The URL can be used to link to this page

Home My WebLink About02-1026Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Thelma T. Cober also known as John G. Cober Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' or 'B' BELOW:) Deceased Social Security No. 159 -14 - 7500 OX A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut or named in the last Will of the Decedent, dated 02/15/1996 and codicil(s) dated - none - 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: - no exceptions - B. Grant of Letters of Administration (c.t.a.; d.b.n.c.t.a; pendente life; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: or principal residence at 310 Somerset Drive, Lower Allen Townshi (list street, number, and municipality) Decedent, then 85 years of age, died 05/08/2002 at Harrisburg Hospital , PA (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (If not domiciled in PA) Personal property in Pennsylvania (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania situated as follows: TOTAL 35,000.00 35,000.00 Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate form to the undersioned: o~nnted name and residence John G. Cober 310 Somerset Drive, Shiremanstown, PA 17011 ~ / '~0~ ~ Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form f; H/-~ (1991) Decedent was domiciled at death in Cumberland County, Pennsylvania with his/her last family Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. ~~~ ~ ~ Sworn to or affirmed and subscribed ~ ~~7~ ~~~~ ~~~~~ Z~ i ohn G. Cober before me this 1$ttglay of November 2002 For the Register `~ Donna M. Otto,lst Deputy No. 21-2002-1026 Estate of Thelma T. Cober Deceased Social Security No: 159-14-7500 Date of Death: 05/08/2002 AND NOW, November 18th 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 (c.t.a.; d.b.n.c.t.a.; pendente life; durance absentia; durante minoritate) are hereby granted to John G. Cober in the above estate and that the instrument(s) dated 02/15/1996 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters . $ 70.00 ~,r,,,,,,,~~ ~ f Short Certificate(s) . 1, $ 3.00 Renunciation. $ Affidavits ( ) $ Extra Pages (( ) . $ 18.00 Codicil. $ JCP Fee . $ r o „ 10.00 Inventory. $ Other $ Re is er Donna M. Otto,lst Depu~y Attorney: Gary L. James, Esq. I.D. No: 27752 James, Smith, Durkin & Connelly Address: 134 Sipe Avenue Hummelstown, PA 17036 Telephone: 717/533 - 3280 MAILED LE`I"I'ERS TO ATTORNEY UN 11-18-2002 TOTAL......... $ 101.00 Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form f{W-1 (1991) I.OSBfh Rfl~'-9/A( This is to certifythat the information here given is correctly copied from a~~1 original certificate of death duh~ filed with me as Local Registrar. The original certificate will he forwarded ro the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $?.00 ~`"' Local Registrar ~,~ P H2O67~1 Nu. h1AY 0 ~ 2~~12. Dare a3 Rev. tie? COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH STATE i~lE Nl NAME OF DECEDENT Ifxsr. MWdle.:astl -ice ,. Th l SEx SGCUL SECURITY NUMBER Da7E UEATH;MCrxn~` - - ~ ry ~ e ma T. Cober i :. 7• 14 .. f 4 n~ ~ AGE (Last 8xnwayl UNDER 1 YEAR UNDER 1 DAY DATE OF &R7H BIRTHPLACE rC•ly ar4 PLACE OF DEATH rCheck aay nne -- ,ee ~nsnu:lAr~ on ane; sxlel _ - MagM . Days Hows .r Mnutp Monm. DaY Mewl SuteafcregnUwnovl HOSPITAL: OTHER: - . 85 y" Dec 20 1916 Indiana Pa w '""' ~ ER1OiApai""' 'J °OA ^ ~ ^ R••'«rc• ~ a ~d ^ _ , , , , Y1 COUNTY OF DEATH CRY, BORO. TWP OF DEATH FACILRY NAME (11 rN)I ;n9iUIWn. y.~e slreal and nurnl)er; VMS E CEDENT OF HISPANIC ORIGIN? RACE -Amarcan In6an, &eck, WnAe. Nc. -D ~77 I~ - ISPecIY) No Lls 1Ls ^ q Y•a WacdY Cuban . • ' eb Dauphin e Harrisburg Harrisbur Hos ital """'~"~P"°"°Ri""•"` . e- ,,. le. White ' DECEDENT S USUAL OCCUPRION qND OF BUSINES&INDUSTRY VMS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS - Married SURVIVING SPOUSE IGtva ka+d d wak dwre ourxg most U.S. ARMED FORCES? S ~ n ads c tea Never Manred, Widowed, ql wb gva maroon name) d working qAs; do rlolup relxeo) Ch EIM"NVY/So<onoarY Cd49a DrvareeA (SVe'oM) FoX ~°`^ "°~ ' Teacher -Di~Tict '°'Z' 2 "'°''" k,~~.,.,~. ,,.John G. Cober ila. Ilb. 12. 77. 11. l~lOll led ' DECEDENT S MAILING ADDRESS {$Ireel. CdyROwn, Sfax. Zq Codel DECEDENT'S - --- ACTUAL 17 sM Lower Allen ~ 310 Somerset Drive a. la ~]~ Die 17c. ,aecetkfwlivedin ~ RESIDENCE dw:.a.n, AA Shiremanstown , Pa 17011 l ISee uutructnne exe n e "^a^w ~~ Cumberland k>rmpp? "° 0iai0in1n"0 ^ i e- ' 17b. Coumy 17d. we rkr anuM limb of uy,~„o FRHER S NAME IFxsl. MxIWe Lag) MOTHER'S NAME IFvsl. MxJdk. Haden Swname) - - - Farl T~S~ D r S u. ,,, o a nce INFORMANT'S NAME lTYPa'PrinD INFORMANT'S MADJNG ADDRESS (Strew, Cey/bwn, Slw.Zip Cass) - ~a. John G. Cober ,qb. 310 Somerset Drive Shiremanstam Pa 17011 METHOD OF DISPCtiSI710N DATE Of DISPOSITION PLACE OF DISPOSITION • Harr" w Cemwery, Cnmalary LOCrV10N - Cdyrtown Slate Zp Cow - - _ • BteW ~ Cnmitgn ^ RemoxY bom S4ta ^ (MOnM. DeY. Yewl a Otnw PMCe , . , Dartelion^ Ollw {Speceyl ^ . :,. :,b. :,e. ~ 2,d. Shit RE OF EML RsoN ACTING AS SUCH ICENSE NUMBER 011654-L NAME AND AOORESSOFf 1TY 903 et St t ~~~ ~~ ,ze, ~ pa zn _ 1~ 1 ems 23as orgy when nlryirrg Obt d my krgwMdge, haN occared al IM ame. Ogle and plats steed. L EN E NUM ATE SIGNED pltysictan a not svailabN aI tune of death b we era Title) (Mown Day rear) ' cer,dY wwa of dewh. . , ~~ ~• 2x. - _ Dams 21-26 muw W compkled Dy IME OF DEATH / DATE P/ {~( /~NCED DEAD (M .Day. Ye 1 / /~ ~%] ~ WAS CASE REFERRED 70 MEDICAL E%AMINER/CORONER? -- Person who prorlowrcp aem. Yes ^ NoF~ , ~ _ 21. , (, M. 2S. F • ` 4' ` /s-~ 2q. 27. PART 1: Enbr IM dipaps, in)uriea a COmpYCatKMe which caused IM death. Do n01 enter IM ngde of ayirg, s as raraac I resprr orY anesl. snook or Man lailwe ~ Apprexunab PART M: Oqw siytilkaN corldkiortc cawibtdkq to dbm. Dul list otr coup on aaur 1irw. on1Y ~Detwpn not rMtlDinq n IIN undarryxrp Gaup given n PART I. i IYYEDIATE GUSE (FuM1 ' d;seass a condlion JN lYY"p/" t:, t. ri7v i.>~ ~-(~H~ C~ L c G`C ~ , , /{~ puwgnoeaml--~ a. DUE 70108 AS A CONSEQUENCE OF): -. - -..- Sapatawey eve cortdDior" D. - q srly, Nadirtq b annlediate DUE TO fOR AS A CONSEQUENCE OF): _ -'°° - oeup. Emer UNDERLYBKi GUSE ID;seaee a xMury t • tnw irrnaled evraue DUE TD (OR AS A CONSEQUENCE OF): - - - rtuuaeq n daeerl LAST 1 d - VMS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY IWURY AT WORK? DESCRIBE HOW INJURY OCCURRED PERFORMED? ALNDABIE PRK%1 TO . (MOnln. Day, Pearl COMPLETION OF CAUSE ~5 Nal al /61 H i ^ OF DEQM1 a om;c W ^ Wa ^ ~ ^ A[CWeM ParWnglrnastrgalqn ^ ^ ~ ^ ^ ^ ^ 7G. N. 70e. 2Bd. Yp No Yes No Surcida GOWd nd M delermmetl PLACE OF INJURY - AI none, farm, strew. laclory, otkce LOCATION (strew. Cny/G)Wr1, Slate) -- Duil6rg, wc.ISpecAVl 2M. 2eb. 2e. 7qa. CERTIFIER ICneck only chat SIGNATURE OTI EOF TTT IFl ---- - 'CERTIFYING PHYSICIAN IFTysrcan certey;ng Caup d deem wMn anahM p+vsc;an Ms pronwnceo death an" competed Ilan 23f T l tl b i f k d d m ^ ~ • a r p o my rtow e ga, ee xcumed dw b IM coup(s) arW manner as elated ..................................................... 71D. ~ LICENSE MBFR DATE SK3NED IMonm. Day. qwl - -PRONOUNCING AND CERTIFYING PHYSICIAN (Physx;an IxYt: , ror,our;cng ueatn and certdyvg to cause o1 tleaml '~ ~ /~y 7 Mp v6 S 3 7 i / ' To u.. boat of my knowledge, deem «ewr.d st Ln. qme, dale. and place, and dw to LM uuee{e) and manner a staled ...................... ^ ],~. ~_ 71d. ~1 ~/ 1~ (.i NAME ANO ADDRESS OF PERSON WHO COMPLETED CAUSE DEATH • 'MEDICAL EXAMINER/CORONER On 1M buia of sseminetbn and/or investi ation in m ini o n d th d t th ti d (Item 271 Typa a Pnnl \ /~ ~ /] ~ /~~ ~ L C' CI 5 g y , p , occurre o n a me, e ata, and place, snd due to the cause(a) and ^ menner as stated ........ ....... ............. . . . ~ W L NC /e . ~ ..................................... .. ...................... 7ta _ 7:. %~/ /Z ~- Ch' . REGISTRAR'S SIGNATU I ~ J_ ` 'l3z d DATE FILED (MOnM. Oay. Pearl E>S~ /)r~l~~~ ]]. -- -- 7..7~7c~.~ 9 ~oO L Last Will of THELMA T. COBER a~-o~ ida ~ I, THELMA T. COBER, a resident of Cumberland County, Pennsylvania, declare that this is my will. I hereby revoke all my previous wills and codicils. Article One Introductory Provisions Section 1. Marital Status I am currently married to JOHN G. COBER, and all references to my spouse in this will are to him. Section 2. Children a. The name(s) and birth date(s) of my children: Name Birth date LINDA J. COBER September 15, 1948 SANDRA COBER-STASIULIS November 13, 1952 All references to my children in this instrument are to these children and any children subsequently born to or adopted by me. 1 r' -'C. ,, . a/ia "/ ~ 4 Article Two Appointment of My Personal Representatives Section 1. Nomination of My Personal Representatives I appoint the following to be my Personal Representative: JOHN G. COBER If, for any reason, the Personal Representative(s) named above are unable or unwilling to serve, the following successor Personal Representative(s) shall serve until the successor Personal Representative(s) on the list have been exhausted. Unless otherwise specified if Co-Personal Representatives are serving, the next following named successor Personal Representative shall serve only after all of the Co-Personal Representatives cease to act as Personal Representatives. (1) LINDA J. COBER; THEN (2) SANDRA COBER-STASIULIS Section 2. Waiver of Bond No bond or undertaking shall be required of any Personal Representative nominated in my will. Section 3. General Powers My Personal Representative shall have full authority to administer my estate under the laws of the Commonwealth of Pennsylvania relating to the powers of fiduciaries. My Personal Representative shall have the power to administer my estate under the Pennsylvania Probate, Estates and Fiduciaries Code. 2 ~c Article Three Disposition of My Property Section 1. Distribution to My Revocable Living Trust I give all of my property of whatever nature and kind and wherever located to my revocable living trust of which I am the Trustor known as: THELMA T. COBER and JOHN G. COBER, Trustees, or their successors in trust, under the THELMA T. COBER LIVING TRUST dated ~ ~~ 1 5 jJ~b and any amendments thereto Section 2. Alternate Disposition If my revocable living trust is not in effect for any reason, I give all of my property to my Personal Representative under this will as Trustee who shall hold, administer and distribute my property as a testamentary trust the provisions of which are identical to those of my revocable living trust on the date of execution of my will. Article Four Death Taxes Section 1. Definition of Death Taxes The term "death taxes" as used in my will shall mean all inheritance, estate, succession and other similar taxes that are payable by any person on account of that person's interest in the estate of the decedent or by reason of the decedent's death including penalties and interest but excluding the following: a. Any addition to the federal estate tax for any "excess retirement accumulation" under Internal Revenue Code Section 4980A. b. Any additional tax that may be assessed under Internal Revenue Code Section 2032A. 3 . j (' c. Any federal or state tax imposed on ageneration-skipping transfer as that term is defined in the federal tax laws unless the applicable tax statutes provide that the generation-skipping transfer tax is payable directly out of the assets of my gross estate. Section 2. Payment of Death Taxes Pursuant to the terms of my revocable living trust all death taxes whether or not attributable to property inventoried in my probate estate shall be paid by the Trustee from that trust. However, if that trust does not exist at the time of my death or if the assets of that trust are insufficient to pay the death taxes in full, I direct my personal representative to pay any death taxes that cannot be paid by the trustee from the assets of my probate estate by prorating and apportioning those taxes among the beneficiaries of this will. Notwithstanding any other provision in my trust all death taxes incurred by reason of assets transferred outside of my trust or probate estate shall be assessed against those persons receiving such property. Article Five General Provisions Section 1. No Contest Clause If any person or entity other than me singularly or in conjunction with any other person or entity directly or indirectly contests in any court the validity of this will including any codicils thereto the right of that person or entity to take any interest in my estate shall cease and that person or entity shall be deemed to have predeceased me. Section 2. Captions The captions of Articles, Sections and Paragraphs used in this will are for convenience of reference only and shall have no significance in the construction or interpretation of this will. 4 ~ , ._i,o. Section 3. Severability Should any of the provisions of my will be for any reason declared invalid such invalidity shall not affect any of the other provisions of this will, and all invalid provisions shall be wholly disregarded in interpreting this will. Section 4. Governing Law This will shall be construed, regulated and governed by and in accordance with the laws of the Commonwealth of Pennsylvania. I signed this, my last will, on FEB 1 5 1996 THELMA T. COBER 5 The foregoing Will was, on the day and year written above, published and declared by THELMA T. COBER in our presence to be her Will. We, in her presence and at her request, and in the presence of each other, have attested the same and have signed our names as attesting witnesses. We declare that at the time of our attestation of this Will, THELMA T. COBER was, according to our best knowledge and belief, of sound mind and memory and under no undue duress or constraint. ,. ~ S S J `^~_ Address: / r~? 4t-~1-~ / ~ ~ ~E E Address: I 6 COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF DAUPHIN We, THELMA T. COBER,/~c_ ~~`~ ~ and ~,4~~ f,, { L , i\~ rt , ~~ A, the Testatrix and the witnesses, respectively, whose names are signed to the foregoing Will, having been sworn, declared to the undersigned officer that the Testatrix, in the presence of witnesses, signed the instrument as her last Will, that she signed, and that each of the witnesses, in the presence of the Testatrix and in the presence of each other, signed the Will as a witness. THELMA T. COBER ~ des W - S WI ESS Subscribed and sworn before me by THELMA T. COBER, the Testatrix, and by ---- - ~ o and ~ 1~e t_,,, I 1_ , ~ h ~1,~ 1 Q the witnesses on ~ , 1996. %Notary ublic ' ~~ \ h J'~I>> ~ oar=~~ission expires: NDTADIAL SEAL NN Hum~~!stawn, Dauphin Cou~ My Cor~ission expires Nov. 29,1999 ~~ 7 ~--~~ CERTIFICATION OF NOTICE UNDER RULE 5.6(A) Name of Decedent: Thelma T. Cober Date of Death: May 8, 2002 Will No.: Admin. No.: 2002-01026 TO THE REGISTF,R OF WILLS OF CUMBERLAND COUNTY: I certify that Notice of Estate Administration 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 February 3, 2003 Name John G. Cober, individually, and as surviving Trustee, Thelma T. Cober Living Trust dated February 16, 1996 310 Somerset Drive Shiremanstown, PA 17011 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: - no exceptions - Date: 02/03/2003 Signature: ~~~~~U 1~~~~~~ ~ Name: Gary L. James, Esq. Address: James, Smith, Durkin & Connelly LLP 134 Sipe Avenue Hummelstown, PA 17036 Telephone: (717) 533-3280 Capacity: Personal Representative X Counsel for Personal Representative \1- Ib\- '5 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT REV-1500 EX + (6~OO) CAPS HpRL EplO CRAC KOTK ES C P o 0 R N R D E E S N T C o M P T U A T X A T I o N D E C E D E N T . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 2:80601 HARRISBURG, PA 17128-0601 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Cober Thelma T. DATE OF DEATH (MM-DD-YEAR) FILE NUMBER 1/ OFFICIAL USE ONLY 21-02-1026 COUNTY CODE YEAR SOCIAL SECURITY NUMBER 159-14-7500 THIS RETURN MUST BE ALED IN DUPUCATE WITH THE NUMBER REGISTER OF WILLS SOCIAL SECU N M8 R o o COMPLETE MAILING ADDRESS 3 date of death . RemaInder Return riot to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 91 13(A) (Attach Sch 0) NAME Gar L. James Es . FI RM NAME (If Applicable) James, Smith, Durkin & Connell, LLP TELEPHONE NUMBER 134 Sipe Avenue Hummelstown, PA 17036 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) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G cr L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 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. Nel Value Subjectlc Tax (Line 12 minus Line 13) (1) (2) (3) I NG SPOUS None None None None 39,795.00 None 587,266.38 10,507.00 None .0 0 .045 .12 .15 OFFICIAL USE ONLY (8) 627,061. 38 (11) 10.507.00 (12) 616,554.38 (13) 42.555.58 (14) 573,998.80 (15) (16) (17) (18) (19) 0.00 0.00 0.00 0.00 0.00 Cober, John G. X 1. Original Return 4. Limited Estate X 6. Decedent Died Testate (Attach copy of Will) D 9. LItigation Proceeds Received 2. 4a. 7. Supplemental Return Future Interest compromise (date of death after 12-12-82) Decedent Maintained a Living Trust (AttaCh copy of Trust) Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 010. R E C A P I T U L A T I o N (4) (5) (6) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, crtransfers under Sec. 9116(a)(1.2) 573,998.80 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20. X X X X CopyrIght (c) 2000 form software only The Lack:ner Group, Jnc. FormREV-1500 EX (Rev. 6-00) Decedent's Complete Address' STREET ADDRESS :no Somerset Drive CITY T STATE I ZIP Carno Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (I) 0.00 0.00 Total Credits ( A + B + C) (2) 0.00 3. Interest/Penalty if applicable O. Interest E. Penalty ,'Hi,!!, !]i!]W' Total Interest/Penalty ( D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This: is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (s) A. Enter the interest on the tax due. (SA) B. Enter the total of Line S + SA. This is the BALANCE DUE. (5B) Make Check Payable 10: REGISTER OF WILLS, AGENT ;\\\\\\\\\\\\\\;!m\\!!\!!\\m\\\\\~\\\I\\I!\\\\\\\I\\\ii\i,\\!i\ml\l\\\\\\\\\\ii\\\lii\\\\i!\mm\\\\\\\\\\\\\\\\111!ll!ilmlllll\\\\\\\\\\\\\\\\I\\II\\1111\1\\\\\\\\\\\\\\\\\\\\\lll\\\\\mmm~mlll~\lli!l\ \\l\\lmmm\\mlllmlll\lll\\llmlllllmlllllrimm\Il\l1l\lm\\1ll11111l\lllllmmm':1Iillllmmlllllllll111mllll\'illl\lllllllmlllll\ll PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; . . . . . . ~i ~ b. retain the right to designate who shall use the property transferred or its income; . c. retain a reversionary interest; or. . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? . . , . . . . Z. If death occurred after December 't 2, 't 982, did decedent transfer property within one year of death without receiving adequate consideration? . . , . . . . . . , 3. Did deceden\ own an "in trust for" or payable upon death bank account or security at his or her death? .. . . , . . , . .. .,........... 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . , . . . . . . . . IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 0.00 0.00 0.00 0.00 0.00 o o D9 D9 w o Under penaltfesof perjury, I declare that I have examined this return, Includlr1f1 accompanying schedules and statements, and to the best of my knowledge and belief, It Is true, correct and complete. Dedariltton of preparer other than the personal representatIve Is based en all InformatIon ofwhlch preparer has any Icl'lOwledge. SIGNATURE of PERSON RESPONSIBLE FOR FILING RETURN John G. Cober 310 Somerset Drive -- -Cem --iiil-i; - PA -~ ri6ir - - - - - - -- - -- - - -- - - - - - - - - -- JAMES, SMITH, DURKIN & CONNELLY, LLP _ _ _1.~L, _ _s. ~p~_ _~,,~!'.~'? _ _ _ - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Hummelstown, PA 17036 DATE "1- /'3 I1~J DATE ' -v--> < ......"''.3 For dates of de on uly 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to orfor the use ofthe surviving spouse is 3% [72 P.S. 9116 (.) (I. I) (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% t72 P.S. 9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1.2)]. The ta)( rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2) [72 P.S. 9116(.X1)J. The tax. rate imposed on the net value of transfers \0 or for the use of the decedent's siblings is 12% [72 P.S. 9116(a){1.3H 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. cepyrlght(c:)2000form software only The Laclcner Group, Inc:. Form REV-1S00 EX (Rev. 6-00) REV-1508 EX ...(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Thelma T. Cober SS# 159-14-7500 05/08/2002 21-02-1026 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ITEM NUMBER 1 DESCRIPTION Allstate Insurance Company - Final settlement of any and all claims arising from bodily injury caused by accident on 04/04/2002. VALUE AT DATE OF DEATH 25,000.00 2 Allstate Insurance Company - Final settlement of any and all claims for bodily injury under under insured motorist coverage arising from accident on 04/04/2002. 10,000.00 3 Decedent's vehicle - 1994 Buick LeSabre, 4 door sedan in good condition with approximately 50,000 miles, titled in decedent's name alone, valued per online services. 4,795.00 TOTAL (Also enter on line 5, Recap~ulatlon) $ 39,795.00 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software onty CPSystems, Inc. Form REV-15GB EX (Rev. 1-97) REV-1S10 EX + (1-97) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCETIV( RETURN RESIDENT DECEDENT ESTATE OF Thelma T. Caber SSf! 159-14-7500 05/08/2002 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. ITEM NUMBER 1 DESCRIPTION OF PROPERTY RELAt~8~M~I~ t~b~~~5~~lt;J~J~~~1fkr~E6F t~~~SFER. ATTACH ACOPYOF THE DEED FOR REAL ESTATE. American Express Financial Advisors - Annuity account #93005249501 5 004, titled in the names of the Thelma T. Caber Living Trust dated 02/15/1996, and any amendments thereto, and the John G. Caber Living Trust dated 02/15/1996, and any amendments thereto, as joint tenants with the right of survivorship; valued per death settlements processing team letter. DATE OF DEATH VALUE OF ASSET 26,449.57 2 American Express Financial Advisors - Annuity account #93006782207 0 004, titled in the name of the Thelma T. Caber Living Trust dated 02/15/1996, and any amendments thereto; beneficiary is the John C. Caber Living Trust; valued per death settlements processing team letter. 29,330.79 3 American Express Financial Advisors - Mutual fund account #02137215809 3 002, titled in the name of the Thelma T. Caber Living Trust dated 02/15/1996, and any amendments thereto; valued per death settlements processing team letter. 1,316.57 4 American Express Financial Advisors - lMA account #00056406853 4 021, titled in the name of the Thelma T. Caber Living Trust dated 02/15/1996, and any amendments thereto; valued 76,274.88 Total of Continuation Schedule(s) % OF DECD'S INTEREST 50.00% EXCLUSION (IF APPUCABLE) 0.00 100.00% 100.00% 100.00% TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. 0.00 0.00 0.00 FILE NUMBER 21-02-1026 TAXABLE VALUE 13,224.79 29,330.79 1,316.57 76,274.88 467,119.35 587,266.38 Form REV-1510 EX (Rev. '-97) Estate of: Thelma T. Cober Soc Sec #: 159-14-7500 Date of Death: 05/08/2002 Continuation of Schedule G (Inter-Vivos Transfers & Misc. Non-Probate Property) Item Description of Property # Date of Death % Decd Exclusion Taxable Value Value of Asset Intrst per death settlements processing team letter. 5 American Express Financial Advisors - WMS account #00023053788 8 021, titled in the name of the Thelma T. Cober Living Trust dated 02/15/1996, and any amendments thereto; valued per death settlements processing team letter. 71,592.45 100.00% 0.00 71,592.45 6 American Express Financial Advisors - SPS Advantage account #00047181938 3 021, titled in the name of the Thelma T. Cober Living Trust dated 02/15/1996, and any amendments thereto; valued per death settlements processing team letter. 238,159.30 100.00% 0.00 238,159.30 7 American Express Financial Advisors - SPS Advantage account #00047241070 3 021, titled in the name of the Thelma T. Cober Living Trust dated 02/15/1996, and any amendments thereto; valued per death settlements processing team letter. 80,097.60 100.00% 0.00 80,097.60 8 Decedent's residence - House and lot situate at 310 Somerset Drive, Lower Allen Township, Cumberland County, PA; titled in the names of John G. Cober and Thelma T. Cober, Trustees, or their successors in trust under the John G. 154,540.00 50.00% 0.00 77,270.00 Estate of: Thelma T. Cober Soc Sec #: 159-14-7500 Date of Death: 05/08/2002 Continuation of Schedule G (Inter-Vivos Transfers & Misc. Non-Probate Property) Item Description of Property # Date of Death % Decd Exclusion Taxable Value Value of Asset Intrst Cober Living Trust dated 02/15/1996, and any amendments thereto, and Thelma T. Cober and John G. Cober, Trustees, or their successors in trust under the Thelma T. Cober Living Trust dated 02/15/1996, and any amendments thereto, as tenants in common; Deed reference Book 135, Page 299; valued per county assessment. 467,119.35 REV-1S11 EX+(1~97) COMMONWEAL 1'H OF PENNSYLVANIA INHERITANCETAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Thelma T. Cober 88ff 159-14-7500 05/08/2002 FILE NUMBER 21-02-1026 Debts of decedent must be reported on Schedule I. . ITEM NUMBER A. B. AMOUNT DESCRIPTION 1 FUNERAL EXPENSES' Myers-Harner Funeral Home, Inc. - Funeral goods and services 7,875.00 1. ADMINISTRATIVE COSTS, Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. 3. Attorney's Fees James, Smithl Durkin & Connelly, LLP Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 2,500.00 4. Probate Fees Register of Wills 101.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Other Administrative Costs Cumberland County Register of Wills - Filing fee for inheritance tax return and inventory 28.00 2 Cumberland County Register of Wills - One (1) short certificate 3.00 TOTAL (Also enter on line 9. Recapitulation) $ 10,507.00 (If more space is needed, insert additional sheets of the same size) copyright (c) 1996 form scHware only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97) REV-1S13 EX +(9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Thelma T. Gober SSjl 159-14- 7500 05/08/2002 FILE NUMBER 21-02-1026 R~LATIONSHIP TO D~C~Q~N r mOUl'IT OR SHAR~ Do Not List Trustee(s) OF ESTATE NUMBER NAME AND ADDRESS OF PERSONtS) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS [Include outright spousal dIstributions, and transfers under Sec. 91 16{a){1.2)] 1 John G. Cober 310 Somerset Drive Shiremanstown, PA 17011 Spouse Residue in Survivor's Trust ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET II, NON-TAXABLE DISTRIBUTIONS, A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1 John G. Gober Living Trust (a General Power of Appointment Trust) 13,224.79 c/o John G. Gober, Trustee American Express annuity account #93005249501 5 004 2 John G. Gober Living Trust (a General Power of Appointment Trust) c/o John G. Gober, Trustee American Express annuity account #93006782207 0 004 29,330.79 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 42,555.58 (If more space is needed, insert additional sheets of the same size) Copyright (c) 2000 form software only The LaCKner Group. Inc. Form REV-1513 EX (Rev. 9-00) l ~-10/-0 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 } ~ ~u - ~~;~ '03 ,.lU~! -6 GARY L JAMES ESQ JAMES ETAL lam'.,°f 134 SIPE AVE ~,~lf{ix ::,._ :~.: HUMMELSTOWN PA 17036 REV-1547 EX RFP t03-OS) -DATTE 06-03-2003 ESTATE OF COBER THELMA DATE OF DEATH 05-08-2002 F1ILE NUMBER 21 02-1026 ~q~CO~~TY CUMBERLAND ACN 101 Anount 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 FCTOTE nF COBER THELMA T FILE NO. 21 02-1026 ACN 101 DATE 06-03-2003 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( Xl CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule Bl (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this form with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 39,795.0 0 tax payment. F) d l (S h t (6) .00 6. e e u c y Jointly Owned Proper G) (7) 587 , 266.38 7. Transfers (Schedule 061.38 627 8. Total Assets (g) , APPROVED DEDUCTIONS AND EXEMPTIONS: 10,507.00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) [10) .00 11. Total Deductions (11) 10.507.00 616,554.38 12. Net Value of Tax Return (12) 573,998.80 13 Charitable/Governmental Bequests; Nonelected 9113 Trusts (Schedule J) (13) . [14) 42,555.58 14. Net Value of Estate Subject to Tax 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: 42,555.58 X 00 = .00 15. (15) Amount of Line 14 at Spousal rate 0 0 045 .00 16 Amount of Line 14 taxable at Lineal/Class A rate (16) . . X . 17 Anount 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 1 5 . (19)= .00 19. Principal Tax Due TAX GRED11,' DATE NUMBER + INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, 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.) x REV-7470 EX (6-88) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 INHERITANCE TAX EXPLANATION OF CHANGES PROBATE ® JBA ^ DATE:S/19/03 UGI.000rv 1 J rvHlVlt FILE NUMBER Thelma i . Cober 2102-1026 ACN 101 SCHEDULE 'N0:' EXPLANATION OF CHANGES G 1 & 2 Subject to tax at the zero rate. J II-A Line 13 adjusted to include the value of a qualified trust for which an election to tax has not been made on a timely filed tax return as required by Section 9113. The value of the trust will be subject to tax in the estate of the surviving spouse at the value as of his date of death. The value of the assets in the qualified trust has not been verified by the Department as the asset value is not relevant to the taxable value of the estate. TAX EXAMINER: S118Wr1 E. Young PAGE 1 Register of Wills of CUMBERLAND INVENTORY Estate of Thelma T. Cober Signature: also known as Address: 310 Somerset Drive John G. Cober, Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I /We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative Name of / ~~.-~j~~ Attorney: Gary L. James Esq. Signature: ~ hn G. Cober I.D. No.: 27752 Address: 134 Sipe Avenue Hummelstown, PA 17036 Telephone: 717/533 - 3280 County, Pennsylvania No. 2002-01026 Date of Death 05/08/2002 ,Deceased Social Security No. 159-14-7500 Camp Hill, PA 17011 Telephone: 717/737 - 8983 Dated: ~.~3~'z~~3 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the electron of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. Prepared by the Pennsylvania Bar Association Copyright {c) 1996 form software only CPSystems, Inc. Form #RW-7 (1992) INVENTORY Estate of: Thelma T. Cober Date of Death: 05/08/2002 County: Cumberland CASH: Allstate Insurance Company - 25,000.00 Final settlement of any and all claims arising from bodily injury caused by accident on 04/04/2002. Allstate Insurance Company - 10,000.00 Final settlement of any and all claims for bodily injury under underinsured motorist coverage arising from accident on 04/04/2002. 35,000.00 PERSONAL PROPERTY: Decedent's vehicle - 1994 4,795.00 Buick LeSabre, 4 door sedan in good condition with approximately 50,000 miles, titled in decedent's name alone, valued per online services. 4,795.00 TOTAL RECEIPTS OF PRINCIPAL ............... 39,795.00 -1- February 5, 2003 Donna M. Otto, Deputy Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 Re: Estate of Thelma T. Cober, deceased Dept. of Revenue File No. 21-02-1026 Dear Ms. Otto: Our office represents the Estate of Thelma T. Cober who died on May 8, 2002, a resident of Lower Allen Township, Cumberland County, Pennsylvania. Enclosed please find an original Pennsylvania Inheritance Tax Return with attachments and two (2) copies with no attachments for the referenced Estate. Please forward the original to the Department of Revenue and keep one copy for your files. Kindly time-stamp and return the extra copy to me along with your receipt for the enclosed check in the amount of $28.00 payable to the Cumberland County Register of Wills for filing fees. Also enclosed please find an original and one copy of an Inventory. Should you have any questions, or need any additional information, please do not hesitate to contact me, or Gary L. James, Esq., Counsel to the Estate. Very truly yours, ~` Elizabeth S. Eck Paralegal ~. `~ek /ese Enclosures cc: John G. Cober s ESTATE SECURITY Elizabeth S. Eck Paralegal ese@jsdlegal.com 134 SIPE AVENUE HUMMELSTOWN. PA 17036 MAILING ADDRESS P 0 [30X 650 HERSHEY, PA 17033 TOLL FREE '_800.342.3660 TEL. 717.533-3280 FAX 71 ?.533.7771 www.jamesestateplan.com STATUS REPORT UNDER RULE 6.12 Name of Decedent: Thelma T. Cober Date of Death: May 8, 2002 Will No. Admin. No. 2002-01026 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: State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a.. Did the personal representative file a final account with the Court? Yes No X b. The separate Orphan's 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 maybe filed with the Clerk of the Orphans' Court and maybe attached to this report. Date: ~ ~'' •., r~ i J -~ M .. ~ a. 11:AHOM t~~F.SE~ ~:a 'r.. x`a -,) ,._ "..}' ii Capacity: CoberAThelma 14.doc Personal representative X Counsel for personal representative JAMES SMITH, DIETTERICK & CONNELLY ccP 134 Sipe Avenue Hummelstown, PA 17036 (717)533-3280 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX INHERITANCE TAX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO BOX 280601 HARRISBURG, PA 17128-0601 OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 ER ~FP (09-047 DATE 11-29-2004 ESTATE OF FOLTZ R C DATE OF DEATH 11-22-2002 FILE NUMBER 21 02-1126 COUNTY CUMBERLAND GERALD K MORRISON ESQ 1.~~Y - - ~~~ ~ - ACN 101 PO BOX 232 Amount Remitted NEW BLOOMFIELD PA 1,7068 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 FOLTZ R C FILE N0. 21 02-1126 ACN 101 DATE 11-29-2004 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 00 000 105 NOTE: To insure proper . , 1. Real Estate (Schedule A) (1) (2) 191,632.00 credit to your account, 2. Stocks and Bonds (Schedule B) 00 submit the upper portion Closely Held Stock/Partnership Interest (Schedule C) (3) . 3 . Mortgages/Notes Receivable (Schedule D) (4l .00 4 of this form with your . Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5l 1 24,9 85.54 5 tax payment. . Jointly Owned Property (Schedule F) (6) .00 6 . 7. Transfers (Schedule G) (7) .00 617.54 421 (8) 8. Total Assets , APPROVED DEDUCTIONS AND EXEMPTIONS: 23,797.20 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 7.269.85 (11) 31 .067 . D5 11. Total Deductions 390,550.49 12. Net Value of Tax Return (12) .00 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) 39 0,550.49 14. Net Value of Estate Subject to Tax (14) 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: 155,000.00 X 00 _ - .00 15. Amount ofi Line 14 at Spousal rate (15) 49 550 235 045 = 10,599.77 16. Amount of Line 14 taxable at Lineal/Class A rate (161 . , X 12 00 (17) .00 X = . 17. Amount of Line 14 at Sibling rate QO 15 . 00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) , X = 599.77 10 19. Principal Tax Due (19)= , - ° - - - utswun i i ~ ~ AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 08-14-2003 CD002907 .00 9,000.00 10-01-2004 CD004462 77.10- 1,680.44 i-~ * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 10,603.34 3.57CR ; . 0 0 ~ 3.57CR ( 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.)