HomeMy WebLinkAbout01-0021
REV .1500 EX + (6.00)
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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COMMONWEALTH OF PENNSYLVANIA
(lEPARTMENT OF REVENUE
. DEPT. 280601
HARRISBURG, PA 17128.0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
E Ie Mar Jane
DATeOF DEATH (MM. DO. YEAR)
&
FILE NUMBER
/ ~ - / qq - /(J
OFFICIAL USE ONLY
21-01-0021
COUNTY CODE YEAR
SOCI.L SECURITY NUMBER
196-14-0644
THIS RETURN MUST BE FILED IN DUPliCATE WITH THE
NUMBER
REGISTER OF WILLS
SOCIAL S URI Y NUMBER
o
3. Remainder Return ~rci~ t'bf ~2e!ft82)
S. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(11.)
(Attach Sch 0)
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DATE OF 8IRTH(MM.OO.YEAR}
03 14 1924
NAM LAST, FIRS ,"NO \DOLE INITIAL
COMPLETE MAILING AODRESS
John E. Slike
FIRM NAME (If Applicable)
Saidis, Shuff, Flower & Lindsa
TELEPHONE NUMBER
2109 Market St.
Camp Hill, PA 17011
- 4 5
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or
Sole-Proprietorship
4. Mortgages & Notes Receivable {Schedule Dl
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 or LI
8. Totar 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/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Sub'eet to Tax (Line 12 minus Line 13)
Copyright (c) 2000 form software only The Lackner Group, Inc.
X 1. OrigInal Return
4. limIted Estate
X 6. Decedent Died Testate
(Atta.ch copy of Will)
o 9. litigation Proceeds Received
2. Supplemental Return
4a. Future Interestcompromfse(dateQfd~thaner 12.1Z.82.)
7. Oecedent MaintaIned a living Trust
(Attach copy of Trust)
010. Spousal Poverty Credit
{date of death between 12.31-91 and 1~1-95)
(1)
(2)
(3)
92,000'0-00
None
None
None
7,335.82
None
None
18,689.95
863.46
.0 0
.0 45
.12
.15
OFFICIAL USE ONLY
(8) 99,335.82
(11) 19.553.41
(12) 79,782.41
(13) 500.00
(14) 79,282.41
(15)
(16)
(17)
(18)
(19)
0.00
3,567.71
0.00
0.00
3,567.71
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(4)
(5)
(6)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(aX1.2)
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.
79,282.41
x
X
X
X
FormREV-1500 EX (Rev. 6.00)
Decedent's Complete Address:
STREET ADDRESS
203 Norman Road
.
CITY I STATE , ZIP
Carno Hill PA 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
3,567.71
178.39
Total Credits ( A + B + C) (2)
178.39
3. Interest/Penalty if applicable
D. Interest
E. Penally
TotallnterestlPenal1y ( 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 relund (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. (SA)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WillS, AGENT
0.00
0.00
3,389.32
0.00
3,389.32
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PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN
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IN THE APPROPFlIA1'EBL,()CKS
Yes No
~~
Did decedent make a transfer and:
a. retain the use or income of the property transferred;
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? .
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?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN.
o
o
o
o
o
o
Under penalties of perjury, 1 declare that I have examined this return, Including accompanying schedules and statements, and to the best of my knowledge and belfef, it Is true,
correct and complete. Declaration of pre parer other than the personal reprt'S6ntatlve Is based on all informatIon of which pre parer has arfi k.nowledge.
11'?NATURE OEPERSON.flESP9l'.~B~EFORJ"J.I.NG.RETURN Suzanne M Kaufman n/k/ a Suzan!je M. Miner DATE 3/2 JY~' I
~"JV>-+'-fl1tU<LMa~ If rvv>-- ') JL ':'""~ 60 Hummel Ave., 2nd Fl. "" i!a-V'd I s: w,~ ^'-t.R.
"\ --L~mo--- ..-,--pj..- - -17('-43 --- u. - -(3v-.--e>e<etcrof?::t --
SIGNATURE OF PREPARER ERTHANAEPRESENTATIVE Saidis, Shuff, Flower &: Lindsay
2109 Market St.
- - 'earn- - -illYi - - PA - - iiiiii -.- - - - - - - - - - - - - - - - - - - - - --
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DA . I
For dates of d h on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 9116 (a) (1.1) (j)].
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"10
[72 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 fillng 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 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(aXllj.
The lax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 120ft. [72 P.S. 9116(aX1.3}]. 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.
Copyright (c) 2000 form software only The Lackner Group, Inc.
Form REV-1S0D EX (Rev. 6-00)
'REV~ 1502 EX t (1-97)
COMMo.'lWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
, RESIDENT DECEDENT
ESTATE OF
,
Mary Jane Eppley SS# 196-14-0644 12/29/2000 21-01-0021
All real property owned sOlely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price
at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable
knowledae of the relevant facts. Real property which is iOintly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 203 Norman Road, Camp Hill, PA (value based on sale price -
see settlement sheet attached)
SCHEDULE A
REAL ESTATE
FILE NUMBER
92,000.00
TOTAL (Also enter on line 1, Recapitulation) $ 92,000.00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV..1502 EX (Rev. 1-97)
-REVQSOa EX +(1-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary Jane Eppley SS# 196-14-0644 12/29/2000 21-01-0021
Include the proceeds of litigation and the date the proceeds were received by the estate, All property jointly-owned wjth the right of
survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1
DESCRIPTION
Allfirst Bank, checking acct. no 0045732078
VALUE AT DATE
OF DEATH
1,028.13
2
Allfirst Bank, savings acct. no. 80000002183627
accrued interest
25.27
0.01
3
Allfirst Bank, certificate of deposit no. 80000002183795
accrued interest
3,038.56
22.08
4
Refund from cancellation of car insurance policy
138.00
5
1986 Pontiac 6000, poor condition
500.00
6
7
Personal property and household furnishings
(distributed in-kind to heirs)
Personal property and household furnishings (based on
sale prices)
1,175.00
1,325.00
8
The Patriot News, refund
31.55
9
medical expense reimbursement
52.22
TOTAL (Also enter on line 5, Recapitulation) $ 7,335.82
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc, Form REV-1508 EX (Rev, 1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTAT OF
Mary Jane Eppley
Include unreimbursed medical expenses.
ITEM
NUMBER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
,AEV.1512 EX t (1 ~97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
SSfj 196-14-0644
FILE NUMBER
21-01-0021
12/29/2000
DESCRIPTION
AMOUNT
19.87
16.26
67.50
52.00
41. 37
126.26
28.08
19.47
24.34
27.88
175.00
209.34
1.00
8.88
20.66
17.15
8.40
Verizon, phone bill
PAWC, utility expense
Lower Allen - sewer and trash removal
Bar Plumbing, repairs
PPL, utility expense
DGI, utility expense
PPL, utility expense
Verizon, phone bill
Quantum Imaging, medical expense
Lehigh Ambulance, medical expense
Daniel H. Clem, repairs to spouting
Reimbursement to Suzanne Miner for repairs to house (door)
PA Dept. of Revenue, PA40 for 2000
PAWC, utility expense
PPL, utility expense
Verizon, phone bill
PAWC, utility expense
TOTAL (Also enter on line 10, Recapitulation) $ 863.46
(Jf more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rell. 1-97)
REI/.-1511 EXt(1-97)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
C6MMO~WEALTH OF PENNSYLVANIA
INHERITANCE TPoX RETURN
. RESIDENT DeCEDENT
ESTATE OF
Mary'.Jane Eppley
FILE NUMBER
21-01-0021
SS{/ 196-14-0644
12/29/2000
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
Myers Harner Funeral Home
Flowers
Funeral Luncheon
Grave opening
B.
AMOUNT
6,084.00
316.41
169.79
475.00
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
waived
City
State
Zip
Year(s) Commission Paid:
2.
3.
Attorney's Fees Saidis, Shuff, Flower I;, Lindsay
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
4,967.00
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
Register of Wills
229.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Other Administrative Costs
The Cumberland Law Journal, estate
The Patriot News, estate notice
PNC Bank, check fee
Erie Insurance, fire and liability
Costs incurred in sale of house:
realtors commission
notary fees
transfer taxes
prorated taxes
5,050.00
12.00
920.00
194.22
notice
75.00
115.53
13.00
69.00
6,176.22
premium
TOTAL (Also enter on line 9, Recap"ulation) $ 18,689.95
(If more space is needed, insert additional sheets of the same size)
Copyrfght(c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev, 1~97)
,REV..1513 EX +(9~OO)
COMMO~EA~TH OF PENNSY~VANIA
IN-HERITANCET,.;;( RETURN
RESIDENT DECEDENT
ESTATE OF
Marv Jane Eoolev SSj, 196-14-0644
SCHEDULE J
BENEFICIARIES
12/29/2000
FILE NUMBER
21-01-0021
HELATIONSHIP TO DEq:DENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS [Include outright spousal distributIons, and
transfers under Sec. 9116(aX1.2)1
1 Suzanne M. Miner
60 Hummel Ave., 2nd Fl.
Lemoyne, PA 17043
daughter 1/2 of residue
2
Carol Jane Wisner
7543 Carlisle Rd.
Wellsvil1e, PA 17365
daughter
1/2 of residue
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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
Camp Hill Church of God
123 N. 21st St.
Camp Hill, PA 17011
500.00
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
500.00
(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)
SAIDIS, GUIDO,
SHUFF &
MASLAND
2109 Market Street
Camp HilI, PA
i,
,
I
LAST WILL AND TESTAMENT
OF
MARY JANE EPPLEY
I, MARY JANE EPPLEY, of Lower Allen Township, Cumberland
County, Pennsylvania, declare this to be my Last Will and Testa-
i ment, hereby revoking any will previously made by me.
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I - I direct the payment of all my just debts and
funeral expenses out of my estate as soon as may be practical
after my death.
II - I bequeath the sum of $500.00 to the Camp Hill
Church of God.
III - I devise and bequeath all the rest, residue and
remainder of my estate of every nature and wheresoever situate
unto my daughters, Suzanne Marie Kauffman currently of Mechanics-
burg, Pennsylvania, and Carol Jane Wisner currently of Dover,
Pennsylvania, or their issue per stirpes.
IV - I appoint my daughters, Suzanne Marie Kauffman and I
Carol Jane Wisner, Executrices of this, my Last Will and Testa-
ment. Neither of my personal representatives shall be required
to post bond in this or any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on
,f .^'
. "-~ I ...........L-...f
this, the f day of ,J', , 1996.
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MARy'J'ANE EPPLEY' -c\
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Signed, sealed, published and declared by MARY JANE EPPLEY
therein named, on this and one (1) other sheet of paper as and
for her Last Will and Testament, in our presence, who, in her
\ presence, at her request, and in the presence of each other, have
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SAIDIS, GUIDO, :,\
SHUFF &
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MASLAND i
2109 Market Street
Camp Hill. PA
hereunto subscribed our names as attesting witnesses.
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SAIDIS, GUIDO, il
SHUFF & :(
MASLAND I,
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2109 Market Street II
Camp Hill. PA
COMMONWEALTH OF PENNSYLVANIA)
SS.
COUNTY
OF
CUMBERLAND)
WE, the undersigned, the testatrix and the witnesses,
respectively, whose names are signed to the foregoing instru-
ment, being first duly sworn, do hereby declare to the under-
signed authority that the testatrix signed and executed the
instrument as her Last will and Testament and that she signed
willingly (or willingly directed another to sign for her), and
that she executed it as her free will and voluntary act for the
purposes therein expressed, and that each of the witnesses, in
the presence and hearing of the testatrix signed the will as
witnesses and that to the best of their knowledge the testatrix
was at that time eighteen years of age or older, of sound mind,
and under no constraint or undue influence.
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c4lestatrix
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Subscribed, sworn to and acknowledged
testatrix, and subscribed and,sworn to before
nesses, this ki- day of I" ' ,
before me by the
me by both wit-
, 1996.
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Notary Public
OMS NO 2502 0255 -",
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A. B. lYPE OF LOAN:
U.S. DEPARTMENT OF HOUSING &. URBAN. DEVELOPMENT '.oFHA 2.DFmHA 3.0CONV. UNINS, 4.oVA 5. e9CONV. INS.
0, 01042 . , I' ,
SETTLEMENT STATEMENT
0, MvR I vAGE IN5 CASE NUM8ER, I
c. Nv'"' This form is tvmishod to give you a statement of actual sefl/emont costs. Amounts p6id 10 and by 1M settlemcnt agont aro shown. I
Items marked HiPOCr were paid outside the Closing; they are shown herQ for informational purposes and are not includud in the totals.
10 3I9lI (Ol042,~1042120
U. NAMt: AND ADlJRC:SS Of tlURKUWER: E. NAME AND AVU"""" Or SELLER, F. NAME ANu ADuR'-SS V" LtoNutoR'
Elain" A. Tyler Estate of Mary Jane Eppley Gateway Funding Diversified
lIAortgage Services
G, PROPERTY LOCATION, H. SETTlEMENT AGENT, 251-63.6397 l. SETTLEMENT DATE,
203 Norman Road Keystone Land Transfer. Inc.
Camp Hill. PA 17011 March 15, 2001
Cumberland County, Pennsylvania PLACE OF SETTLEMENT
3425 Market Slreet
Camp Hill, PA H011
" vr to" ~ K. S .
1 SS AMOUNT DUE FROM BoRRUWER: 400. l.:iROSS AMOUI'H OUE TO 5ELLEK:
101. Ontract .::i~lles nee I Ontrac aes no.
,u<. erl'iona rope Y I arsona ropcrty I
et emen ar~'Cs to orrowur .ne u I 0 ,.uo,
I 4. i
,"0, I ,
jU, ens u( oms oJJ y e erm vanCe rjUSlments orflolTl31"aui 1Jy e erm a vance
I y own axes '" I i 4Ul:i. L;ltYf own axes to , <og
olmty I axes Uoll"'U1 to UW1IU': 0 .I.;ounty axes I ;:l/U- to U1/U1iU~ ,
1Ul', :5cnOOJ (ax 0 I . ::;.cno ax 01 0 . I
ewe, to ewer
"'sn 0 , ",s 0
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120, GROSS AMOUNT DUE FROM BORROWER I 96,052,08 420. GROSS AMOUNT DUE TO SELLER , 92,492,70
I
200. AMGUNTS PAID BY OR iN BEHALr Ur BORRuWEI<: 500. REDUC IONS IN AMuUNT DUe: TV SELLER:
201. epOSl1 or earnest money I I :;lUl. t:;xcess uepOSlt l~~e InstrucllOns) .
:W:i:::. Principal Amount 01 New LCiJn{S I 01,400,00 ~)U~. ;)etnemem t,;narges to ~e ,er (LUlU 14UU) MoO,'"
200. xlsflng oan{s} taKen suDJeGtld I I ';:l\J~. t:.:<15tmg cants) I""en SUOJCCtlo
204, , I :JU.;o, t"ayol1' Olllfst Mortgage I
200. I I :JU::l. /""ayol1' O( 50cona MOrtgage
2UO.
I eposl also. as procee s
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AOJlJstmems rot lle/1lS unpalU tjy ::>Ciler Ac.lJustmcnts /"or Items unpai y tJlsr
IY/own axes to , t IY own ICllteS to I
ounty axes 0 , ounty axes 0 I
~1~. ~chQOI fax 0 , ,S 00 a, 0
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220. TOTAL PAID BY/FOR BORROWER I 90,400,00 520. TOTAL REDUCTiON AMOUNT DUe seLLER I 6.668.92
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oUU. c 'MIIU , I i:>I.lU. CA;;il1 Al ~l:.l JLI:Mt:; r L:=.l:
lOSS un Ge rom orrower me , 0.;). 0 ross meul'll U. 0 He Ine I I 'L, ;':.iJ
e:s5 moun a;t1 YI or onuwcr Inc " 0 ess e uellons GO e lcq Ine I u,
303. CASH ( X FROM) ( TO) BORROWER , 5,652.08 603. CASH ( X TO> ( FROM) SELLER I 85.823.78
I
The undersigned hereby Clcknowledge rec.elpt of a completed copy of pages 1 &2 of tt1is statement .& any attachments referred to herein.
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BO"owee ." ('" ) '-.. \ ~ ,
~~Ule A. Tyler
~' ~-
Sell ~ {(/J\.-.~ J I Ut..{..<.....L l~
,. sL:.i r i\lal y June ppley
[7bO.--rOTAl. COMMISSION Based on ;Jilce-- - - - S - -...----~.-. u_@
LJlYlS10n Of t.;ommlSSlon me as C OW5;
IIU. . :) i.,/OU.UU 10 e ax ea Y 'SOClateS;ll'iC.
I.UU 10 e <lr -~t;) ace ea S e
~mmlsslon ::11 J e c e
"TU'r." ransacuon rec m ellVl3X ~e:JflY ASSOClams inC.
BOO. ITEMS PAYABLE IN CCNNECTlON WITH LOAN
B'lJT.'T'"oail ,iqll1allon l"'ec 0 0
EQ2:-Lo.:m LJlscoun "to
~pralsa ea 0 """G3Tcw<JY rUlloll1g
~04. (,,;18! e or a eway un Ing
IjU::l. Lancers mspec Ion rea 0
"'BlN:Nlor gagEllns. pp. -ee 0
~ssump Ion es 0
llms. LJe IVery ee 0 a <;jway un mg
umen rep3rGl Ion ae 0 &,.eway un mg
~1U. !-ICO <:rj lea Ion 0 a eway un 109
n erwnung rea 0 a eway r-unom
x .::.ervlce lOl3a1eway un 109
VI W ee 0 a away un log
01<.
,.'0.
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CJITT:
1.1".
"V.
,.LU.
900. ITEM... R BY LEN.DER TO BE PAlO IN ADVANCE
901. \f'terest From O~F\5i()' \0 04i01101 @ ',)
~o gage nsurancc remlUm or mon::; 0
903-:Hazar nsurance remlum or 1.0 years 0
904.
w,.
HlOO. :c.::.En. ~ DEP031 fED WITH l.t:.NDE,
1001. Haz;;rd Insurance :r:oo-O
1Ua2~ortgo.ge Insurance
TrnJ3: I YI own axes
1004. Coun y axes
00 ax
months
men s
1110n s
1110m s
mom s
man s
mom,s
man 5 I>
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IverSI Ie . ongage ~eNlGes
IverSI leCl-MO gage :::iervu:;es
JVerSllIeCl Mar ga e enm;;e
IverSI Ie or gOl~e ervlces
werSllC or age erv s
IVCfSl Ie ag ervlces
Iday
17 days
,
%)
PAli..I,."'-',,l
r'k',-, , "V .
aORROWER'S
FUNOSAT
SETT\.EMENT
SELLER'S
F1JNOSAT
SEmel'''''
-,;lJ'U:UU
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70.
299.20
1 .25 per month- 5 .7
pN mon
pee month
:i.!;I3per mon l.65
0:':.\)4 per montrl 620.J9
pN man
pi.::r mon
pee mon - .,
sqUire
o
e'is one LanQ I ransrer, Inc.
~ ggrega e JUS men
-rn;r.-rn Lo "HAK"c.
1101. SetUement or Closing Fee
-nU2: S.ract or "~ earen
1103, Title Ex:amin3\\on
11 \J.. JlIa Insurance In er
~ uocumen repara on
. 0 ry eas
. mays ees
m u e ova i am nurn crs:
I e I(lsurance 0 eys one n rans ar, nc.
me u es a ve I em numb8,scndorsemel1.s
111\,)9. an e s ove age
IlllU. wne S 0'1 rage
1111. t.;losmg t-'rmec.lon e er
=
rr.
1'20([ 'v'I;RNMEN l ,...[ RDING AND TRANSF~R CHARGe;)
1201. Recording Feas; Deed $ 25.50; Mortgage S 47.50;
1 Y un Y a ..:> mps. e
a e I ax .:l amps: evenue Stamps
203.
204.
ZU5.
1300; A I' luNA
1301, Survey
m. est ns;>ccon
~.. uny?\;;)(
. :.::u~. ~\larfan y
TJOS.
1 O.
ME r CHARGeS
to
o
o
o
Releases $
L.
or .ag8
o gage
."
owers as on ro
ary nn nor, re?SlJrer
,
l.EM..:;NT CHARGES (Enter on l-ines 103, ection J and S02,--SectiQ'n Kl
A
oley I.... ,
12:01:
"."U
13.00
-921T.00
~
3,S"c..J8
. 68-:92
.liy Sloning paOli 1 ", ltlLS S"'l<>",~"'. ''''' ...g"~'''''''" "'~""'NI""~O "'W,~, at a ca",pI"te>! <~p~ 01 t."~,, ~ 01 LI.". 11"0 ~"1I" S II "Ill.
~ f.'I/,# (J
/"
V- V l. (/(f)t Ofr--
1\eys one-rana-Trans er nc.
Settlament Agent
Certified to be a true copy.
!l allflrst -
Account Agreement
and
Receipt for Time Deposit
Pennsylvania (Non-Negotiable and NotTransferable)
BRANCH NO. TYPE NO. TERM TYPE OF ACCOUNT BIRTHDATE
135 103 12 MONTHS FIXED RATE CD 03/14/1924
CONTRIBUTION YEAR TYPE OF CONTRIBUTION SOURCE OF FUNDS ISSUE DATE
.
N/A N/A 25 08/11/2000
INITIAL DEPOSIT INITIAL ANNUAL RATE TYPE OF RATE
3,000..00 . 5.100 PER ANNUM
INTEREST PAYMENT OPTlON(NON-RETIREMENT ACCOUNTS)
COMPOUNDS QUARTERLY; ADDED TO PRINCIPAL AT RENEWAL
DEPOSIT ACCOUNT NO. ACCOUNT NUMBER CERTIFICATE NUMBER
8-000-000-2183795 2183795
NAME(S)/CONTRACT CODE(SI SS NaiT AX ID Owner(s) Signature(s),Theunoersigned hereby:acknowledge
recelpl and acceptance;<llthe AccountDisciasute
a the 8ank's Rules lor COrlSumer Deposit AcCounts.
n\ f'
MARY JANE EPPLEY 196.14.0644 X (Iv"''' } CZ..9-''''. "'-,~\
X -::,. .j '0 4
X
X
X
ACCOUNT ADDRESS TELEPHONE NO. Allfirst Bank I '.
AUTHORIZED SIGN.AT~R , .....
203 NORMAN RD '17.761.5678
....
CAMP HILL PA 170116127 X Jtf~ ......
.....
.....
....
TERMS OF AGREEMENT
Allfirst Bank ("Bank") hereby acknowledges receipt of a deposit contained hereon which shalf bear interest for the rate and term specified on this
agreement, subject 10 the terms of the Account Disclosure and the Bank's Rules for Consumer Deposh Accounts (Rules). Unless otherNise indicated
this Time Deposit (Account) will automatically renewal' maturity for the term of this agreement at the rate of interest then in effect for this accoun1
classification unless redeemed within 10 days aMer the maturity date. It this account classification is no longer offered, the Bank reserves ,the right to
substitute another account type. Payment may be made prior to maturity; however, there is a substantial penalty for early withdrawal. SpeCific early
withdrawal penalties are outlined in the Account Disclosure. Upon the death of any owner of this account and when requested by the deceased
owner's representative or by any ather owner. the redemp1ion 01 this account prior to maturity will be made without penalty. It only one nama is listed
above, this Account is established subject to the sole order 01 that owner. and upon the death of the owner, the funds in the Account will, be paid
the owner's estate. If two or more owners' names are shown above. identified with a contract code of JTWROS, AND, OR or withoula contract code:,
the Account is established as joint tenants (owners) with right of survivorship. A joint account is subject to Ihe order of anyone owner, unless a
conlract code of AND is used. in which case each owner must sign for withdrawals. Far aU joint Accounts, upon the death of one owner, the funds in
the Account shall belong to the surviving owner(s), or the estate of the last owner at hiSlher death, For consumer accounts, the contract code shown
above, after a person's name. indicates the legal relationship between the owner, any other persons on the Account, and the Bank. Each code is fully
explained in the last pages of the Bank's RuJes. including disposition of funds upon an owner's death_ By signing above, each owner agrees that the
contracl code correctly represents hisiher intentions concerning funds in the Account. Account owner(s) further agrees that such rules. terms and
conditions shall bind the owner(s), the heirs, executors, successors or assigns of the owner(s) and all other present and future owners or co-owners
of the Accounl. This Account Agreement is subject to the laws of the State of Pennsylvania.
"'~-2::;":5.~~C6
I
PNC BANK, NATIONAL ASSOCIATION
RETIREMENT SERVICES
P. O. BOX 3499
PITTSBURGH,PA 15230
MARY J EPPLEY
203 NORMAN RD
CAMP HILL PA 17011-6127
Plan TYP~~A _1
Retirement 10 * 6~1003919
~'
PNCBANlR
000040
Tel 1-888-PNC-IRAS
Bank Fin 22-1146430
Statement Period
01-01-00 Thru 06-30-00
Date
07-01-00
Page
1
Date of Birth: 03-14-24
Social Security * 196-14-0644
Principal Balance As Of 01-01-00
Contributions For This Statement
Current Year
Prior Year
Rollover
Interest Credited This Statement
Disbursements
Normal
Fed. Withholding
Principal Balance As Of 06-30-00
Interest Accrued Not Yet Credited
Fair Market Value As Of 06-30-00
Period
0.00
0.00
0.00
Period
1,702.78
0.00
52.47
500.00-
500.00
0.00
1,255.25
6.84
1,262.09
SUMMARY OF INVESTMENTS
Account Maturity
Number Rate Date
75800015085 6.050 11-01-01
Summary Totals
Interest
Credited
Current
Value
Interest
Accrued
Total
Value
52.47
1,255.25
6.84
1,262.0
52.47
1, 255.25
1,262.0
J1S
'72. 7 ~
6.84
Cl'\ '>
. ,/ ...
:!} 7"2<
'./ -....-
-----.
LET PNC BANK HELP YOU PLAN YOUR WAY TO A COMFORTABLE FUTURE
AND RETIREMENT. PLEASE CONTACT US TOLL-FREE AT 1-B88-PNC-IRAS
(1-B88-762-4727) TO ASSIST WITH YOUR NEXT CONTRIBUTION,
ROLLOVER, OR TRANSFER.
OMB No. 1!S4S-0747
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OEPARTMENT OF TRANSPORTATiON
CERTIFICATE OF TITLE FOR A VEHICLE 8,720
- ,- .--
is.wed in accordance with Section I! 05 of the Vehicle r.ode, Title is, PennsylLYJnia COluolidated Sl:6:tutes
....CCOUNT CONTROL. NUMBER
800
M,A~Y J EPPLEY
203 NOR."IAN RO
CAMP HI LL
COCE L.E:GENC
17011
A"ANTIQUE VEHICLE
PA
A38104473
,
Ii>ONTIAC
SON
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\01.. ~~ OF Vl!~IC~E
COOES
lG2AF19RDGT2402b7
","..eLE IOENTll',C-'.,ION NUM~EfI
,
03-11-86 '03-11-8b
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The vehidi? ,j,:.scrihed hereon {.~ sflbjeet to thl' '::)Zlolt'r.rlJ( fir-nol-;
GEi\;E,~AL
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FIRST LlE~
FAVOR OF
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CLERK
GM,AC
2'191 PAXTON
HA~R.ISBURG
ST
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PA
1710S
AU1'HORI2ED REPREStN1'A1'IVE
SECOND LIE:-<
FAVOR OF.
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DA-rE
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A PURCHASER lAS, NAME FIRST NAMe MIDDLE INITIAl,. Pl.Hcha~ef', DIN Ilfaoplicablel eWE warrant !Il,~ Cefllticale " Tille
lorF"il BU;,,1esl,'laml!l and lran,fer ownership " :ni, vehicle
" pu{cha~{(~\ \\~ted '" :r.,. ,,,Cllon
'00 certify thar eltcepr " li~ltd '"
CQ-PURCHt'.Si:t< ~AST NAME FIRST NAME MIDDLE INITIAL 5dc~Jo" C. ,hi, "~'''C;~ ,;110!iulljdCrtol,enlorOlherll:!lJillclamli
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w NOI to "'CI;JO~ ~e'Hh,
:; n Diite'~ from ,C:LlJI m,le~lte tor OMiJea9~' ~'...;r 99.999.
Z CITY STATE ZIP CODE '-J 't'4soni ottH~' :~an CJI,brJ(lon error
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~ WARNING, A.. naccurate odom~t~r ;"lt~,""r1! 10" ,"Jk~ '0" IlaOle
" SLBSCRIBED AND SWORN TO r.l0NTH DAY YSAR ", 'dJmag", " fc)ur T'Jn:\t~r"e pur:\UJnt W . 40' lA, 0' ,Cl" MOIOr
,.. SEF0RE ME Ven,c1" Info,n1a! 0' and Call Sa~lr1qs Act at 1972
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'= SIGNATURE OF PERSON ADMINISTERING OATH SfG~~'.,1't';,zr~J'lt(."'d ,v.- ~I ~---i
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(or f"~11 a,-,..,~ess c)Jmel i 'M (ransfer owner~h,p o ~ :n '$ vehicle
co ?"rChaS\lI\~\ h1t&d m ~:"r, > section
I '0' ~erc,fv that except " listed '0
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, :\11: c~rt"v '0 ,~.~ .'1"$: 0; ""'/.-Oll' knowleoge that the odO"'<l':~r reading ,~
>- STREET ,.,CDRE~3 and rellac:, the aewal mileage~: :I'1ev~hicle
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~ S;"".ATURJ: ,j;: :::.SEl..LER I
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COM:\IISSIC:: ';:XPIRES , :\ I
I DO ....OT SIGN UNLESS PURCHASE A'S NAME AND ADDRESS
I APPEAR TO THE LEFT!
C :...IE:\) O,;.-:-E T....\F NO LIEN, ::::J I _::::~l 'JA TE l.......iF .'JOLIE:. 0
CHECK CHEC:<
Z
lz~ F!RST UE,':HOL:;ER l ,~=COND LlEr~HC_O~M.
:
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0 Tr'l,; '"lndersi<J~,;C hereby make, app'~cation for Certificate 01 ,.tle :0 ::11: vei11cie c~~c:bed 'N,thlll thi, CutificJte of Tir:e, ;'Jblect ~o
th~ ~11~ulT1bn,,:::es and other legal C~JmlS set forth " Seeliop C
Z S:""i3SC116E:: '::','lD SWOR~~ TO ,'.1QNTH DAY Vf,<>..M j S'G;\JArU"lE OF '::'?Pl.ICA,\,T OR AojTHQRIZ;:D SIGNER
Ow OlEi' ~ RiO "lE
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~ "-,,r~, " "'JO:' ,c"~ck~<i :Jtl~'.""; "'~,\i<ledJ5 "T~",J'1(; -Cummon'
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-
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..t16'351
(7~~ }rJAA~ 4 X3086406
~)253
R VALUE OF PAID-UP ADDITIONAL INSURANCE
l VALUES
lCEBDS MAY BE INCLUDABLE IN YOUR GROBS INCOME.
11TH YOUR TAX ADVISOR.
D
oeC11 OUT 48SR CKO0027455
PI 3/ t1 C 7- q ()
CA-SJ..
cLOS-f~
JRANCE COMPANY
OUT 080800 CKOOO27455
FOR $
3,067.00
5204542 FOR INSURED MARY J EPPLEY
:K IS FULL PAYMENT OF AMOUNT SHOWN ABOVE
H OR DEPOSIT WITHIN 30 DAYS
DETACH AND RETAIN FOR YOUR RECOF1D8
U1/.4:::t)/Ul
14: 37
'0'1 3Ul 934 1955
CIS
AUfirst Financial Center N.A.
PO Box 900
Millboro. DE 19966
. January 26, 2001
Saidis, Shuff, Flower & Lindsay
Attorneys At Law
2109 Market Street
Camp Hill, P A 17011
Re: Estate of Marv Jane Eovlev
Social Securitv: 196-14-0644
Date of Death: December 29. 2000
Dear Sir or Madam:
~2/003
allfirst
Per your inquiry dated January 10. 200 I please be advised that at the time of death, the above-named decedent had
on deposit with this bank the following:
L Type of Account Golden Age Checking
Account Number 0045732078
Ownership (Names oj) Mary Jane Eppley
Opening Date 08/14/97
Balance on Date of Death $1.028/3
Accrued Interest $ 0.00
Total 'Jf021i.Tr' ___.__".__n_'____
2. Type of Account Statement Savings
Account Number 80000002183627
Ownership (Names oj) Chandler A. Widmayer,putma
MaryJane Eppley. cus
Opening Date 04108/00
Balance on Date o/Death $25.27
Accrued Interest $ .01
Total "J25.2if __..__<_.__nu._n____n_
Ul.l"O/U.l
,14:~'
"0",1 JU~ MJ4 ~~~~
Cl~
I4J 003/003
3.
Type of Account
Certificate of Deposit
Account Number
80000002183795
Ownership (Names oj)
Mary Jane Eppley
Opening Date
08/11/00
Balance on Date of Death
$3,038.56
Accrued Interest
$ 22.08
--JT06if64.--.-------............--
Total
4.
Type of Account
Safe Deposit Box
Account Number
1000535100001160
Ownership (Names oj)
Mary Jane Eppley
Closing Date
12/05/00
This lelter does not include any accourUs in which the deceased may have been listed as Power afAttorney.
Custodian of Unifol'ln Transfers, Representative Payee. or Trustee under a Written Agreement.
For further account information, closures and/or reimbllrsement offunds refer to helow branch:
HIGHLAND PARK OFFICE
J44 SOUTH lOT. STREET
LEMOYNE. PA 17043
717.737-3322
Sue KimoLe
Assistant III
Cis Services, (302) 934-2909
~cb-~J-~~~l ~~:~~
P.01/01
~PNCBAN<
Decedent Reporting
Firstside Center
P7-PFSC-4-F
500 First Avenue
Pittsburgh, P A 15219-3128
/SCP
February 5, 2001
John E. SJike
2109 Market Street
Camp Hill, PA 17011
RE: Estate of Mary Jane Eppley, Deceased
SSN: 196-14-0644
000: 12129/2000
Dear Mr. Slike:
Please find the date of death balances you have requested listed below.
IRA ACCOUNT
#75800015085
Established 08/ 1811993
MARY J EPPLEY
DOD Balance: $961.74 + $4.77 accrued interest
For Beneficiary or IRA information please call1-888-PNC-IRAS
Our office only provides date of death balances for IRA's, CD's, Checking and
Savings accounts. We do NO Financial Transactions or Statement Orders. For
Further information please clI1l1-800-4-BANKER or your local PNC Branch and
ask to speak with a Financilll Services Representative.
Sincerely, .
~~~
Rachelle Sciullo
1-800-762-1775
A m("mbcr of The PNC I=inancial SCl'Yicc'!i Group
PNC Bark !'\i_A Pittsburgh Pt:r.nsylv;iln:;] ~ 5265
TOTRL P. 01
r~u GO U~ u~:~./p
Carl MIner
'/1'/ '/o<l-~:HiG4 pol
Date: -Z./;;l.f~OI
Tat.1J Palles: C -:2)
...... :~ASE DELIVER. IMMEDIATll.Y
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" ',nullu;.. fails, p/.o.. (0.'0(' send,,_ Patent Pending @ Pen-Tab Indus1rie" Inc. 1997
Estate of
Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Mary Jane Eppley No. ~ 1- c:> /- ;1...1
also known as
, Deceased
Social Security No.
196-14-0644
Suzanne Marie Kauffman and Carol Jane Wisner
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
[K] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut r ices named in the last Will of
the Decedent, dated 07/01/1996 and codicil(s) dated None
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:
none
D B. Grant of Letters of Administration
(c.I.a.; d.b.n.c.l.a; pendente lite; 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:
,
Name
Relationship
Residence
1
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland
County, Pennsylvania with his/her last family
or principal residence at 203 Norman Road, Lower Allen Township, Camp Hill, PA 17011
(list street, number, and municipality)
Decedent, then ~years of age, died 12/29/2000 at PA
(Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PAl All personal property
(If not domiciled in PAl Personal property in Pennsylvania
(If not domiciled in PAl Personal property in County
Value of real estate in Pennsylvania
5,000.00
$
$
$
$
90,000.00
situated as follows:
203 Norman Rd., Camp Hill, Pennsylvania
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 a riate form to the undersi ned:
Si T ed or rinted name and residence
Suzanne Marie Kauffman
60 Hummel Ave., 2nd Fl., Lemo e, PA 17043
Carol Jane Wisner
7543 Carlisle Rd., Wellsville, PA 17365
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems.lnc.
/6 - /?9- /0
Form RW-1 (1991)
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
~1~~y}1A~ tl~
~u nne Marie Kauffman
(2.0 d Jill< 2ju~4A./
Carol Ja Wisner
d..
before me this.-..2C:day of
:;'J~ ' CJ.CJ() I
/Yflh.(j e, .x1UJL~ ~' f.(J. ~~~k
For the Register f'
No.
21-01-21
Estate of Mary Jane Eppley
Deceased
Social Security No: 196-14-0644 Date of Death: 12/29/2000
AND NOW,
JANUARY 5, 2001
, in consideration
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters ~ Testamentary D Of Administration
(c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate)
are hereby granted to
Suzanne Marie Kauffman and Carol Jane Wisner
in the above estate and that the instrument(s) dated
07/01/1996
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Short Certificate(s).
6
$
18.00
Attorney:
~L{, 0 a .~JiL/J. ~+
Register of Wills' .')
~9~,
8" n E. Slike
Letters. . . . . . .
$
200.00
Renunciation. $
Affidavits ( $
Extra Pages ( 2 ) . $
Codicil. $
JCP Fee. $
Inventory. $
Other $
TOTAL $
1.0. No:
06262
Saidis, Shuff, Flower & Lindsay
2109 Market St.
6.00
Address:
Camp Hill, PA 17011
5.00
Telephone: 717/737-3405
229.00
MAILED LETTERS TO ATTORNEY 01-05-2001
Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems,lnc.
Form RW-1 (1991)
H10'))W') REV 9(R()
21-01-21
This is to certify that the information here given is conectly copied from an original certitlc,lte of death duiy flied with
Local Registrar.' The origin,ll certitlLate will be forwarded to the St,lte Vital Records Office for permanent tiling.
me as
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this cerritlcare. $2.00
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P 7022865
JAN 0 2 2001
No.
Date
lTEM # S-
Sl-iC)tJ LX) l~;:l\r) j~S rOLL()\VS:
7&
~ /7C ~OFPENNSVLVAN'A' DEPARTMENT OF HEALTH. VITAl. RECORDS
CERTIFICATE OF DEATH
5. i 43 Rev 2/81
SEX
2. Female
STAre FILE NUMBER
SOCIAL SECURITY NUMBER
N~ME OF DECEDENT tFlrsr, Middle. lasll
I.
AGE (Last
,.
14
11
COUNTY OF DERH
Yro
UNOElllllN
Houro l "''''',..
8lRTHPLACf (ColY""
Slale at FOf8tgn Country!
Enola
~::,ty)D
RACE. Arn.ncan Indian. Black. White. etc..
(S_ty)
lb. erland
DECEDENT'S USUAL OCCUMIOH
(~~~~~~u~;~:f
10.
White
SURVIVING SPOUSE
{Jf WIle, gIve maIdel'\ n1iVl\8)
203 Nonnan Road
11. Camp Hill, Pa 17011
FATHER'S NAME (First. Middle. last}
II. J hn Hildebrandt
INFORMANT'S NAME (f ypelPrint)
200. Suzanne Miner
METHOD OF llISPQSIT'ON
BUfiaJ XJ Cremation 0 Aemoval 'rom Stale 0
Don.."",O OIt.oqSpocdyl
. 21..
S
CUmberland
rnd
-..
liwina
township? No. decedent lived
174.0 w1lhinraaUIIlimll:sof
MOTHER'S NAME (Filst. Middle. MaldeftSurname)
11. Elizabeth Srni th
INFOfl"'ANT'S """lUNG ADDReSS (SItoot. C;Iy/lllwn. Stale. Zip Codel
2~. 60 Hummel Avenue Lemoyne,Pa 17043
PLAce OF DISPOSITION. Name of Cemetery, Crematory LOCATION. CitylTown, S'at., Zip Code
or Other Place
14.
l1C.rlI 'fee. o.cedenllived in
MARITAL STATUS. Ma.nied
N.wtr Married. Widowed.
0N<<c0d (Spoctty)
Divorced
17.. $Iale
Pil
T.nwpr Allpn
Iwp
11b.Cou
crtylbcwo
230.
TI"'E OF DEATH _ t.f J
24. J" -
27. MAT I: En'etlhe disuses. injurieS or compk.atiot'\Swhich caU58dlhe death, Do
List onty one cause on eaCh line
2le.Zion
23b. 23c.
WAS CASE REFERRED 10 MEDICAL EXAMINEAlCORONER?
Ye. D ...8l
211.
l~llimal.
; interval between
, onset ana death
,
i
PART II: Other signitlcent COndilions conlributlng to dltattl. but
I'lO\ resumng In lhe undrtrty;ng cause given in PART I.
DATE OF INJURY
(Monlh, Day. Year)
DESCRIBE HOW INJURY OCCURRED.
Sequentially li$l conditiOns
tfart't,~nQtoim~lat.
c;auH. Enl. UNDEALYING
CAuse IOIwas& or IllJUlV
. .. tha1lMial8d e....enl.S
resutnnQ If\ Qe8.th) l.AST
rd
d
WERE AUlOPSY fiNDINGS
_'LAalE PRIOA TO
COMPLETION OF CAUSE
Of DEATH?
TIME OF INJURY
Accident
PendifIQ In....estigatiOR
o
o
o :O~CE OF INJURY _ At home. lar~~eet. 1actory, oft\c. M.
budding, etC, ISP6C11vl
3De.
v.. D
NOD
Suicide
.<J
o
D
Homicide
HalUf-'
. PRONOUNCING AND CERTIFYING PHYSICIAN (Pt\YSlC1an bolh ;:nonourlC;ng oedlh and Cer1lli/ln9 10 cause of deafh)
To lhe bint of my knowl4tdg., d..th occurred a. the 11m., dale,.illr1d pl.ce, and due to the caUM..) and manner u staled..
o "..
LICENSE NUMBER
o 31e. t1 fJ - D 7 () 6 72 - L- 31d.
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF
(lIem 27) Type orPr;nl L- i M"'1 L,'IA./ M. [?
o lM>P"" h~// ~() ;Vi.d-IJ, Jknl
n. - I' /
No~
Y.. D
NoD
Could not be dete""lOed
a.. 28b.
CIJfHf\EA (Check Only Oflel
'CERTlFYlNG PHYSICIAN l,PhVSlClan certllVfng cause oi death when another Dh~~,an has pronounceo dealh ana completed \tern 23\
To ttw -.. 0' my knowhtdQ.. d.ath occurred d~ \0 ttw C8USe(S) and m.illnner.illa stated. .
29.
'",eDICAl EXAMINER/CORONER
On the b..i. 0' ex.mln.tlon .ndlor Investlg,lion, in my opinion, death occurred at the Um.. date, and place, and due to the C.use(l) and
manner...tat_.. ......,... ...
31..
fA 17i)'fj
Lf'r'VVjAf/
REGISTRAR'S SIGNATURE AND NUMBER
~~~
I~/I?"/I!I
34.
~/"-/99-/0
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
91-
C/
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
~
REV-1547 EX lfP IlZ-DOl
05-21-2001
EPPLEY
12-29-2000
21 01-0021
CUMBERLAND
101
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
MARY
J
JOHN E SLIKE
SAIDIS ETAL
2109 MARKET ST
CAMP HILL
Amount Remitted
PA 17011
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS __
REV =l5'47-'Ex-AFP--li'2:ooY-NoTIc'E--oF-YNH'EifiTAifcE-TAx-APPRA-is'EifiNT-;-ALioWAifcE-oR"-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF EPPLEY MARY J FILE NO. 21 01-0021 ACN 101 DATE 05-21-2001
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
92,000.00
.00
.00
.00
7,335.82
.00
.00
(8)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
99,335.82
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
18,689.95
863.46
(9)
(10)
19.5;3 41
79,782.41
500.00
79,282.41
(11)
(12)
(13)
(14)
NOTE: If an assessment was issued previously, lines 14, 15 and/or 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)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 = .00
79,282.41 X 045 = 3,567.71
.00 X 12 = .00
.00 X 15 = .00
(19)= 3,567.71
PAYMENT RECEIPT DISCOUNT (+) AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
03-29-2001 AA478222 178.39 3,389.32
TOTAL TAX CREDIT 3,567.71
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
t
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Mary Jane Eppley
Date of Death: December 29, 2000
will No.
21-01-0021
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.
complete: Yes
State
X ;
whether
No
administration of
the
estate
lS
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 Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative
account informally to the parties in interest? Yes X
state
; No
an
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Clerk of the Orphans' Court and may be attached to this report.
Date:
"7 //7/ ~I
. I '
\./\...--
ture
: John E. Slike,
I . No.06262
SAIDIS, SHUFF, FLOWER
2109 Market Street
Camp Hill, PA 17011
(717) 737-3405
p
Esquire
& LINDSAY
Capacity:
X Personal Representative
Counsel for Personal
Representative
Eo
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
CERTIFICATION OF NOTICE UNDER RULE 5.6(A)
Name of Decedent: Mary Jane Eppley
Date of Death: December 29,2000
Will No.:
21-01-0021
Admin. No.
To the Register:
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 January I D , 2001.
Name
Address
Camp Hill Church of God
Suzanne Marie Kauffman
Carol Jane Wisner
123 North 21st Street, Camp Hill, PA 17011
60 Hummel A venue, 2nd Floor, Lemoyne, P A 17043
7543 Carlisle Road, Wellsville, PA 17365
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
none
Date:
( (/6 f () (
!\./~.
J n . Slike, Esquire
AlDIS, SHUFF, FLOWER & LINDSAY
2109 Market Street
Camp Hill, PA 17011
(717) 737-3405
Capacity:
_Personal Representative
X Counsel for Personal
Representative
4
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