HomeMy WebLinkAbout02-0857
.
PETITI
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Estate of Ann a.e-J
a/so known as
N FOR PROBATE and GRANT OF LETTERS
gensen
No.
To:
71 07-R'i7
Sociat Security No. 15 -40-1462
Deceased.
Register of Wills for the
County of Cumberland in the
Commonwealth of Pennsylvania
The petition of the ndersigned respectfully represents that:
Your petitioner(s), w 0 is/are 18 years of age or older an the executor
in the last will of the a ve decedent, dated
and codicit(s) dated
July 10,
named
1995
,-
(. ate relevant circumstances, e.g. renunciation, death of exec~. etc.~~
Decendent was domi i1ed at death in Cumberland kJ"df 1'....N~'1tunty, Pennsylvania, with
her last family principal residence at 103 Green RIdge Lane,;. ewville, P A 17241
(list street, number and muncipality)
Decendent, then 93 years of age died April II , 192002
at West Pennsboro To 'p, Cumberland County, Pennsylvama
Except as follows, de edent did not marry, was not <;livorced and did not have a child born or adopted
after execution of the w II offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owed 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 ennsylvania
situated as follows:
$ 35,000.00
$
$
$
WHEREFORE, petit"oner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and he grant of letters testamentary
(testamentary; adminisrration c.t.a.; administration d.h.D.c.t.a.)
theron.
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OA H OF PERSONAL REPRESENTATIVE
COMMONWEALT OF PENNSYLVANIA t "
J :s:s
COUNTY OF Cum erland
The petitioner(s) abov -named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the b 5t of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above de edent petitione~(S) will well an;l-1rulyadmini ter the estate according to law.
Sworn to or afflrme and subscribed \1oJ. . '"
before me this 4th daY of . raig Jurge e ~.
S PTEMBER 20U2 ~
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No. 21-02-857
Estate of ANN Gf"ol,RE JURGENSEN , Deceased
DEeRE] OF PROBATE AND GRANT OF LETTERS
5E.pTEiIYl8ER.
AND NOW _ ~23 192002 ,in consideration of the petition on
the reverse side hereof, atisfactory proof having been presented before me,
IT IS DECREED that t e instrument(s) dated July 10, 1995
described therein be adm tted to probate and filed of record as the last will of
Ann c::Iaf<l.Jurgensen ;
and Letters testamentary
are hereby granted to J. raig Jurgensen
'~d/ /7} t'Yh to-h L:t~i'
Regist.er of Wills
FEES
Probate, Letters, Etc. .. ....... $ 70.00 James D. Flower, Jr.. #27742
Short Certificates( ).. 0 $ 9.00 ATIORNE'/ (Sup. Ct. I.D. No.)
....... 15.00
x-pages
Renunciation ......... ....... $ 26 West High Street, Carlisle, PA 17013
JCP $ 5.00 ADDRESS
TOT L_$ 99.00
.~ .200.2 . . . . . . . . . . 717-243-6222
Filed . . . SEI'.IEmlM . 2
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This is to certify that the informat on here given is correctly copied from an original certifIcate of death duly filed with me as
Local Registrar. The original cerci care will be forwarded co the State Viral Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Fee for this certificate,
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No,
APR 1 4 2002
Date
21-02-857
Hl05.1"31'\ft.2/17
COM ONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
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NAME Of' DECEDENT I'''', _.lMl
Ann
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Clare
Jur ensen
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Cumberland
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DECEDf:HT':!I...-.......aADOAl:.lSlIl<<.~.s..Zlp~
103 Green Ridge Lane
Newville ,Penna. 17241
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~.SIWoIEIF""."'jOl1rt Conrad
INl'OAMNfrSIWllE(1~
Charles A. Jur e
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arles A. Jurgensen
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West Pennsboro
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21-02-857
31ia t lIIill aub Wtstamtnl
OF
ANN C. JURGENSEN
I, ANN . JURGENSEN, of 103 Greenridge Lane, Newville, Cumberland
County, Pennsylvania being of sound and disposing mind, memory and understanding,
do make, publish a declare this as and for my Last Will and Testament, hereby
revoking and making void any and all former Wills, Codicils, or writings in the nature
thereof, by me at any time heretofore made.
FIRST: I hereby order and direct my Executor or Executrix, hereinafter
named, to pay all just debts, funeral expenses, testamentary expenses and all
Inheritance, Estate, ansfer and Succession Taxes, as soon as may be conveniently
done after my death, ut of my residuary estate.
: For many years, my husband, CHARLES A. JURGENSEN and
I had made contributi ns to the Rutgers University Foundation for the establishment of
the Charles A. Jurgen en Family Fund, also named the Jurgensen Family Fund. These
contributions include ash contributions and annuities made by Charles A. Jurgensen and
Ann C. Jurgensen f the establishment of the Jurgensen Family Fund and include
additional and subse uent funds, contributed or to be contributed, by other family
c:\wp51\wi1ls\jurgMCh.wil
members. All schol rship contributions made before the formal establishment of the
Family Fund have be n internally transferred at my husband's request to the Charles A.
Jurgensen Family Fu d. The Charles A. Jurgensen Family Fund is to be administered by
the Office of Financial Aid of Rutgers, the State University of New Jersey, in accordance
with terms and provis ons set forth in a statement entitled "The Jurgensen Family Fund'~
signed and dated Ju e 7, 1993, by Charles A. Jurgensen and Ann C. Jurgensen, and
June 14, 1993, by J. raig Jurgensen and Joan E. Jurgensen, which statement has been
accepted by Rutgers the State University of New Jersey. The Charles A. Jurgensen
Family Fund is an en owment fund, the income from which is to be used for scholarship
purposes. In recogn tion of the benefits which family members have received from a
Rutgers experience, I ive the sum of One Thousand ($1,000.00) Dollars, to the Charles
A. Jurgensen Family undo
THIRD: I make the following specific bequests:
to St. John's Episcopal Church, of Carlisle, Pennsylvania, the sum
of $1,000.00, for app ication to the St. John's Episcopal Church Endowment Fund. I
hereby direct that to t e extent that I may have a capital pledge to the building fund of the
church (however desi nated) which is unpaid, I direct that this One Thousand ($1,000.00)
Dollar gift be applied t said building fund to the extent necessary to complete my capital
pledge. Any portion t ereof remaining shall be applied to the St. John's Episcopal church
Endowment Fund.
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B. I give to the Greenridge Village Fund, an affiliated fund held by Presbyterian
Homes, Inc., the sun of Two Thousand ($2,000.00) Dollars.
: All the rest, residue and remainder of my estate, be it real,
personal or mixed, of hatsoever kind and wheresoever situate, I hereby give, devise and
bequeath to my husb nd, CHARLES A. JURGENSEN, provided he shall survive me by
thirty days.
FIFTH: In the event that my said husband shall fail to survive me by thirty
(30) days, and if und r the applicable circumstances at that time, and in accordance with
our agreement with P esbyterian Homes, Inc., there are residual unamortized funds in our
Health Care Investm nt Deposit held by Presbyterian Homes, Inc., which would be due
to my estate I hereb give any such funds to the Greenridge Village Fund, an affiliated
fund held by the Pre byterian Homes, Inc.
SIXTH: In the event that my said husband shall fail to survive me by thirty
(30) days, I hereby gi e, devise and bequeath aU the rest, residue and remainder of my
estate, be it real, pers nal or mixed, of whatsoever kind and wheresoever situate, in equal
shares, per stirpes, 0 my children, ALICE M. STRACK, of Titusville, New Jersey,
CHARLES A. JUR ENS EN, II, of Florham Park, New Jersey, and J. CRAIG
JURGENSEN, of Car isle, Pennsylvania.
I nominate, constitute and appoint my son, J. CRAIG
JURGENSEN, to be t e Executor of this my Last Will and Testament. Should my son be
3
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unable to act for a reason whatsoever, then I appoint my daughter-in-law, JOAN E.
JURGENSEN, to act as Executrix in his place and stead. No executor shall be required
to file bond in this or any other jurisdiction.
IN WIT
/{J d day of
have hereunto set my hand and seal this
,1995.
~/
SIGNED, SEALED, P BLISH ED and
DECLARED in the pr sence of:
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COMMONWEALTH F PENNSYLVANIA
COUNTY OF CUMB
ss
I, ANN . JURGENSEN, Testatrix, whose name is signed to the attached
or foregoing instru nt, having been duly qualified according to law, do hereby
acknowledge that I si ned and executed the instrument as my Last Will; that I signed it
willingly; and that 1 igned it as my free and voluntary act for the purposes therein
expressed.
Sworn r affirmed to and acknowledge
JURGENSEN, the Te tatrix, this ) n tJ-\ day of
/{
ANN C.
,1995.
L
NOTAIlIALSEAl
MERLENE MARHEVKA. NoWy PIllIi:
Catisle, CU_Coldy,Pll
Commiosion ElIpiH_
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COMMONWEALTH F PENNSYLVANIA
COUNTY OF CUMB
ss
We, JM-1ES D. FLOWER JR. and TERESA J. BURKHOLDER ,
the witnesses whose names are signed to the attached or foregoing instrument, being
duly qualified accord ng to law, do depose and say that we were present and saw
Testatrix sign and ex cute the instrument as her Last Will; that ANN C. JURGENSEN
signed willingly and t at she executed it as her free and voluntary act for the purposes
therein expressed; th t each of us in the hearing and sight of the Testatrix signed the Will
as witnesses; and th to the best of our knowledge the Testatrix was at that time 18 or
more years of age, 0 sound mind and under no constraint or undue influence.
Sworn or affir
ed to and subscribed to before me ~ JAMES
. this 1 -t..YI
,1995.
D. FLOWER, JR.
day of
NOTARIAl SEAl
MERLENE MARHEVKA. NoWy PlAlI~
Carlillo, CU_Cold'(, Po.
My Commiosion ElIpiH 6IMl8
6
;
CERTI ICATION OF NOTICE UNDER RULE 5.6 a
Name of Decedent:
Date of Death:
Estate No.:
To the Register:
ANN C. JURGENSEN
April 11, 2002
21 - 02 - 0857
I certify that no ce of the beneficial interest estate administration required by Rule
5.6(a) of the Orphan's Court Rules was served on or mailed to the following beneficiaries
of the above-captione estate on October 25, 2002.
Name
Address
Charles A. Jurgensen amily Fund
Rutgers, The State Un versity
of New Jersey
542 George Street
New Brunswick, NJ 08901
St. John's Episcopal C urch
Greenridge Village
Charles A. Jurgensen
North Hanover Street, Carlisle, PA 17013
410 Big Spring Road, Newville, PA 17241
103 Greenridge Lane, Newville, PA 17241
Notice has now been g ven to all persons entitled thereto under Rule 5.6(a) except: None
Date: October 25, 20
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Name
Address
James D. Flower, Jr.
26 West High Street
Carlisle, PA 17013
Telephone (717) 243.6222
C pacity:
_ Personal Representative
...2L. Counsel for Personal Representative
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. COMMONWEALTH OF
PENNSYLVANIA
. DEPARTMENT OF REVENUE
DEPT. 28060'
HARRISBURG. PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 - 02
00 85 7
COlJNTYCOOE YEAR
NUMBER
DECEDENT'S NAME (LAST, FIRST AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
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JURGENSEN, ANN C.
DATE OF DEATH MM-DD-YEAR)
40
- 1462
DATE OF BIRTH (MM-OD-YEAR)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
04/11/2002 11/08/1908
(IF APPI..lCABLE) $UR\I\\llHG SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL)
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D9.litigationproceedsReceived
o 3. Remainder Retum (dIleolclealhprlor\o 12-13-42)
o 5. Federal Estate Tax Relurn Required
8. Total Number of Safe Deposit Boxes
o 11. Eleclionto lax under Sec. 9113(A) atlachScl'loo
D2.suPPlementalRelurn
D 4a. Future Interest Compromise l~ale olll-ollh ,nlr 12.12-82)
D7,DecedentMaintainedali....ingTrustattachacoP10fTNSl)
010. Spousal Po....erty Credit \~a\'ttl~u\hblllwllh12.31.111 ahdl.I.9Sj
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THIS SECTION MUST BE COMPLETED ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO
NAME COMPLETE MAILING ADDRESS
James D. Flower, Jr., Esquire
S~fj)~,A~&~fr,';\,;'i6wer & Lindsay
TELEPHONE NUMBER
717-243-6222 26 West Hi h Street, Carlisle, FA 17013
(1) $ 0.00
(2) $ 0.00
(3) $ 0.00
(') $ 0.00
(5) $ 34,995.00
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Clos'a\Y Hel\! Ccrpcralion, Partnership orSole-Prop(tetorship
4. Mortgages & Notes Receivable (Schedule 0)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(SChedule E)
(6) $101,731.85
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-ViI/os Trall'i>fers & Miscellaneous Non-Prohale properly
{Schedule G orll
(1) $0.00
(8) $ 136,726.85
8 Total Gross Assets (total lines t-7)
9. Funeral Expenses & AQmi!\islra\i'll! Costs (Schedule H)
(9) $ 3,783.00
(10) $ 0.00
10. Debts of Decedent, Mortgage Liabililies. & liens (Schedule 1)
11. Total Deductions (Iotal lines 9 & 10)
(11) $ 3,783.00
(12) $ 132,943.85
(13) 4,000.00
(14) $ 128,943.85
x .0 .2..- (15) $ 0.00
X.o 45 (16) $ 0.00
x .12 (11) $0.00
x ,15 1"1 $ 0.00
(19) $ 0.00
12. Net Value of Estale (Line 8 minus Line 11)
13. Charitatlle an\! Governmental l3equestsiSec 9113 Trusts for which an election to tn has not been
made (SChedule J)
14. Net Value SUbject 10 Tax (Line 12 minus line 13)
SEE lNSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RA rES
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15. Amountofline 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a){1.2)
$ 128,943.85
$
$
16. Arnoui'\\ 01 line 14lalCatlle at lineal rate
17. Amount ofUne 14 taxable atsiblin~ r;'l\e
18. Amount of line 14 taxable alcollateral rate
19. Tax Due
200
CHECK HERE IF YOU ARE REOUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent's Complete Address:
STREETADDRESS 0 G Rid L
1 3 rcen ge ane
CITY Newville I STATE PA I ZIP 17241
Tax Payments and Credits:
1. Tax Due IPage 1 Line 19) (1) $ 0.00
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits IA+ B + C) (2) 0.00
3. Interest/Penalty if appllcable
O. Interest
E. Penalty
TolallnteresUPenal~ ( 0 + E ) 13) 0.00
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 (4) 0.00
5. ]fUne I + line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
B. Enter the lotal of Line 5 + SA This is the BALANCE DUE.
(5) $
(5A) 0.00
(\\31 $ 0.00
A. Enter the interest on the tax due,
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIA TE BLOCKS
. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; - - ~ - - - - - - ~ - . - - - - ~ - - - - - - - - - ~ - ~ - - - . 8 I
b. retain the right \0 designate who shall use the property transferred or its income; ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .
c. retain a reversionary interest; or_ . - - - - - - . - ~ - ~ ~ ~ ~ - - - - ~ - - - - - - ~ - - - - - - . - - . - . - - . - B
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? - . ~ - - - - - - - - - - - - . - - - - - - . - - - - - - - - - - - - - - . - - 8 181
3. Did decedent own an "in trust for"dfayable 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 t8J
IF THE ANSWER TO ANY OF THE ABOVE QUESTiONS is YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Und.r plnlltiu of p41jllry, \ lIK\a-r. that I lIav. .Xlmined this r.turn, includinll ac~mplnyinll scllldulh and stat.m.nts, ana to ttK 0",\01 my knawlldll' and blli." ills Inl', corr~t
and campl.lI.
Otelaration of pr.par.r olll" Illan Ill. plfSanal t.p{,""tatlv. \s baSld an ailln'ormatian or which pr.parer has Iny knowl.dll',
. /./'--
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10/01/2003
DATE
10/0 112003
17013
For dates of dealh on or after July 1, 1994 and Before January 1, 1995, the tax rate imposed on the net value of transfers to or to the use of the surviving spouse is 3%
{72 PS. 19116 ('I (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 sUlViving spouse is 0% 172 P .S. 99116 (a) (1.1) (ii)J.
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 sill! 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 twenly-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a slepparenl of Ihe child is 0% [72 RS. 19116(a)(1.2)1
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 RS. 99116(1.2) (72 RS. ~9116(al(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)J. A sibling is defined, under Section 9102, as an
indiv'lduar who has at least one parent in common with the decedent, whether by blood or adoption.
RE'."'~.".""".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESlOENT DECEDENT
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Ann C. Jurgensen
FilE NUMBER
21-02-00857
Include \he proceeds of lltigalion and the dale the proceeds were received by the estate. All property joilltly-owned wittl the fight of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
OESCRIPTION
Fanners National Bank, Certificate of Deposit No. 928
VALUE AT DATE
OF DEATH
$ 34,995.00
TOTAL (Also enter online 5, Recapitulation) $ 34,995.00
(If more space is needed, insert additional sheels of the same size)
"""'''''1''"1''.
COMMONWEM.TH Of f'ENNSYlIJMilil.
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
Ann C. Jurgensen
If an asset was made joint within one year of lhe decedent s date of death, It must be reported on Schedule G,
FILE NUMBER
21-02-00857
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Charles A. Jurgensen
210 Big Spring Road" Newville, PA 17241
B.
c
Husband
JOINTLY.OWNED PROPERTY:
LEITER DATE DESCRIPTION OF PROPERTY 'OF DATE OF DEATH
ITEM FOR JOINT MADE lne(lJo:It name (If linlllt:ia\ insli'!.llillll and banI! accolln\ number or similar iaenlilying number DATE OF DEATH DEeDS VALUEQF
NUMBER TENANT JOINT Attach dnd forjoinUy-heldrtal estate VAlUE QF ASSET INTEREST DECEDENTS INTEREST
I. A. Cadaret Grant, Account #43C 179983 $ 11,258.87 50% $ 5,629.43
2. A M & T Bank, Account No. 1188151 6,882.08 50% 3,441.04
3. A M & T Bank, Account No. 15004200080870 3,570.75 50% 1,785.39
4. A Farmers National Bank, C.D. #201 2,901.00 50% 1,450.00
5. A Merrill-Lynch, Account No. 2AR-24Jl9 38,405.00 50% 19,202.50
6. A Farmers National Bank, C.D. #996 25,000.00 50% 12,500.00
7. A Farmers National Bank, CD. #929 5,354.00 50% 2,677.00
8. A Farmers National Bank, CD. #208 1,000.00 50% 500.00
9. A Farmers National Bank, Account #18-119-6 2,901.00 50% 1,450.50
10. A M & T Bank, C.D. #9821 6,287.00 50% 3,143.50
II. A M & T Bank, C.D. #00194 24,915.00 50% 12,457.50
12. A 800 sh. Exxon Mobil @ $41.30/sh. 33,040.00 50% 16,520.00
13 A 120 sh. IBM @ $85 .60/sh. 10,272.00 50% 5,136.00
14. A 100 sh. Public Service @ $45.76/sh. 4,576.00 50% 2,280..00
15. A Kemper Annuity 27,101.00 50% 13,550.50
TOTAL (Also enter on line 6, Recapitulation) $ 101,731.85
(If more space is needed, insert additional sheets of the same size)
""'''".".,,''''.
COMMONWEALTH OF PENNSYLVANIA
INHERITI\NCE TAX RETURN
RESIDENT OECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Ann C. Jurgensen
FILE NUMBER
21-02-00857
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
I. pwing Brothers
2,409.00
B. ADMINISTRATIVE COSTS:
I. Personal Representative s Commissions
Name of Personal Representative (S) N/A
Social Security Number(sjl EIN Number of PersQrlal Rej)reser.\a\ive($)
SlreelAddress
City Slale Zip
Year(s) Commission Paid:
2. Attorney Fees ISaidis, Shuff, Flower & Lindsay I 1,275.00
3. FamHyExemplion: {if decedents address is nollhe same as claimant s, altach explanation}
Claimant n/a
S\leelMdress
City Stale Zip
Relationship of Claimanl to Decedent
4. Probate Fees
5 Accountant s Fees
6. Tax Return Preparers Fees
Register of Wills, Probate Fee 99.00
7.
TOTAL (Also enter on line 9, Recapitulation) I 3,783.00.00
(If more space is needed, insert additional sheets oflhe same size)
"""un,,,,,,,,,.
COMMONWEALTH OF PENNSYLVANIA
IKKERITANCe TAX RElURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OFESTATE
1- TAXABLE DISTRIBUTIONS (include outnghl spousal dislnbulions)
I. Charles A. Jurgensen Surviving Spouse Residuary Estate
ID Big Spring Road
Newville, PA 17241
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES IS 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- Green Ridge Village Fund $ 2,000.00
St John's Episcopal Church 1,000.00
Rutgers University 1,000.00
B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1-
TOTAL OF PART 11. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 4,000.00
(If more space IS needed, insert additional sheets of the same size)
v
i
STATUS REPORT UNDER RULE 6.12
Name of Decede t:
ANN C. JURGENSEN
Date of Death: A ril 11 2002
Will No. Admin. No. 21-02-00857
Pursu nt to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administra ion of the above-captioned estate:
1.
tate whether'administration of the estate is complete:
es X No
2.
representative
complete:
f the answer is No, state when the personal
reasonably believes that the administration will be
3.
If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final
account with th Court? Yes No
b. The separate Orphans' Court No. (if any) for
the personal re resentative's account is:
c Did the personal representative state an
account informa ly to the parties in interest? Yes X No
d
approvals of fo
Cerk of the Orp
Copies of receipts, releases, joinders and
al or informal accounts may be filed with the
ans' Court and may be attached to this report.
C-J
Li~~
James D. Flower, Jr.
Name (Please type or print)
26 West High Street
C.~rl;slp., PA 17013
Address
Date: 10 01 03
". '
,-.,
CL
<'^I
I
;~..J
Cl
( 7171 243-6222
Tel. No.
~
'~
-.::~:
Capacity:
Personal Representative
(MAH: rrnfl AM3)
XX Counsel for personal
representative
\. /7-90 -....3
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRIS8URG~ PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEIlENT, ALLOIlANCE OR OISALLDIIANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
\ .'
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
i COUNTY
ACN
11-24-2003
JURGENSEN
04-11-2002
21 02-0857
CUMBERLAND
101
Anount R..itted
JAMES D FLOWER JR
SAIDIS ETAL
26 W HIGH ST
CARLISLE P
SQ
17013
'*'
REY-U41EltlR'Ul-lln
ANN
C
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CD COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS ...
REV=isiWEiC"FP-ciiFci3Y-N i"iCE--OF-yNHER-ii'ANCri'AX-APjiRAisEMEN:r,--"LL"OtiANCniR-----------------
DI ALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF JURGENSEN ANN C FILE NO. 21 02-0857 ACN 101 DATE 11-24-2003
TA RETURN liAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FU URE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A
2. Stocks and Bonds lSche 1. BJ
3. Closely Held stock/Part ership Interest (Schedule C)
4. Mortgages/Notes Receiv 1. (Schedule OJ
5. Cash/Bank Deposits/Mise Personal Property (Schedule E)
6. ~ointly Owned Property SChedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(S)
(6)
(7)
.00
.00
.00
.00
34.995,00
101. 731. 85
.00
(8)
APPROVED DEDUCTIONS AND E EMPTIONS:
9. Funeral Expenses/Adm. C sts/Misc. Expenses (Schedule K)
10. Oebts/Hortgage Liabilit es/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Ret rn
13. Charitable/Govern.en 1 Bequests; Non-elected 9113 Trusts (Schedule ~)
14. N.t Value of Est.te bject to Tax
(9)
(10)
3,783,00
.00
Ill)
(12)
(13)
(14)
NOTE: If an assess.ent
reflect figures t
ASSESSMENT OF TAX:
15. Amount of Line 14 at S
16. AItO...,t of Line 14 tax8bl
17. ~t of Line 14 at Sib
18. A.ount of Line 14 taxabl
19. Principal Tax Due
S'
NOTE: To insure proper
credit to your account I
sub.i t the upper portion
of this fo~ with your
tax payment.
136,726,85
3.78:'1 00
132,943,85
4,000.00
128,943.85
s issued previously, lines 14, 15 and,or 16, 17, 18 and 19 will
t include the total of ALL returns assessed to date.
128,943.85 X 00 =
.00 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
sal rat. (15)
.t Lineal/Class A rete (16)
ins rate un
et Collateral/Class Brat. (18)
AHOUNT PAID
DATE
NUHBER
INTEREST/PEN PAID (-)
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
. IF PAID AFTER DATE INDICATED, EE REVERSE
FOR CALCULATION OF ADDITIONAL NTEREST.
,00
.00
.00
.00
,00
.00
,00
.00
.00
IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A nCREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR TN~T.lrTT~ ,