X 15 = DATE 11-22-2002 04-15-2003 + INTEREST/PEN PAID (-) 526.32 .00 AMOUNT PAID 10,000.00 515.00 NUMBER CD001878 CD002450 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE NOTE: To insure proper credit to your aceount, subllit the upper portion of this forll with your tax paYllent. (8) 259,194.60 21.276.68 237,917.92 .00 237,917.92 (9)= .00 10,706.30 .00 .00 10,706.30 11.041. 32 335.02CR .00 335.02CR . IF PAID AFTER DATE INDICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSF !':.Tnl:' n", ...u..... p--.. --- ~ REV-1470 EX (6-88) INHERITANCE TAX EXPLANATION OF CHANGES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG PA 17128-0601 DECEDENTS NAME Russell L. Bream FILE NUMBER REVIEWED BY CHARLES WRIGHT ACN 2102-0846 101 ITEM SCHEDULE NO. EXPLANATION OF CHANGES Changed tax rate from 15 percent to 4.5 percent since a son-in-law is a lineal beneficiary. ROW Page 1 1'7-29', / ~ BUREAU OF XNDXVXDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT w REV-I"" EX AFP el1-05' DAVID A BARIC OBRIEN ETAL 17 W SOUTH ST CARLISLE ESQ '03 JUL 11 1~1l :29 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 06-23-2003 BREAM 09-14-2002 21 02-0846 CUMBERLAND 101 Allount Rellitted RUSSELL L (;1 S~(}.\ o.lIlJt:.Q:l3; . MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS. LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv=ii.'ifj-ix-AFP--{oY:oiY------...--iNHE"RITANc'E-fAx--sTAyEMEiif-o"F-ACCOUtiy--...--------------------- ESTATE OF BREAM RUSSELL L FILE NO.21 02-0846 ACN 101 DATE 06-23-2003 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-03-2003 PR I NCI PAL TAX DUE: ..._._........................................................................................_..............................._.................................................. ........_................... 10,706.30 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 11-22-2002 CD001878 526.32 10,000.00 04-15-2003 CD002450 .00 515.00 06-05-2003 REFUND .00 335.02- TOTAL TAX CREDIT 10,706.30 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 II! IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE 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 HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 8/03/2004 BARIC DAVID A ESQ 19 WEST SOUTH ST CARLISLE, PA 17013 RE: Estate of BREAM RUSSELL L File Number: 2002-00846 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register'of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 9/14/2004 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, GLENDA FARNER STRASBAUGH REGISTER OF WILLS CC: File Personal Representative(s) Judge STATUS REPORT UNDF.~ RULE 6.12 NameofDecedent: /~c°'~'(---L- L. f~::T&~ Dateof eath: &-oze-- oo No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State w~ether administration of the estate is complete: yes, Kl No ID 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: ao bo Did the personal ~resentative file a final account with the Court? Yes _ No The separate Orphans' Court No. (if any) for the personal representative's account is: .~ c. Did the personal re_~presentative state an account informally to the parties in interest? Yes ]~ No Co Copies of receipts, releases, joinders and approval of formjkl;pr informal accounts may be fi%with the Clerk/9~he ~t~,~s' Court and may be attached to thi~~~ Signature Blame '1 ddress Telephone No. Capacity: ~_.tPersonal Representative ,J~,Counsel for personal representative