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Home My WebLink About01-0067 REV-1500 EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 21 2001 0067 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Henderson, Rosie Mathilda 213-56-9675 DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 09/02/00 05/10/1913 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 3. Remainder Return CHECK ~ 1. Original Return ~' Supplemental Return B (date of death prior to 12-13-82) APPRO- 4. Limited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required ~ateof death after 12-12-82) PRIATE 6. Decedent Died Testate 7. ecedent Maintained a living Trust 0 8. Total Number of Safe Deposit Boxes (Attach copy of Will) (Attach acopyofTrust) BLOCKS 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death between D 11. Election totaxunderSec.9113(A) 12-31-91 and 1-1-95} (Attach Sch 0) fjjl$'~ln\.ljj!\'tIli$!:l_l$filpj;@ij!:lQ!lIl~.!:!$l'liieQ!!~iQmiAlitAXI"liQ!lMA'tlPfj1ilijQl!U1lmQm$'ijpm91 NAME COMPLETE MAILING ADDRESS COR- Jerrv A. Weiale, Esauire 126 Fast King Street RE- FIRM NAME (If Applicable) Shippensburg , PA 17257 SPON DENT Weiale, Perkins & Associates TELEPHONE NUMBER (717) 532-7388 None OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 203,268.;00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) None 4. Mortgages & Notes Receivable (Schedule D) (4) None 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 2,203.00 6. Jointly Owned Property (Schedule F) D Separate Billing Requested (6) 36,447.79 RECA- PITULA- 7. Inter-Vivos Transfers & Miscellaneous TION Non-Probate Property (Schedule G or L) (7) None 8. Total Gross Assets (total Lines 1-7) (8) 241,918.79 9. Funeral Expenses & Administrative Costs (Schedule H)(9) 9,709.31 10. Debts of Decedent, Mortgage Liabilities, &Liens(Schedule I) (10) 645.18 11. Total Deductions (total Lines 9 & 10) (11) 10,354.49 12. Net Value of Estate (Line 8 minus Line 11) (12) 231,564.30 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax (13) None has not been made (Schedule J) 14. Net Value Subject to Tax (Une 12 minus Line 13) (14) 231,564.30 SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) X .0 (15) TAX 16. Amount of Line 14 taxable at lineal rate 231,564.30 X .0 45 (16) 10,420.39 - COMPU- 17. Amount of Line 14 taxable at siblin9 rate 0.00 X .12 (17) 0.00 TATION 18. Amount of Line 14 taxable at collateral rate 0.00 x.15 (18) 0.00 19. Tax Due (19) 10,420.39 20. D I.Q~Klli$R~ijjYpjjAij~ij~ij~mrm~i'l~j,jp~>>!lil'll!lii9;'v~ijtl /6-doS2- 67 <!-- ..')"..'..""""'}}.}.)'.)")")).}}.~...'. BE.,SU...'.R.E..'.T..d. A. .N5... .WEa..., .........Allli.,.. QQilSTI.,'.di\i. 5. .,.,GN. .,.,.AA(l. ....E.llAi\iD.".R..E. G. H. .EcK. '.'. .. 'MA1'H#M)})...... ...,......... ......................-.. ...........................---- ......................_-----,-.,..,.. o PA15001 NTF 29755 Copyright 2000 Greatland/Nelco LP ~ Forms Software Only Estate of: Rosie Mathilda Henderson SUJIt.1ARY OF ALI.CX:ATIONS 'ID BENEFICIARIES Taxable at lineal rate David Roy Henderson Jeanne M. Henderson 230,921. 01 643.29 231,564.30 21-2001-0067 PA REV-1500 EX (6-00) Decedent's Com lete Address: STREET ADDRESS 210 Bi rin Road Page 2 CITY Newville Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount STATE PA ZIP 17241 (1) 10,420.39 0.00 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total InteresVPenalty (0 + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference, This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund 5. If Line 1 + line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax dUe. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT (3) 0.00 (4) (5) 10,420.39 (5A) 0.00 (5B) 10,420.39 :,::,:,:::,:::;::::':':::':;::';';:;':'::;':":;':::"::,::,::,:;,::::::,:::::;:;:,:::::,:::::::::,:::::,:::::::::,:::::,:::::,::,,:,::,,:,,:,,::;:,,::,::,c,,"'C",:,c",:,c",:,:",:,:",:,;",:,:,:::,:,::: ,:,,::,:"",:"",:::",:,:",:,:",:,:)::,:::,:::::,,::,c,:,:::::,:,:::",:,:",:::"::::":,::,,,,::,:,,::::,,,:::,:,::::,,::::,,:,:::,(c :..-:.:.,.:.:".:.:,:.:.:,:.,,:.;.:,c.;.:,:.;,:,c.:,:.:.::c.,.:::...:.,.:::.;.:.:.:,:.;.:,;.;,:.:.:".;.:.,.:.:.:':"':':"-:':"-"":-:"-:-:':-:-:::-,-:;:-,-:;:-,-::,-,.::,.,.::,.,.::,.,.::,.,.::,...,.:.. .>:"...:::...:::",>:,.,:-:,;,;,::.:,c::.:,c,.:.,::.::,-,.:::-,-:,:.;.,.::,.,.::,...,::,..:.:::.,.:::.,.:::.,.:-:.,.;.:.,.:.:"':'::"":::',_:,: pLEASE ANSWER THE FOttOWING QUESl'IONS SYPLACINGAN ...'...'...'...'-,_._,.,-,.,.......".,..,...'....-..--..,.,.,.'....'..'.'..'..'...............-..-,.,.,... ::,...:::...:::-,-:;:-,.:::.,.::,...:::...:::.;.:::.:-:.,.:.:.,.,.:.;-:.:.,-:,:.,.::,...:.,.:,:...:::...:-:.;,:.,.:::.:.:".:.:.,.:.:.:-:.:.,-:.:"-:.:.,.:.::,.,.:,,.,.::,.:...:::...:.: ,.,:",,,:::,,-:::-,-:,:.,.::,.,.:::...:::...:::...:,;.,.:""':""':';-:-:-"::""::":':'.'>:'.':::':':-:':':...:".:.:".,.:.,.:.:.,-:.:,,-,.:.:.:.:.,.,.:,:...:,:...:-:::...>:.:.' "X" .'j~'fH~j~~~8~~ijf~..~t8bk~""""" 1. 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 withoutreceiving adequate consideration? . . . . . . . . . , . , . . . . . . . . . . . . . . , . . , . . Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 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. 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 information of which e arer has an knowled e. SI AT RE OF ER N RESP IBLE FO ILlNG RETURN DATE 3. 4. Yes No ~ I B ~ D ~ (}~O , PA 17257 on on use (72 P.S. 1i9116(a)(1.1)(i)]. For dates of death on or after January 1, 1995. the tax rate is imposed on the net value of transfers to orforthe use of the survivin9 spouse is 0%[72 P.S. 119116(a)(1.1)(ii)]. The statute nn.." nnt """mnt 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.!i9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or fotthe use of the decedent's lineal beneficiaries is 4,5%, except as noted in n.p.s.1i 9116(1.2) [72 P.S.1i9116(a)(1)], The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% 172 P.S. Ii 9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood oradoption. o PA15002 NTF 29756 Copyright 2000 Greatland/Nelco LP ~ Forms Software Only Estate of: Rosie M3.thilda Henderson 21-2001-0067 The following person(s) are signing the return as representative(s) of the estate: David Roy Henderson 10 Chestnut Road Nev..>burg, PA 17240 REV-1'503 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rosie Mathilda Henderson SCHEDULE B STOCKS & BONDS FILE NUMBER 21-2001-0067 All property Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NO. DESCRIPTION VALUE AT DATE OF DEATH 1 U. S. Series EE Savings Bonds - total of 42 b::mds of various denaninations 203,268.00 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 203,268.00 7 CPA31 NTF 10905 Copyright Forms Software Only, 1997 Nelco, Inc. REV-150B EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rosie Mathilda Henderson SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-2001-0067 IncllJde proceeds of litigation & date proceeds were received by the estate. All crop. lolntlv-owned with rlaht of survIvorship must be disclosed on Sch. F. ITEM NO. DESCRIPTION VALUE AT DATE OF DEATH 1 U. S. Treasury - 2000 federal incane tax refund 2,186.00 2 Ccmronwealth of pennsylvania - 2000 state incane tax refund 17.00 TOTAL (Also enter on llne 5, Recanitulation) $ (If mOrEl space is needed, insert additional sheets of the same size) 2,203.00 7 CPA81 NTF 10908 Copyright Forms Software Only, 1997 Nelco, Inc. REV-1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rosie Mathilda Henderson SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER 21-2001-0067 If an asset was made Joint within one year of the decedent's date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A David Roy Henderson ADDRESS 10 Chestnut Road Newburg, PA 17240 RELATIONSHIP TO DECEDENT Son B Jearme M. Henderson 10 Chestnut Road Newburg, PA 17240 Daughter-in-law JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH Include name of financial institution and bank ITEM FOR MADE account number or similar identifying number. DATE OF DEATH DECD'S VALUE OF JOINT NO. TENANT JOINT Attach deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1 A 1993 Allfirst Bank Checking Account 5,034.81 50% 2,517.40 #0010294082 opened 06/11/93 joint with David R. Henderson, son A 1993 Interest on above item accrued 1.33 50% 0.66 as of decedent's death 2 AB 1980 Allfirst Bank Checking Account 3,858.31 33.3333400 1,286.10 #0097286427 opened 01/28/80 joint with David R. Henderson, son, and Jearme M. Henderson, daughter-in-law AB 1980 Interest on above item accrued 1.44 33.3334% 0.48 as of decedent's death 3 A 1997 Allfirst Bank M:>ney Fund 5,277.79 50% 2,638.89 Alternative Account #0098037951 opened 02/05/97 joint with David R. Henderson, son A 1997 Interest on above item accrued 8.52 50% 4.26 as of decedent's death Total fran continuation Dacre (s) 30,000.00 TOTAL (Also enter on line 6, Recaoitulation) $ 36,447.79 7 CPA91 NTF 10909 (If more space is needed, insert additional sheets of the same size) Copyright Forms Software Only, 1997 Nelca, Inc. Estate of: Rosie Mathilda Henderson Item Joint No. Tent. 4 A Date Made Joint 1998 SCliEDULE F Jointly-Owned Property Description u. S. Treasury Notes j ointl y owned with David R. Henderscn, scn Date of Death Value of Asset 60,000.00 % of Decd's Interest 50% TOTAL. (Carry fo:rward to main schedule) . . . . . . Page 2 21-2001-0067 Date of Death Value of Deed's Int. 30,000.00 30,000.00 REV-1511EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rosie Mathilda Henderson SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-2001-0067 Debts of decedent must be renorted on Schedule I. ITEM NO. DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Fogelsanger-Bricker Funeral Heme 6,544.30 2 Burial Clothing 24 .48 3 Toll Gate Restaurant - funeral reception 140.48 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN No. of Personal Representative(s) Street Address Ciry State 0.00 Zip Year(s) Commission Paid: 2. 3. Attorney Fees NaIre: Weigle, Perkins & Ass=iates Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 2,500.00 0.00 4. Probate Fees 0.00 5. Accou ntant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 See Schedule attached Total from continuation page (8) 500.05 7 CPA11 NTF 10911 Copyright Forms Software Only, 1997 Nelco, Inc. TOTAL (Also enter on line 9, Rec1mitulation) $ (If more space is needed, insert additional sheets of the same size) 9,709.31 Estate of: Rosie Mathilda Henderson S01EDUI.E H, PART B -- Administrative Costs Item No. Description 7 Register of Wills, Cumberland County - Letters Testamentary and Short Certificates 8 Cumberland Law Journal - advertising Letters Testamentary 9 Valley Times Star - advertising Letters Testamentary 10 David Roy Henderson - reimbursement for copies rrade 11 Register of Wills, Cumberland County - filing PA Inheritance Tax Return 12 Register of Wills, Cumberland County - filing Family Settlement Agreement 'IOI'AL. (Carry forward to rrain schedule) . . . . . . Page 2 21-2001-0067 Arrount 258.00 75.00 101. 00 1.05 15.00 50.00 500.05 REV-1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rosie Mathilda Henderson Include unreimbursed medical expenses. ITEM NO. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER 21-2001-0067 DESCRIPTION AMOUNT 1 Continuing Care Rx - 9/8/00 statement 138.18 2 Presbyterian Homes, Inc. - final billing 3 Carlisle Imaging Associates - 10/12/00 and 1/9/00 statements 360.52 68.00 4 Pharmacy - 8/29/00 prescriptions 3.48 5 Joseph V. Brown, C.P.A. - 2000 federal and state income tax preparation 75.00 7 CPA12 NTF 10912 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 645.18 Copyright Forms Software Only, 1997 Nelco, Inc. REV-1513 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES Rosie Mathilda Henderson No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 David Roy Henderson 10 Chestnut Road Newburg, PA 17240 2 Jearme M. Henderson 10 Chestnut Road Newburg, PA 17240 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Son Daughter-in-law 21-2001-0067 AMOUNT OR SHARE OF ESTATE 230,921. 01 643.29 ENTER DOLLAR AMTS. FOR DISTRIBS. 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 None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS None 7 CPA13 NTF 10913 TOTAL OF PART II -- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ Copyright Forms Software Only, 1997 Nelco,lnc. (If more space is needed, insert additional sheets of the same size) 0.00 J =::-=--: o. LAST WILL AND TESTAMENT OF ROSIE MATHILDA HENDERSON I, ROSIE MATHILDA HENDERSON, a resident of Takoma Park, Prince George's County, Maryland, and residing therein at 1103 Haverford Road, being over the age of twenty-one (21) years and of sound and disposing mind and memory, and not acting under duress, menace, fraud or undue influence of any person, do make, publish, and declare this my last will and testament, as follows: 1. I direct that all my debts, including my funeral expenses, expense of my last illness and the expenses of the administration of my estate, to be paid by my executor, hereinafter named, out of the first monies coming into his hands and available therefor. 2. I hereby declare that I am married; that my husband's name is Roy Burge Henderson; and that I have but one (1) son, David Roy Henderson. 3. I give, devise and bequeath all of the rest and residue of my property, after payment of the debts and expenses provided for in paragraph 1. hereof, whether such property be real, personal or mixed, of whatsoever kind or character and wheresoever situated, to my husband, Roy Burge Henderson. If my husband shall predecease me or if we both shall die under circumstances rendering it impossible to determine which of uS survive the other I give, devise, and bequeath all of the rest and residue of my property, after payment of the debts and expenses provided for in paragraph 1. hereof, whether such property be real, personal or mixed, of whatsoever kind or character and wheresoever situated to my son, David Roy Henderson. 4. I hereby nominate and appoint my husband, Roy Burge Henderson, Executor of this, my last will and testament, to serve without bond. If my husband shall predecease me or if we both shall die under circumstances rendering it impossible to determine which of us survive the other, I hereby nominate and appoint my son, David Roy Henderson executor of this, my last will and testament to serve without bond. 5. I hereby revoke all former wills and codicils to wills heretofore by me made, In witness whereof, I have hereunto set my hand and seal to this, my Last Will and Testament, which consists of two (2) typewritten pages, V. /J h/u:t. this included, on this I CJ - day of ~T -- , 1972, ~~ :JJla~~~'(L,S.) Rosie Mathilda Henderson The foregoing instrument, consisting of two (2) typewritten pages, this included, was on this / (; ~ day of ~ ' 1972, signed, sealed, and declared by the Testator to be her Last Will and Testament in the presence of us, who at her request~ in her presence, and in the presence of each other, have subacribed our names as witnesses hereunto. residing at ?l6~ 7iJ~ I ,1L),)/J 111. /f~.. ~ 7wP~ W ~ ;;;leOf.;). -14<<11 J.$(f'i ~~# #0--- ~;~') 1/ ~4/rJut~ residing at 7tJ6~~12a-J residing at ,,9-a,A_.'~h~ 11"--4,, ~rJo<{)o/,;;. Page 2 of 2 pages .. , , \ EE.> *~ /hA ~-ul~ .t.;r~0?1 ~. oJ21' (7,00/'->- (,:[ ('-(1 D I C Issue Date Serial Number Face Dale (Mo_. Yr.) (wIth prelix and suflix) Value Cashed Amount /(1.,- 'i3 Ix *'706 os-a; IO.k. '.112. /.2-'73 Ix 1S7tJ60J1.E"F II/) k. ~:m. )J.-93 XiK70603~E :'O/<. (.. Cj/2. , iJ..-CJ3 )(535"3 .g 87 EE" 10 l<- t. '712 , J..-<j3 VnG3?I,elE 10/< (,..'WL /J. - '13 x')3t;":;877 C;; JOK f., 'lll. . 03 -'11 XifS9S-4f,"'96 I)/)K l. 1m. , rJ3-11 XJj01.r160~~ lOt:::. 10, '1/2. '3-1>1 --461 IE;;- '0 I< ',1''2 ':13-14 x5"3J3~'Jf a /01<. t'i/2 , !r-94 I X:J3'0 fl 79 e[; Illk '-.., 12. 9r9Jf IXD53i9J'O ,E5' '0 I< , '1/2 , 09-96 Iv.;o~,..-'7 . EE S'k! ~ 'lID ~ . b , -y:H6 v5'ORJ,,75-eE (j/<.. ~ 'Po 'J'j -'16 V ~O~357J1E'c f!("!<. ~ ,'170 'l-1{~ V.<:o8~573 ~ s-}<. .;l. '170 , ':fl-CJ6 VtJog]S"7rXfflE S-f:. l.2QiD , 'l..t!6 V:;-O?;571 a !:k ),'170 "<;-'16 Y'SJI1361S-c E 5""-1< J.., '110 71-'16 V~f'l Jill ifEi= 5'"1<. ~,'170 'fl-<fO V 5'7f1 '3(;,/ 3,EJ:: !i-K, ~.'11D ~ ~ * *" fr * Issue Date Serial Number Face Dale (Mo.. Yr.) (with prefix and sullix) Value Casned Amount j-* ;<,'1'70 :;-/< ~.'I1U sl<. 2 '170 , X53s?;g~/E'E 'OJ<. 5 fib 5'353 a>8).,~& JO I<. s.m. 5. g 1(, IOJ< 58/1. ok. i.Blb 101<. 3 fIb , /ok 5,(,.18 )()k ~. b).B ok 5,~B I I J. (,;J. B i ! 5. t,;J.'i ,~e I ).,~70 i ~k, ;'.'7D ~I< ;.'-70 ~k 2,/,70 ,1<. 2,{,7i:> H<.. ~,"7{) J ;;'03, 2. bt. 0.3 . !l allnrst :\lIfirst FinJIll.:ial Ct'T1lt'f ;\.:\. po. Bm.. LIllO r..ltlbborll. DE llj'IM January 30,2001 Weigle, Perkins & Associates Attorneys at Law 126 East King Street Shippensburg, PA 17257-1397 RE: Estate of Rosie M. Henderson Date of Death: September 2, 2000 Social Security Number: 213-56-9675 Dear Mr. Weigle: In response to your request, please be advised that at the time of death, the above- named decedent had on deposit with this bank the following accounts. 1. Account Type........................... Checking Account Number.......................0010294082 Ownership {Names of}.............. David R. Henderson, Rosie M. Henderson Opening Date...........................06/ 11/93 Balance on Date ofDeath.........$5,034.81 Accrued Interest $ 1.33 Total................................... ....$5,036.14 2. Account Type...........................Checking Account Number................... ....0097286427 Ownership {Names of}.............. David R. Henderson (or) Jeanne M. Henderson (or) Rosie M. Henderson Opening Date....... ....., ,.............01/28/80 Balance on Date of Death....... ..$3,858.31 Accrued Interest $ 1.44 TotaL .... ... ... ... ........... .... ... ... ....$3,859.75 . Page 2 January 30, 2001 3. Account 7Ype...........................Money Fund Alternative Account Number.................... ...0098037951 Ownership (Names oj).............. David R. Henderson, Rosie M. Henderson Opening Date.......................... .02/05/97 Balance on Date of Death........ .$5,277.79 Accrued Interest $ 8.52 Total...................................... .$5,286.31 These accounts were converted from the acquisition of another financial institution. Unfortunately, we are unable to access any information pertaining to the date the accounts were made joint TItis letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Tnlstee under a Written Agreement For any additional information on these accounts, please contact our branch at: 35-39 East King Street Shippensburg, PA 17257 Phone: (717) 532-4132 Sincerely, Charlene 9!::~s7f~;r (302) 934-2722 ~~l '9") M<tlting Number: 020016920 t" TREASURY DIRECT. www "~asUlydI19ct gOY 1 -800-943-6864 (Electronic Services) I STATEMENT.OF ACCOUNT!:,. Page 1 01 . 2 , I \'011.. r,./,aw,ryIJirer( orncc ROSIE M HENDERSON OR DAVID R HENDERSON 8 PARTRIDGE TRAIL SHIPPENSBURG PA 17240-9442 TREASURY DIRECT I'.O.BOX 2076 BOSTON MA 02106-2076 I'IIONE: (877) 973.898.1 PnVlllcnt [nfurUlafftln . :'. . ITlIxlHlycr Idl'ulilicutiun No: I Confidclllil1l l':1ymclI(~ nmdc by direct dcpo,!;'j( to: IJAUI'IIIN DEI'OSIT BANK Rouling Number: 03 1.1008.14 Naill" 011 Aceolllll: ROSIEJlJA vm IIENDERSON CIIECKING Aeeollnl Nllmhcr: 10294082 ITelel'hlllle Nllmher: I (717) 5.\2.9344 ITax Wlthllf)Jdh'g SIIIIII<: I No withholding T,.t!a511'J'I);,.~ct I\Ctflullt Numbci.: 4800.611.2828 ~Tot.lljllr.~ of 08118/2000: I $15,000~ ACCOUNT 1I0LIHNGS ,., ~ . .,' ;.'. ..;,. :r .,Of-f2000) OM!:I.No l:i3:i-OOti9 Hailing Number: 014539 .lment of lhe Treasury ",au of the Public Debt .0. Box 1254 Parkersburg, VVV 26106-1254 t~ TREJl$URY DIRECT. ..,; ~, ,;;.;. ~ ...-.'.. .:~ ~:;*';,;:~1:' . .t'.."--' ,:',:.";' . ,,:","':, REINVEST DIRECT NOTICE-<:,;. \\~.: ;::;;;,:t,'/~:-r,~,ti :H;"; ':J::;:t,~',';: "';;'"""f "';:., ""''':;, .r','~, ';'.:' ;:-."?:'!:;';-,,';;--,:r', STATEMENT DATE: 01/0812001 DAVID ROY HENDERSON OR ROSIE M HENDERSON 10 CHESTNUT DR RR 1 BOX 77 NEWBURG PA 17240-9105 ''J.f.. r... ". ')jl:)~' <"""'!f1I......"~1."'....!fI:'''Ii'''','''k,,,t\\,-u.'jil,\Jl'.W''''''-''''.,.. """",.,..",.,.Ii.""':0i.i''I1Mh1!i1i\i'' :iI~W .. .\~f, ~'"' "}"In'~'" I"''''''''' " " .''''''''~'''' .."", . II R r V ~,'(."it . ,:"'" t *''k1;;_~..."...-l.''''''~JI.''.> _~;, "...... _"~c=,;,....l.M...,,...... ~....;""F-4....~..~'.....,,, The amount of your maturing security is (fi 5, 0 0 0 . O!!..:> To use our convenient telephone reinvestment service, call 1-800-722-2678 by 02l1B/2001. If you don't want to reinvest, disregard this form. Live outside US? Dial 1-617-994-5500 Have this form and a pen or pencil ready when you telephone. You will be prompted to enter the following Information: 1. Enter your TreasuryDlrectAccount Number 4700-033-3976 ~ 2. Enter the CUSIP I 912795FV8 ~ whlctylifatureson 03/0112000 3. Enterthe Validation Number I 10000151 , 4. Select the appropriate security term offered. When using the telephone, If your CUSIP contains the... letterQ press 7 5. Select the appropriate number of relnveslment.. Confirmations will no longer be mailed. Listen carefully to verify the information you entered. For your records, write your Conffrmatlon Number here: I TN "To request partial reinvestments use PO F 5180 "Reinvestment Request" or contact your TreasuryDirectOflice at: 1-800-722-2678 IetterZ number or letter 0 press 9 press Zero r You can also reinvest by vlshing our webslte at www.treasurydlrecl.gov Please see the back of this form for important information about Treasury securities. " Of.1B. No 1535-0069 Mailing Number: 014608 ;enl of the Treasury oJ of the Public Debt . Box 1254 ..ukelsburg, WV 26106-1254 REINVEST DIRECT NOTICE I STATEMENT DATE: 08/22/2000 DAVID ROY HENDERSON OR ROSIE M HENDERSON 10 CHESTNUT DR RR 1 BOX 77 NEWBURG PA 17240-9105 ... . . .... . . . . Instructions for Requesting Full Reinvestment * ""'~'W""""""'""";">"'" ..',". ,",,' ^,,,..<..,""""'. _',',," ..,.. -'._' .., .d. ..."., .,.. _.. ,,'....,..,.... -...~, .. ,- " .. ' The amount of your maturing security is ~ To use our convenient telephone reinvestment service, call 1-800-943-6864 by 10/01/2000. If you don't want to reinvest, disregard this form. Live outside US? Dial 1-304-480-7955 Have this form and a pen or pencil ready when you telephone. You will be prompted to enter the following information: 1. Enter your TreasuryDirect Account Number I 4700-033-3976 ~ When using the telephone, 2. Enter the CUSIP I 912795EG2 ~ which matures on cfO/12/2~ if your CUSIP contains Ihe... Validation Number I 20000158 ~ letterQ press 7 3. Enter the letterZ press 9 4. Select the appropriate security term offered. number or press 5. Select the appropriate number 01 reinvestments~ lellerO Zero Confirmations will no longer be mailed. Listen carefully to verify fhe information you entered. For your records, write your Confirmation Number here: I TN , *To request partial reinvestments use PD F 5180 "Reinvestment Request" or contact your Servicing Office: FRB BOSTON 1 (877) 973-8983. You can also reinvest by vistling our website at www.treasurydlrect.gov Please see the back of this for":! for important information about Treasury securities. ,DOl OMS, No. 1535.0069 Mailing Numb.r: 014507 .nsnl of the Treasury dU ollhe Public Debt .J. Box 1254 'arkerohurg. WV 26106.1254 I REINVEST DIRECT NOTICE I ;..,f- STATEMENT DATE: 09/1912000 DAVID ROY HENDERSON OR ROSIE M HENDERSON 10 CHESTNUT DR RR 1 BOX 77 NEWBURG PA 17240-9105 .... ;,', :";ii.:;,~.i'lJ).~;lt~~~~~#'!~I'-'~!9r!~i!I'~ff~I,I.8.;j~"~stn1~n~:)f'~~':<"'ii ,'. " The amount of your maturing security is Gi 5,000 . O~ To use our convenient telephone reinvestment service, call 1-800-943.6864 by 10/2912000. "you don't want to reinvest, disregard this form. Live outside US? Dial 1-304-480-7955 (;'~::":)i:t~'\\',,'~' +;t: d, < ;;'N'~;{';::::' Have this torm and a pen or pencil ready when you telephone. You will be prompted to enter the following information: 1. Enter your TreasuryDlrectAccount Number I 4700-033-3976 ~ 2. El\terlhe CUSIP I 912795EHO ~ whichmatureson{1l/0912000-:) 3. Enter the Validation Number I 20000158 ~ When using the telephone, If your CUSIP contains the... letterQ press 7 press 9 press Zero 4. Select the appropriate security term offered. letterZ number or lellerO 5. Select the appropriate number of reinvestments. Confirmations will no longer be mailed. lislen carefully 10 verify Ihe information you entered. For your records, write your Confirmation Number here: I TN "To request partial reinvestments use PO F 5180 RReinvestment Request" or contact your Servicing Office: FRB BOSTON 1 (877) 973-8983. r You can also reinvest by visiting our website at www.treasurydirect.gov Please see the back of this form for important information about T Teasury securities. ,. PETITION FOR PROBATE and GRANT OF LETTERS Rosie Mathilda Henderson ~ r7 Estate of Rosie M. Henderson No. t7\ l.::12.l- OOlu , a/so known as To: Register of Wills for the I Deceased. County of Cumberland in the Social Security No. 213-56-9675 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(x), who is/Jme 18 years of age or older an the executor in the last will of the above decedent, dated April 10 and codicil(s) dated none named , 19..1.2- Roy Burge Henderson predeceased Rosie M. Henderson 11/17/98 (state relevant circumstances, e.g. renunciation, death of executor, etc.) Oecendent was domiciled at death in Cumb e r land County, Pennsylvania, with h er last family or principal residence at Swaim Health Center, 210 Big Spring Road, Newville, PA 17241 (list street, number and muncipality) Decendent, then , 87 years of age, died September 2 )Cl{~ 2000, at Swaim Health Center, Newville, PA 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: ----,-_none Oecendent 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 d0I11iciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: $ 165,000.00 $ $ $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters testamentary (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. '" 1)' u t:: 1) :9-;;;- In _ cl) .... 0::1) t:: -00 t::'= ~.= 3~ cl) '- ~ 0 c; t:: 0() i:/i 10 Chestnut Road Newburg, PA 17240 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 1. ss COUNTY OF CUMBERLAND J 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 represen- tative(s) of the above decedent petitioner(s) will wel nd truly administ_er the estate according to law. ~ ~. ::s ~ - s:: ~ ~ Sworn to or affirmed and subscribed before me this t ~Tff- day of ..:r~ LLPrlZ '-j , ." ~UArC.~-Luu.', ' I ~-_ 801--_ } ~ No. ~ / -Of - ()D to'7 Estate of Rosie M. Henderson , Deceased DECREE OF PROBATE AND GRANT OF LETTERS LOOI AND NOW SA N LlkR- 'i 1l.JJ 1/'-, 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 April 10, 1972 described therein be admitted to probate and filed of record as the last will of Rosie M. Henderson and Letters Testamentary are hereby granted to David R01 Henderson $ ~15 ,00 Probate, Letters, Etc. ......... ~..;L Sh~r~ C~~.i~icates(5) . . . . . . . . .. $ 15 - 00 n ^ JJ~ $ .3 . 00 PlI:eUURclatlon ................ ~U' $ 5.00 TOTAL _ $ ':A5g,oD Filed ... J --:-.I.lp:-:Q.1. . . . . . . . . . . . . . . . . . . . . . FEES 'rll 'f}' . /1 Y '(Jet-it ~. .Y-ij~/JfL~ VII} jM~av Register of Wil s v tpJy t Jerry A. Weigle, Esqu~re #01624 ATTORNEY (Sup. Ct. I.D. No.) WEIGLE, PERKINS & ASSOCIATES 12n Ra~t King Street ADDRESS Shippensburg, PA 17257 (717) 1)12-7388 PHONE LE-rTfd\S fYlm lrd). , OJ n ~ } - 0 J - 00 0/'-7 REGISTER OF WILLS OF COUNTY OATH OF SUBSCRIBING WITNESS codicil (each) a subscribing witness to the will presented herewith, (each) being dul law, depose(s) and say(s) that ualified according to present and saw the testat , sign the same and that request of testat_ in h presence and (in the other subscribing witness(es)). signed as a witness at the sence of each other) (in the presence of the Sworn to or affirmed and subscribed befo me this of 9_ (Name) (Address) Register (Name) (Address) REGISTER OF WILLS OF C.LLm 1321\I-fh-J b COUNTY OATH OF NON-SUBSCRIBING WITNESS (lA-IIID (20Y t/~IJ/l6R5V }f/ (each) a sub~criber hereto, (each) being duly qualified according to la~> depose(s) _and say(s) that .. I -H~ familiar with the signature of /COSt f: Hft11f-ILf}!f H ELVIJt-fC'Jlv codicil testat~ of (one of the subscribing witnesses to) the @ presented herewith and codicil believes the signature on the will is in the handwriting of tf~ that flocs~ I1frtthi-J?tt J-jBi/lEI?5tlV to the best of His knowledge and belie/! - ::Itl / - /1 Sworn to or affirmed ar:f.-subscribed before ~/l'~ _ fkLidlA~ me this t (p ~ day of (Name ~::;~~Luth~~.- (Address) I · ~ ( Register r (Name) (Address) ~J-OI-O{;/7 REGISTER OF WILLS OF OATH OF SUBSCRIBING WITNES Y codicil (each) a subscribing witness to the will presented erewith, (each) being duly qualified according to law, depose(s) and say(s) that present and saw the testat , sign the same a that signed as a witness at the request of testat_ in presence and (in the presence of each other) (in the presence of the other subscribing witness( Sworn to or affirme and subscribed before me this day of 19_ (Name) (Address) Register (Name) (Address) REGISTER OF WILLS OF CUMBERLAND COUNTY OATH OF NON-SUBSCRIBING WITNESS Dominique LeMillour Henderson ~X4h9 a subscriber hereto, (~) being duly qualified according to law, depose(s) and say(s) that she is familiar with the signature of Rosie M. Henderson XX1dicik test at rix of ~x:tO:txtheK~soribbtgcx~xtx$ the will presented herewith and ~)c that she believes the signature on the will is in the handwriting of Rosie M. Henderson to the best of her knowledge and belief. Sworn to or affirmed and subscribed before ~.!) 0 lVf..-i N:~ \ e.}{ ; LLo tl R- - f\ 'f.1\JJ).c 6(5 0 tV me this I V -rtr- day of (Name) ~ .. ~~'~Dominique Lemillour Henderson ~ ._~VlJY .. 10 Chestnut Rd.(Address) . . - Register . Newburg, PA 17240 (Name) (Address) JltU).nu) tU"'..\' '-J/X() T;lis is to certify that {he -information here given is correctly copied from an original certificate of death duly filed with Ine as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. Fee for this certificate, $2.00 p 6716435 J//'f ~~ Date '\... 2111 COMMONWEALTH OF PENNSYLVANIA I DEPARTMENT OF HEALTH I VITAL RECORDS CERTIFICATE OF DEATH NAME OF DECEOENTfF~". M~--'-'---- ...---------------- SEll ,. Rosie M. Henderson a. Female !lTAr' '11.. ~A SOCIAL SECURITY NUM8ER :1.213 - 56 AGE (La. !I<<Ihclay) UNDER 1 YEAR Matlltll 01\'1 8IRTHI'IJICI (CoIy Iftd 31811 01 F 0l1oQll Counlly) Pt..ACl OF OER'H <<:'-10 0Ny 01'1-. _ """ucloOnl on ""'" _I HOSPITAL; - OT"": / III(lIfleIlI 0 ==- er ~ 0 =.,10 87 v... COUNTY OF Dl!.CI'H RACE . A_ 1_, 8Iiock. WtMlI .... (Specll'yl . .. Cumberland ~. . DECEDENT'S USUAL OCCUMTION (~~~:O~::~:i' . n Housewife nil. DEaDENT'S MAl\.INO ACOMSI (SIr... c.,no-. s... Zip Codel MARITAL STR'US . U8rrtId ~MarrillcJ.~. ~~ . Widowed 'L ,,..00.......,.....;. Southampton '0. White SUfMVlNG SPOUSE 11l_.~"""""'_1 '. ... 8 Partridge Trail ,.. Shippensburg, PA 17257 F.Q'H(R'S NAWE (F ~.. MtCldII. l"" t. Kristen Jensen "'OfIlMAHT'S HAUl (T ypelPrlnl) David R. Henderson ME'THOO OF OISPOSlT~ O 1IurIIlI1J C~1lIft 0 o..IIaft ow.. (Spec"'" . it.. ~ PA 17240 LOCR1ON . ClIyITown. St.... ~ Code Shippensburg,Cumberland Ct. ~~ PA _1c:AUAlF..... _ 01 eoncllIoon '-*'lI" dIIltIl- ,'''''''-' '1nhlNIIIlIIwMfl : _ end cIMIIl , I , Mln'1I: 0lIlIr ~ ClCInCIlioM ~ 10 _. bur 110I ~in"'" ~.,...._ on""," I ~ ~..____ b II.,. ...... . irIWnIIdIIN _. E_ UNDeRLYING CMM jo-OI.."V I c. . ...-- '-*'9" 0.111 LAST d. .. AN AUTClPSY - Pf:fIlFOAUED'P ~AE AUTOPS'Y FINDINGS ~E PAlOfllO COMP\.ETlON '" CAUSE OF oeRH1 MANNER OF DEATH OATE Of' INJUl'IY (MantII. OIy. __, TIME OF INJUAV lNJUAY 1ft WOAI<1 MSCAl8E HOW INJURY OCCUMEO _ONo .....0 No[)-"'" SuIcide g.-- o o Heot\IclcIe ........~1lIft o o o PlACE OF INJURY. AI. hamI. "",,, .........", 0lllcI Y. lIu-.g. _ ISpec1lvI :101. _ 0 NoD ......... "-<<lInl .WOtCAL EXAMINER/CORONER On "'- Nell ot I..minet'on .ndI<< Invlallgallon.ln my opinion, dellft\ occurred 111M tlml, d.t.. .nd p'ecl. and dUI to tM clu..(a) lnet _...tlted....., ..... ........... ....... ........ ..... ............... ......" .................... .... ........ J,.. REGISTRAR'S SIGNATURE AND NUM8ER I~I II~ /151 ~ Lit- CoIllct 110I III dei_WIld 2IIL 2a. CUIT1P1Mt ll>eck otlly onel 'aJn'1I"tfNQ l'M'fIlClAH (Ph~- CfIt1IIylnQ CauM d dftll1 ~ ~_ d\YSlC..... IIn pt~ "'11tI ana camlllellld "- 23) To_...........,..---... death occ.......... lite c...M(.I...."".__.,._. ......................,............................, :II. .~ AND Ct!ln"U'YlNG ,"YSlClAN tPhytc_ _II jJ'onouncono _ anct c:It1!1ylnq to c..... ell de."'1 ... _ _ of my knowledQfl. death occ........t lite _. ""a. and plKa..nd dua'a "'" uuM(.'and m.nne' a. a'atM.. . . . . . . . . , . . . . . . . . . . . . . . . u. M. ;115 JS to certify that .th@ information here given is correctly copied from an original certificate of death duly tIled with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. ~8cOL ~al Registrar No. ", ",/1111//"/"""'" \1\11'11~~\.\\\ OF PEil"-,,__ i#~--- - -..__ - ~~"\ ~~--- - ~\ ~~ -- -----:- -- - -- '?~ ~ ~{-fc . - \~~ ~ S .{-t.~ !i:~ ~ *~"--"- '"- "% * ~ \. ~ -'~.' -- ~~l ~ ~ A('~\'\ -=:.....-,!1MENl \\~ ~~II""\ ""'/"'//////111111//" I //-/'~-/996 Fee for this certificate, $2.00 5308499 Date I Rev 2117 COMMONWEALTH OF PENNSYlVANIA. DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH NAME OF DECEDENT (Fit" Middle. La, t. _'ff S UNDER t yEAf'I Mont". Deye 8lATHfI\..Aa lCotv IIId S1ale co f Cleq1 Counrry) WARlTAL STAl'US . ....... Newt ....*11. WIIIDwM. ~~ rs ,.. Married 11. Rosie H. Jensen ,,..lXI....dICedM...... Southampton Townsh i 0 ..... ,.. FATHER'S NAME (Fir... M~. lnl) tl. 1Nf'000000'S HAW (TyplIIf'rirlll ie M. Henderson METHOD OF DIsPOSITION ..... all CNmIIllIn 0 Oltler lSPc ~ PA _DlATI~(f'..... .... 01 conclIIion '-*'!IondMlhl- ~ .. t ApploUMle '1nlefWI_ : __ MId dMtII I I I MAT .: Oltler sigrliIbfII____ ~ 10 dHtII, llul _'-'ing"_~~_" PlI'RT I ~ 10 lOR AS" CONSEOUE..cE Of): ~.. ClDIIIIIlOnI ...... ....-ng 111----. _. E_ueaM.YING CAuse 10- Of......V ....~- '-*'0 on dMIh)LM1' lb. c. d. DUe 10 lOR AS A COI-lSEOUE..ce Of): DU! 10 (OA AS A CONSEOUE..cE Of): 'MIlS AN AUTOPSY WERE AUlOPSY FINDINOS "'ANNER Of DEATH P'EAFOAMIED? MtllA8lE PRlOA 10 COMf'\.ETION OfF CAUSE ....."., ~ 0 OF DEATH? Homlc:lde AccldM 0 Pendlng~1On 0 .....0 No __0 Hotif' Suletde 0 CouId_ be clel.....1ned 0 DATE OF INJURY (Monlt OIly. ..... TIME Of INJURY INJURY J(J WORK? DESCRIBE: HOW INJURY OCCURRED .. 0 NoD lie. 2111. C2"'.... 10lecI0 oriy one! "cunJf'YIIIQ PHYSICIAN (Phvu:- c...1tIytnQ C8uM 01 delllh wlltlf' antJlher pl'tySIC<et\ hell pt<lrlOUnced dealh 8tl<I completllCl II.,., 231 To........ of "" .............. deetll occUIftICI..... eolhe c:evse4....... manner _ 1tateCI. . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . ft. M. PlACE Of' 'NJUAY . N. 1IOfIle. ,..".. .... l~. oIllce buIdIng, ., cSpecM ... '.DICAl EXAIIlNltAlCOROHEA On.... baIlI of ..MIlnatlon end10r Investlg'llOn. in my opinion. dellllt occurred et 1M time. date, and p1ac',1ncI due to the CeuM(l) and _~.. "eted.. . . . . . . . . . . . , . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . "e. REGISTRAA'S SIGN I~/ ,:21 )1.)- I<';./ .~ ANa cefITlFYINO "",SICI"" (Phvu:oa" boIh pronounc1n<;lllealh ~nd cert~ytnQ IO~ 01 dftlhl ,..........of...y 11I~WfIecIO', dNlhoccUlftlCletlhe tlftw. Nt., .ncIplec.. and due to tMc:eUUCs) snd mann__ ..t..... ........ .. . " " .., ...... D. REGISTER OF WILLS, CUMBERLAND COUNTY STATUS REPORT UNDER RULE 6.12 Name of Decedent: Rosie Mathilda Henderson Date of Death: 9/2/2000 Will No. 21-01-0067 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 informal accounts may be filed with the Cerk of the Orphans' Court and m be attached to t .s r rt. Jerry A. Weigle, Esquire Name (Please type 0 print) WEIGLE, PERKINS & ASSOCIATES 12"6 East King Street Address Shippensburg, PA 17257 ( 717) 532-7388 Tel. No. Date: <g -1.--.--0 1 Capacity: Personal Representative (MAH:rmf/AM3) x Counsel for personal representative y ~ -. c::'Jo~- / c:tJ-I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX JERRV A WEIGLE ESQ WEIGLE ETAL 126 EKING ST SHIPPENSBURG PA 17257 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 07-02-2001 HENDERSON 09-02-2000 21 01-0067 CUMBERLAND 101 REV-1547 EX AFP <12-00> ROSIE M Amount Remitted 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 ~ ifEY-=is4'-EX-AFP-fi'2:0(ff-NO'TicE--OF-YNHEifiTANCi-'TAX-APPR]risEirENT~--AiLOWANCE-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HENDERSON ROSIE M FILE NO. 21 01-0067 ACN 101 DATE 07-02-2001 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED 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: IS. Amount of Line 14 at Spousal rate (IS) 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 = .00 231,564.30 X 045 = 10,420.39 .00 X 12 = .00 .00 X 15 = .00 (19)= 10,420.39 RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 203,268.00 .00 .00 2,203.00 36,447.79 .00 (8) 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 (9) (10) 9,709.31 645.18 (11) (12) (13) (14) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 241,918.79 10.354 49 231,564.30 .00 231,564.30 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-11-2001 AA496578 .00 10,420.39 TOTAL TAX CREDIT 10,420.39 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.) IN RE: ESTATE OF ROSIE MATHILDA HENDERSON, late of the Township of West Pennsboro, Cumberland County, Pennsylvania, deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE NUMBER 21-01-0067 CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: Rosie Mathilda Henderson Date of Death: September 2, 2000 Will No. 21-01-0067 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 18,2001: David Roy Henderson 10 Chestnut Road Newburg, PAl 7240 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except NONE. Address: Weigle, Perkins & Associates 126 East King Street Shippensburg, P A 17257 January 18, 2001 f\ ( I \ SignatJre. Name: Telephone: (717) 532-7388 Capacity: Personal Representative X Counsel for Personal Representative WEIGLE. PERKINS & ASSOCIATES - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 ESTATE OF ROSIE MATHILDA HENDERSON File No. 21-01-0067 F AMIL Y SETTLEMENT AGREEMENT THIS AGREEMENT made this ~ day of ~ ,2001, BETWEEN: DAVID ROY HENDERSON, being the legatee under the Last Will and Testament of Rosie Mathilda Henderson, late of West Pennsboro Township, Cumberland County, Pennsylvania, AND DAVID ROY HENDERSON, Executor of the Estate under the Last Will and Testament of Rosie Mathilda Henderson, deceased, WHEREAS, Rosie Mathilda Henderson died September 2, 2000, testate, and under her Will left her estate to the party herein; and WHEREAS, Letters Testamentary were granted to David Roy Henderson on January 16,2001, by the Register of Wills of Cumberland County, Pennsylvania; and WHEREAS, all assets of the late Rosie Mathilda Henderson have been liquidated or distributed and all her debts paid in full, and further the period of four months having been terminated since the first advertisement of the issuance of Letters to the said Executor, the said parties hereto desire to waive the duty of the Executor to file a First and Final Account with Proposed Schedule of Distribution for purposes of confirmation by the Court of Common Pleas of Cumberland County, Orphan's Court Division, AND FURTHER desire that a Family Settlement Agreement be executed, which Family Settlement will be duly recorded among the deed records in and for Cumberland County. WEIGLE, PERKINS & ASSOCIATES - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG. PA 17257-1397 NOW, THEREFORE, WITNESSETH, that the parties hereto, in consideration of the premises above stated, and of the Accounting and Proposed Schedule of Distribution attached hereto and made a part hereof, and the receipt of their distributive shares as therein shown, do mutually bind themselves to the said Distribution and Accounting as set forth and further mutually release each other and in particular David Roy Henderson, Executor, from all claims and demands whatsoever arising out of settlement of the Estate of Rosie Mathilda Henderson. The parties hereto do further agree that should any liability come due to the estate of the said decedent after the signing of this agreement, we and each of us do hereby covenant and agree with each other and the aforesaid personal representative that we will contribute pro rata our 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. IN WITNESS WHEREOF, the parties have hereunto set their hands and seals the day and year first above written. Ckl / .- ~ th:iIhV~AL) David Roy H nd son . WEIGLE, PERKINS & ASSOCIATES - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 COMMONWEAL TH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND '7 .!!i On this, the v day of ~ , 2001, before me, the undersigned officer, personally appeared DAVID ROY HENDERSON, 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. ;t~l.. J< K~ (SEAL) Notarial Seal Unda K KJein, Notary Public Shippensburg! PA Cumberland County My Commis.sion Expires August 15, 2004 WEIGLE, PERKINS & ASSOCIATES - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 EXECUTOR'S ACCOUNT FIRST AND FINAL ACCOUNT OF DAVID ROY HENDERSON, EXECUTOR FOR ESTATE OF ROSIE MATHILDA HENDERSON, DECEASED Date of Death: Date of Executor's Appointment: Dates of Advertisement of Letters: Valley Times Star Cumberland Law Journal Accounting for the Period: September 2, 2000 January 16, 2001 January 24, 31, February 7, 2001 February 9,16,23,2001 January 16, 2001, to July 11, 2001 Purpose of Account: David Roy Henderson, Executor, offers this account to acquaint interested parties with the transactions that have occurred during his administration. The account also indicates the proposed distribution of the estate. It is important that the account be carefully examined. Requests for additional information or questions or objections can be discussed with: Jerry A. Weigle, Esquire Weigle, Perkins & Associates 126 East King Street Shippensburg, P A 17257 717-532-7388 WEIGLE, PERKINS & ASSOCIATES - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257~1397 StMv1ARY OF ACCOUNT Estate of Rosie Mathilda Henderson For Period 09/02/00 Through 7/11/01 Page Principal Receipts Net Gain (or loss) on Sales or Other Dispositions Other Receipts 1-2 Less Disbursements: Administration Expenses (Prin) Fees and Carmissions (Prin) Funeral Expenses (Prin) Other Expenses (Prin) 3 3 3 3-4 $10,920.44 2,500.00 6,709.26 645.18 Balance before Distributions Distributions to Beneficiaries 5 Principal Balance on Hand IncaTe Receipts less Disbursements Balance before Distributions Distributions to Beneficiaries Income Balance on Hand Canbined Balance on Hand Fiduciary Acquisition Value $300,428.08 0.00 0.00 $300,428.08 20,774.88 $279,653.20 279,653.20 $ 0.00 $ 0.00 0.00 $ 0.00 0.00 $ $ 0.00 0.00 ----------- ----------- RECEIPTS OF PRINCIPAL Estate of Rosie Mathilda Henderson As of 7/11/01 Assets Listed in Inventory (Valued as of date of death) Checking Accounts Allfirst Bank Checking Account #0010294082 opened 06/11/93 joint with David R. Henderson, son $1.33 Accrued Interest $ 5,036.14 Allfirst Bank Checking Account #0097286427 opened 01/28/80 joint with David R. Henderson, son, and Jeanne M. Henderson, daughter-in-law $1.44 Accrued Interest 3,859.75 IVloney Market Accounts Allfirst Bank fvbney F\md Alternative Account #0098037951 opened 02/05/97 joint with David R. Henderson, son $8.52 Accrued Interest Federal Notes and Bonds U. S. Series EE Savings Bonds - total of 42 ronds of various denaninations 42 Units $203,268.00 U. S. Treasury Notes jointly owned with David R. Henderson, son 4 Units 60,000.00 Refunds U. S. Treasury - 2000 federal incane tax refund $ 2,186.00 Cbmmonwealth of Pennsylvania - 2000 state incane tax refund 17.00 Page 1 Fiduciary Acquisition Value $ 8,895.89 5,286.31 263,268.00 2,203.00 RECEIPTS OF PRINCIPAL Estate of Rosie Mathilda Henderson As of 7/11/01 Page 2 Assets Listed in Inventory (Valued as of date of death) Fiduciary Acquisition Value Miscellaneous Property Contribution by David R. Henderson to canplete payment of debts, expenses, administrative costs, fees, and taxes $ 20,774.88 TOTAL INVEN1DRY $300,428.08 ----------- ----------- DISBURSEMENTS OF PRINCIPAL Estate of Rosie Mathilda Henderson For Period 09/02/00 Through 7/11/01 Administration Expenses (Prin) 1/13/01 David Roy Henderson - reimbursement for copies rrade 1/16/01 Register of Wills, Cumberland County - Letters Testamentary and Short Certificates 1/18/01 Cumberland law Journal - advertising Letters Testamentary 3/12/01 Valley Times Star - advertising Letters Testamentary 5/10/01 Register of Wills, Cumberland County - filing PA Inheritance Tax Return 5/10/01 Register of Wills, Cumberland County - filing Family Settlement Agreement 5/10/01 Register of Wills, Cumberland County - PA Inheri tance Tax Fees and Carmissions (Prin) 5/10/01 Weigle, Perkins & Associates - attorney fee Funeral Expenses (Prin) 9/7/00 Burial Clothing 9/9/00 Toll Gate Restaurant - funeral reception 9/18/00 Fogelsanger-Bricker Funeral Home Other Expenses (Prin) 9/8/00 Continuing Care Rx - 9/8/00 statement 9/18/00 Presbyterian Homes, Inc. - final billing 9/30/00 Pharmacy - 8/29/00 prescriptions 1/6/01 Carlisle Irraging Associates - 10/12/00 and 1/9/00 statements $ 1.05 258.00 75.00 101.00 15.00 50.00 10,420.39 $ 24.48 140.48 6,544.30 $ 138.18 360.52 3.48 68.00 Page 3 $ 10,920.44 2,500.00 6,709.26 DISBURSEMENTS OF PRINCIPAL Estate of Rosie Mathilda Henderson For Period 09/02/00 Through 7/11/01 4/18/01 Joseph V. Brawn, C.P.A. - 2000 federal and state incane tax preparation TOTAL DISBURSEMENTS OF PRINCIPAL $ 75.00 Page 4 $ 645.18 $ 20,774.88 ----------- ----------- DIS1RIBUTIONS OF PRINCIPAL 10 BENEFICIARIES Estate of Rosie Mathilda Henderson For Period 09/02/00 Through 7/11/01 To: David Roy Henderson Allfirst Bank Checking Account #0010294082 1/17/01 Cash $ 5,036.14 To: David Roy Henderson Allfirst Bank Checking Account #0097286427 1/17/01 Cash 3,859.75 To: David Roy Henderson Allfirst Bank MJney Fund Alten1ative Account #0098037951 1/17/01 Cash 5,286.31 To: David Roy Henderson u. S. Series E Bonds 3/28/01 U. S. Series EE Savings Bonds 42 Units 203,268.00 To: David Roy Henderson U. S. Treasury Bills 3/28/01 U. S. Treasury Notes 4 Units 60,000.00 To: David Ray Henderson u. S. Treasury 2000 federal income tax refund 4/18/01 U. S. 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