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Home My WebLink About02-1037PETITION FOR PROBATE and GRANT OF LETTERS Estate of ALBERTA DANZEISEN also knotun as Deceased. Social Security No. 15 4 - 2 0 - 6 319 No. ~~ -02- ~ 03~ To: Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older ~~ the executor named in the last will of the above decedent, dated June , 19~_ and codicil(s) dated N /A (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumberland County, Pennsylvania, with h e r last family or principal residence at Sara Tod d 1000 West South Street, Carlisle PA 17013 (list street, number and muncipality) Decendent, then 8 ~ years of age, died November 4 ~ ~ j 2 0 0 2 at Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: 150, 000.00 (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: N/A WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters T e s t a m e n t a r y (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. Roger L. Danzeisen b.. ~ ~ ~~. rx ~ C O cd '~, Q. a~ w ~ O G b0 V] OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF CUMBERLAND The petitioner(s) abo~~e-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the b:,st off' the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above deceden~ petitioner(s) will well a~uly administer the estate according to law. Sworn to or affirmed and subscribed ~'-~ 1- ''"< ~ before me this 2 0th day of ~ J~ XH XX Register t 117 Susan Lane Car is e PA A -Z~ln7_'~ No. 'Z I- O 2- 1 O 3'~- Estate of ALBERTA DANZEISEN ,Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW NOVEMBER 21, 2002 X~'gXX , in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated 6 -14 -19 9 5 described therein be admitted to probate and filed of record as the last will of ALBERTA DANZEISEN and Letters TESTAMENTARY ' are hereby granted to ROGER L DANZEISEN FEES Probate, Letters, Etc.......... $ 2 3 5. 0 0 Short Certificates( ) .......... $ 6 . 0 0 ~~~,~ extr. a ~~c~es $ 6.00 jr_p $ 10.00 TOTAL $ 257.00 Filed 11-21-2002 "cal'Iea,"atEy"I1'=2Y=2'Ob'2' Register of Wills Patricia R. Brown #27474 ATTORNEY (Sup. Ct. I.D. No.) 10 West Pomfret Street Carlisle PA 17013 ADDRESS (717) 249-3024 PHONE his is to ccrta=l~ that the inrocrz~atiu~ here bicen is correctly copied ~run~ <in original certificate of dc.~~h d~~i~ riled wit+i me a_s Local ilc~istrar. ~,'l~e o(tin<~l /~rtFtcate will be.fotv~arded to the St_ac Vital lZecords Office for per(r la~ent filing. WARfVlNCa: it is illegal to duplicate this ropy by photostat or photograpi~. I ee ~rl l- LI"11S QI1~C'fl~ lCe, ~Sr .~F~ ,lira i. ~ E~ ~"1• ~~~~~~~~~~ ,,,~'" "p,`TH t~f Ff rl y~F•' ~ ~ ~ - -- Igo, cd'; g,~ i ~~ ~l 67Q3640 ;_~,~ -~'9ryE~~ o~~~~' '' N 0 V 6 2002 .o, ~II~ H105. i aJ Rev. 7787 `INT ENT NK a COMMONW EALTH OF PENNSYLVANIA • DEPARTMENT O HEALTH • VITAL RECORDS CERTIFICATE OF DEA H NAME OF DECEDENTiFrx Midde. Lap) SE% ~ St7CUl SECURITY NUMBER DATE OF OEATN,MOnm. pay, Aarl '• lberta Danzeisen 7•Female 7.154 - 20 - 6319 ..November 4, 2002 AGE (Lap BKmdaN UNDER 1 YEAR UNDER 1 DIN' DATE OF BIRTH BIRTHPUCF ICay and PLACE Of DEATH/Check only oM- aee nyrruclbrro onomp LtlH Morefu ( Days Noes i Mkwtw IMOrah, Day. werl Sme"F"spn COUnay, HOSPITAL OTHER: 82 Vro. March 28 IrpatkeN ^ EIT/putpnbnt ^ DOA ^ ~ ~ R id ^ ^ _ e. 1920 T. JamesbU NJ ee enu (SPetnyl a, COUNTY OF DEIGN CRY. BORO. TWP OF DEATH FACILRY NAME 01 nd msnNkon, give eOM arM numbari WAS DECEDENT OF HISPANIC ORIGIN7 RACE - Amenun olden, Boca. NTNS, ate, (SOet1Y) N• ® ~YS ^ N yea, speedy Cuun , Carlisle Sarah Todd Memorial Home ~ •~•~R~.«t• Cumberland • White ~ ,~ ,0. ~p OECEDEM'$USUAL OCCUPATION gN00F BUSINESSANDUSTRV WAS DECEDENT EVER iN DECEDENT'S EIXICATION MARRAL STATUS-Mande SURVNIN(T BPOVSE ' (GM Me~ddwork aoM durmgmM U.S.ARMED FORCE97 n Newer Mankd, WkbwW. IN wee, a.•mawn MrMl d workkq MK OO rlel userMxad.) ~^ No® ENmentary/SecoMery Censgs Dhorcetl (Spenlyl Manufacturing Assembl Worker - 'o-'~ "''a5" „• „ „e• ,,,• ,. Widow ,,, DECEDENT'S MAILING ADORESS(StrM. Ciryrtown. SMN. ZO Code) DECEDENT'S PA I)a^ Ys 17 Stp d d MlN k 1000 West South St. a. a s. ec . M t nwo RESDENCE a~eceesM Carlisle PA 17013 ~ h ~"`~' ~ b rl C d '°"~"p7 9 ~~ li l B ~~ I~ ~ ^m e ar an ,Te. . s e oro d fAiMER•S NAME (fip. Mk1Ge. Lap) MOTHER'S NAME dap. Middle, MaWM Surname) Lewis F~nens Sophie Firestone „• „• NIFORMANi•9 NAME RrvnPbNl INFORMANT'S MAllINO ADDRESS ISNM, CdYROwn• Slw, Zip Coul 20.. Danzeisen :oe.117 Susan Lane, Carlisle PA 17013 METl100 DISPOSITI N O DATEOF DISPOSITION PLACE OF DISPOSTION-Named Cempery,Cromtlory LOCATION•CXy/TOrm, Sble Zip Coda T-p p pqAt I rnt LP Crerrlwion^ Re al l B o m $ip P~I • (MOnm, DeY•YMI "OIMr Pfau . u m v ro e Dorntlnl^ an.rlso.tm ^ November 8, 2002 Fernwood Cemetery Jamesburg NJ t,e. 210. 2te. 2/d. ' SIGNAr of UNEM SERVICEUC N EO P RSONACTINaASSUCH LICENSE NUMBER NAME ANDADORESSOFTACILITV Hoffman-Roth Funeral Home • 22L Q ,,,. 013144-L 2x. CompNte Aeme 27at ony wtlul urtllyirq Toth l»pdmy knowledge, deem Occurred altM lima. dataaM pace paled. LN:EN ENUMBER DATE SIGNED .. PlrYpenrl n dal M140N M Ikne d esam M • Mrol epn.da.m ISprMlure and Tine) ^ n y ~ / / ~ r-~ ,~~' Sas yuy-~ ~ (MOM+. Daµ NVI . y -QXJ~1.._ /y. eS+.P~,~d./~- , n. 274. :7e. a,X,.,h.. v,zdc nerve 242e map u oempn4d W TI/1~~E OF OEATN ~ / DATE PRONOUNCED DEAD IMmm, Day, Yeaq WA9 CASE REFERRED TO MEDICAL E%AMINEW'CORONERt • ersonwro rorg elese death ' p p t . //P~~xrm• f rA q h.^ No~ 27. -AITT I; EderlM dieeapn. kljreha or compaeatnM whKh uueadiM Uath. Do MlamerlM rtqu of dyke, auen as eardne"roapiratory arrM.shxk"Man ladwe. ~APPreaknpe PART N: OlMrspnNkaM COrWNi"re comrlMkgbdsaM, ern L'ot enY oM urns "1 eaM ant. , kderW IMUVaen n" roauMng in tlN bWedykigoetM glw+n M PART I. l Abel MMdea111 IMMEDIATE CAUSl6v+el I ~n~"~ .. AS N , un U ~zlx~-, DUE TO N7R AS A CONSEQUENCE OF): B•NUnmaNY M fDlldebM D. r ' Harry, klaAnq MkmmWlab DUE TO tOR ABA CONSEQUENCE Onj: I ulna. Edw UNDERLYeq t ' CAUSE pAeee.ad eyury e. + • mM'vklWed swerb DUE tO IpI ASA CONSEWENCE OF): ~ rasulMq n Osae1(LAST e. WAS AN AITiOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OFINJURY TIME OFINJURY INJURY AT WORK7 DESCRIBE HOW INJURY OCCURRED. PERFORME% AMVUBLE PRIOR ro (Manor. Day, Merl COMPLETION OF CAUSE Np p ~ N ^ k W OF DFAN7 " nn e : 11e ^ ~ ^ AceiderA ^ Pending lnveetlgstkm ^ Ytl ^ No~. Y ^ No ^ Sukide ^ Coukl MI u tlpermined ^ PUCE OF INJURY -M tgma, irm,~rM, belary, oNiu M IOCATK)N (Strap. CM/town. SbMI Wildkp, ale. ISpecMl 2k 2!0. 29. 70e. 70f. CEIyTIF1ERICMdradyaM) SIGNAT E Di1TLEpFC T IER 'CERTIFYINf: PHYSICIAN IPnyprMn cereMrq eauea d Deem wnen andner pnypcrn nn ponounced deem arq campped nem 271 G~ lb tlIe leel el my knewNdge, dram oeturted due Po me eaufe(a) ant manner a atalM ..................................................... y~ ]l0. L ~ ~"~• ` "~ LICENSE NUMBER D S IG N EDIMOnm, Day YMI '-RONOVNCNq ANO CERTIFYING PHY9ICIAN (Pnyxun Dam prpwun6rq deem ant CMayng tocause d uaml ' lb the Deaf d my kn•rrledge, loam oeeurrad al tIb lima, dab, eM plaee, arM ern b the eeufe(s(end manner a patee ......................... . ^ ~ a ~ ~y IJ Jle. O ~ i• \ ~ 710. n•e-' V ate. NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH • 'MEDICAL P.XAMINER/CORONER On me bola of gaminetlon anlLOtmveali alion In lt inion deelh oeturred al the time o date and l d d t th M Item 27) Type a PNM ~C ~ ` P 3 (•` ~'~ J~~,~ J r1 ~}.~ •• g , ry p , , , p ate, an ue o e cause(s) nI manna. ae ateted ................................................................................................ ^ 7,.. ~(] '~T~ p~ p 72. USIA V.~l..\~ `pD +l ~ 1"1)~(~'yS~,. REGISTRAR'S SIGNATURE A ER t~ ~ A ~~ ~ DATE FILEDIMOmn.Oay. Yea I (~ ,,. • eaa~cx~ , c~ aooa- 7.. ALBF'RTa nAN7EISEN ~, 21-°02-1Q:,~7 ~~-LBERTA DANZEISEN, residing in the Borough of Milltown, County of Middlesex and State of New Jersey, being of sound and disposing mind, memory and understanding, do make and execute this instrument as and for my Last Will and Testament in the manner and form as follows, that is to say: FIRST: I direct that all my just debts and funeral expenses be paid as soon as conveniently may be after my decease. SECOND: I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, wheresoever the same may be situate and of whatsoever the same may consist, to my husband, CHARLES F. DANZEISEN. THIRD: In the event that my husband, CHARLES F. DANZEISEN, predeceases me, of if my husband and I are both killed in the same catastrophe, or seriously injured in the same accident, or stricken simultaneously with a fatal illness, so that we, or either of us shall not have an opportunity to provide for the contingency, then and in any of those events, I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, wheresoever the same may be situate and whatsoever the same may consist, to my son, ROGER L. DANZEISEN, or if he should predecease me then, bearing in mind my grandson ERIC J. DANZEISEN since he has no need for the same, I give, devise and bequeath the rest, residue and remainder of my estate to my grandchildren BETH ANN MORPETH, TAMMY L. DANZEISEN and KITTRICK DANZEISEN, or the survivor or survivors of them, in equal shares, share and share alike. FOURTH: I hereby nominate, constitute and appoint my son, ROGER L. DANZEISEN, sole executor, without bond, of this my Last Will and Testament, but if he should predecease me or be unable or 1 unwilling to serve, then my granddaughter, BETH ANN MORPETH, sole executrix, without bond, giving to m~ said executor/executrix full Dower and authority to sei.l or convey any and all real estate whereof I may die seized or possessed or in which I have any death. My said interest whatsoever at the time of my executor/executrix shall also have the full power and authority at his/her discretion, as it may seem advisable, to sell, convey and convert the whole, or any part of my said estate into cash at such prices, upon such terms and to such persons as to my said executor/executrix shall deem proper, and for the purposes aforesaid, to execute and deliver all necessary and proper conveyances, assignments and transfers, with or without covenants of warranty. I hereby revoke and any and all former Wills by me at any time heretofore made. I, ALBERTA DANZEISEN, the testatrix, sign my name to this ~'~ and bein dul sworn, do instrument this ~~ day of JUNE, 1995, g y hereby declare to the undersigned authority that I sign and execute this instrument as my last Will and that I sign it willingly, that I execute it as my free and voluntary act for the purposes therein expressed, and that I am 18 years of age or older, of sound mind, and under no constraint or undue influence. ,.,~ C.. , ALBERTA DANZEISEN THE witnesses, being first duly sworn, do each hereby declare to the undersigned authority that the testatrix signs and executes this instrument as her last Will and that she signs it willingly and that each of us states that in the presence and hearing of the testatrix, they hereby sign this Will as witness to the testatrix° 2 signing, and that to the best of their knowledge, the testatrix is 18 years of age or older, of sound mind, and under no constraint or undue influenceo STATE OF NEW JERSEY: COUNTY OF MIDDLESEX: Subscribed, sworn to and acknowledged before me by ALBERTA DANZEISEN, the testatrix, and subscribed and sworn to before me by ~.~) ~ r i g~' v (`~ L~ t"~ S'~}~3 and ~~_ ~;~° ~ ~ ~f°'t`~'Ti3 ~ ~ ~ ~!~ t (('('! ~~~{ .. C ~ r ..; `) -~-~~'' witnesses, this ~ day of JUNE 1995, HOSERT S.'EtiUll A No1sry P~bfc d Ner JBiiNy Cuy Cortniaion Expires Na.17,1~ 3 Name of Decedent: Date of Death: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) ALBERTA DANZEISEN November 4, 2002 Will No. 21- 0 2 -10 3 7 Admin. No. To the Register: I certify that notice of (beneficial interest) 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 December 30, 2002 Name Address Roger L. Danzeisen 117 Susan Lane, Carlisle PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: /~ < ~.z-,---- ~ ., ;' _7 0 1_-c~ ,~ .z~ ~ r, Signature `.~--L~--~--z...-..-~ ~; az--ti,,~..,.,, Name Patricia R. Brown Capacity 10 West Pomfret Street Address Carlisle PA 17013 Telephone ( ) 717-249-3024 Personal Representative X Counsel for persona] representative ~` 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 REV-1162 EX(11-96) NO. CD 0021 16 BROWN PATRICIA R 10 WEST POMFRET STREET CARLISLE, PA 17013 ACN ASSESSMENT AMOUNT CONTROL NUMBER fold ESTATE INFORMATION: ssrv: i54-20-says FILE NUMBER: 2102-1037 DECEDENT NAME: DANZEISEN ALBERTA DATE OF PAYMENT: 02/03/2003 POSTMARK DATE: 00/00/0000 couNTY: CUMBERLAND DATE OF DEATH: 1 1 /04/2002 101 ~ 57,500.00 TOTAL AMOUNT PAID: REMARKS: PATRICIA R BROWN ESQ SEAL CHECK#1003 INITIALS: JA RECEIVED BY: DONNA M. OTTO 57,500.00 DEPUTY REGISTER OF WILLS REGISTER OF WILLS v/ o~ STATUS REPORT UNDER RULE 6.12 Name of Decedent: Alberta Danzeisen Date of Death: November 4, 2002 Will No. 21-02-01037 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State 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 X No Filed Family Settlement Agreement 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 Cerk of the Orphans' Court and may be aL-tached to this report. Date: S ~ Q3 o~ :-:- ~ ,_ ci, .._ J ... >.. -' :. ~ ~.... ~' ~ ~ `` ~.,~ C.: (MAH:rmf/AM3) Signature Patricia R. Brown Name (Please type or print) 10 West Pomfret Street Carlisle PA 17013 Address X717) 249-3024 Tel. No. Capacity: Personal Representative X Counsel for personal representative ~~-~~~-~ COMMONWEALTH OF PENNSYLVANIA ~, BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 28D601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 E% RFP (01-03) DATE 04-14-2003 ESTATE OF DANZEISEN ALBERTA DATE OF DEATH 11-04-2002 FILE NUMBER 21 02-1037 COUNTY CUMBERLAND PATRICIA R BROWN ACN 101 10 W POMFRET ST Amount Remitted CARLISLE PA 17013 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 DANZEISEN ALBERTA FILE N0. 21 02-1037 ACN 101 DATE 04-14-2003 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 (i) .00 (2) .00 (3) .00 (4) .00 (5) 181,611.75 (6) .00 v) .00 (8) NOTE: To insure proper credit to your account, submit the upper portion of this fora with your tax payment. 181,611.75 APPROVED DEDUCTIONS AND EXEMPTIONS: 13,167.17 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 1,786.0 0 11. Total Deductions (11) 14.953.17 12. Net Value of Tax Return (12) 166,658.58 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 14 Net Value of Estate Subject to Tax [14) 166,658.58 . 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. Amount of Line 14 at Spousal rate (15) •0 0 X 00 = .00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 166,658.58 X 045 = 7,499.63 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 15 = .00 19. Principal Tax Due (19)= 7,499.64 rwv noenrrc. DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 02-03-2003 CD002116 374.98 7,500.00 TOTAL TAX CREDIT 7,874.98 BALANCE OF TAX DUE 375.34CR INTEREST AND PEN. .00 TOTAL DUE 375.34CR * 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.) REV-1St,joEXlli.Q0! COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 \ "\ - L~ d.. REitt:1500 w ..., "'~"' ,,"'''' w"" ",00 ,,"''''' ..Ill .. '" INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z W C W o W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) DANZEISEN, ALBERTA ~ OFFICIAL USE ONLY FILE NUMBER 21-02 o 1 0 3 7 DATE OF BIRTH (MM-DD-YEAR) 03/28/20 DATE OF DEATH (MM-DD-YEAR) 11/04/02 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) ~ 1. Original Return o 4. Limited Estate [] 6. Decedent Died Testate (Attach copy olWill) D 9. Litigation Proceeds Received D 2. Supplemental Return D 4a. Future Interest Compromise (date 01 death after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach copy 01 Trust) D 10. Spousal Poverty Credit (date 01 death between 12.31-91 and 1-1-95) COUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 154 ~ 20 6319 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Return (date 01 death prior to 12-13-82) o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Attach Sch 0) ..., Z W C Z o .. "' w '" '" o " NAME Patricia R. Brown FIRM NAME (II Applicable) COMPLETE MAILING ADDRESS 10 West Pomfret Street Carlisle PA 17013 (11) (12) (13) 14,953.17 166,658.58 (1) 0 OFFICIAL USE ONLY (2) 0 (3) 0 (4) 0 (5) 181,611. 75 (6) 0 (7) 0 (8) 181,611.75 (9) 13,167.17 (10) 1.786.00 x.O_ (15) x ,0 45 (16) 7,499.63 x .12 (17) x .15 (18) (19) TELEPHONE NUMBER 717 249-302L, (14) 166,658.58 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule 0) z o < ..J ::J l- ii: < o W D:: 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. lnter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or l) 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 Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o !;;: .... ::J a.. ::iii o o ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of line 14 taxable at lineal rate 166,658.58 17. Amount of line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20~ CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: STREET ADDRESS Sarah Todd Memorial Home 1000 West South Street CITY Carlisle I STATE PA I ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 7,500.00 C. Discount (1) 7,499.63 Total Credits (A + B + C ) (2) 7,500.00 3. InteresVPenalty if applicable D. Interest E. Penalty TotallnteresVPenalty ( 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. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT _1IH1&..ml;I!~!1Ilml r I~jfi_- [.~~___ -.-.- 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; ....................... .................. ........................... D [R) b. retain the right to designate who shall use the property transferred or its income; ............................. ...... D [lC] c. retain a reversionary interest; or ................... .......................................... ......... 0 ~ d. receive the promise for life of either payments, benefits or care? ........ ........................................ .. D [R) 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................. .................. .................... .. ..... D [}g 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ............. 0 ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . ............................................. ............................................ ...... D ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN, Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATU~E O~EPARER OTHER THAN REPRESENTATIVE ~~~'..JY{~ ADDRESS DATE /. J ,;, ;.2.0 ~oa3 , 10 West PomEret Street, Carlisle PA 17013 _~IIliIIJjLJi_I1I1I1_,~~,~_1III1I\IIII~_..h.,I_il:lI\IIII_mll.___l . For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 PS. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the deoedent's siblings is 12% [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has a11east one parent in common with the decedent, whether by blood or adoption. REV"",,'~'I''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF DANZEISEN, ALBERTA FILE NUMBER 21-02-01037 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION Wachovia Securities, Inc. CAP Acct. No. 8881331916 Investment Acct. No. 22086311 VALUE AT DATE OF DEATH 94,345.86 2 . First Union Personal CD Acct. No. 247412051764486 60,921.73 3. 11organ-Stanley U.S. Gov't Securities 17,755.34 4. Sure Trust Choices (prepaid funeral trust fund) 8,588.82 TOTAL (Also enler on line 5, Recapitulation) $ 181, 611 . 75 (If more space is needed, insert additional sheets of Ihe same size) REIJ~1511 EX+ (12-99) ^ ~k COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Bronson & Guthlein Funeral Home 7,129.00 (Mill town, N.J. ) Travel Expenses (Gas, Turnpike Tolls) for Family 544.85 After Service Meal (Jon Athan's, Jamesburg, N.J. ) 94.50 Flowers 450.00 Misc. Expenses 186.71 B. ADMINISTRATIVE COSTS: 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 Patricia R. Brown, Esquire 4,500.00 3. Family Exemption: (It decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State _Zip Relationship of Claimant to Decedent 4. Probate Fees Probate Petition, Short Certs, etc. 257.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Postage Fees 5.11 TOTAL (Also enter on line 9, Recapitulation) $ 13,167.17 DANZEISEN, ALBERTA Debts of decedent must be reported on Schedule I. FILE NUMBER 21-02-01037 ESTATE OF (If more space is needed, insert additional sheets of the same size) . REV_15t2EX.(1_97) -'~. ., "" ...~ :;. SCHEDULE) DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-02-01037 COMMONWEALTH OF PENNSYLVANI/\ INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DANZEISEN, ALBERTA Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT Sarah Todd Memorial Home 1,129.10 656.90 2. Phar-America (medicines) TOTAL (Also enter on line 10, Recapitu!ation) $ 1,786.00 (If more space is needed, insert additional sheets of the same size) REV.1513~X+(1-971 '* SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. ROrer L. Danzeisen Son 100% 11 Susan Lane Carlisle PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ DANZEISEN, ALBERTA FILE NUMBER 21-02-01031 ESTATE OF (If more space is needed, insert additional sheets of the same size) -. o o 19tf~i{(ol ana (rJioml'nf 01 ~ ,:aLBERTA ALBERTA DANZEISEN .. 21--02-1037 DANZEISEN, residing in the Borough of Milltown, County of Middlesex and state of New Jersey, being of sound and disposing mind, memory and understanding, do make and execute this instrument as and for my~ast will and Testament in the manner and " form as follows, that is to say: FIRST: I direct that all my just debts and funeral expenses be paid as soon as conveniently may be after my decease. SECOND: I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, wheresoever the same may be situate and of whatsoever the same may consist, to my husband, CHARLES F. DANZEISEN. THIRD: In the event that my husband, CHARLES F. DANZEISEN, predeceases me, of if my husband and I are both killed in the same catastrophe, or seriously injured in the same accident, or stricken simultaneously with a fatal illness, so that we, or either of us shall not have an opportunity to provide for the contingency, then and in any of those events, I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, wheresoever the same may be situate and whatsoever the same may consist, to my son, ROGER L. DANZEISEN, or if he should predecease me then, bearing in mind my grandson ERIC J. DANZEISEN since he has no need for the same, I give, devise and bequeath the rest, residue and remainder of my estate to my grandchildren BETH ANN MORPETH, TAMMY L. DANZEISEN and KITTRICK DANZEISEN, or the survivor or survivors of them, in equal shares, share and share alike. FOURTH: I hereby nominate, constitute and appoint my son, ROGER L. DANZEISEN~ sole executor, without bond, of this my Last will and Testament, but if he should predecease me or be unable or 1 unwilling to serve, then my granddaughter, BETH ANN MORPETH, sole executrix, without bond, giving to my said executor/executrix full power and authority to sell or convey any and all real estate whereof I may die seized or possessed or in which I have any interest whatsoever at the time of my death. My said executor/executrix shall also have the full power and authority at , . '~ "- his/her discretion, as it may seem advisable, to sell, convey and convert the whole, or any part of my said estate into cash at such prices, upon such terms and to such persons as to my said executor/executrix shall deem proper, and for the purposes aforesaid, to execute and deliver all necessary and proper conveyances, assignments and transfers, with or without covenants of warranty. I hereby revoke and any and all former wills by me at any time heretofore made. I, ALBERTA DANZEISEN, the testatrix, sign my name to this instrument this J4.\-" day of JUNE, 1995, and being duly sworn, do hereby declare to the undersigned authority that I sign and execute this instrument as my last Will and that I sign it willingly, that I execute it as my free and voluntary act for the purposes therein expressed, and that I am 18 years of age or older, of sound mind, and under no constraint or undue influence. Cuj~~~~ ALBER':t'A DANZEISEN (J THE witnesses, being first duly sworn, do each hereby declare to the undersigned authority that the testatrix signs and executes this instrument as her last Will and that she signs it willingly and that each of.us states that in the presence and hearing of the testatrix, they hereby sign this will as witness to the testatrix' 2 signing, and that to the best of their knowledge, the testatrix is 18 years of age or older, of sound mind, and under no constraint or undue influence. Ji2 ' , 'A./7 --ru _ j/ t?e~^-- c:kfufLeu~ (J !/tiJJ!/ f!k d "- ~ STATE OF NEW JERSEY: COUNTY OF MIDDLESEX: Subscribed, sworn to and acknowledged before me by ALBERTA DANZEISEN, the testatrix, and subscribed and sworn to befOrjme by h; 0 he V ReAls,()J\\ and~IH ItFA)fL mOc("'clYtL , witnesses, this ~ day of JUNE 1995. ~ ~/ RO!EAT S. i!EGUIl . ANCIlaIy_llNw,*"" l.Iy Comri&IlOn EJlllAI..... 17. 1118 3 -...- FAIVIILY 8ETTLEMENT AND FINAL RELEABE IN EBTATE OF ALBERTA DANZEIBEN (File No. 21-02-1OS7) KNOW ALL MEN BY THESE PRESENTS, that WHEREAS, ALBERTA DANZEISEN, of Carlisle Borough, Cumberland County, Pennsylvania, deceased, died testate on November 4, 2002, having first made her Last Will and Testament, which was duly executed on June 14, 1995, and is duly recorded at the Register of Wills in Cumberland County, Pennsylvania. WHEREAS, the said Alberta Danzeisen, by the aforesaid Last Will and Testament, named Roger L. Danzeisen, as Executor of said Last Will and Testament; WHEREAS, letters testamentary on the estate of the said decedent were duly issued by the Register of Wills of Cumberland County, Pennsylvania, to the said Executor, hereinafter called personal representative; WHEREAS, the said personal representative has gathered the probate assets of the estate of the said decedent and the said assets consist of only personal property; to a total value of $181,611.75, as set forth in Exhibit A, which is a statement of account of the said personal representative, and which is attached hereto and made a part hereof, and marked Exhibit A; WHEREAS, the debts and deductions, including the payment of inheritance tax in the said estate, amount to $22,452.81, leaving a balance for distribution of $159,158.94, also as set forth in the statement of the said personal representative, which is attached hereto and marked Exhibit A; NOW, THEREFORE, KNOW YE, that I, Roger L. Danzeisen, the heir under the Last Will and Testament of the said decedent, and being that person entitled to inherit under said Last Will and Testament, does hereby acknowledge that I have this day had and received from the aforesaid personal representative, in full Page 1 of 4 satisfaction and payment of all sum or sums of money, legacies, bequests, and devises as are given, devised and bequeathed to me by the said Last Will and Testament, the amount due me under said Last Will and Testament, which amount I have received this day, and which amount is in the amount set opposite my name in the table and schedule of distribution in said statement attached hereto and marked Exhibit A; AND, I do hereby stipulate that in order to avoid the expense and time involved in the filing of a formal account and schedule of distribution, I agree that no account is necessary and I do consent to distribution being made without the filing of an account and schedule of distribution, the same to be with the same force and effect as if they had been filed and confirmed by the Orphans' Court Division of the Court of Common Pleas, Cumberland County, Pennsylvania. THEREFORE, I do hereby remise, release, quitclaim and forever discharge the said personal representative, Roger L. Danzeisen, his heirs, executors, and administrators and assigns, of and from the said estate and from all actions, suits, payments, accounts, reckonings, claims, and demands whatsoever for or by reason thereof, or for any other use, matter, cause or thing whatsoever, touching upon the estate of the said decedent, and I do further hereby covenant and agree that should any liability come due to the estate of the said decedent after the signing of this agreement, I do hereby covenant and agree that I will contribute my share of the estate to satisfy any and all claims, demands, suits, or causes of action which may be successfully prosecuted against the said estate or the aforesaid personal representative after the signing, sealing and delivery of this family settlement agreement and final release. Page 2 of 4 IN WITNESS WHEREOF, I have hereunto set my hand and seal this "~ i day of ;~ . ` ~ , 2003. Witness: r._...~..._ 2 ~. ~e-~..~ Y~, ~ < ~ ~:~ _ (SEAL) Rog L. Danzei n COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND On this, the ~~ day of ~"~ ~~ , 2003, before me, a notary public, the undersigned officer, personally appeared Roger L. Danzeisen (known to me or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. NOTARIAL SEAL ~ ~ , DENISE PINAMONTI, Notary Public Carlisle Borc., Cumberland Count Public M Commisnien s 20 4 Page 3 of 4 F.~IT -A~- STATEMENT OF ACCOUNT OF ROGER L. DANZEI3EN, Executor ASSETS: 1. Wachovia Securities, Inc. $ 94,345.86 CAP Acct. No. 8881331916 Investment Acct. No. 22086311 2. First Union Personal CD $ 60,921.73 Acct. No. 247412051764486 3. Morgan-Stanley $ 17,755.34 U.S. Gov't Securities 4. Sure Trust Choices $ 8,588.82 (Prepaid funeral trust fund) TOTAL, AS3ET3 $ 181, 611.75 DEBTS and DEDUCTIONS: 1. Funeral & Administration Expenses $ 13,167.17 2. Miscellaneous Expenses $ 1,786.00 3. PA Inheritance Taxes $ 7,499.64 TOTAL DEBTS and DEDUCTIONS Balance for Distribution to Heir: NAME DISTRIBUTION Roger L. Danzeisen $159,158.94 Page 4 of 4 $ 22,452.81 $159,158.94 COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280681 NOTICE OF INHERITANCE TAX HARRISBURG, PA 17128-0601 APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REY-1547 ER 1FP (R1-O37 DATE 04-14-2003 ESTATE OF DANZEISEN ALBERTA DATE OF DEATH 11-04-2002 FILE NUMBER 21 02-1037 COUNTY CUMBERLAND PATRICIA R BROWN ACN 101 10 W POMFRET ST Amount Remitted CARLISLE PA 17013 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 DANZEISEN ALBERTA FILE N0. 21 02-1037 ACN 101 DATE 04-14-2003 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 n) .00 (2) .00 [3) .00 (4) .00 (5) 181,611.75 (6) .00 (7) .00 (8) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 181,611.75 APPROVED DEDUCTIONS AND EXEMPTIONS: 13,167.17 9 Funeral Expenses/Adm. Costs/Misc. Expenses [Schedule H) (9) . 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 1.786.00 17 953 11. Total Deductions (il) . 14. 166,658.58 12. Net Value of Tax Return (12) .00 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) 166,658.58 14. Net Value of Estate Subject to Tax (14) NOTE: if an assessment was issued previously, lines 14, f ALL ret t l 15 andior 16, 17, urns assessed to da 18 and 19 will te. o a reflect figures that include the to ASSESSMENT OF TAX: .00 X 00 _ .00 15. Amount of Line 14 at Spousal rate (15) 58 X 045= 658 166 7,499.63 16. Amount of Line 14 taxable at Lineal/Class A rate (16) . , 1 2 - 00 .00 17. Amount of Line 14 at Sibling rate (17) X . 15 00 .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) = X . 7 499.64 (19)= , 19. Principal Tax Due ~wv ,+A CATTC. ~~--R~~- I ulsCUUni ~*~ I AMOUNT PAID DATE NUMBER INTEREST/PEN PAID ( - ) 7 ~ 50 OJO 0 _n~-~nn3 CD002116 374.98 TOTAL TAX CREDIT 7,874.98 BALANCE OF TAX DUE 375.34CR INTEREST AND PEN. .00 TOTAL DUE 375.34CR * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. pFREFUND.DSEEIREVERSECSIDEAOFATHISEFORM FOR)INSTRUCTIONS,DUE ~" BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 PATRICIA R BROWN 10 W POMFRET ST CARLISLE COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT •~~ ;V ~~~ ,., . PA 17013 r-~, REY-1607 EX pFV (O1-OS~ .DATE 05-19-2003 ESTATE OF DANZEISEN ALBERTA DATE OF DEATH 11-04-2002 FILE NUMBER 21 02-1037 ::"COUNTY CUMBERLAND ACN 101 Amount Remitted 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 u pper portion of this form with your tax payment. -------------- CUT ALONG THIS LINE - RETAIN LOWER P_ORTI_O_N___F_OR YOUR RECORDS REV-1607 EX ------------------------- AFP (O1-03) °-°--°°°-- *** INHERITANCE TAX ---------------- ACCOUNT ~~* STATEMENT OF ------------------------------- ESTATE OF DANZEISEN ALBERTA FILE N0. 21 02-1037 ACN 101 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATETESHOWN BELOW003 IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 04-07-2003 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID (-) 02-03-2003 CD002116 04-28-2003 374.98 REFUND .00 AMOUNT PAID 7,500.00 375.34- TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. * IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE SIDE 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 TWSTDI1PrTnuc 7,499.64 7,499.64 .00 ~_ .00 .00