HomeMy WebLinkAbout02-0967Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of Rachel T. Hoffman No, p~' - ~ ~-~0'~,
also known as
Deceased Social Security No. 192-34-7415
Peti[ionerlsl, who is/are 18 years of age or older, applylies) for:
(COMPLETE "A" OR "B" BELOW:)
A. Probate and Grant of Letters and aver that Petitioner is the executor named in the Last Will of
the Decedent, dated
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered
for probate; was not the victim of a killing and was never adjudicated incompetent:
B. Grant of Letters of Administration
Id. b.n.c.t. a.. pendente lire; durante absentia; durante minontate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse
lif anvl and heirs:
Name Relationship Residence
Charles Tittle Hoffman Son 2143 Augusta Drive
Evergreen, CO 80439
Sally Hoffman Stobbart Daughter 285 Deer Drive
Lusby, MD 20657
(See Accompanying Renunciations)
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County, Pennsylvania, with her last family or principal residence at Outlook Point
1100 Grandin Way, Mechanicsburo. PA 17055
(list street, number and municipality)
Decedent, then 91 years of age, died October 21,2002 , at Holy Spirit Hospital, Camp Hill PA
(Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property .......................... 5950,000
(If not domiciled in PA) Personal property in Pennsylvania ............ 5
(1f not domiciled in PA) Personal property in County ................ 5
Value of real estate in Pennsylvania ..................................... 5 -0-
Total ..................................................... 5
Real Estate situated as follows:
Wherefore, Petitioner(s) respectfully requestls) the probate of the last Will and Codicil(s) presented with this Petition
and the grant of letters in the appropriate form to the undersigned:
Signature Typed or printed name and residence
~„~-'~~
~ ,/~ ~
`~ `~'~ c ~` ~`~, "--~ Patricia Armstrong, Esquire
THOMAS, THOMAS, ARMSTRONG & NIESEN
212 Locust Street, Suite 500
P.O. Box 9500
Harrisbur , PA 17108-9500
roan nvv i rage i or ~ waupnin ~ountyl - nev. s/9z ' ~ ..- ~ ~ ` r--~
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and
correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent,
Petitioner(s) will well and truly administer the estate according tcylaw.
Sworn to and affirmed and ~tabscribed
before me this 2 5 t r~ day of
No. 2 1 -02-
Estate of Rachel T. Hoffman Deceased
Social Security No: 192-34-7415 Date of Death: October 21, 2002
AND NOW, OCTO):zER 29 , 2002 2002, in consideration of the Petition on the reverse side
hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters ^ Testamentary ~ of Administration
d.b.n.c.t.; pendente liter durante absentia; durante minoritate
are hereby granted to Patricia Armstrong 212 Locust Street Suite 500 Harrisburg PA 17101
in the above estate and that the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters ........................... $ 515.00
Short Certificate(s)....? $ 21 , 00
Renunciation ................ $ 1 0 . 0 0
~~
Register of Wills d~ ' V
Affidavit ( ) ................ $
Extra Pages ( )........... $
Codicil .......................... $ //~/(~
-- '//
JCP Fee ........................ $ 5 . 0 0 ~
Attorney:_Patricia Armstrong r
Inventory ...................... $ I.D. No: 23725
Other ............................ $ Address: 212 Locust Street Suite 500
Harrisburg, PA 17101
TOTAL ................ $ 551.00 Telephone: 717/255-7600
filed 10-29 -2002 mailed to atty 10-29-2002
F:\CLIENTS\MISC\Hoffman\Estate\Petition for Grant of Letters.wpd
OCTOEER _~- 2002
ARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
..
Rachel T._ __ _ Hoffman
Female 192-34--7415 ~, , 10--21-2002
Feb. 28, 1911 _ Harrisburg, PA
Holy Spirit Hospital Cumberland E.Pennsboro Twp.
White Homemaker No
__ ~ ~~=:_
~~,~
__
1100 Crandon Way
Widow ,, ~,,-,• Outlook Point Mechanicsburg PA 17055
,. Sally H. Stobbart - Sally A. Myers
David_Myers Funeral Home, Newport, PA 17074
_ __ ___ __
Septicemia
__ _ _ __
__
_.
-_ _
'•~. ~ XX
____
_.
~~ ,
.. G. Ergantner D.O.
820 Poplar Church Road, Camp Hill, PA 17011
• _._
___
Register of Wills of Cumberland County, Pennsylvania
RENUNCIATION
Estate of Rachel T. Hoffman No. ,~~ - ~ ;~- ~ ~ ~-
also known as
Deceased
The undersigned, Sally Hoffman Stobbart daughter of
(Relationship) (Capacity)
the above Decedent, hereby renouncels) tl~e right to administer the estate and respectfully requestls) that
Letters of Administration be issued to Patricia Armstrong Esquire
Witness hand this ~~~~t'"'day of ~~~,..J2-~-~. 2002
-- ~-~
(Signature)
Sworn to or affirm d n~i subscribed
before me this ~~~-- day of
October, 2002.
~ ~~ _ ~~~,
Notary Public
My Commission Expires:
(Address-
(Signature)
(Address)
Nofarisi Stvet
Yicloria R. Moore, NOtany Pu61i~
~y Of Harrisburg, Dauphin CotNKy
My formiission ExpM'a Ei~pt, 3,1QQ0
MMnbPx, Pamghrania AttOdriYAn
(Signature and seal of Notary or other official NOTE: Renunciations executed outside the Office of Register of
qualified to administer oaths. Show date of Wills are required in some counties to be notarized.
expiration of Notary's commission.)
Form RW-4 (Dauphin County -Rev. 9/921
Register of Wills of Cumberland County, Pennsylvania
RENUNCIATION
Estate of Rachel T. Hoffman No. _~ (' ~ j(- ~(p
also known as
Deceased
The undersigned, Charles Tittle Hoffman son of
(Relationship) (Capacity)
the above Decedent, hereby renouncels) the right to administer the estate and respectfully requestls) that
Letters of Adminis\t-ration be issued to_Patricia Armstrong Esquire
Witness YU.t, hand this ~~ dav,~ --~c ~~. ~? ~ 2 , 20
" 4/.,LGi ~ ~--~f/~
(Signature)
~%f `~~ ~7Gvs ~ 1~ ~~
(Address)
(Signature)
(Address)
(Signature)
Sworn to or affirmed a~subscribed
before me this 2.4 day of
October, 2002.
~~toua, ~, ~ ~ht~u,~
C~
(Address) --
Notary Public
Vicbrifl R. Moore, hlota~y PubMc
~Y of fig, ~AUpt>Iln Counq-
MY taorrrr~ssion E~iree Sept, 3, 2Q08
Mme, Penr~ylvania AssociaYon Of
(Signature and seal of Notary or other otficial
qualified to administer oaths. Show date of
expiration of Notary's commission.)
Form RW-4 (Dauphin County -Rev. 91921
My Commission Expires:
NOTE: Renunciations executed outside the Office of Register of
Wills are required in some counties to be notarized.
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Rachel T. Hoffman
Date of Death: October 21 2002
Will No. 2002-00967 Admin. No.
To the Register:
I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules
:vas served on or mailed to the following beneficiaries of the above--captioned state on November
1, 2002:
Name Address City, State Zip
Sally Hoffman Stobbert 285 Deer Drive Lusby, MD 20657
Charles Tittle Hoffman 2143 Augusta Drive Evergreen, CO 80439
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: November 1, 2002 ~ ~ ~~
Si nature
Name Patricia Armstrong Esquire
Address 212 Locust Street P.O. Box 9500
Harrisburg PA 17108-9500
Telephone (717) 255-7600 _
Capacity: X Personal Representative
X Counsel for personal
representative
Adopted April 30, 1992, to apply to decedents dying on or after July 1, 1992.
F:\CLIENTS\MISC\Hoffman\Estate\C E RT5.6A.wpd
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 002044
ARMSTRONG PATRICIA
212 LOCUST STREET
P O BOX 9500
HARRISBURG, PA 17108-9500
fold
ESTATE INFORMATION: ssN: 192-34-7415
FILE NUMBER: 2102-0967
DECEDENT NAME: HOFFMAN RACHEL T
DATE OF PAYMENT: 01 / 1 4/2003
POSTMARK DATE: 00/00/0000
couNTY: CUMBERLAND
DATE OF DEATH: 1 0/21 /2002
REMARKS:
CHECK#1002
SEAL
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 ~ $42,500.00
TOTAL AMOUNT PAID:
INITIALS: VZ
RECEIVED BY: DONNA M. OTTO
REV-1162 EX(11-96)
$42,500.00
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
/O(G~00(L ~('o~yy/ /O~L~I/I/ILV.L¢Yy / U. ~UQ¢Y /LO ~I/lLV// ~Ul.' ~/ ~'(~f~¢]~~~
U, ~~~~/°~~~~e4° ~~~lL ~~~~a4°(~66~~/°og° 4/fQ/G~ oLQU~
SUITE 500
212 LOCUST STREET
P. O. Box ~J500
HARRISBURG, PA 17108-9 5 0 0
www. ttanlaw. com
PATRIC[A ARMSTRONG CHARLES E. THOMAS
FIRM 1717) 255-7600 1913 - 1998)
Direct Dial: (717) 255-7627 FAX (717) 236-8278
E-Mail: parmstron~ttanlaw.com
January 14, 2003
Mary C. Lewis
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013-3387
In re: Estate of Rachel T. Hoffman
Date of Death: October 21, 2002
Social Security Number: 192-34-7415
File No. ~.02-00967
Dear Register of Wills:
Enclosed is a check in the amount of $42,500 for payment of Inheritance Taxes within the
discount period for the above referenced estate. Also enclosed is aself-addressed stamped
envelope for return of a receipt with respect to same.
If you have any questions, please contact the undersigned.
!!ery truly yours,
THOMAS, THOMA -ARMSTRONG & NIESEN
-~,, ,
Patricia Armstrong
Enclosure
F:\CLIENTS\MISC\Hoffman\Estate\Letters\030113 Reg. of Wills.wpd
~~ is-tea
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX BIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
CAROL S GROFF
1 CHELTON CIR
CAMP HILL
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REV-1547 EX AFP (01-03)
DATE 01-20-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
.FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
ACN 101
PA 17011 Anount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF SIMONIC JOSEPH J FILE N0. 21 01-0967 ACN 101 DATE 01-20-2003
TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule El
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
[1)_ 116,500.00
(2)_ 122,288.00
(3) .00
(4) .00
(5) 78,728.90
(6) .00
(7) .00
(8)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this fore with your
tax payment.
317,516.90
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 11,229.0 0
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .00
11. Total Deductions (11) ) 9.00
.
12. Net Value of Tax Return (12) 306
,287.90
13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) (13) .00
14. Net Value of Estate Subject to Tax (14) 306,287.90
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:
15. Anount of Line 14 at Spousal rate (15) .00 X 00 _ .00
16. Anount of Line 14 taxable at Lineal/Class A rate (16) 306,287.90 X 045. 13,782.96
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) .00 X 15 - .00
19. Principal Tax Due (lq)= 13,782.96
TAX CREi)iTS•
DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID
11-22-2002 CD001875 370.70- 14,153.66
TOTAL TAX CREDIT 13,782.96
BALANCE OF TAX DUE .00
INTEREST AND PEN. .O1
TOTAL DUE .O1
* IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED.
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
e wrruun crr orvrocr CT,\r nr T„T,. .-...... ~.... _..___..____.__ _
\.. BUREAU OF INDIVIDUAL TAXES COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 171zs-Dbol INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS REV-1604 EX RFP (01-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
CAROL S GROFF SSN/DC 186-03-5765
1 CHELTEN CIR ACN 01152748
CAMP HILL PA 17011-0000 Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ------- RETAIN LOWER PORTION FOR YOUR RECORDS -~
----------- -------------------------------------------------------------------------------
REV-1604 EX AFP (01-031
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~*
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152748
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 866504
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 07-08-1997
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
.00 NOTE:
X 0.166
.00
- .00
.00
X .15
.00
TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN A80VE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 0
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
COMMONWEALTH OF PENNSYLVANIA
sUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-obol INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS REV-1604 E% AFP coi-asp
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
CAROL S GROFF SSN/DC 186-03-5765
ACN 01152750
1 CHELTEN CIR .
Amount Remitted
CAMP HILL PA 17011-0000
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (O1-03)
~~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS **
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152750
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 2183679
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 05-08-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN A80VE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID C-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 00
IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
BUREAU OF INDIVIDUAL TAXES COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE 7AX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601 INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS REV-16U4 E% ~FP (31-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER Z1 01-0967
COUNTY CUMBERLAND
CAROL S GROFF SSN/DC 186-03-5765
ACN 01152756
1 CHELTEN CIR
CAMP HILL PA Amount Remitted
17011-0000
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-03)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~~
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152756
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 0079220169
TYPE OF ACCOUNT: ( ) SAVINGS (X) CHECKING ( ) TRUST C ) TIME CERTIFICATE
DATE ESTABLISHED 08-28-1964
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 0
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTioNS_1
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA I7IZ8-o6D1 INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS REV-1604 EX ~FP (D1-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
CAROL S GROFF SSN/DC 186-03-5765
1 CHELTEN CIR ACN 01152758
Amount Remitted
CAMP HILL PA 17011-0000
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-03)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS *~
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152758
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 2183577
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 03-10-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 0
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBl1RG, PA 17128-0601
CAROL S GROFF
1 CHELTEN CIR
CAMP HILL
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
REV-1604 E% -FP (D1-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
SSN/DC 186-03-5765
ACN 01152760
Amount Remitted
PA 17011-0000
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE------- RETAIN LOWER PORTION FOR YOUR RECORDS ~
------------- -------------------------------------------------------------------------------
REV-1604 EX AFP (O1-03)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~~
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152760
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 2183183
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST CX) TIME CERTIFICATE
DATE ESTABLISHED 03-30-1999
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.]
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
CAROL S GROFF
1 CHELTEN CIR
CAMP HILL
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
REV-1604 E% RFP (01-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
SSN/DC 186-03-5765
ACN 01152762
Amount Remitted
PA 17011-0000
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-03)
~~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~~
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.5/D.C. N0. 186-03-5765 ACN 01152762
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 0098203959
TYPE OF ACCOUNT: ( ) SAVINGS (X) CHECKING ( ) TRUST ( ) TIME CERTIFICATE
DATE ESTABLISHED 03-30-1999
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN A80VE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
REV-1477 EY (GRB)
INHERITANCE TAX
EXPLANATION
COMMONWEHLIN GF FCNNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENT'S NAME
Simonic Joseph FILE NUMBER
2101-0967
REVIEWED BY ACN
Emerson Luciano SEE BELOW
SCHEDULE I ITEM I EXPLANATION OF CHANGES
NO.
The above referenced ACN has been reduced to zero, as this account was reported
on the probate return.
ACN # 01152748, 01152750,01152756, 01152758, 01152760 and 01152762
Page 1
~...
~, BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280681
(+ARRISBURG, PA 17128-0681
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
SUSAN C THOMAS
RR 1 BOX 36
BLAIN PA 17006-0000
REV-1604 E% AFP (01-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
SSNiDC 186-03-5765
ACN 01152747
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
-----------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-03)
~* INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~~
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152747
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 866504
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 07-08-1997
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 0
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
.00 NOTE:
X 0.166
.00
.00
.00
X .15
.00
TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN A80VE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
SUSAN C THOMAS
RR 1 BOX 36
BLAIN PA 17006-0000
REV-1604 E% pEV [01-OS)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
SSN/DC 186-03-5765
ACN 01152749
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-03)
~~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~*
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152749
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 2183679
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 05-08-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID C-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
SUSAN C THOMAS
RR 1 BOX 36
BLAIN PA 17006-0000
REV-1604 EX AFP (Y1-037
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
SSN/DC 186-03-5765
ACN 01152755
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-03)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS *~(
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152755
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 0079220169
TYPE OF ACCOUNT: ( ) SAVINGS (X) CHECKING ( ) TRUST ( ) TIME CERTIFICATE
DATE ESTABLISHED 08-28-1964
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
SALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 0
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
BUREAU OF INDIVIDUAL TAXES
INHERITANCE 7AX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
SUSAN C THOMAS
RR 1 BOX 36
BLAIN PA 17006-0000
REV-1604 EX IFP (01-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
SSN/DC 186-03-5765
ACN 01152757
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-03)
~~ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~~(
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152757
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERUICE ACCOUNT N0. 2183577
TYPE OF ACCOUNT: C ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 03-10-2000
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 00
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
SUSAN C THOMAS
RR 1 BOX 36
BLAIN PA 17006-0000
REV-1604 EX RFP (01-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
SSNiDC 186-03-5765
ACN 01152759
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS -~
----------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-031
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~*
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152759
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 2183183
TYPE OF ACCOUNT: ( ) SAVINGS ( ) CHECKING ( ) TRUST (X) TIME CERTIFICATE
DATE ESTABLISHED 03-30-1999
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN A80VE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE 0
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
REV-1604 E% RFP (01-03)
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J
DATE OF DEATH 09-11-2001
FILE NUMBER 21 01-0967
COUNTY CUMBERLAND
SUSAN C THOMAS SSN/DC 186-03-5765
ACN 01152761
RR 1 BOX 36 Amount Remitted
BLAIN PA 17006-0000
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (01-03)
** INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS ~*
DATE 01-24-2003
ESTATE OF SIMONIC JOSEPH J DATE OF DEATH 09-11-2001 COUNTY CUMBERLAND
FILE N0. 21 01-0967 S.S/D.C. N0. 186-03-5765 ACN 01152761
ADJUSTMENT BASED ON: ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
FINANCIAL INSTITUTION: ALLFIRST FINANCIAL SERVICE ACCOUNT N0. 0098203959
TYPE OF ACCOUNT: ( ) SAVINGS (X) CHECKING ( ) TRUST ( ) TIME CERTIFICATE
DATE ESTABLISHED 03-30-1999
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
TAX CREDITS:
.00
X 0.166
.00
- .00
.00
X .15
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
T0: "REGISTER OF WILLS, AGENT."
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE
* IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
REV-1470 EX (&88)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
INHERITANCE TAX
EXPLANATION
OF CHANGES
DECEDENT'S NAME FILE NUMBER
Simonic Joseph 2101-0967
REVIEWED BY ACN
Emerson Luciano SEE BELOW
SCHEDULE I NO. I EXPLANATION OF CHANGES
The above referenced ACN has been reduced to zero, as this account was reported
on the probate return.
ACN # 01152747, 01152749, 01152755, 01152757,01152759 and 01152761
Page 1
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
N0. CD 002668
THOMAS THOMAS ARMSTRONG NIESEN
212 LOCUST STREET
SUITE 500 PO BOX 9500
HARRISBURG, PA 17108
told
ESTATE INFORMATION: ssN: i 92-as-74i 5
FILE NUMBER: 2102-0967
DECEDENT NAME: HOFFMAN RACHEL T
DATE OF PAYMENT: 06/ 1 1 /2003
POSTMARK DATE: 06/10/2003
couNTY: CUMBERLAND
DATE OF DEATH: 1 0/21 /2002
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 ~ 52,027.74
TOTAL AMOUNT PAID:
REMARKS: PATRICIA ARMSTRONG
THOMAS ETAL
CHECK#1009
SEAL
INITIALS:
DONNA M. OTTO
RECEIVED BY:
REV-1162 EX(11-96)
52,027.74
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
BUREAU OF INDIVIDUAL TAXES
~ ~~ ~~~
INHERITANCE TAX DIVISION
DEPT. 280bD1
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
` :;- ~
PATRICIA ARMSTRONG ESQ~`'' "`` `~-
THOMAS ETAL
212 LOCUST ST STE 501
HBG PA ~71•S1
REV-1547 E% ~FP (01-037
DATE 07-28-2003
ESTATE OF HOFFMAN RACHEL
DATE OF DEATH 10-21-2002
FILE NUMBER 21 02-0967
COUNTY CUMBERLAND
ACN 101
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
T
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~
----------------------------------------------------------------------------------------------------------------
REV-1547 EX AFP [01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF HOFFMAN RACHEL T FILE N0. 21 02-0967 ACN 101 DATE 07-28-2003
TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1) .00
(2) 1,048,982.20
(3) .00
(4) .00
(5) 10,325.10
cb) .00
(7) .00
(8)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this fora with your
tax payment.
1,059,307.30
APPROVED DEDUCTIONS AND EXEMPTIONS: 18,773.42
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 1,321.01
(11) 20.094.43
11. Total Deductions 1,039,212.87
12. Net Value of Tax Return (12) 00
13 Charitable/Governmental Bequests; Nonelected 9113 Trusts (Schedule J) (13) .
. T
t t (14) 1 , 039 , 212.87
14. ax
o
Net Value of Estate Subjec
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:
0 0
0 0
. 0 0
15 . Amount of Line 14 at Spousal rate (i5 ) .
=
X
16. Amount of Line 14 taxable at Lineal/Class A rate (16) 1,039,212.87 X 045. 46,764.58
17. Amount of Line 14 at Sibling rate (17) .00 X 12 .00
18 Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 1 5 .00
. (19)= 46,764.58
19. Principal Tax Due
~wx ~rcayi~a-
DATE
NUMBER +
INTEREST/PEN PAID (-)
AMOUNT PAID
01-14-2003 CD002044 2,236.84 42,500.00
06-10-2003 CD002668 .00 2,027.74
TOTAL TAX CREDIT 46,764.58
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.)
~~-9~-3
BUREAU OF INDIVIDUAL TAXES
y INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
PATRICIA ARMSTRONG ESQ
THOMAS ETAL
212 LOCUST ST STE 500
HBG PA 17101
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment.
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR FILES 1
----------------------------------------------------------------------------------------------------------------
REV-483 EX AFP CO1-03) ** NOTICE OF DETERMINATION AND ASSESSMENT
OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN **
ESTATE OF HOFFMAN RACHEL T FILE N0.21 02-0967 ACN 201 DATE 08-18-2003
ESTATE TAX DETERMINATION
1. Credit For State Death Taxes as Verified
2. Pennsylvania Inheritance Tax Assessed
(Excluding Discount and/or Interest)
3. Inheritance Tax Assessed by Other States
or Territories of the United States
(Excluding Discount and/or Interest)
4. Total Inheritance Tax Assessed
5. Pennsylvania Estate Tax Due
TAX CREDITS:
35,395.93
44,527.74
.00
44,527.74
.00
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT C+)
INTEREST/PEN PAID (-) AMOUNT PAID
*IF PAID AFTER THIS DATE, SEE REVERSE SIDE
FOR CALCULATION OF ADDITIONAL INTEREST.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF DETERMINATION AND
ASSESSMENT OF PENNSYLVANIA
ESTATE TAX BASED ON FEDERAL
ESTATE TAX RETURN REV-4B3 EX AFP (01-03)
DATE 08-18-2003
ESTATE OF HOFFMAN RACHEL T
DATE OF DEATH 10-21-2002
FILE NUMBER 21 02-0967
COUNTY CUMBERLAND
ACN 201
Amount Remitted
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
CIF TOTAL DUE IS LESS THAN 81, NO PAYMENT IS REQUIRED
IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE
REV-1470 EX (8-88)
.{i~Yt.
•cr~'rat
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
INHERITANCE TAX
EXPLANATION
OF CHANGES
DECEDENT'S NAME FILE NUMBER
Hoffman, Rachel T. 2102-0967
REVIEWED BY ,,,,,,
Daniel Heck
201
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
The maximum "State Death Tax Credit' has been recalculated according to the revisions
to the Pennsylvania Estate Tax as revised by ACT 89 of 2002. This revision is effective
for decedents dying on or after July 1, 2002.
Row Page 1
COMMONWEALTH OF PENNSYLVANIA
BUREAU of INDIVIDUAL TAXES DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601 NOTICE OF DETERMINATION AND
ASSESSMENT OF PENNSYLVANIA
ESTATE TAX BASED ON FEDERAL
CLOSING LETTER REV-736 EX AFP (01-02)
~fr~~;' -- DATE 03-08-2004
. -. - ESTATE OF HOFFMAN RACHEL T
DATE OF DEATH 10-21-2002
FILE NUMBER 21 02-0967
~QQ ~iti~ -~ ~~ .!~ COUNTY CUMBERLAND
PATRICIA ARMSTRON G ESQ ACN 202
THOMAS ETAL
212 LOCUST ST STE
500 ~:=' Amount Remitted
H BG PA 1 ~t0~1 fY
MAKE CHECK PAY ABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment.
CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR FILES -~
----------------------------------------------------------------------------------------------------------------
REV-736 EX AFP CO1-02) ** NOTICE OF DETERMINATION AND ASSESSMENT
OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER ~*
ESTATE OF HOFFMAN RACHEL T FILE N0.21 02-0967 ACN 202 DATE 03-08-2004
ESTATE TAX DETERMINATION
1. Credit For State Death Taxes as Verified
2. Pennsylvania Inheritance Tax Assessed 44,527.74
CExcluding Discount and/or Interest)
3. Inheritance Tax Assessed by Other States .00
or Territories of the United States
(Excluding Discount and/or Interest)
4. Total Inheritance Tax Assessed
5. Pennsylvania Estate Tax Due
6. Amount of Pennsylvania Estate Tax Previously Assessed
Based on Federal Estate Tax Return
7. Additional Pennsylvania Estate Tax Due
TAX CREDITS:
PAYMENT
DATE RECEIPT
NUMBER DISCOUNT (+)
INTEREST/PEN PAID (-) ~ AMOUNT PAID
*IF PAID AFTER THIS DATE, SEE REVERSE SIDE
FOR CALCULATION OF ADDITIONAL INTEREST.
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
CIF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED
IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE
nnr w ocu wn crr ~rvrncr crnr nr rurc rnnu rnn r.,ctnnrr r...,~
16,877.28
44,527.74
.00
.00
.00
REV-l500 EX (6-00)
\\-q-"]-3
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
'* COMMONWEALTH OF
PENNSYLVANIA
_ DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
I-
Z
W
C
w
o
w
C
DECEDENT'S NAME (lAST, FIRST, AND MIDDLE INITIAL)
Rachel T, Hoffman
~
V-
OFFICIAL USE ONLY
DATE OF DEATH (MM-DD-YEAR)
10/21/02
DATE OF BIRTH (MM-DD- YEAR)
02/28/11
FILE NUMBER
21 02
00967
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
W
I-
::r:::!cn
,,0:>:
w...,
",00
"O:..J
....
..
"
(!] 1. Original Return
D 4. Limited Estate
o 6. Decedent Died Testate (AlIad1 copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust {Mach copy of Trust}
o 10. Spousal Poverty Credit {dale of death between 12-31-91 IInd 1-1-95}
COUNTY CODE
YEAR
NUMBER
SOCIAL SECURITY NUMBER
192-34-7415
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Return (daleofdealh prior 10 12-13-a2)
[!] 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Alt&ch Sch 0)
>--
z
w
o
z
o
..
U)
W
0:
0:
o
"
NAME
Patricia Armstron , Esquire
FIRM NAME {If Applicable)
THOMAS, THOMAS, ARMSTRONG & NIESEN
TELEPHONE NUMBER
(717) 255-7627
COMPLETE MAILING ADDRESS
212 Locust Street, Suite 500
Harrisburg, PA 17101
Oi'-FICIAL USE ONLY
(1)
(2)
(3)
(4)
(5)
1,048,982_20
90
3 ~',
()
1 O,325:~0
:lJ
:n~"t'
m ,-')
d
VJ
t.;
'--
c::
:z:
z
o
S
;:)
l-
ii:
<
o
w
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
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inler-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G Of L)
(7)
'...,
~
(6)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
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)
13. Charitable and Governmental BequestsJSec 9113 Trusts for which an election to tax has not been
made (Schedule J)
(9)
(10)
14. Net Value Subject to Tax (Une 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z
o
~
I-'
::>
l1.
::E
o
o
~
15. Amount of line 14 taxable at the spousal tax
rate, Of transfers under Sec. 9116 (a)(1.2)
,,0_ (15)
1.039,212_87 ,_0 ~ (16)
-..;
W
N
1,059,307.30
16. Amount ofUne 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
, ,12 (17)
, ,15 (18)
(8)
18,773.42
1,321.01
(11)
(12)
(13)
20,094.43
1,039,212.87
1.039,212.87
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
(14)
1,039,212.87
46,764_58
(19)
46,764.58
Decedent's Complete Address:
STREET ADDRESS
'-nut/oak pnint 1100 GrFlndon Wa"
CITYM h ' b I STATEpA I ZIP 17055
ee ames urg
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A, Spousal Poverty Credil
S, Prior Payments
C. Discount
(1)
46.764.58
42.500.00
2.236,84
Total Credits ( A + B + C ) (2)
44.736.84
3.
InteresVPenalty if applicable
D.lnterest
E. Penalty
0.00
4.
TotallnteresVPenalty ( D + E )
If Line 2 is greater than Line 1 + Line 3, enler Ihe difference. This is Ihe OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund
(3)
(4)
(5)
(SA)
0.00
5.
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
2.027.74
A. Enter the interest on the tax due.
B. Enter the total of Une 5 + SA. This is the BAI.ANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
2.027.74
~t~ti:::dtf~~lt~.iimL 'f'
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes
..".........,..0
b. retain the right to designate who shall use the property transferred or its income: .........................................,.. 0
"..,...........,0
o
o
o
o ~
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. Old decedent make a transfer and:
a. retain the use or income of the property transferred;....................................................
No
~
~
~
~
c. retain a reversionary interest; OL........................................... ........................
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 fo~ 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? ................................................... ......................... ......................... ...................
~
~
Under penalties of pe~ury, I declare thaI I have examined this relum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is lrue, correct
and complete.
Declaration of prepal'9r o\heI" \hall \he pel'SOOallevTes&ntltN& is based 00 all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPON OR FILING RETU~
0A-- 6 t4 J< '
ADORES
~/d- La ~ JI- {:Ie 5l'Jo
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
c,. 10 ZLN3
/--J..c-t 'it "OJ;; u r ~
..
I ::J '--
17ru/
DATE
ADDRESS
~ ;~ll1l!Wlt'<l'"~Iiii' .
For dales of dealh on or after July 1, 1994 and before January 1, 1995, the tax rale imposed on the net vatue of transfers to or for the use of the surviving spouse is 3%
[72 P,S, ~9116 (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, ~9116 (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 stil applica~e 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 tor the use of a natural parent, an adoptive parent,
or a slepparenlof Ihe child is 0% [72 P.S, ~9116(a)(1,2)].
The tax rate imposed on the net value of transfers 10 or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P,S, ~9118(1.2) [72 P,S. ~9116(a)(I)J,
The tax rate imposed on the net value of Iransfers to or for the use of the decedent's siblings is 12% [72 P,S, ~9116(a)(1.3)J. 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.
REV-1503 EX+ (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
Rachel T. Hoffman
FILE NUMBER
2002-00967
All property jolntJy-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
Vanguard Group
Prime Money Market 34,881.000 Shares $ 34,910.69
Admiral Treasury Money Market Fund 50,000.830 Shares 50,044.94
GNMA Fund 4,522.285 Shares 48,255.20
Total Bond Market Index 13,818.976 Shares 140,147.15
ST Treasury FUnd Adm. 13,917.092 Shares 150,620.04
IT Treasury Fund Adm. 11,506.646 Shares 134,877.31
ST Bond Index Fund 4,845.149 Shares 49,278.17
Tax Managed Small Cap 4,255.508 Shares 53,619.40
International Value Fund 2,817.267 Shares 53,049.14
Value Index Fund 17,155.528 Shares 251,328.49
PA L T Tax Exempt Fund 6,361.323 Shares 72,848.54
PA Tax Exempt Money Market Fund 10,000.000 Shares 10,003.21
TOTAL (N.o enter on line 2. Recapitulation) $ 1,048,982.20
(If more space is needed, insert additional sheets of the same size)
REV-'5DB EX+ (6-9B) '*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Rachel T. Hoffman
FILE NUMBER
2002-00967
Include the proceeds of litigation and the dale the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1_
Allfirst Bank - Acct. No. 0043432115
$ 8,484.46
2.
Outlook Point Refund
239.64
3.
Miscellaneous Personal Property in Nursing Home
1,000.00
4.
Income Tax Refund
601.00
TOTAL (Also enter on line 5, Recapitulation) S
(If more space is needed, insert additional sheets of the same size)
10,325.10
REV.1511 EX+ 112.99.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Rachel T. Hoffman
FILE NUMBER
2002-00967
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
,.
Myers Funeral Home $8,283.40
B. ADMINISTRATIVE COSTS: Waived
1. Personal Representative's Commissions
Name of Personal Representative{s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State_Zip
Year{s) Commission Paid:
2. Attorney Fees 8,500.00
3. Family Exemption: (If decedenrs address is not the same as claimant's, attach explanation) -0-
Claimant
Street Address
City State _Zip
Relationship of Claimanllo Deceden!
4. Probate Fees $93.80 + $75.00 + $551.00
719.80
5. Accountant's Fees 500.00
B. Tax Return Preparer's Fees 770.22
7.
TOTAL (Also enter on line 9, Recapitulation) $ 18,773.42
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (6-98)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Rachel T. Hoffman
FILE NUMBER
2002-00967
Include unrelmburted medical expenses.
ITEM
NUMBER DESCRIPTION
1. West Shore EMS
VALUE AT DATE
OF DEATH
$ 51.85
2. West Shore EMS
50.60
3. Verizon
13.76
4. Outlook Point
239.64
5. Brochie Pharmaceutical
447.07
6. West Shore EMS
483.09
7. Pennsylvania Income Taxes due
35.00
TOTAL (Also enter on line 10. Recapitulation) $ $1,321.01
(If more space is needed, insert additional sheets of the same size)
REV.1513 EX. (9-00) '*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
Rachel T. Hoffman
FILE NUMBER
2002-00967
ESTATE OF
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
1 TAXABLE DISTRIBUTIONS {include outright spousal disln'butions. and transfers under
Sec. 9116 (01 (1.2)]
2. Sally H. Stobbart Daughter 50%
285 Deer Drive
Lusby, MD 20657
3. Chartes T. Hoffman Son 50%
2143 Augusta Drive
Evergreen, CO 80439
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET
II NON.TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV.1500 COVER SHEET $
(If more space Is needed, ms.ert additional sheels of the same size)
PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF
THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY
UNTIL COMPLETION
r.
` ~
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Rachel T. Hoffman
Date of Death: 10/21/02
Will No.:
Admin. No.: 2002-00967
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to
completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2
3
If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
If the answer to No. 1 is yes, state the following:
A. Did the personal representative file a final account with the court?
Yes No X
B. The separate Orphans' Court No. (if any) for the personal representative's account
is:
C. Did the personal representative state an account informally to the parties in
interest? Yes X No
D. Copies of receipts, releases, joinders and approvals of formal or informal accounts may
be filed with the Clerk of the Orphans' Court and maybe attached to this report.
Date: December 1.2003 ~~"~ ~~~ ~"~- ~'~-- ~~ '• ~ ~ "-~` ~~~ '` '~~~~~
Signature
Patricia Armstrong
Name (Please type ar print)
212 Locust Street, Suite 500, Harrisburg, PA 17101
Address
X717) 255-7627
Telephone No.
(MAH:rmt/AM3)
Capacity: X Personal Representative
X Counsel for Personal Representative
R.W. - 27