HomeMy WebLinkAbout01-0047
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OFFICIAL USE ONLY
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
REV-15QO EX ~ (6-00)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 2.80601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Hoerneman Lucille A.
DATEOF DEATH (MM-OD-YEAR)
21-01-0047
NUMBER
COUNTY coDe YEAR
SOCIAL SECURITY NUMBER
206-46-5518
THIS RETURN MUST BE F'LED\N DUPUCATEWlTHTHE
DATE OF BIRTH(MM-DO-YEAR)
05 23 2000 07/04 1917
I APPU ABL SURVIVIN SPOUSE'S AME LAST, IRS ,AND MIOOLEINITl/l.l
REGISTER OF WILLS
s IALS CURl YNUM R
Hoerneman, Calvin A.
X 1. Original Return
4. LImited Estate
X 6. Decedent Died Testate
o
3 date 0 death
. RernalnderReturn rlorto 12~13-8Z)
5. Federal Estate Tax Return ReC\ulred.
8. Total Number of Safe Deposit Boxes
2.
40.
7.
Supplemental Return
Future Interest Compromise (date of death after 12-12-82}
Decedent Maintained a Living Trullt
(Attach copy of Trust)
o 10. Spousal Poverty Credit 0 11. ElectIon to tax under Sec. 9113(A)
(date of death between 12#31-91 and 1-1-95) {Attach Sch O}
l*nTHIS'SECTf6rtMoST:BEo'Cin.1p't.'ETED:&A't.lSeORRESPONDENCEfI:CON~jDENTJA' o'AlCI FdFjI.lATICl "5.1:1 out li sO FiE~
NIo.ME COMPLETE MAILING ADDRESS
(Attach copy of Will)
o 9. Litigation Proceeds Received
James D. Bo ar
FIRM NAME (If Applicable)
One West Main Street
Shiremanstown, PA 17011
TELEPHONE NUMB~A
NCiO<>o
29, 719~012
None
OFFICIAL USE:ONL Y
(1)
(2)
(3)
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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 or 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. Net Value Subject to Tax (Line 12 minus Line 13)
--
(8) 29,719.12
(11) 0.00
(12) 29,719.12
(13)
(14) 29,719.12
(4)
(5)
None
None
(6)
None
None
None
None
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.
29,719.12 X 00 0 (15)
X 00 6 (16)
X 012 (17)
X 015 (18)
(19)
0.00
0.00
0.00
0.00
0.00
FONO.QJ!:'Al'l OVERPAYMENTo.
NS:ON"FiEVERSESIDE:ANOoTO:RECHeci(:M T 0
Copyright (c) 2000 form software only The Lacl;neI' Group, Inc.
Fo,mREV-1500 EX (Re,o 6-00)
Decedent's Complete Address:
STREET ADDRESS
203 Todd Circle
CITY I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Ta)( Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
Total Credos ( A + B + C) (2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( D + E) (3)
4. 11 Line 2 is greater than Une 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 + SA. This is the BALANCE DUE. (58)
Make Cheek Payable to: REGISTER OF WILLS, AGENT
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PLEASE"ANSWER' THE FOL.lOWING QUEsrioNSBYPlACINGAN"'j(;;INTHi(APPROPRiATEBLOCi('if"
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ~ ~ix
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 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
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Under penalties of perjury, I declare that I have examined this return. Including accompanying schedules and statements, and to the best of mJ Knowledge and bel\e1, 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.
SIGNATUREOF PERSON RESP SIBLE FOR FlUNG RETURN Calvin A. Hoerneman
; f! ~ ---~~h-l;f~;c;t~C:~j\6h-------___h_---_----__h-
James D. Bogar Esquire
One West Main Street
- - -Shi;:emar;sto;m - - PA - - ii6ii - - - - - - - - - - - - - - - - - - --
DATE
02/13/01
DATE
For dates of death on or after Ju y 1, 1994 and betore January 1, 1995, the tax rate imposed on the net value of transfers to or tor the use of the
surviving spouse is 3% [72 P.S. 9116 (all 1.1 ) (i)].
For dates of death on or after January 1. 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. 9116 (a) (1.1) Oil). The statute does not exemct 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 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(aX1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 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 forms()ftware only The Lackner Group. Inc.
Fo,m REV-1500 EX (Rev. 6-001
REV-1503 EX + (1-97)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
Lucille A. Hoerneman
SSII 206-46-5518
OS/23/2000
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
21-01-0047
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE
NUMBER OF DEATH
1 642.5756 shares Be11South, eUSIP 11079860102 - Common 46.25 29.719.12
stock (book entry shares)
TOTAL (Also enter on line 2, Recapitulation) 29,719.12
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
Form REV-1503 EX (Rev. 1-97)
~ Prudential
January 18, 2001
Prudentiel Securities Incorpo..ted
3 Lemoyne Drive
Lemovne. PA 17043
P.O. 80x 7. Camp Hill. PA 17001-9852
Tel 717 761-7344 800 468-8685
Fax 717 975-8426
James D. Bogar
Attorney At Law
One West Main Street
Shiremanstown, PA 17011
RE: Estate of Lucille A. Hoerneman
Dear Mr. Bogar:
In regards to your recent request for the above referenced Estate account, I have provided
all the information that we have on this matter.
It appears that Mrs. Hoerneman's shares of Bell South were held in the Transfer
Department of Bell South in book entry form, meaning no certificates numbers are
available. We have processed paperwork to begin re-registration for these shares to be
put into Mr. Hoerneman's name, but are still waiting for a Short Certificate or Waiver of
Probate, in order to complete this. If you will provide us with one I will forward it to
BellSouth along with copies of the documents we sent up in November. The following is
the information that I do have on these shares:
Cusip:
642.5756 Book Entry shares (no certificates issued at this time)
$46.25 per share
$29,719.12 total value on 5-23-00
079860102
Number of Shares:
Date of Death Value:
I hope this is what you need for your inheritance taxes. Should you require any
additional information, please do not hesitate to contact our office.
Sincerly, 71/4
/ Betsy F. ebb
Client Service Assistant
REV-1513 EX + (1-97)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Lucille A. Hoerneman
OS/23/2000
SSff 206-46-5518
NUMBER
I.
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions):
Calvin A. Hoerneman
203 Todd Circle
Carlisle, PA 17013
RELATIONSHIP TO DECEDENT
Do Nol LI51 T'.51"(.)
Husband
FILE NUMBER
21-01-0047
AMOUNT OR SHARE
OF ESTATE
Beneficiary of
all probate
and
non-probate
assets
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 17, 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
TOTAL OF PART 11- ENTER TOTAL NON- TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET S
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
0.00
Form REV-1513 EX (Rev. 1-97)
. .
. '
LAST WILL AND TESTAMENT
OF
LUCILLE A. HOERNEMAN
.:..
I, LUCILLE A. HOERNEMAN, of Carlisle, Cumberland,
Pennsylvania, make, publish and declare this as and for my Last
will and Testament, hereby reVOking all other Wills and Codicils
heretofore made by me.
FIRST: I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment and
together with any insurance policies thereon, unto my husband,
CALVIN A. HOERNEMAN, provided he survives me by sixty (60) days.
SECOND: Should my husband, CALVIN A. HOERNEMAN,
predecease me or die on or before the sixty-first (6Ist) day
following my death, I devise and bequeath all the rest, residue
and remainder of my estate of whatever nature and wherever
situate, including any property over which I hold power of
appointment and together with any insurance policies thereon, in
equal shares, to my children, CALVIN A. HOERNEMAN, JR. and ANN V.
SHULTS, provided that should either of my children predecease me,
I give and bequeath such child's share unto his or her issue per
stirpes by representation, and if there be a failure of same,
then I give and bequeath such deceased child's share to my
surviving child as provided herein.
THIRD: In addition to all powers granted to them by
~ law and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all proper-
ty, exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease,
for any period of time, any real or personal property and to give
options for sales, exchanges or leases, for such prices and upon
such terms (including credit, with or without security) or
conditions as are deemed proper. This includes the power to give
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legally sufficient instruments for transfer of the property and
to receive the proceeds of any disposition of it.
(B) To partition, subdivide, or improve real estate
and to enter into agreements concerning the partition, subdivi-
sion, improvement, zoning or management of real estate and to
impose or extinguish restrictions on real estate.
(e) To compromise any claim or controversy and to
abandon any property which is of little or no value.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds, without
restriction to investments authorized for Pennsylvania fiduci-
aries, as are deemed proper, without regard to any principle of
diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws.
(G) To make distributions to my herein named benefici-
aries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in order
to pay debts, taxes, or estate or trust administration expenses,
to protect or improve any property held under my will, and for
)
.j investment purposes.
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(1) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee
stock ownership plan, or any other type of qualified plan) to the
extent the plan or the law permits them to do so, and to exercise
any other rights which they may have under the plan, in whatever
manner they consider advisable.
FOURTH: 1 direct that all ~nheritance, estate,
succession and death taxes, of any kind whatsoever,
which may be payable by reason of my death, whether or not with
!
. :; transfer,
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2
.
respect to property passing under this Will, shall be paid out of
the principal of my residuary estate.
FIFTH: All interests hereunder, whether principal or
income, which are undistributed and in the possession of the
fiduciaries acting hereunder, even though vested or distribut-
able, shall not be subject to attachment, execution or sequestra-
tion for any debt, contract, obligation or liability of any
beneficiary, and furthermore, shall not be subject to pledge,
assignment, conveyance or anticipation.
SIXTH: I nominate and appoint my husband, CALVIN A.
HOERNEMAN, Executor of this, my Last will and Testament. In the
event of the death, resignation or inability to serve for any
reason whatsoever of the said CALVIN A. HOERNEMAN, I nominate and
appoint CALVIN A. HOERNEMAN, JR. and ANN V. SHULTS, Co-Executors
of this, my Last will and Testament. I direct that my Executor
or Executrix, as the case may be, and their successors, shall not
be required to post security or a bond for the performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal to this, my Last will and Testament, this .}c~ day of
v \u::.~(,'-
, 2000.
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.......1 it ~:fi.:~ L..l. ./... ce'~'f(C .. ~ <: /
LUCILLE A. HOERNEMAN --
(SEAL)
Signed, sealed, published and declared by the above-
named Testatrix as and for her Last Will and Testament in our
presence, who, at her request, in her presence and in the
presence of each other, have hereunto subscribed our names as
attesting witnesses. _ ~ /
(' /. . (- .. ///
LA' ~4-Ul L"r:-;~-~,~J---!tu.:Z"'-t- ! '
Address
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Address
3
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of Lucille A. Hoerneman
also known as
No.
To:
Register of Wills for the
Deceased. County of Cumberland in the
Sodal Security No. 206-46-5518' Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/~ 18 years of age or older an the executor
in the last will of the above decedent, dated March 20
and codicil(s) dated None
21-01-47
named
,19 2000
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in CUmber land County, Pennsylvania, with
h er last family or principal residence at Todd Home. 203 Todd Circle. Carlisle.
PA 17013 ';30R.D'
(list street, number and muncipality)
Decendent then 82 years of a~e died May 23
at Borough of Carlisle, CumberIand County, Pennsylvanla
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the \\rill offered for probate; was not the victim of a killing and was never adjudicated
incompetent: None
Decendent 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:
,Xf9 2000
$ 30,000.00
$
$
$
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will 4tl\1I~~)
pre<;ented herewith and the grant of letters testamentary
(testamentary; administration c.La.; administration d.b.n.c.t.a.)
theron.
~ a.?L~/Jdd~
Calvin A. Hoerneman
ToddHane
)01 rrnr=lii rirrlp
Carlisle. PA 17013
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA I s~
COUNTY OF Cumberland J :s
The petitioner(c;) 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 represen-
tative(s) of the above decedent petitioner(s) will well a truly administer t estate according to law.
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Sworn to or af.nrmed~ and su bscribed. { . ~ / I ......
before me this _----1D day of Calvln A. Hoerneman
\ Janua~ _ 19~
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N 21-00-47
o.
Estate of
Lucille A. Hoerneman
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW JANUARY 10 ~ 2001, 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 March 20, 2000
described therein be admitted to probate and filed of record as the last will of Lucille
A. Hoerneman
and Letters Testamentary
are hereby granted to calvin A. Hoerneman
( .~/
/7;7r-I.t/ / (, _ ~///~ j&/.LI'./ d/ / X)'cu-Q/
Regis r of Wills 1
FEES
~Lcpbcf1g~sLetters, Etc. .........
Short Certificates( )..........
Renunciation ................
JCP
$ 62:lm-
$ 6 no
$
$
TOTAL _ $ 77.00
. . . J"A~l]~RX ) 9,. .~Q9 L . . . . . . . . . . . .
James D. Bogar, Esquire 19475
5.00
A rrORNEY (Sup. Ct. LD. No.)
One W. Main St.
Shjr~manstown, PA 17011
ADDRESS
(717) 737-8761
Filed
PHONE
21-01-47
REGISTER OF WILLS OF ClM3ERLAND COUNTY
OATH OF SUBSCRIBING WITNESS
Calvin A. Hoerneman and James D. Bogar
witnesses ~
}(DclJ}}6 subscribing ~ to the will presented herewith, ~~ being duly qualified according to
law, depose(s) and say(s) that they were present and saw
Lucille A. Hoerneman
the testatrix , sign the same and that they signed as a witness at the
request of testag:ix in h er presence and (in the presence of each other) (in the presence of the
other subscribing witness(es}),
~bHq~~
' ame)
203 Todd C1rcle, C l' 1 PA 17013
Todd Home ar 1S e,
Sworn to or affirmed and subscribed before
h' 10th d f
me t IS .____ ay 0
I January . X9; 2001
ry}.// /' (? ';/~-L/;"f~.{j /4;( jJ. ~L4/
" Register 1/ (
J
1
PA 17011
(Address)
R ~ ISTER OF WILLS OF COUNTY
---" ~:rH OF NON-SUBSCRIBING WITNESS
(each) a subscriber hereto, (each) ing duly qualified according to law, depose(s) and say(s) that
faml . r with the signature of
codicil
testat_ of (one of the subscribing nesses to) the will presented herewith and
codicil
that believes t signature on the will is in the handwriting of
to the best of
knowledge and belief.
Sworn to or affirmed and subscribed before
me this day of
19_
(
e)
(Address)
Register
(Name) ~
\
(Address)
\.
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V"AFlNING: It is iiIIegalto dupHcate this G()P'~ by photostat or phiotonl'aph.
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Fee for this certificate. $2.00
P 6~)47818
MAY 2 5 2000
No.
I.TEMt~/~ .
~HOULI' READ ~ FOLLOWS ~
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Date
21-00-47
l3 Aev 2187
COMMONWEALTH OF PENNSYLVANIA · OEPARTMENT OF HEALTH e "'TAL RECORDS
CERTIFICATE OF DEATH
CumbVl.lan.d
CaAl..i-6le.
STATE "'lE NUMBER
----------------:<< Femate]~~:cu...::;";"'.
BIRTHPLACE :C.1y and PLACE OF OEATH 'Cl\eck only ope -- -;ell ,nSlrucloOOS on OIhe. _,
Slale 01 fcreogn CounllY, HOSPITAl.: -
Y OUn.g.6tOWn., OH lopab.nl D ERlOulpaII.nl 0 00,.. 0
7. ...
FACILITY NAME (It no! IO!./olUllOn, g,ve slleel anCl numl)4lfl
DATE OF DEATH ,Mcnlll. Da~. '~a"
NAME OF DECEDENT {F""~;-Mld~ L<lSI' ---- _u_______
,.
Luc~lle. A. HOeAn.e.man.
5578
... 5-23-2000
82
UNDER 1 YEAR
Monlha Oars
UNDER , D~-
Hours Minul..
AGE (laSl Birthday'
YIS
g'=,lyIO
$.
COUNTY OF DEATH
lb.
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RACE - Amencan Indian, 8lack. While. ell:
\$peclly, Wh,i..te.
10.
. 11.. ~ lIb. - - - - - - - - - - - - -
DECEOENT'S MAILING ADDRESS (Street CllylTown, SCala, Zip Code\ OECEDENT'S
ACTUAL
RESIDENCE
(See ,nSlrUC11OOS
on Olher SIde'
WtoS DECEDENT EYER IN
US ARMED fORCES?
Ye.D NoD
MARITAL STATUS. Marrilld
Nev... Marrilld, Widowed.
OlWtl:eeS (Speclly'
,...MaJo( -Le.d
SURVIVING SPOUSE
(It ....e. ~ve maoc:len name.
12.
Ilb. County
Did
dec;edant
Weill a
CumbeAlan.d !owns,"p? 17d.O =h~':=OI
MOTHER'S NAME IFusl. Moddle. Malden Sulname)
S lvia Sm-Lth
17e:.D ~. daCedantlived in
"""
7000 We.-6t South
,.. CaAf.-L-6le., P A 7707 3
FATHER'S NAME (FIIS1. Mlodle. laSl'
'I. P auf. L e.L6.6
INFORMANT'S NAME (T ypeolPllOl)
2OIl. MJt. alv~n HOe./l.n.eman
MElHOOOF D POSITION
Bun.l 0 Cremaloon 00
Other (Specify
11a. Slale
CaJl.l~-6le
cltylboro
DATE OF DISPOSITION
(MOIlIh, Day. 'tNt)
o 21b. ,L)',;<8- .-2u'()
LICENSE NUMBER
,..
INFORMANT'S MAILING ADDRESS (Str88l, C'lyflOwn. SllI'e, lip Code)
1000 South We.6t CaJl.f.i~le PA 17013
LOCATION. CilyfTown, SIal., Zip Code
2Ob.
PLACE OF DISPOSITION. Nama 01 Cemalary. CramalOry
Of at.... Place CJr. e.mail 0 n. S 0 c~ et
21e:. On PA CJr.e.matoJl.Y
NAME AND ADDRESS OF FACILITY Jr. e.ma
22e:. 41 00 J on.e.-6town. Rd
LICENSE HUMBER
NoD
IIams 24-26 must be I:ompleled by
__ peqon whO pronounces death
~ _ M.
_==::I 27, PART I: Enle' Ihe d,..ases, Inluftes or compllCahons which C.IIused Ihe dealh Do nolenle' Ihe mode 01 dYing, uc:h as cardIac orresp"alory a"esl, shock or heart ladUle
l.. only one causa on each hna
Othar sigrtillcanl c:ondiliona COtlIrobuling 10 dealh. but
noc reaulling IIllhe Undaf1yIng cause QlY8/l in PART I.
IMMEDIATE CAUSE (Final
'''sease or concJ,hon
__'-...no III dealh)-
-~
:! Sequentially hst ~ions
~~~~u~~..:
.-::II CAUSE (D<seasa 01 ,nlUry
"'1tlaI1f'Obale() e'VenlS
~'~ III deathl LAST
~4~ Ar~
~~~ A CONSEOUENCE CF):
)'f;...(OA A1> A CONSEOU~NCE Of):
~ 5L\(...u~
DUE 10 (OA AS A CONSEOUE NCE .
M\"w
~~
"",'C..
WAS AN AUTOPSY
[i PERfORMED?
..
~
d
WERE AUTOPSY FINDINGS
AVAILABlE PRIOR TO
COMPLETION Of' CAUSE
OF DeATH?
MANNER OF DEATH
DATE OF INJURY
(MOl'Ih Gay. Year)
TIME OF INJURY
INJUAY AT WORK?
DESCRIBE HOW INJURY OCCURRED.
Nalural
0"
o
n
Hom'clda
Accldenl
Pend.ng Invesli9alion
o
o
[] ~~CE Of'INJURY . AI home. lar~~;~I. ;aC1orv, offic.
bUIlding. .IC (Spec,tvl
JOe.
Yes 0
NoD
No
Yea 0
No[2(
SuICide
M. 3Oc.
3Od.
LOC.laION (S1r_. C,lyfTown, Slalel
~O
Could nol be delermlOed
2... 2Ita.
Cl:RTlfIER let-tICk OIllY onel
'CERTIFYING PHYSICIAN IPhyslClan C"'hly,ng cause of dealh whe" .:lnOI!>e, phvSIC,an has pronounced Oealh ano compleled Item 23)
To lha baal 0' my knowledg.. death occurred due \0 th. cause(sl snd manner a. ataleeS. . . . . . . . . . . . . . , . . . . . . . . . . .
29.
AR S SIGNA~E ANO~
//;':7 t.;7~
<~-
U~,/(l
[]
::;
~I
~
-'II
;J
-'II
..
. PRONOUNCING AND CERTIFYING PHYSICIAN IPhvs.c.an bo,r ;J'Q"ouroe,ng oealh and certlfy,ng 10 cause 01 dedt~l
To Ih. ~I 01 my kno",'edg", dealh occurred at U\a lime, date, and place. and due to Iha cauae(a) and manner aa slaled..
.MEDICAL EXAMINER/CORONER
On Itle basis of examinallon andlor Invesligation. in my OpinIon, dealh oCl:urred allhe lime, dale, and place. and due 10 Ihe cause(s) and
manner as ,'aled.. . . . , . . . . . . ., . . . . . . .
31a
LJ
34.
M~.2 6~/ ~ tJO 0
/b-~/~6
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG~ PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
03-26-2001
HOERNEMAN
05-23-2000
21 01-0047
CUMBERLAND
101
JAMES D BOGAR
1 W MAIN ST
SHIREMANSTOWN
~." 1 7 0 11
*'
REY-lS..7 EX AFP <12-00)
LUCILLE
A
Amount Remitted
) CHANGED
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
29,719.12
.00
.00
.00
.00
.00
(8)
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 ~
RE-v:i'54j-Ex-AFP-(i2:iicir-No'~ficE--oF--fNHEifi;:AircE-TAX-APPRA-isEifENT~--Aii-oWANCE-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF HOERNEMAN LUCILLE A FILE NO. 21 01-0047 ACN 101 DATE 03-26-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
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. Hortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E)
6. ~ointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Hisc. Expenses (Schedule H) (9)
10. Debts/Hortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule ~)
14. Net Value of Estate Subject to Tax
NOTE: If an assessment was issued previously, lines
reflect figures that include the total of ALL
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:
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
29,719.12 X 00 = .00
.00 X 06 = .00
.00 X 00 = .00
.00 X 15 = .00
(19)= .00
.00
.00
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
29,719.12
00
29,719.12
.00
29,719.12
PAYHENT RECEIPT DISCOUNT (+) AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
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 PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
t.
----
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Lucille A. Hoerneman
Date of Death: May 23, 2000
Will No.
21-01-0047
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 No X
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes X No
d. Copies of receipts, releases, joinders and
approvals of formal or info~mal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
/'1- i)~
'~~~'t'/fre .
James D. Bogar, Esquire
Name (Please, type or print)
One West Maln St.
Shiremanstown, PA 17011
Address
Date: 02/13/01
(717) 737-8761
Te 1. No,
Capacity: Personal Representative
x Counsel for personal
representative
(MAH:rmf/AM3)
E
CERTIFICATION OF NOTICE UNDER RULE 5.6 (a)
Name of Decedent: Lucille A. Hoerneman
Date of Death: May 23, 2000
will No. 21-01-0047
Admin. No.
To the Register:
I certify that notice of beneficial interest 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 12, 2001:
Name
Address
Calvin A. Hoerneman
203 Todd Circle
Carlisle, PA 17013
Calvin A. Hoerneman, Jr.
c/o Calvin A. Hoerneman
203 Todd Circle
Carlisle, PA 17013
Ann V. Shults
9 Riddle Road
Camp Hill, PA 17011
Notice has now been given to all persons entitled thereto under
Rule 5.6 (a) except:
None
Date: January 17, 2001
r, Esquire
One West Mai Street
Shiremanstown, PA 17011
(717) 737-8761
\
x
Personal Representative
Counsel for Personal
Representative
Capacity: