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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 01 0103
COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
Nelson, H. Blaine 174-05-3465
DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE
DENT
01/20/01 09/28/1905 WITH THE REGISTER OF WILLS
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~ 3. Remainder Return
CHECK r Original Return ~. Supplemental Return (date of death prior to 12-13-82)
APPRO- 4. Umited 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. Utigation Proceeds R.eceived 10. Spousal Poverty Credit(date of death between 0 11. Election to tax under Sec. 9113(A)
12-31-91 and 1-1-95) (Attach 5eh 0)
j'ij1J~1!;M!llttjip__p;AWQQRj)j~~j'ji;,QI!!'.ipj!ltlm;ltA1(jlllfQjjMA'tIQjijP!.ffiPl:mm!!IM;ifl!llfQi
NAME COMPLETE MAILING ADDRESS
COR- Peter J. Ressler, re 3401 North Front Street
RE- FIRM NAME (If Applicable) P.O. Box 5950
SPON
DENT Jlllatte, Evans & W:xxlside Ha=isburg, PA 17110-0950
TELEPHONE NUMBER
(717) 232-5000
112,500.00 OFFICIAL USE ONLY
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2) 239,828.87
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) N::lrle
4. Mortgages & Notes Receivable (Schedule 0) (4) N::lrle
5. Cash, Bank Deposits & Miscellaneous Personal
Property (Schedule E) (5) 48,629.27
6. Jointly Owned Property (Schedule F)
0 Separate Billing Requested (6) N::lrle
RECA-
PITULA- 7. Inter-Vivos Transfers & Miscellaneous
TION Non-Probate Property (Schedule G or L) (7) 394,120.98
8. Total Gross Assets (total Unes 1-7) (8) 795,079.12
9. Funeral Expenses & Administrative Costs (Schedule H)(9) 41,805.93
10. Debts of Decedent, Mortgage Liabilities, & Liens(Schedule I) (10) 16,377.12
11. Total Deduollons (total Lines 9 & 10) (11) 58,183.05
12. Net Value of Estate (Una 8 minus Line 11) (12) 736,896.07
13. Charitable and Governmental Bequests/See 9113 Trusts for which an ejection to tax (13) None
has not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 736,896.07
SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or 'transfers under Sec. 9116(aX1.2) X .0 (15)
TAX 16. Amount of Line 14 taxable at lineal rate 736,896.07 X.o 45 (16) 33,160.32
-
COMPU- 17. Amount of Line 14 taxable atsibling 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) 33,160.32
20. 0 1~!:li~iij~j#NQljwl'\~Qij~l@iAR~M:'jb!1AijQ\$ijP.ji,,*~!ftWl
. . '. . . ......"'M~\i:liW!'\EiT9J\N$Vl1E!%I\U?Ql)Ji;OO1QN$QNffI\G!i2ANtlll"G!'IE"*M!\tB!F..i...'....................
o PA15001
NTF 29755
Copyright 2000 Greatland/Nelco LP- Forms Software Only
Estate of: H. Blaine Nelson
ffiMIIARY OF ALWCATIOOS 'ID BENEFICIARIES
Taxable at lineal rate
Jeanne N. Sunday
Iblores N. Cloyes
Sabrina A. Sunday
Michael Sunday
Stephen S. Sunday
Wendy Brown
Robert W. Brown
183,448.04
323,448.03
60,000.00
60,000.00
60,000.00
25,000.00
25,000.00
736,896.07
21-01-0103
PA REV-1500 EX (6-00)
Page 2
Decedent's Complete Address:
STREET ADDRESS
687 Hamilton Street
CITY I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2, Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
33,160.32
28,000.00
1,473.68
Total Credits (A . B . C)
(2)
29,473.68
3. InteresVPenalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D. E)
4. If Line 2 is greater than line 1 + Una 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 -I- 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) 3,686.64
(SA) 0.00
(5B) 3,686.64
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
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.
Under penalties of perjul)', t 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 re arer has an knowle e.
SIG TURE OF PERSON RESPONSIBLE FOR FILING RET N DATE
)(
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Yes No
~ I
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o
~
DATE
rC 1(, ,_ (1/
ADDRESS
See Schedule attached "-
SIGNA1i)IRE OF PREPAR OTHER THAN REPRESENTATIVE
t1-
ADDRESS
3401 N. Front Street, P.O. Box 5950, Harrisburg, PA 17110-0950
::::::';:::::::::::'::::::::::';'::.:::":::::?;:;:::::';:::";:::;"::::::::::::;,::;:::':::':::::,::':,::,::,.;:;::,,:::,,::::::,:::,::?,:::,.:,.:,.:-.:,,::::,.,'::',:',:',:::',<:>:':":':,),:',::"::':
':'::::":",::'':':":';'::';::',::,:::,:,:::::',;:,,:,;:;,::,;,:;:',:>:':::;',;,,:',;'.:'-,::'.::::;,::,::':::::;::';',;,.;'-:';:';,::<::'::,;:;,:,;:::,):::,;:::,,:;,;::::,,::::,::,;:::;,:::::;,;::,::
::,::::::::;:,,::;:,;,;,::;,,:,:::::,::,,::::::,:';:;';:;:':'::::::;::::::;:;'::::':'::::':;::;:,:,::;:'::::":'::",:::::::',:;:,:,:::::';:::;:::';:::::,::
~:~;::~~~;~:'b:rd;~~:i:~::~;~::'b>~~:i:~/j~:i:/'{:%9;g:~'i~~:~:b:/~'S~~:~;;i'~::f::N~t::i:h::~:'i~~:'~1d:@~:b:~:~:J':g:~\~;~::~:~:i:~~TU'~::6:ni'~~:~~~i;;\b:;:6/nnh:~':U~:~:'~n:k;';~:~~;i;J:=~;~;:~;~
;~:~;~'~::i;;;Mt:::'.
[72 P.S. Ii 9116(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 or for the use of the surviving spouse is 0% [72 P.S. Ii 9118 (a)(1.1) (ii)l.
The statute dn",,, n"t .."",met 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 tile 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. 89116(aX1.2)).
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. 89118(1.2) [72 P.S.!i 9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use 01 the tlecedent's siblings 'IS 12% {72 P.S.!i 9118(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 or adoption.
o PA15DD2
NTF 29756
Copyright 2000 Greatland/Nelco LP- Forms Software Only
Estate of: H. Blaine Nelson
21-01-0103
The followiIlg persan(s) are signing the retum as representative(s) of the estate:
Dolores N. Cloyes
406 Ep\I.Drth Cburt
unit 526
801=, MD 20688
Jeanne N. SUnday
40 s. Middlesex Road
Cll'lisle, PA 17013
REV-1502 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
H. Blaine Nelsan
SCHEDULE A
REAL ESTATE
FILE NUMBER
21-01-0103
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 knowledge of the relevant facts. Real property which Is Jointly-owned with right 01 survivorship must be disclosed on Schedule F.
ITEM
NO.
DESCRIPTION
VALUE AT DATE
OF DEATH
1 687 Hamilton Street, Borough of Carlisle, a.nnberland County, PA;
tax ID #06-20-1800-045. See attached settlerrent sheet dated
05/30/01.
83,500.00
2 Lot on Hamilton Street, Borough of Carlisle, PA, adjoining
decedent's residence. See attached settlerrent sheet dated
08/31/01.
29,000.00
TOTAL (Also enter on line 1, Recanitulabon\ '$
(If more space is needed, insert additional sheets of the same size)
112,500.00
1 CPA21 NIl" 10904
Copyright Forms Software Only, 1997 Nelco, Inc.
REV-1503 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
H. Blaine Nelson
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
21-01-0103
All property Jointly-owned with ~ght 01 survivorship must be disclosed on Schedule F.
ITEM
NO.
DESCRIPTION
VALUE AT DATE
OF DEATH
1 Van Karrpen PA Tax Free Fund B
121,989.92
2 Series HH US Savings Band #X346101HH; face arrount $10,000; issue
date August 1988
3 Series HH US Savings Band #D1947946HH; face arrount $500; issue
date August 1988
10,000.00
500.00
4 Fort Cherry School District lIhmicipal Band
52,218.75
5 West Chester PA Area lIhmicipal Authority Water lIhmicipal Band
41,611.80
6 Tucker Anthony RESI ACCR 9QSlA4 (REMIC)
13,508.40
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
239,828.87
7 CPA31 NI~ 1O'aC~
Copyright Forms Software Only, 1997 Nelco, Inc.
REV-1508 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
H. Blaine Nelson
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21-01-0103
Include proceeds of litigation & date proceeds were received by the estate. All prop. Jointly-owned with r'aht of survlvorshlD must be disclosed on Sch. F.
ITEM
NO. DESCRIPTION
VALUE AT
DATE OF DEATH
1 l'IEllon Bank Premier Checking Acct.
#182-672-6075
43,Oll.32
2 Freedcm Cash Management Fund under 'fucker
Anthony Acct. #DSH-005091-21
3 Household goods and furnishings, sold at
public auction, 03/2001
4 Everett Mutual Insurance Cb. - refund of
haTEowner's insurance premium
426.91
1,032.00
158.00
5 Internal Revenue Service - refund on 2000
personal incare taxes
2,942.00
6 PA Dept. of Revenue - refund of 2000 personal i.ncare taxes
7 Internal Revenue Service - Taxpayer Relief refund
50.00
300.00
8 Refund (source unknown)
34.46
9 Thornwald Hare - refund of nursing bane expenses
674.58
TOTAL (Also enter on line 5, Recapitulation' $
(If more space is needed, insert additional sheets of the same size)
48,629.27
7 CPA81 NTF 1090B
Copyright Forms Software Only. 1997 Nelco, Inc.
REV-1510 EX. (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
H. Blaine Nelson
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
21.-01.-01.03
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF EXCLUSION
ITEM INCLUDE NAME OF THE TRANSFEREE, THEIR DATE OF DEATH DECD'S (IF TAXABLE VALUE
RELATIONSHIP TO DECD & DATE OF TRANSFER.
NO. ATTACH COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST APPLICABLE)
1. Series HH US Savings Band 1.0,000.00 1.00% 1.0,000.00
#X79U44HH; face anount $1.0,000;
issue date May 1.996; roD to
decedent's daughter, Dolores N.
Cloyes
2 Waypoint Bank Certificate of 57,757.1.2 1.00% 57,757.1.2
Deposit #1.761.305451., In Trust Fm"
Dolores Cloyes
Interest an above item accrued as 1.51..1.2
of decedent's death
3 Waypoint Bank Certificate of 57,757.1.2 1.00% 57,757.1.2
Deposit #1.761.305450, In Trust Fbr
Jeanne Sunday
Interest an above item accrued as 1.51..1.2
of decedent's death
4 J\rrerican General Annuity Cbnt:ract 1.61.,71.3.87 1.00% 1.61.,71.3.87
#ClXl00946; beneficiaries were
Jeanne N. Sunday and Dolores N.
Cloyes
5 Jackson National Optimax 4 Annuity, 1.06,590.63 1.00% 1.06,590.63
Policy #0058985440; beneficiaries
were Jeanne N. Sunday and Dolores
N. Cloyes
TOTAL (Also enter on line 7, Recapitulation) $ 394,1.20.98
7 CPAOl
NTF 10910
Copyr"lght Forms Software Only, 1997 Nelco, Inc.
(If more space is needed, insert additional sheets of the same size)
REV-1511EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
H. Blaine Nelson
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
2l-0l-0l03
Debts of decedent must be reported on Schedule I.
ITEM
NO. DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
l Hoffman/Roth Funeral Hare 6,545.00
2 Funeral luncheon l,200.00
3 George's Florist - funeral flcmers 227.90
4 Carlisle Mem:>rial Service - engraving 190.00
ins=iption on headstane
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions 0.00
Name of Personal Representative(s)
Social security Number(s)/EIN No. of Personal Representative(s}
Street Address
City state Zip
Year(s) Commission Paid:
2. Attorney Fees Narre : Matte, Evans & W:Jodsicle 20,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 0.00
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 356.00
5. Accou ntant's Fees 0.00
6. Tax Return Preparer's Fees 0.00
See Schedule attached
'Ibtal fran continuation page (s) l3,287.03
TOTAL (Also enter on IlnB 9, Recapitulation) $ 4l,805.93
(If more space is needed, insert additional sheets of the same size)
7 CPA11 NTF "J911
Copyright Forms Software Only, '997 Nelco, Inc.
FBtate of: H. Blaine Nelson
SCHElXJLE H, PARI' B -- Administrative Cbsts
Item
No. Des=i.ption
7 Om1berland Law JounJal - legal notice
8 The Sentinel - legal notice
9 Net settlerrent expenses inctrrred in the sale of
the residence at 687 Hamilton Street
10 Settlerrent expenses inctrrred in the sale of
the Hamilton Street lot
11 zeigler Cbnstruction - installation of new r=f at decedent's
residence
12 HaltenEI1' s Tree Service - tree renoval and trinming at
decedent's residence
'!OrAL. (Cany forward to main schedule) . . . . . .
Page 2
21-01-0103
AnPtmt
75.00
113.27
6,067.38
2,392.00
3,559.38
1,080.00
13,287.03
REV-1512 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
H. Blaine Nelson
Include unreimbursed medical eXDenses.
ITEM
NO.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
FILE NUMBER
2~-0~-0103
DESCRIPTION
AMOUNT
1 Check #792 written pre-death to Thornwald Nursing Hare but did
not clear decedent's checking account until after death.
4,766.93
2 Check #793 written pre-death to lsaaanan Kem but did not clear
decedent's checking account until after death
3 Check #787 written pre-death to Lakeview but did not clear
decedent's checking account until after death
4 Check #794 written pre-death to NurseFinders but did not clear
decedent's checking account until after death
592.00
4,083.75
990.25
5 Jeanne N. Sunday - reinil::JursenEnt for lawn care and maintenance
services at decedent's residence
1,200.00
6 NurseFinders - nursing services
01/13-01/20/01
496.00
7 Lakeview - hcrre health care aides,
12/25/00-01/18/01
2,963.25
8 lsaaanan Kems - rredical services,
01/13-01/20/01
136.00
9 Dr. Baker - rredical services rendered pre-death
24.83
10 Kathy Wilson, LPN - rredical services rendered pre-death
11 Dr. Albright , Belvedere Medical - rredical services rendered
pre-death
300.00
51.40
~2 PharaIrerica - pres=iption rredicine
187.05
13 PP&L - electric
183.08
14 Carlisle Borough - water
54.57
15 Darlene JVbyer, Tax Cbllector - 2001 Cbunty and Township real
estate taxes
338.11
16 Darlene JVbyer, Tax Cbllector - 2001 per capita tax
9.90
7 CPA12 NTF 10912
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
16,377.12
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
FILE NUMBER
H Blaine Nelson
2l-0l-0l03
RELATIONSHIP TO DECEDENT AMOUNT OR
No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not LIst Trustee(s) SHARE OF ESTATE
I. TAXABLE DISTRIBUTIONS (Include outright spousal distributions)
See Schedule attached
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
TOTAL OF PART 11-- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00
7 CPA13 NTF 10913
(If more space is needed, insert additional sheets of the same size)
Copyright Forms Software Only, 1997 Nelco, Inc.
Estate of: H. Blaine Nelson
SCEEOOLE J, Part 1 -- Taxable Distributions
Item
No.
NaJre and Address of Beneficiary
1 Jeanne N. Sunday
40 S. Middlesex Road
Carlisle, PA 17013
2 Dolores N. Cloyes
406 Epworth Cburt
Unit 526
Solarans, MD 20688
3 Sabrina A. Sunday
40 S. Middlesex Road
Carlisle, PA 17013
4 Michael Sunday
40 S. Middlesex Road
Carlisle, PA 17013
5 Stephen S. Sunday
84 Appalachian ori ve
Carlisle, PA 17013
6 Wendy Brown
21 Sunnywoods Lane
Jackson, N.J 08727
7 Robert W. Brown
1176 Loraine Avenue
Plainfield, N.J 07062
Relationship
Daughter
Daughter
Granddaughter
Grandson
Grandson
Granddaughter
Grandson
.
Page 2
21-01-0103
AnPunt
183,448.04
323,448.03
60,000.00
60,000.00
60,000.00
25,000.00
25,000.00
.
LAST WILL AND TESTAMENT
OF
HAROLD BLAINE NELSON
I, HAROLD BLAINE NELSON, of 687 Hamilton Street, Carlisle,
Cumberland County, State of Pennsylvania, being of sound and disposing mind, memory and
understanding, do hereby make, publish and declare this as and for my Last Will and
Testament, and I hereby revoke all prior Wills and Codicils that I have made.
ARTICLE I
I direct my hereinafter named Executors to pay all of my just debts and
funeral expenses as soon after my death as may be found convenient to do so.
ARTICLE II
I direct that all of my belongings and furnishings shall be divided
equally among my hereinafter named two children as they shall agree.
ARTICLE III
All the rest, residue and remainder of my estate, real, personal an
mixed, and wheresoever the same may be situate, I give, devise and bequeath unto my two
children, their heirs and assigns, share and share alike, the share of any deceased child to
pass to the issue of such deceased child, per stirpes, my two children being as follows:
Jeanne Emma Nelson Sunday, 40 Middlesex Road, Carlisle, Pennsylvania and Dolores Mae
Nelson Cloyes, 38 West 86th Street, Brighton Beach, New Jersey.
'1/. ~,/V
Initials
,
ARTICLE IV
I hereby nominate, constitute and appoint my said daughters, Jeanne
Emma Nelson Sunday and Dolores Mae Nelson Cloyes, as Co-Executors of this my Last
Will and Testament.
No Executor or Executrix of this Will shaH be required to furnish bond
or other security as Executor or Executrix for the faithful performance as my Executor or
Executrix. As used in this Will, the terms "executor" or "executrix" and "executors"
designate the court-appointed fiduciaries or fiduciary of my estate from time to time qualified
and acting in any jurisdiction.
*
*
*
*
*
*
Page 2 of 4
]!).tI
Initials
.
>
IN WITNESS WHEREOF, I, HAROLD BLAINE NELSON, set my
Hand and Seal this I ~ tr. day of A4 i 1<;' -+ , A.D. Two Thousand (2000).
)( (}/I..e../!.J. ~e.-:O! ,",'^~ i~gP'-'"
HAROLD BLAINE NELSON - Testator
(SEAL)
Signed, sealed and declared by HAROLD BLAINE NELSON to be his
Last Will and Testament, in our presence, who in his presence, at his request and in the
presence of each other, sign our names as witnesses the day and year last stated above.
:rID r; fYI. lJc '{ +
residing at I <4(\7 Di'lJ~ /", n,. Cr, r /, aL Pc..
~(j~h ct1~
residin" at -3 f
"
L<-'. <t (, f-t..
51 _ ~ I ~~"'" /.3,L.--&c
( ).., d':
o 9' c/o g
residing at
Page 3 of 4
74./3, 77lli~
lni tials
STATE OF 1~C\..
COUNTY OF Cc.. '" b-'.... \ evv-.d
)
) 55
)
Before me, the subscriber, on this day personally appeared HAROLD BLAINE NELSON,
r:/,Yro.- m.vcrrf , polocrs N. (101;'''
and I , known to me to be e Testator and the
witnesses, respectively, whose names are signed to the attached or foregoing instrument and,
all of these persons being by me first duly sworn, HAROLD BLAINE NELSON, the
Testator, declared to me and to the Witnesses in my presence that the instrument is his Last
Will and he had willingly signed or directed another to sign for him, and that he executed it
as his free and voluntary act for the purposes herein expressed; and each of the witnesses
stated to me, in the presence and hearing of the Testator, that such person signed the Will as...
witness and that to the best of such person's knowledge the Testator was eighteen (18) years
of age or over, of sound mind and under no constraint or undue influence.
'i J fr at.o Aul (ME' R;.c '50\1
HAROLD BLAINE NELSON - Testator
:fC71r:i_ n,. tJ()'j+
Witness:
,f) .J0-4v h
Witness:
()?;<t.-0
/ -
Witness:
Notarial Seal
Rora M. Vogl. Notary Public
North Middleton. Twp.. Cumberland COlJl'\t;y
My Commission Expires May 21. 2001
Member, Penfl.S'/(vama AsSocIatIon of Notaries
Page 4 of 4
#!3;v
Initials
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHAN'S COURT DIVISION
In Re:
ESTATE OF HAROLD BLAINE NELSON,
alkJa H. BLAINE NELSON, Late of the
Borough of Carlisle, Cumberland
County, Pennsylvania, deceased
Estate No. 21-01-0103
DISCLAIMER
I, Jeanne N. Sunday, hereby declare that I am the daughter of Harold Blaine Nelson,
alkJa H. Blaine Nelson (deceased), who died on January 20, 2001. Under the terms of his Last
Will and Testament dated August 18, 2000, which was duly probated with the Cumberland
County Register of Wills Office on January 24, 2001, I am a beneficiary of fifty percent (50%) of
the residual probate estate of my father.
I hereby irrevocably and completely disclaim and refuse to accept the sum of One
Hundred Eighty Thousand Dollars ($180,000.00) from the total amount that I may be entitled to
receive from my fifty percent (50%) interest in the Estate of Harold Blaine Nelson, a/kJa H.
Blaine Nelson, as a result of the decedent's death.
Dated this ~L\~ day of ~
,2001.
Witness:
p
{,cerA
}.
p, A A ...(.01_/
/
r , ~__ CZ:5
G~r:~:~a7c, ..~I
(SEAL)
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ll()JVtb./\L~
5S.
On this d ijtiday of&.p!err>bc r
, 2001, before me, the
undersigned officer, a Notary Public in and for the said county and state, personally appeared
Jeanne N. Sunday, who, being duly sworn according to law, deposes and says that the facts
set forth in the foregoing Disclaimer are true and correct to the best of her knowledge,
information, and belief and that she executed the same as her voluntary act and deed.
cda aJ rX tti'( 0
Notary Public
Notanal Sea\
ilne. L Otto Notary Public
, . Dauphin county
~u~~T~ires S~!.~;..~?O!-
M,....~'>)':':"!;:_..,_.'. ,'C' \:,-'....~::' -.,,,,'
271367
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHAN'S COURT DIVISION
In Re:
ESTATE OF HAROLD BLAINE NELSON,
a/kJa H. BLAINE NELSON, Late of the
Borough of Carlisle, Cumberland
County, Pennsylvania, deceased
Estate No. 21-01-0103
RECEIPT OF DISCLAIMER
The undersigned, being duly sworn according to law, depose and say that they are the
Co-Executors of the Estate of Harold Blaine Nelson, alkJa H. Blaine Nelson, and that on the
date and place as hereinafter set forth, they received the foregoing signed Disclairner from
Jeanne N. Sunday.
Date
q\d-.l\\O\
Place
Signature
fuU,A2c
l?~
i ",-
J
/~-: "., '--';7,0
~\...,::~~~".'-c:.._' -e
(Jeanne N. Sunday, Co-Executor ,7
d.;.j.7'-day Of,--<Yple;;~r.)
SWORN TO AND SUBSCRIBED before me this
2001.
VtwX tJ7:ts
Notary Public
Notarial Seal
Tina L Otto, Notary Public
Susquehanna Twp.. Dauphin County
My Commission Expires Sept. 14, 2002
Mom\1ol,Ptl:Y")II''''''lIS9:X:ilib'1dt_
Date
" .- J, I{ -6 (
Place
~ o-Ia f'1 n-tJ / )" 4-
(
Signature
,A)vlMu ~. tit; ~-IA/
Dolores N. Cloyes, Co-E ecutor
"7 1.'11::- [1 . 1..,)
SWORN TO AND SUBSCRIBED before me this cA - day of <vt-PTEJ;lbl.:;I(.
2001.
\~L
( /2
JLJ r0fj
Public
:271367 _1
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHAN'S COURT DIVISION
In Re:
ESTATE OF HAROLD BLAINE NELSON,
a/k1a H. BLAINE NELSON, Late of the
Borough of Carlisle, Cumberland
County, Pennsylvania, deceased
Estate No. 21-01-0103
DISCLAIMER
I, Dolores N. Cloyes, hereby declare that I am the daughter of Harold Blaine Nelson,
a/k1a H. Blaine Nelson (deceased), who died on January 20, 2001. Under the terms of his Last
Will and Testament dated August 18, 2000, which was duly probated with the Cumberland
County Register of Wills Office on January 24, 2001, I am a beneficiary of fifty percent (50%) of
the residual probate estate of my father.
I hereby irrevocably and completely disclaim and refuse to accept the sum of Fifty
Thousand Dollars ($50,000.00) from the total amount that I may be entitled to receive from my
fifty percent (50%) interest in the Estate of Harold Blaine Nelson, a/k1a H. Blaine Nelson, as a
result of the decedent's death.
Dated this ~if ~ day of ~ f ..Lfvcl-&Y ,2001.
Wit~:
;F~/f~
I;/) ~ M-Vi ),. tfi 'I ~
Dolores N. Cloyes )
(SEAL)
ACKNOWLEDGMENT
STATE OF MARYLAND
COUNTY OF C41-tJE!!T
S8.
OnthiS~aYOf 0t?PTD)Am
, 2001, before me, the
undersigned officer, a Notary Public in and for the said county and state, personally appeared
Dolores N. Cloyes, who, being duly sworn according to law, deposes and says that the facts
set forth in the foregoing Disclaimer are true and correct to the best of her knowledge,
information, and belief and that she executed the same as her voluntary act and deed.
~~fJ 11;111
~ tary Public
271360
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHAN'S COURT DIVISION
In Re:
ESTATE OF HAROLD BLAINE NELSON,
a/kJa H. BLAINE NELSON, Late of the
Borough of Carlisle, Cumberland
County, Pennsylvania, deceased
Estate No. 21-01-0103
RECEIPT OF DISCLAIMER
The undersigned, being duly sworn according to law, depose and say that they are the
Co-Executors of the Estate of Harold Blaine Nelson, alkJa H. Blaine Nelson, and that on the
date and place as hereinafter set forth, they received the foregoing signed Disclaimer from
Dolores N. Cloyes.
(- ~
-It/oJ../ /..Y i
/1
y?-@{
Signature
Date
q\2.l\\O\
Place
~~
- st'
~..--~ ," - ""~. '-~
(J~~nne N. Sunday, Co~!:.x~ or
SWORN TO AND SUBSCRIBED before me this ;;(l;d day OfU~/)jf/Yd:l.&I )
2001.
\j/7Li))9 i0iJ:6
Notary Public
Notarial Seal
TIna L Otto. Notary Public
Susquehanna Twp., Dauphin Counly
My CommissIon Expires Sept. 14, 2002
-m,p"",,)Wia-..:tNliaOOs
Date
"1-;,Z'I-o\
Place
,4 ~() fy, {)'uQ/ 11-1..{.
I
Signature
oJ dJU-4 h, () .ec
Dolores N, Cloyes, C -Executor
SWORN TO AND SUBSCRIBED before me this ,;J,L.j4:-- day of 0EPTEMbI.::---x:'
2001,
:271360 _1
C -
, _ '- ,'J
l i~ 1 C/
A. H.U.D. SETTLEMENT STATEMENT B.LOAN TYPE:
OUR FILE #: RE01-141 #0015465347 LENDER: ERA Mortgage/Secretary of HUD
C.ThiEl form is furnished to qive you a statement of actual settlem.ent costs. Amounts paid
to and by the settlem.ent agent are shown. Items marked P.O.C. were paid. outside closing_
D. NAME OF BORROWER: E. NAME OF SELLER:
Zemir Alic H. Blaine Nelson Estate
Hasiba Alic
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: I. SETTLEMENT DATE:
687 Hamilton Street, Carlisle, PA 17013 DOUGLAS, DOUGLAS & DOUGLAS Wednesday 30-May-01
27 WEST HIGH STREET
Carlisle Borough, Cumberland County CARLISLE, PA. 17013 1:30p.m.
J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION
100 GROSS AMOUN'!' DUE 'ROM BORROWER '00 GROSS AMOUNT DUE TO SELLER
101 Contract Sah~1I Price $83,500.00 '01 Contract Bille. price $83,500.00
102 Personal Property 0.00 '02 PorsonAl Property 0.00
103 Settlement Charges (line 1(00) 4979.27 '03
10' 0.00 '0'
105 Adjustments items prepaid by Beller:
AdjuBtmente items prepaid by Belllllr: .05 LOCAl taxe. <0 31-08<:-01 199.16
10' Local tClxes <0 31-080-01 199.16 ,0' AElBeSament8
107 ABB8BBlfIents <0 '07 School tax".. to JO-Jun-Ol 61.95
lOB School tax.. <0 30-Jun-Ol 61.95 .OB
10' '0'
120 GROSS DUE FROM BORROWER 86740.38 420 GROSS DUE TO SELLER 83761.11
200 AMOUNTS PAID BY OR FOR BORROWER 500 REDUCTIONS ,. AMOUNT DUE TO SELLER
201 Deposit. or Earnolllt Money 2000.00 501 Excess deposit
202 'ew l(';:J1:t9e.'3& Amount; 82845.00 502 settlem&nt chargee 6328.49
203 Existing 10400 taken subject <0 503 Existing loans taken
20. 50. PAyoff '" MortgAge 0.00
205 505
20. 50.
207 507
AdjustmentI' for itellls unpaid by ee11er SOB
2'0 Local Tax.s to 30-May-01 0.00 Acl.juatm8ntll for itlllma unpaid by seller
211 Ae8&aa:mants <0 510 Loca.l 'taxes 30-May-Ol 0.00
212 school Taxe8 to 30-May-Ol 0.00 511 A8S8eamenta <0
215 512 School tAxeD to 30-May-Ol 0.00
216 513
217 51.
220 TOTAL PAID BY BORROi4ER 84845.00 520 TOTAL REDUCTIONS SELLER 6328.49
300 CASH FRON/TO BORROWER .00 CAS" 'I'O/FROM SELLER
30' GrOBS amount due from borrower 88740.38 '01 GrOBS amount to seller 83761.11
'02 LeBs amounts paid by/for borrower 84845.00 '02 Reduction. to jleller 6328.49
303 QAsf.\ Ff\qMIfo)sof\i=lpWef\:........... $3,895.38 60aPASFrQ.(Ff\OMr.S.gllt.iEl'ii>......... $77 ,432.62
I have c~refully reviewed the HUD-l settlement statement and to the best of my knowledge
and belief, it is a true and accurate statement of all receipts and disbursements made on
my account or on my behalf and I have received a copy
Zemir Alic
Hasiba Alic
Pf,GE #2 HUD DISCLOSURE/SETTLEMENT STATEMENT
PAID BY
BORROWER
PAID BY
SELLER
700 TOTAL REAL TOR'S COMMISSION 6% X $83,500.00 5010.00
701 listing Agency: Jack Gaughen Realtor ERA $5010
702 Sellin g Agency:
703 Commission paid at settlement Jack Gaughen Realtor ERA 100.00 100.00
800 ITEMS PAYABLE IN CONNECTION WITH LOAN
801 Origination Fee 0.125% ERA Mortgage 102.03
802 Loan Discount ERA Mortgage/Secretary of HUQ
803 Appraisal Fee Stars 375.00
804 Credit Report First American/Credco 20.50
805 MI Premium Department of HUD 1224.32
806 Document Preparation Fee
807 Inspection fee Stars 100.00
808 Tax Service Fee
809 Flood Certification FOSI/Stars 19.50
810 Ovemight Mail.Charges: GEORGE F. DOUGLAS, III 0.00 0.00
900 ITEMS LENDER REQUIRES TO BE PAID IN ADVANCE
901 Interest @ $H.31/day from 31-May-Ol to 31-May-Ol H.31
902 Mortgage insurance
903 Hazard insurance
904
1000 RESERVES DEPOSITED WITH LENDER
Escrows collected: # mos. due: X $ per mo.:
1001 Hazard insurance 3 16.70 50.10
1002 Mortgage insurance 0 0.00 0.00
1003 County/Local taxes 4 28.18 112.72
1004 School taxes 12 60.78 729.36
1005 Aggregate Adjustment (Initial Escrow Deposit $729.36) -162.82
1100 TITLE CHARGES
1101 Settlement or closing fee:
1102 Abstract or title search:
1103 Transaction Fee: 0.00 0.00
1104 Title insurance binder:
1105 Document preparation:
1106 Notary fees: Notary 8.00
1107 Attorney's fees: 0.00 0.00
(includes above item numbers):
1108 Title Insurance: AGENT FOR FIDELITY NATIONAL TITLE 882.75
(includes above item numbers):1101-1104 Endorsements 1003008.1 $150
1109 Owner's coveraQe $83,500.00 $732.75
1110 Lender's coverage $82,845.00
1111 Insured Closing Letter Fidelity National Title 35.00 0.00
1200 GOVERNMENT RECORDING AND TRANSFER CHARGES 0.00
1201 Deed 0.00 Mortgage 35.50 35.50
1202 Reiease/Satisfaction 0.00 Assignment/Stip 0.00 0.00 0.00
1202 County/Local transfer tax (1 %) 835.00
1203 Pa. State transfer tax (1 %) 835.00
1300 ADDITIONAL SETTLEMENT CHARGES
1301 Radon testing: Penn Pest Inc. 100.00
1302 Pest inspection: Penn Pest Inc. 35.00 0.00
1303 Water/Sewer: Acct.401 -942-01 Carlisie Borough 23.49
1304 Mitigation System for Radon: H.E. Beers Co. $720.00 escrow 360.00 360.00
1400 TOTAL SETTLEM ENT CHARGES: } ..... ...... / ....}. . .}/. ...... 4979.27 6328.49
(also entered on line 103 lor Borrower; line 502 for Seller)
A. US Department of Housing & Urban Development THE INFORMATION CONTAINED IN BLOCKS E,G,H,1 AND LINE 401 IS
IMPORTANT TAX INFORMATION AND 15 BEING FURNISHED TO THE
IRS. IF YOU ARE REQUIRED TO FILE A RETURN, A NEGLIGENCE
SETTLEMENT STATEMENT PENAL TV OR OTHER SANCTION WtLt.. BE IMPQSEO 00 YOU IF THIS
ITEM IS REQUIRED TO BE REPORTED AND THE IRS DETERMINES
THAT IT HAS NOT BEEN REPORTED.
B. Type of Loan
1. FHA 2. FmHA 3. Conv. Un ins. 16. File No: 17. Loan No: I 8. Mortgage Ins Case No:
4. VA 5. Conv. Ins. I I I
C. NOTE: This fonn Is furnished to give you a slatemtlnt 01 actual selllement costs. Amounts paid 10 and by the settlement agent are shown.
Items marked "PoC" were paid outslde the dOsin<;;; they ar~ shown hefa tOll1"ofmmatlona\ purposes and are nollncluded in the tolals.
D. Name and Address of Buyer: E, Name and Address of Seller: F, Name and Address of Lender:
JEANNE N. SUNDAY
DAVID PHAN NGUYEN DOLORES N. CLOYES WAYPOINT BANK
LAP THI NGUYEN Executrices to the Estate of
H. BLAINE NELSON
G. Property Location: H.. Settlement Agent: I. Settlement Date:
'HAROLD S. IRWIN,III
HAMIL TON STREET Place of Settlement: AUGUST 31,2001
CARISLE, PA 17013 35 EAST HIGH STREET
CARliSLE, PA 17013
J. SUMMARY OF BUYER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION:
100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER:
101. Contracl Sales Price 29,000.00 401. Contract Sales Price 29,000.00
102. Persona!f'{Qpe.rty 402. Personal property
103. Selllemenl Charges 10 Borrower (line 1400) 5,614.75 403.
104. Payoff 404.
"105. Pa " 405.
Adjustments for Items paid by SeUer In advance Adjustments for ilems paid b Seller In advance
106. eilyn-own Taxes 406. Ci rrownTaxes
107. County Taxes 407. County Taxes
108. Schoo/Taxes 406. School Taxes
109. Water/Sewer 40 . Water/Sewer
110. 41
111. Construcllon Fund 100,000.00 411.
112. 4'2.
120. GROSS AMOUNT DUE FROM BORROWER 134,614,75 420. GROSS AMOUNT DUE TO SELt.ER 29,000.00
200. AMOUNTS PAID BY OR FOR BORROWER: 500. REDUCTIONS IN AMOUNT DUE SELLE.R:
201. Deposit Of Earnest Mone 1,000.00 501. Excess De sit
202. Principal amount of new Ioan(s) 100,000.00 50 Selllement charges to Setler (line 1400) 2,392.00
203. Existing Ioan(s)laken sub!ect to 50'. Existing Io~n~s) taken subject 10
204. 504. Pa off first mortgage loan
205. 505.
206. 508. Payoff second mortgage loan
207. 50.
20B. 508.
209. 509.
Adjustments for lIems unpaid by Seller Adjus1ments for Items unpaid by Seller
210. CltyITowo Ta)(e5 51t!. C IJown Taxes
211. Coun Taxes 511. Crn" taxes
212. School Taxes 512. School Taxes
213. WaledSewe'l" 513. Water/Sewer
214. 514.
215. 515.
2'6. 516.
217. 517.
218. 518.
219. 519.
220. TOTAL PAID BY/FOR BORROWER 101,000.00 520. TO AL REDUCTIONS FROM SELLER 2,392.00
300. CA.SH Al SETlLEMENT TOIFM BORROWER 600. CASH AT SETTLEMENT TOIFM SELLER 29,000.00
301. Gross amount due from Borrower (tine 120) I 134,614.75 601. Gross amount due 10 SeUer 29,000.00
302. Less amounts paid b !for Borrower (line 220) 101,000.00 602. Less reductions from Seller (tine 5'20) 2,392.00
303. CASH X FROM TO BORROWER 33,614.75 603. CASH FROM , TO SELLER 26,608.00
I have carefully reviewed thiS Selllement Statement and to the best or my knowledge and belief, il is a true and accurate statement 01 all receIpts and
disbursements made on my accoul\t or by me in t"ls ~ransactlol\. I further certify thatl have Il!celved a copy of Ihis HUO-1 Selllement Statement I
direct and aulhorize the Setttement Agent to make the distributions indicated for my account, recogni;!:ing that the Selllement Agent is nol responsible
for the accuracy or validity 01 the isbursement amounts Of the completeness of ch ~s made by ot ers\ Any Interest earn ,on funds deposited with
SeWement Agent hereundet m ,e retained by Sememen\ Agent ) )
{/
j-
BUYER:
BUYER:
the HUD1 Settlement S\alemenl whIch I have prepared IS a true & accurate account ollhe funds which were received and
,lIleme Of' Is transaction. Q'1.....,. "h
<5/..I('~/
HAROLD S. IRWIN, III DATE: '
L. SETTLEMENT CHARGES Page 2 FTPA3-HUD-1 REV. (4/90)
700. TOTAL SALES/BROKER'S COMMISSION: PAID FROM PAID FROM
BASED ON PRICE $29,000.00 @ Flat Rate = $2,000.00 BUYER'S SELLER'S
Division of Commission (line 700) as follows: FUNDS AT FUNDS AT
701. $2,000.00 to JACK GAUGHEN SETTLEMENT SETTLEMENT
702. $ 2,000.00
703. Commission paid at settlement
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Oriaination F ea to
802. Loan Discount 3.250% to WAYPOINT BANK 3,250.00
803. Appraisal Fee to DAVID POTTS
804. Credit Report to
805. Lender's Inspection Fee to WAYPOINT BANK 210.00
806. Mortgage Insurance Application Fee to
807. Document Preparation Fee 10 WAYPOINT BANK 290.00
808. Tax Service Fee to WAYPOINT BANK 75.00
809. Underwriting Fee 10 WAYPOINT BANK 100.00
810. Processina Fee to
811. Flood Inspection Fee 10 WAYP01NT BANK 16.00
812. Overnight Mail Fee to WAYPOINT BANK 16.00
813. Application Fee 10 WAYPOINT BANK ($325.00) POC
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest from to @ / day X days
902. Mortgaoe Insurance Premium for months to
903. Hazard Insurance Premium for months to POC
904.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard Insurance months @ $ per month
1002. Mortgage Insurance months @ $ per month
1003. CityfTown Taxes months @ $ per month
1004. County Taxes months @ $ per month
1005. School Taxes months $ per month
1006. months @ $ per month
1007. Aggregate Adjustment
1100, TITLE CHARGES
1101. Selllement or closing fee to
1102. Abstract or title search to
1103. Title examination to
1104. Title insurance binder to
1105. Document preparation to
1106. Nolary fee to CASH 10.00 2.00
1107. Allorney's Fee to
(includes item numbers: )
1108. Title Insurance to PENN ATTORNEYS TITLE INSURANCE COMPANY 1,158.75
(includes item nos.: 1101,1103,1104,1105,1107,1108,1109,1110,1112)
1109. lender's coverage $100,000.00
1110. Owner's coverage $
1111. Domestic Relations Lien Search
1112. Overnight Mail Charges 20.00
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recordinq fees: Deed $27.50 Mortgaoe $51.50 Other $ 79.00
1202. Local transfer tax/stamps: Deed $290.00 290.00
1203. Slale Iransfer lax/stamps: Deed $ 290.00 290.00
1204.
1205.
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Pest Inspection
1302. Final Water Bill to
1303. EXTRA TRANSACTION FEE CHARGED BY JACK GAUGHEN 100.00 100.00
1304.
1305.
1306.
'\400. TOTAL SETT1-EMENT CHARGES (enter on lines 103, Sec. J and 502, Sec. K) 5,614.75 2,392.00
$O~-"''''''TOONOf liElU~.S TUP"YEN IOEN"r";UOON "UM.t~: SEUER '5 ~tOU'REO Vl........TOPROV'ot THE liETT MEO'll ..."tNT ....'TH "'SfMER CORRECT T...~p...vtR'oeNTIF'(;jI,Tl N......~E ,r'HECORRECT
TUP"'YER 1OI:/lTIFlc,o,TlQNNIJ".ER IS NOT PROV'DEo. snlER .....Y.E Sua.eCT TO CM\- O~ Cfll"'lt/.O.l PEN"'lTIf$ "'POSEDIlY\.AW, ITE'" E.. WHICti~"'INS ,"'s .....ORW.TION SHOUlo M o<ECKEO
fOR
"'CCURAI;Y. UOIOER PE.....lTIES Of pEIUURY., CnlTl'YTHU THe T.I.N. SHOWNINTHIS ST"'TEMT<NlIS ,,"y CO!>!\EC~ H.l<P,o,'Il:R\OE"'T\fIC"tlONK\l>.>BE1'l
-TUCKER ANTHONY
__~=-_ MID~ATI-ANTrC DIVISION
March 13,2001
95 Altxander Spring ROild
Carlisle, PA 170]3
Phone 717.'24-1.3055
Mette, Evans & Woodside
3401 North Front Street
PO Box 5850
Harrisburg, P A 17110-0950
RE: Estate of Harold Blaine Nelson
Dear Lisa:
Listed below are the dates of death value for the above-mentioned estate:
Prices for January 19, 2001
40,000
Ft. Chmy P A SID RO
AO 6.15% 10/10/2012 $104.448
Freedom Cash Money Market $1.00
RESI ACCR 9QS lA4 RG
MP 6.50% 01125/2029
Van Kampen PA Tax Free
Fund B
West Chester PA AR RO
AO 5.90% 10/10/2005
Prices for January 22, 2001
$52,224.00
$426.91
50,000
426.91
15,000
$90.286
$13,542.90
$122,132.35
7,121.420
$17.15
$104.039
$41,615.60
50,000 Ft. Cherry P A SID RO
AO 6.15% 10/0112012 $104.427 $52,213.50
426.91 Freedom Cash Money Market $1.00 $426.91
15,000 RESl ACCR 9QSIA4RG
MP 6.50% 01125/2029 $89.826 $13,473.90
7,121.420 Van Kampen PA Tax Free
Fund B $17.11 $121,847.50
40,000 West Chester PA AR RO
AO 5.90% 10/0112005 104.020 $41,608.00
If 1 can be of further assistance, please let me know.
Sincerely,
/.r:/' ,,/'-_.~---'- ::-
. / /7\
{cL~~-.._
George A. Sneed
Senior Vice President
~: \l: _~-'~ I" . -- : , _!..):t:--'-~
'!l~twmE~~!lH~Qij~~mJ]f1.UfJ..~
ATTtlE MATURITY tlEREOFWIL.l. 'AV
~r~lt~~~nM'Ri$1
174~05-3465 c08028
H. 8LAINE NELSON nw::xc
687 H~MILTON ST.
C~RLlSU. PA. 17013
tI,,t,E K. t,F:LSON
8.571.'';3
ACCRlI€OINTERESTOfS ON SAVINGS 801111SlS",VINGS 1I0TES e1-t)l"IIGEP
~OR TIllS BONO AND INtlUllED IN!TS IUUE~KltE \S UlllllABU. fOR feDERAL INCOME TAX PllRPtlSU,
tOl\lIlE'rEAROtREOEr.ll'TlON.OISPOSI1IONDRf 1'I't1fnnSBONO.WtlICHEVERISEAIlLlEIl,
SERIES HH
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'ilHrE\ m:Ir:rrn.:'D\$m.>A.~lllSj t"iJ1lil'A.i.;UIER-3\~. .
';.j;~_ _~~Ji~-;,;,.r.':;:;;;,1_~. "~_____~
AT. THE .....tu~rt'fl1ERt;OI'Wn..l.'A,y .
l\t~\j!illH\~12~E~)~'@:r~~'y~.' .
171t-05-3465" . .. . E08028
H~ BLAINE NELSON INDEXC
687 HAMILTON $T.
C.AHLl SU:, PA. 17013
I~
[i
I'.
I\.
"
I~,
ii OR liAr: K. NELSON
U; '" , " AtCi\\JH.lIl1fIlES1 Of t ~ 28. ~~AVI"'GSBll"])SISAVfNIl.lYD"TnfXCHANGrD
~ ""\st " fOA tillS ~'JM\ Jl,IlC IlltlllDlD m ITS ISSUE PAICr AHORTA81f FDA fEDERAL lIlC'JME 10\.)( P\Ji\POSU
;t fOllTHE'I'EAllOf llEOEMrn(l!-1 OlSl'IlSll11l1l0 TYOfTHI~80NO WHICHEVI;A IS UflLlli\
< SERIES HH '"...::::;;;":~,"~,,,W ;:b~:~'"' ~
W,'- "".."...,0<,..'......,.. &,_oI....~
~\ .~"L.""'"'''~'''!~.~..:;"'~~<>:l~~~,''''~_~I~=::......~...=~''''lo";::-;iIlM>lU1.~<~..._.,~,NO ,~.~.~'~ rtU'
ISSUE. DATE
Wl"\\CI-\ j-;, 11;[ FlfI,ST DAr Dr
-..,A1JG.""_,,ns
I"'ON'T"'I~ _ _..' ~...rtJtI
, FRS PHlL
FrS CS"'l\'3'l""'IiS "
st P J.,:i ST.J. ns
, '
x-a XO~045"fC?f1H'~
ISSUE DATE
'WHICH:lsTHE.nflsiDAy-or
, FRa PHIL
HSc:-AIi*..,US" i
StP 13 19813 i
O,o.T,NG ..".........: I
o -m '4~'9 4'~' HH ~
...._".....",.,,,""',,,2~
UNITED STATES SAVINGS BOND-SERIES HH (EXCHANGE)
Not Transferable PAYMENT INFORMATION
REQUeST FOR PAYMENT Thi~ tlGII1l. i$UI!ll in exchang. lor olliff savings bonlil/~in~ nntlJS.. ml'i n. 1\C"ll'r\'ll AT T'AR al any lime
I AM THE OWNER OF THIS BONO, AND HEREBY REQUEST PAYMENT. .ntl Sill mtlfl1h1 from in lUlle date, upon pr~entlltion. wilh a duly ti~neo:! and urtifitllllquuttor payment, to I
FIliI\''' R.~M Bank Of Branch or thl Bueuu of th. Public Cebt, l'irkmbufg. Wn'l Virgin;. 26101. T~! ,ff!limrtd
GYlr.fl 1)1 eithlll' CQOWf)I' must first IPpqrbelortlnlutllcrll.adtlrtilvingr;flictf, Inll~ $1\ h11 or III i; mtity in
u.cllfllanu wil'n authorized Trmury guid.lines, and lfllet 1M f'lIllln btlort the officer, WilD ~1lS1 Co,n:PI.tt .nel
nlilllll the urtification. TIl, bond t/Jould tilt" b'1ubmlttt4 to 11M of II" Ildlm;tt"n ar'I'ICI1.I1pfClfled abovt.
~uthoriua ,.nilying olfictn include officill, Ind d~ted tmlllo'fW o1l1VinllS b\...1... paY'~09 ag.nts. ,
It ,,"emption is r'lluutHl during th. mQflm Ilfeeedil'l9 tilt iflttlut piyment Ilatt, the bOlld ~In nol ~I
rednm.d until fb.t dati. If thl bonl! is rldlemad u 0').1 I ~htl "the!' thin .n interest payment date, Il'lurest Will
UUIIJ 01 the prKedlng tntenn payment dltl.
SIGN IN INK IN PRESE""CE OF CERTJFY"INGOfF\GER
lNUMB.EAJ
MAIl.. AOORE.S.S.I'"OP. CEUV",-R'r' OF CHECK
(STREET)
(CliYI
(STATE)
(ZIPCOOE\
CERTIFICATION
\ "S,fi1\Ff THAT THE ABOVE.NAMEiJ PERSON, WHOSE IOENitTY IS WEll-KNOWN TO
M~ D1\ HAS &EEN POSITIVELY ESTA8LISHED, SIGNEO THE A8iJVE REOUeST IN MY
PRESENCE ON
OA TE. 01' R€.QutST
GFflCIAlSEAL
SIGNATURE OF OFFICER
OR
'JAlI'Ot.iltHi SiAM,.
TITL..E OF Ofl"ICE.R
FOR CERTIFYING OfFICER
NCltebelowlh'identifitatiOlll.l~libvt\'\'p"uennf.
(Se-t MUfhcd~~ T'MJI~U'Y fI'Iid./in<osJ
.. OtlCumefltllrvillentitical'IOn lDucription and datel
.. Account idelltiHca{iGII\N(l,tll\llllat"st~olisnedl
. Personally identified by lNam~, addc~ and si'1.IIi\llIt\
SIGNATUF\t::: QF \OE.N;\I'IEA
REQUEST FOR PAYMENT
I AM THE OWNER OF THIS BONO, AND H~REe'{ REQUEST PAYMENT.
UNITED STATES SAVINGS BOND-SERIES HH
Not Transferable
SIGN IN INK IN PRESENCE OF CERTifYING OfFICER
(NUMBER)
MAIL ADDReSS fOR OELNEl'IY OF CHeCK (STREET)
lCl'l"'fl
(STATE)
(ZlF'CO~\
CERTIFICATION
1 CERtlFY THAT THE MOVE.NAMED PERSON, WHOSE IDENTITY IS WEll.KNOWN TO
ME OR HAS BEEN. POSIT\\IEI.'1 ESTA8l1SHED, SIGNED THE MOVE REQUEST IN MY
F'RESENCEDN
DATe OF REOUEST
OFFICIAL SEA~
SIGNATURE OF OFFICER
"
.
VALIDATING STAMP
TITLE OF OFFICER
"l"EP.MS AND CONor IONS
Thh oond il iuuad punulllt to D8part.
m'nl of lh, TrelUury Ciri tar, Public Debt
Serin No; 2.80, whit" conlllills lullllartic.
ulan ~oncerning Ihe offering, illclllllfnq
in,,'utmenl yield {inurtstJ ,nlprl'llltion. Till
bonrl illubject to tll. re_rms.nd conditioll:1
sellonh in t/lat Circular, ndjntheqov,rning
ceglllilrionl, Oepar1mlnf 01 th, TrelUutlf
CifL"lar. Public Debt Seri~ No. 3.8t" Bot/l.
circulmrnay bl oblainedfrom. l~a1
AIIUrvf I!en~ DC BrJndl oc the Bureau of
the PubliC Debl. Pickel'$burq, We~ Vif~inia
26101. THE aONP IS NOT Tf\ANS.
I'EAAi!Lf and rrIil~ nOI bl \lUll! at clli-
lateral.
PAYMENT INFOFlMAnoN
This \:mnd may bt redetmed at any ~me attec six l1lQl\tns trom ~ issue oale uplln presanlalioo. with a Oldy $igc;ea
aOOtertiflwreqUIl5IIOcJl3Yl1lent,loaFedetalRes.tiveBankor8ranchorllleBufeauotlhePubIicOebt,Par~,
VltSI Virginia 26106-1328. Thete\JStefeGC'NlltftfellhlltcOOWtll(must fll'St appear baloct all aut!lGfim Ctlt ~ng
otlicer,whomustcoi'lJ;lleteatlClwtklalethecertllitalion.Thebona'shoula'thenbesubmi~toQl\tcltheredt!rripUDrl
agetlr;iessp.ecllietlabovt.A\lllulli2elleerJilyingofllcersintlua'eomcralSand~ttdtll'olllCJeSotsavKt9sbOl'l.paying
agantt. The bond w\II be redeemed lIpoI1 presenlalion wilhoul regard tolntsftsl payment cale, unitsS tile bOildo'M1e,
specffically requests, in writing, to delay Sl.d1 transac.tiQtIs lJ\t~ Ihe lmetm payment dale. Paying ag/lnlS will not l\Qmr
requastslowil11hoJo't!dtmptionilreceivedll\llle.tt'larIllnemonlhbeloceanlnleceslpaymooldale.lflhebcndis.~
on a dale other than an inwest payment tliil8, interest w~1 etas! as of !he preceding interest paymel'ot dale
FOR CERTIFYING OFFICER
Note below lhe idenWical!onusttl~ lIlepctSenler_
(Sl:a authotizSd TI"$8Sl6y guA1elinp~
. OOCllmen\aIY illenlirlcation {Descciplion alld date\
. ACCOl!ntidef\tilic~litlnINo. ard dalt established)
. Personally idMli~e(j by (Name, adtlfesS and signalurs)
SIGNAtURE OF lCEw1lFlER
TERMS ANO CONDITlOHS
This band is issuecl p.-'suanl I- Olljlat1mt 1
of the Treasury Circular., uf::IlIc.Q;..Jt Series t.~
2.80.whichCOlltain.slultpartil:llldl~toneeming
!tie of{erifl9,incWl'IIkNes~t yielr3(inleresl}
informaUan.Thebondissubjacllolheterms
ana: <:<<lditmns ~et loll inlhal CiccUlar and in
thlgtWemin1lregulaftnns,Depactmenrofllle
Ttl!Uury Clcwar, Publit Der.eeriesNo.3.80
as h,>>yas it herein selfonl"BlllhCicC!Jlats
may be Qbtailltll tram a Federal Re.wlle. 811ll
or8ranehocthe 8ureauof \he; Putl!icQebt
Parkersb~g, Wesl Vicginia 21jIQIi.132e. This
bondisnottransfnt!le.;m 1I1~1l beu,seo
ascohlafffi
~ Mellon Bank
Monday, May 14, 2001
Account
Number Account Title
182-672-6075
H Blaine Nelson
Date Opened: 02/02/2001
Principal Ba! !nt from Last
as of DOD Posting to DOD
$43,011.32 $0.00
Account Type: DO
Account Ba! YTD !nt to
as of DOD DOD
$43,011.32 $101.37
Page 2 of 2
,I
ROWE'S AUCTION SERVICE (RR 79L)
Bill Rowe (AU 1538L)
Ben Rowe (AU 1092L)
2505 Ritner Highway . Carlisle, PA
249-2677 697-4794 249-1978
Bob Rowe (AU 2276L:
Dave Rowe (AU 22951
,
'""
''i"~*'
Auction Is Action Call "Rowe" For Satisfaction
SELLERS NAME !};.
<::/'.
;
LI
ADDRESS
OTHER
.{~~rY0: ~>l~~._~-h
\ I . (:l --.-" .
, "" (<. ",-, ,\, q ,/I '(J
41...
) 5., 1V1,.o..lllr>~>,;'>l. ill!)
}
(; , ,C".;-' T, tlt1/1/1/1{
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'.'- .
AuC'I'lON DATE/LOCATION
_ h~s-
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,-
-:';'I711/,/t'\..
1.:l.>A:b
/),~" .11--
I"~
/2...., ,,, ~ ';r .-;"
DESCRIPTION OF MERCHANDISE
V\I\_! (' Ii_~j 1.~ ...... vn
t.,.I,_.~.t (~t I Jt'\r)....-(JI rA F, A/n_) -;"6 fr--
~ ~._~/ .(\ "". t, L. j) /1'~
,) ,- : I' (~~ / ,.'/' 0::
j t''::.. t.:' (00;..<:
1\ 1./11 k
VtH\ck<..
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l",_ /1 i) I')/).."g,
tJ (J...rJ ("" <;" rc. /L.
--7'~
'v
DATE rF,'<.A 7.. ~, '" \
PHONE ;;7. ({ 1 - "( -7 "r L,
AUCTIONEER % :::z- 'S
dJ~K ~/" 10
/' ~",,/
~/...
(c), 1 ' 1,1" ',J i', ,/11".
F ('.Ph ";2. '" /1....
I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction, Merchandise
to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen.
tative of the merchandise. goods and or property and have good title and the right to sell and that they are free
from all incumbrances, I agree to accept all responsibility for providing merchantable title and for delivery of
title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in
this a eement. () .. /'_ / /
_~--.J-'_~___'
NATURE ,"- /
/
/
SELLERS SIGNATq,ItE
~/0-~7.'~
Total Sales (Clerking Tickets Attached) $
_~f?
'/'1b.~v
Less Sale Expense:
f
,'1!, _, "
~1- ~ /' ~7 ''i
III
} t'
% Commission Auctioneer $
% Commission_~I~'t'K'~~l~
$
~,.tU-\-r 7r-D
OTHER:
TOTAL SALE EXPENSE DEDUCTED $
SELLERS NET-$
.- ~_.)' .) ,-
c,.c__ _ (, /
. , .>- - . ,,; (:"7<'--<'7 ._'
A TTfTlflN SHiN A 'T'TT RB
~~
..ry~-
, I D3')' cO
SELLERS SIGNATURE
/
-"
DEFERRED INTEREST $
. '.",w:ot, _- ~ Ill: _- _-~ t.
~!rnlm~g)~~mr~
':I\I;l\I;:~\iq;;iiiwlil;';'flSl
7;;
174':05-3465
HBLAINE NELSON
687-HAIIILTON;ST_
CARLISLE, PA 17013
: . , ~,' "i '!: ;
INTe:It!:IT C!:A'!S 20 Yt;A"S
FItO'" ISSUE DATE OF
05 I 11996
,. ,r", ," n f'\
1 '~. "Ii~''rt:~\~i'
00791144
POD DOLORES NCLOTES
8,176.80
Xl911ttttHH
00414096143143 I. 7
~~2....~
gB00007"lI.I.I.I.II'
.... .-- .., - ..-. --.... .-
.
; .
,-
\
/
"----'
~
.
VI Way~qiraKt
LOOK FOR US. WE'LL GET YOU THERE.
FEBRUARY 16, 2001
METTE EVANS & WOODSIDE
3401 N FRONT ST
HARRISBURG PA 17110
The information which you requested on the H BLAINE NELSON DECEASED
(Social Security Number 174-05-3465) is as follows.
Account Number(s) 1761305450 1761305451
Class of Account CERTIFICATE CERTIFICATE
Date Opened 012297 012297
Princi pal Balance 57757.12 57757.12
Accrueu Interest 151.12 151.12
Balance at Date of Death 57908.24 57908.24
Account Ownership TRU TRU
Name of Joint Owner, if any JEANNE SUNDAY DOLORES CLOVES
Date Ownership Was Established 012297 012297
Additional1nformation Requested PLEASE COMPLETE W-9
srY':I .
~::;:'y~ 1fP,
Senioc E'el:vices REp.
P.O. Box 17\ I. HARRISBURG. PENNSYLVANIA 17105-1711
Toll Free 1-866-WAVPOINT (1-866-929-7646) . www.waypointbank.com
Decedent-Insured (fo be filed by the executor with Form 706, United States Estate (and Generation.Skipping Transfer) Tax Relurn,.Cl(
Form i06.NA. United States Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States.)
, Decedent's first name and middle initial 2 Decedent's last name 3 Decedent's social security number 4 Date of death
H. Blaine Nelson [Ii known) 174-05-3465 1- 20- 2001
5 Name and address of insurance company
AMERICAN GENERAL ANNUITY LIFE INSURANCE COMPANY-P.O. BOX 871-AMARILLO, TX 79105-081
6 Type of polic;:y . 7 Policy number
Non Quallfled Tax Deferred Annuity
8 Owner's name. If decedent is not owner. 9 Date issu-ad
attach copy of application.
Fo<m 712
(Rev. May 2000)
Depil/"vnent or lhe Treasury
InleTnalRe-~SU'l\ce
Life Insurance Statement
CD000946
7-7-1997
10 Assignor's name. Attach copy of
assignment.
12
Value of the policy at the
time of asstgnment
13 Amount of premium (see instructions)
$159,085.08
14 Name of beneficiaries
Jeanne N. Sunday & Dolores N. Cloyes
15 Face amount or policy
16 Indemnity benefits
17 Additional insurance
1 B Other benefits. . .
19 Principal of any indebtedness to the company that is deductible in determining net proceeds
20 Interest on indebtedness (line 19) accrued to date of death.
21 Amount or accumulated dividends
22 Amount of post.mortem dividends.
23 Amount Of returned premium
24 Amount of proceeds if payable in one sum
25 Value of proceeds as of date of death (If not payable in one sum)
26 Policy provisions concerning deferred payments or installments.
Note: If Olher than lump-sum seWement is authorized fo( a surviving spouse, aaach a copy of the
insurance policy.
..........,......,.............,............,',....................................,...................................
.............-.........................................................................................................
27 Amount of installments .... . . . . . . . . . . . . . . . . . . . .
28 Date of birth, sex. and name of any person the duration of whose life may measure the number of payments.
.......................................................................................................................
.....................................................u................................................................
29 Amount applied by the insurance company as a single premium representing the purchase of
installment benefits. . . . . . . . . . . . . . . . . . . '. . . . .
30 Basis (mortality table and rate of interest) .used by insurer in valuing installment benefits.
OMS No, 1545.0022
11 Date assigned
15 S -0-
16 S ~O-"
17 $ -0-
18 $ .0-
19 S .0-
20 S -0-
21 S -0-
22 $ -0-
23 S -0-
24 S 16 71 .8
25 s .0-
II
-0.
.
-0-
........................................................................................................................................................
31 Were there any transfers of the policy within the three years prior to the death of the decedent? . . 0 Yes 0 No
32 Date of assignment or transrer: I I
Month Da)' Year
33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? . 0 Yes 0 No
34 Did the decedent nave any incidents of ownership on any policies on nislne, life. but not owned by
nlm/her at the date of death? . . . . . . . . . . _ . . . . . . . . . . . 0 Yes 0 No
35 Names of companies with which decedent carried other poflcies and amount 01 such pondes if this information is disclosed by your records.
: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::V~~~~~~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
ance company lor appropriate Federal agency or retirement system officiaO hereby certifies that this statement sets
Tode ~ Vice President
Cat. No. l0170V
Signature ~
<
Date of Certification ~ 6- 5- 2001
Form 712 (Rev. S.2,,\/0)
~
Form 712
(Rev. May 2000)
Department of the Treasury
lntemal Revenue Service
Decedent -Insured {To be filed by the executor with Form 706, United States Estate {and Generation-Skipping Transfer) Tax Return, or
Form 706 ~ NA, United Slates Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United Stales.)
Life Insurance Statement
OMS No 1545-0022
H. BLAINE
NELSON
3 Decedent's social security number 4 Date of death
(ifknown) 174-05-3465 1{20/01
Decedent's first name and middle initial
2 Decedent's last name
5 Name and address of insurance company
JACKSON NATIONAL LIFE INSURANCE COMPANY 1 CORPORATE WAY LANSING, MI 48951
6 Type of policy 7 Policy number
SPOA
005B9B5440
8
Owner's name. (f decendent is not owner, attach copy of
application.
9 Date issued
10 Assignor's name. Attach copy of
assignment.
11 Date assigned
NELSON, H BLAINE 1{16{97
12 Value of the policy at the 13 Amount of premium (see instructions 14
time of assignment $37,143.87 ANNUAL
Name of beneficiaries
SUNDAY, JEA.NNE N CLOYES, DOLORES N
29 Amount applied by the insurance company as a single premium representing the purchase of
installment benefits
15 $ 106,590.63
16 $
17 $ 0.00
18 $
19 $ 0.00
20 $ 0.00
21 $
22 $
23 $ 0.00
24 $ 106,590.63
$
.
0.00
.
15 Face amount of polic
16 Indemnity benefit
17 Additional insuranc
18 Other benefit
19 Principle of any indebtedness to the company that is deductible in determining net proce ~oa1'J Pr(nciple
20 Interest on indebtedness (line 19) accrued to date of deat . Loa(llnt.eres~
21 Amount of accumulated dividends
22 Amount of post.mortem dividends
23 Amount of returned premium
24 Amount of proceeds jf payable in one sum
25 Value of proceeds as of date of death (if not payable in one sum)
26 Policy provisions concerning deferred payments or installments.
Note: If other than lump-sum settlement is authorized for a surviving spouse, please attach a copy of the
insurance policy.
27 Amount of installment
28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments.
30 Basis (mortality table and rate of interest) used by insurer 'In valL/lng installment benefits.
31 Were there any transfers of the policy within the three years prior to the death of the decedent?
DYes
~ No
32 Date of assignment or transfer:
/
Month Day Year
33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company?
34 Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by
him/her at the date of death?
DYes
~ No
DYes
~ No
35 Names of companies with which decendent carried other policies and amount of such policies if this information is disclosed by your records.
The undersigned officer of the above-named insurance company (or appropriate Federal agency or retirement system official) hereby certifies that this statement sets forth
true and correct information.
~~/
..-/
VICE PRESIDENT
Title ..
May 20, 2001
Date of Certification ..
Signature ..
Cat. No. 10170V
Form 712 (Rev. 5-2000)
Oct 03 01 p1:5~p
Hof'f'man Roth
7172433723 .
p.1
Hoffman-Roth Funeral Home, Inc.
219 North Hanover Street
Carlisle, P A 17013
(717)243-4511
October 3, 2001
Dolores Cloyes
406 Epworth Ct, Unit 526
Solomons, MD 20688
ATTENTION:
LISA KNODE
The Funeral Service for H, Blaine Nelson
13419-22
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can, Please
feel free to contact us if you have any questions in regard to this statement.
THE fOLLOWING IS AN ITEMIZED STATEMENT OF TIiE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT.
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS,
(Al OUR SERVICE:
SERVICES OF FUNERAL DIRECTOR&STAFF,EQUIPMENT&FACILlTIES ,
FUNERAL HOME SeRVICE CHARGES . . . . . . . ,
$3390.00
53390.00
SELECTED MERCHANDISE:
Sandhursr Casket. . . . . . . . . . . . . . . . . . . . . .
MontlceHo Intenncnt Receptacle. . . . . . . . . . . . . . . . .
THE COST OF OUR SERVICES, EQUIPMENT. AND MERCHANDISE
THATYOUHAVIlSELECTED , . . . , , . . . , , . , .
$1570,00
$9BO,00
55940.00
CASH ADVANCES
Opening Grave, . . . . . . .
Certified Copies of D~th Certificates .
Organist. . . . . . . . . .
$500.00
$30,00
$75,00
TOTAL CASH ADVANCES AND SPECIAL CHARGES.
5605.00
CONTRAC.T PRICE
$6545.00
HISTORY
021161100 I Estate.
$-6545,00
TOTAL AMOUNT DUE.
$0.00
ThiS statement is net and payable in full within 30 days of receipt.
......................... ........................................... ---.... - -.... -...... ...... -...... -.............. -........
Please return this portion with your Remittance
$
Amount Enclosed
Service 10 # 13419-22
H. Bla~ne Nelson
Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of
Harold Blaine Nelson
No.
21-01-103
also known as
H. Blaine Nelson
, Deceased
Social Security No. 174-05-3465
Petrtioner(s), who isJare 18 years of age orok:ler, appty(ies) for:
(COMPLETE "A" OR "B" BELOW:)
~
A. Probate and Grant of Letters and aver that Petitioners are the executors_named in the Last Will of the
Decedent, dated Auqust 18, 2000 and codicil(s) dated
State relevant circumstances, e.g., renunclation. 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:
c;a B. Grant of Letters of Administration
(c.t.a.. d.b.n.c.t.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
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland
at 687 Hamilton Street, Carlisle. PA
(list street, number and municipality)
County, Pennsylvania, with his/her last family or principal residence
Decedent, thenJ!L years of age. died January 20.2001, at
( Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PAl AI! 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 ........................................................... $
Total ........................................................................... $
Real Estate situated as follows: 687 Hamilton Street. Carlisle. PA
f~ S"G! d 00
.
-i- If;)('l 0
'3-<. 1'7c;) D
Wherefore. Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters in the
appropriate form to the undersigned:
/' _-:.-~~
Signature
Typed or printed name and residence
--:fe a ..-'Y\
tZ/YJ/nr+. IVI'ft...so J S'u f<./~
Lo
/6' - c26...s--~
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner(s) above-named swear(s) and 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 and affirmed and subscribed ~ ~ 4"'t <~ ~~- . ~_
before me this 24th day of L
JANUARY 2001. ,4)0." 1./ ~tl-' Vd's...." CO~O r~ ./
~LY (l >ji<.~~~)/2ej ~~y
DECREE OF REGISTER
Deceased No. 21-01-103
Estate of
Harold Blaine Nelson
H. Blaine Nelson
also known as
Social Security No: 174-05-3465
Date of Death:
January 20. 2001
AND NOW, JANUARY 24 ,2001, in consideration of the Petition on the reverse side
hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters .HlTestamentary D of Administration
(c.t.a.; d.b.n.c.t.: pendente lite; durante absentia; durante minoritate)
are hereby granted to Jeanne N. Sunday and Dolores N. Cloves
JEANNE EMMA NELSON SUNDAY and DOLORES MAE NELSON CLOYES
in the above estate and that the instrument(s), if any, dated Auqust 28. Z-QOO . . ..
described in the Petition be admitted to probate and filed of record as the laSfWiII o'f:Decedent.
FEES
Letters.......................... .
Short Certificate(s)..........
Renunciation................. .
Affidavit ( ).................
Extra Pages ( )............
Codicil....................... ....
JCP Fee........................
Inventory & Tax Forms...
Other.............. .... ..........
TOTAL................
~Jr-l Page2of2
$ 305.00
7/<(r? !t:,u7'n~ )~k/
egister of Wills: I
..~
$ 12.00
$
$
$ 9.00
$
$ 5.00
$
$
......
Attorney:
1.0. No:
Address:
Peter J. Ressler
06844
3401 North Front Street
Harrisburg, PA 17110-0950
717-232-5000
JANUARY 24, 2001
$ 331. 00
Telephone:
DATE FILED:
w"".",
rr:\" n/<::(
This is to certify that the information here given is correctly copied fron: an original certitlcate of death dul~ tiled with
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent ftlll1g.
me as
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
",01111111"",1'",...-,
...,,~ ~\.\\\ OF PE;;---...
.\\~'\,.~ 'f-t ""
l~' . ~~
f~_- ~\
~ ~.,~. . Y'~
~ ~ - .. - ~~
...c:::a -# _ -...
~ c...)\ ,f~J', . i:b~
..*~...'.......,/*~
;.a..... /~~
\.~ ~.l
- :.t,o~ ~\.y..\\
"'>"'>.--;tMENT \)~ """"
""'"#,,,#,,1111""
~~. ~~~~'b.~
Local Registrar
fee for this certificate, $2.00
P 6947988
JAN 2 4 2001
Dare
21-01-103
H105. ~4.3 A..... 2187
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
'"1
'.N"
'K
NAME Of OECEOENf (ForSl. t.4.dc:.e,l_l
SEX
STATE FilE NUMB[A
SOCIAL. SECURITV NUMBER
95 Y...
PlXE ~ DEATH fCl'\eock Of'ly Of'e -- ..,;ee ,nSlfUC!oOO9 on ort'oef .,.,
HOsPtTAt..
I.t-.. 0 ER/OUCp.IIli.". 0
...
FACILlT'I' NAME (If I"IOt IO$f<fUtlOf1. gwe Slreet andnt.lmber.
81RTHPLACf ie,ty and
Stale or Fete.qnCOtJtllfvt
=",,0
I. H. Blaine Nelson
AGE (last BII'1NJ8'f1 uNOER' '1EAA
_ o.ys
2. Male
3. 174
05 -
January 20, 2001
~.\
Blain, PA
COUNTY OF QEJlIH
. .. CUmberland
DECeDENT'S USUAL OCCUP~IOH
t~~'::~~:::zlr:T
11L '1~
DECEDENT'S M INO AOOAESS (SuMt Cilyfbotoon, SlaM. Zip Cadi
687 Hamilton St.
Carlisle, PA 17013
...
Thornwald
WA.S DECEDENT EVER IN
U.S. AAMEDFOAC'ES?
Yu 0 No1O
MARITAL stAtus. MernId
N.~ Married, Widowed.
"""'...-
White
SUfMVlNG SPOUse
l"""'e,QIY'8",.oOenf\NT\e1
17b. Coun
I'A
CU1tberland
""'
---
.....i',.
toolwnst\ip? 17d.~~~oI
MOTHER'S NAME IFors!. Middle. Malden Surnamel
Ettie Sturn
...
17c.D YM..~N.hMif\
17.. Stat.
Carlisle
""'''''''''
~I
...c ' (,-< re
."se""s.f
:II.
I "wCltimal.
l==;
! c,,,.,,,>
PART II: Qlher Sigrliftcanl c:oncII&ioM c:onttibuIing 10 dealh, buI:
not rnuling in It'Ie ~ C8UM g;v.n in PAAT I
C. hl"'.::"'\'< r<2~"\u.(
.(. c..' (I....... r..)
DUE TO (OA AS A CONSEQUENCE OF):
.
WE~E AUlOPSY FINOtNGS
"""LABlE PRK>A TO
COMP\.ETJON OF CAUSE
OF OERH1
MANNER OF DEATH
OATE OF INJURY
(Uonlh, Day, _att
TIME OF INJURY
INJURy ..:r WORK?
DESCRIBE HOW" INJURY OCCURRED
Noff'
HalUlal [3-"'
Atcidllllt 0
Suteide 0
HomiOcM
Pending Investig.liQn
o
o
o PlACE OF INJURY. At home, tarm, screal,lactOty, office
buikIinQ. etc. ISpec""1
....
_ 0 NoD
REGISTRAR'S SIGNATURE AN
t\. ~tu-&..~
~ \13-1. 110 I
0&., Ytlal\
Yo> 0
M. JOe.
Could not be <wlarm.n6d
a.. 28b.
CE:RTIFlER rCI'eck Q(liy onel
.CEJlTlFYtNG PHYSICIAN fPhySoc""n CP.fl1f)o1f'lQ cause 01 ~8tt1 wt'Ien anOl"er Dl"....soc.an has Pf<>nouf'lCe(l dear" ano comPleted Hem 231
To the ~t ol".y kno.~. de.th ~un.cS ~ 'lo the causels) Ind maroner a. ,tat.cl.
,..
'PRONOUNCING AND CERTIFYING PHYSICIAN (Phv-..:oal'\tlol.t', O)C\JO()Uf'IC.\f\9 uealf1 and tel1l1y,nQ 10 cause 01 (lealhl
To the bHt ot my _l'Ow1ed9"". d.all'l occurr" al fh_ltme. date, .nd place, Ind du.to Il'Ie ca....Hj.) itAd manner.. .taled..
.UEDtCAl EXAMINER/COAONER
~::::'~b:~:,::::'.,~~~~~I.i~~ and/or inveStlgalion. in my opinion. duth ~~~~~r.e.d. ~t. t.h.~ time. dat., and place. ~~ .d.~~ ~~ ~~~ ~~u.e(.) and 0
]lb.
...
REGISTER OF WILLS OF COUNTY
OATH OF SUBSCRIBING WITNESS
codicil
(each) a subscribing witness to the will presented herewith, (each) being duly qualified according to
law, depose(s) and say(s) that present and saw
the test at , sign the same and that signed as a witness at the
request of testat_ in h presence and (in the presence of each other) (in the presence of the
other subscribing witness(es)).
Sworn to or affirmed and subscribed before
me this day of
19_
(Name)
(Address)
Register
(Name)
(Address)
REGISTER OF WILLS OF COUNTY
OATH OF NON-SUBSCRIBING WITNESS
~L)IOf< ~s IV (lJ(')I/QC
I
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
familiar with the signature of IYPM'ri/d Lq/~~/?E #r:I.:,oiV
Gedieit-
will
test at co r of (one of the subscribing witnesses to) the
that
She.'
presented herewith and
codieil
believes the signature on the will is in the handwriting of
1/.&RrJ/cl h3//l/~e N5/50/.;.
to the best of h eft! .~__ knowledge and belief.
,/1.()~~
7J f tf~1~f
(Name)
Sworn to or affirmed ana subscribed before
me this 24th day of
JANUARY ~2001
~(/L1t/C2~::///~1/) AY/~ ~y
/ Register
(Address)
(Name)
(Address)
21-01-103
REGISTER OF WILLS OF COUNTY
OATH OF SUBSCRIBING WITNESS
codicil
(each) a subscribing witness to the will presented herewith, (each) being duly qualified according to
law, depose(s) and say(s) that present and saw
the testat , sign the sameaQ~_that signed as a witness at the
request of testat_ in h prese~e and (in the presence of each other) (in the presence of the
"
other subscribing witness(es)).
",
.-//
/
Sworn to or affirmed and subs<;ribed before
me this, /' day of
19_
. " fNalll~2.
(Address)
Register
(Name)
(Address)
REGISTER OF WILLS OF COUNTY
- OATH OF NON-SUBSCRIBING WITNESS
Prr17t~ I -
4<;<; /~
(each) a sUbscr~er heret,o, (each) being duly qualified according to law, dep'o~(s) and say(s) that
..e., ( ~ familiar with the signature of ~ riA ~OLt:J ~rjJ,[ ;jr4..s.
eodlcil " (J It
testat-L.. of (one of the subscribing witnesses to) the will presented herewith and
cm:iicit-
that hi<.-. believes the signature on the will is in the handwriting of
(~>t.- /) .t3j.....,4r~h tV&t.. so/- tJ
to the best of ~L- knowledge and belief.
~-7~
-,
Sworn to or affirmed and subscribed before
me this 24th _ day of
I JANUARY . :w2001
77JAUY~;/<d ,b/b JD~A, ?,n, <U7
Register
(Name)
fk ~ /_ /{,e;;~~ 4--fC'(-..
(Address)
Z-fo 0 P/T?--c ~..J c4 ,qi)
/
(Name)
1114::1/1/1U I'-- S /{tal G
Ai
( 70'5'-;-
(Address)
METTE, EVANS & WOODSIDE
A PROFESSIONAL CORPORATION
ATTORNEYS AT LAW
HOWELL C. METTE
ROBERT MOORE
CHARLES B. ZWALLY
PETER J. RESSLER
LLOYD R. PERSUN
CRAIG A. STONE
JAMES A. ULSH
DANIEL L. SULLIVAN
STEVEN D. SNYDER
CHRISTOPHER C. CONNER
JEFFREY A. ERNICO
KATHRYN L. SIMPSON
P. DANIEL ALTLAND
ANDREW H. DOWLING
MICHAEL D. REED
PAULAJ. LEICHT
GARY J. HElM
DAVID A. FITZSIMONS
GUY P. BENE VENT ANO
THOMAS F. SMIDA
3401 NORTH FRONT STREET
P.O. BOX 5950
HARRISBURG. PA 17110-0950
TELEPHONE
(717) 232-5000
FAX
(717) 236-1816
JOHN F. Y ANINEK*
VICKY ANN TRIMMER
TIMOTHY A. HOY
KATHLEEN DOYLE Y ANINEK
JAMES M. STRONG
JENNIFER A. Y ANKANICH
RANDALL G. HURST*
SUSAN D. ANDERSON
OF COUNSEL
JAMES W. EVANS
IRS NO.
23-1985005
*MARYLAND BAR
http://www.melte.com
October 24,2001
Register of Wills Office
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
ATTN: Sue
" /1
c U
"v
HE: Estate of H. Blaine Nelson
File No. 21-2001-0103
10866.1
Dear Sue:
Enclosed is a check in the amount of $35 in payment of the additional probate
fees which have been assessed against this estate by your office. Please return a
receipt for payment in the enclosed postage prepaid envelope.
Thank you for your assistance.
Very truly yours,
~~~, \LN\()~
Lisa J. KnoQ
Paralegal to Peter J. Ressler, Esq.
Enclosures
:276088 I
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
Estate of Harold Blaine Nelson
No. 21-01-0103
also known as
H. Blaine Nelson
Date of Death
January 20, 2001
late of the Borough of Carlisle, Cumberland
County, Pennsylvania,
Deceased Social Security No. 174-05-3465
Personal Representative(s) of the above Estate, deceased. verify that the items appearing in the following inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned
no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory.
I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made
subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Name of
Attorney: Peter J. Ressler
I.D. No.: 06844
Address 3401 N. Front Street, P.O. Box 5950
Harrisburg, PA 17110-0950
Telephone: (717) 232-5000
DESCRIPTION
Real Property:
687 Hamilton Street, Borough of Carlisle, Cumberland County, PA
Lot on Hamilton Street, Borough of Carlisle, Cumberland County, PA
Personal Property:
Van Kampen PA Tax Free Fund B
Series HH U.S. Savings Bond #X346101HH; face amount $10,000
Series HH U.S. Savings Bond #D1947946HH; face amount $500
Personal Representative:
Jeanne N. Sunday
~ ~~
Oated: '0\ '5\0 \ .,
Personal Representative:
Dolores N. Cloyes
)i.. .J!J rJ (Y'Uv )\' 06 r ~
Dated: q ! '30/0 I
i
VALUE
83,500.00
29,000.00
121,989.92
10,000.00
500.00
~
Persona/ Property (cont.):
Fort Cherry School District Municipal Bond
West Chester PA Area Municipal Authority Water Municipal Bond
52,218.75
41,611.80
13,508.40
43,011.32
426.91
Tucker Anthony RES I ACCR 9QS1A4 (REMIC)
Mellon Bank Premier Checking Acct. #182-672-6075
Freedom Cash Management Fund, Tucker Anthony Acct. #DSH-
005091-21
Household goods and furnishings, sold at public auction, 03/2001
1,032.00
158.00
Everett Mutua/Insurance Co. - refund of homeowner's insurance
premium
Internal Revenue Service- refund on 2000 personal income taxes
2,942.00
50.00
300.00
674.58
34.46
PA Dept. of Revenue - refund of 2000 personal income taxes
Internal Revenue Service - Taxpayer Relief refund
Thornwald Home - refund of nursing home expenses
Refund (unidentified source)
TOTAL
400,958.14
(Attach Additional Sheets If Necessary)
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value
of each item, but such figures should not be extended into the total of the Inventory.
FO(m RW-7 (DaI.lphin County) - Rev. 9192
:273223 _1
'\"
/ 6 -c2o~~
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
RecorcCeJ Of
Reg:,,',G'
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
12-10-2001
NELSON
01-20-2001
21 01-0103
CUMBERLAND
101
.01 ole 17 Pl2 :02
PETER J RESSLER
METTE ETAL
PO BOX 5950
HBG
ESQ
Cleft,
PA 1 'fllfijbendilO
--."--~':...ll "-
~ PA
Allount Rellitted
'*
REY-15~7 EX AFP 112-DDl
HAROLD
B
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=is4j-i3f-AFP--li'2=oOY-NOT-ici--OF-YNHiifiTAN-CE-TAi-AppRA-isiifiNT-:--AL1-oWANcE-oR'------------ -----
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF NELSON HAROLD B FILE NO. 21 01-0103 ACN 101 DATE 12-10-2001
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. Mortgages/Notes Receivable (Schedule D)
S. 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)
( ) CHANGED
112,500.00
239,828.87
.00
.00
48,629.27
.00
394,120.98
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
If an assessment was issued previously, lines
reflect figures that include the total of ALL
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (lS)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX eRE-DITS:
PAYMENT
DATE
04-13-2001
10-19-2001
NOTE:
RECEIPT
NUMBER
AA478279
CDoo0407
DISCOUNT (+)
INTEREST/PEN PAID (-)
1,473.68
.00
(9)
(10)
41,805.93
16 .377 .12
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
795,079.12
58.183 05
736,896.07
.00
736,896.07
14, IS and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
736,896.07 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
AMOUNT PAID
28,000.00
3,686.64
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
.00
33,160.32
.00
.00
33,160.32
33,160.32
.00
.00
.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 FORM FOR INSTRUCTIONS.)
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF DETERMINATION AND
ASSESSMENT OF PENNSYLVANIA
ESTATE TAX BASED ON FEDERAL
ESTATE TAX RETURN
of
i h~.J.o5""-c:?
W5t
RU-483 U .FP <12-00)
Record",
Res,;"
.02
JAN 11
DATE
ESTATE OF
DATE OF DEATH
P 3 '21 FILE NUMBER
. COUNTY
ACN
01-14-2002
NElSON
01-20-2001
21 01-0103
CUMBERLAND
201
HAROLD
B
PETER J RESSLER
METTE ETAL
PO BOX 5950
HBG
ESQ
C~erk
Curnbe. ;(J
PA 17110
Allount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR FILES ......
Rifv:48]f-Ex--AFP--fi2-:o0)-----j(i-NCificif-oF--DE~IfRMiiiATiCiN-AiiD-AffsESffHENif----------------------------
OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN ..
ESTATE OF NELSON
HAROLD
B FILE NO.21 01-0103
ACN 201
DATE 01-14-2002
ESTATE TAX DETERMINATION
1. Credit For State Death Taxes as Verified
20.450.56
2. Pennsylvania Inheritance Tax Assessed
(Excluding Discount and/or Interest)
31. 686.64
3. Inheritance Tax Assessed by Other States
or Territories of the United States
(Excluding Discount and/or Interest)
.00
4. Total Inheritance Tax Assessed
31. 686.64
5. Pennsylvania Estate Tax Due
.00
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
-IF PAID AFTER THIS DATE, SEE REVERSE SIDE (IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ, YOU HAY BE
DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
/?~c2L0-: ~
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
PETER J RESSLER ESQ
METTE ET AL
PO BOX 5950
HBG PA 17110
NOTICE OF DETERMINATION AND
ASSESSMENT OF PENNSYLVANIA
ESTATE TAX BASED ON FEDERAL
CLOSING LETTER
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
'*
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
REV-75' EX AFP (01-02)
03-17-2003
NELSON
01-20-2001
21 01-0103
CUMBERLAND
202
HAROLD B
Allount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR FILES ~
Rifv=;3Er-EX--AFP--foi~-02j-----.ii-NiDificif-OF--DETEiiMiN~fiCiN-AN-D-ASisESSiMENir----------------------------
OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER ..
ESTATE OF NELSON
HAROLD
B FILE NO.21 01-0103
ACN 202
DATE 03-17-2003
ESTATE TAX DETERMINATION
1. Credit For State Death Taxes as Verified
20,450.56
2. Pennsylvania Inheritance Tax Assessed
(Excluding Discount and/or Interest)
31,686.64
3. Inheritance Tax Assessed by Other States
or Territories of the United States
(Excluding Discount and/or Interest)
.00
4. Total Inheritance Tax Assessed
31. 686.64
5. Pennsylvania Estate Tax Due
.00
6. Amount of Pennsylvania Estate Tax Previously Assessed
Based on Federal Estate Tax Return
.00
7. Additional Pennsylvania Estate Tax Due
.00
TAX CREDITS:
PAYMENT
DATE
RECEIPT
NUMBER
DISCOUNT (+)
INTEREST/PEN PAID (-)
AMOUNT PAID
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
-IF PAID AFTER THIS DATE, SEE REVERSE SIDE (IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE
DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
RESSLER PETER J
P.O. BOX 5950
HARRISBURG, PA 17110-0950
____un fold
ESTATE INFORMATION: SSN: 174-05-3465
FILE NUMBER: 21-2001- 0103
DECEDENT NAME: NELSON HAROLD BLAINE
DATE OF PAYMENT: 10/19/2001
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 01/20/2001
NO. CD 000407
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $3,686.64
I
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TOTAL AMOUNT PAID:
$3,686.64
REMARKS: DOLORES N COYES &
JEANNE N SUNDAY C/O PETER J
CHECK# 1017
SEAL
INITIALS: SK
RECEIVED BY:
MARY C. LEWIS
REGISTER OF WILLS
REGISTER OF WILLS
->--
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Harold Blaine Nelson. a/kJa H. Blaine Nelson
Date of Death: January 20, 2001
Will No. Admin. No. 21-01-0103
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 February 7. 2001 :
Name
Jeanne N. Sunday
Address
40 S. Middlesex Road, Carlisle. PAl 70 13
Dolores N. Cloyes
406 Epworth Court Unit 526. Solo mons, MD 20688-3034
Notice has now been given to all persons entitled thereto under Rule 5.6(a).
(
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Date: February 7. 2001
'I-J (r~~
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Signature
Peter J. Ressler, Esquire
Name
3401 North Front Street
Harrisburg, PA 17110
Address
(717) 232-5000
Telephone
Capacity: _ Personal Representative
.. ~
-'." .
..,i>' ',..-",,",
~ Counsel for Personal
Representative
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STATUS REPORT UNDER RULE 6.12
Name of Decedent:
Harold Blaine Nelson, a/k/a H. Blaine Nelson
Date of Death:
January 20, 2001
Will No.
Admin. No.
21-2001-00103
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 may be attached to this report.
Date: n-/7-d~
0tIf1 ~
Signature
Peter J. Ressler, Esquire
Name (Please tyoe or orint\
3401 N. Front St~~et, P.~. Box 5950
Harrisburg, PA 17110-0950
Address
( 717) 232-5000
Tel. No.
Capacity: Personal Representative
x Counsel for personal
representative
(MAH:rmf/AM3)
..
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 12/06/2002
JEANNE EMMA NELSON SUNDAY
40 S MIDDLESEX ROAD
CARLISLE, PA 17013
RE: Estate of NELSON HAROLD BLAINE
File Number: 2001-00103
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
wills a Status Report of completed or uncompleted administration.
This filing will become delinquent on: 1/20/2003
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
MARY C. LEWIS
REGISTER OF WILLS
cc:
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Counsel
Judge
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METTE. EVANS & WOODSIDE
A PROFESSIONAL CORPORATION
ATTORNEYS AT LAW
HOWELL C. METTE
ROBERT MOORE
CHARLES B. ZWALLY
PETER J.Ib:SSLER
LLOYD R. PERSUN
CRAIG A. STONE
JAMES A. ULSH
DANIEL L. SULLIVAN
STEVEN D. SNYDER
CHRISTOPHER C. CONNER
JEFFREY A. ERNICO
KATHRYN L. SIMPSON
P. DANIEL ALTLAND
ANDREW H. DOWLING
MICHAEL D. REED
PAULAJ. LEICHT
GARY J. HElM
DAVID A. FITZSIMONS
GUY P. BENEVENTANO
THOMAS F. SMIDA
3401 NORTH FRONT STREET
P.O. BOX 5950
HARRISBURG. PA 17110-0950
TELEPHONE
(717) 232-5000
FAX
(717) 236-1816
JOHN F. Y ANINEK*
VICKY ANN TRIMMER
TIMOTHY A. HOY
KATHLEEN DOYLE Y ANINEK
JAMES M. STRONG
DRY AN S. MEGARY*
RANDALL G. HURST*
SUSAN D. ANDERSON
OF COUNSEL
JAMES W. EVANS
IRS NO.
23-1985005
*M.\RYLAND BAR
http://WoNW.mette.com
April 13, 2001
Mary C. Lewis
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
RE: Estate of Harold Blaine Nelson, a/k/a H. Blaine Nelson
File No. 21-01-0103
Dear Ms. Lewis:
Enclosed please find a check payable to "Register of Wills, Agent" in the
amount of $28,000, representing a prepayment of inheritance tax in the above-
referenced estate. Please send a receipt for this payment to my attention in the
enclosed envelope.
Thank you for your assistance.
Very truly yours,
L~~.~~oL
Paralegal to Peter J. Ressler
LJKI
Enclosures
cc: Dolores N. Cloyes, Co-Executrix
Jeanne N. Sunday, Co-Executrix
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