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Home My WebLink About01-0106 RF't.l_~I(.(ll~ . . *' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 260601 HARRISBURG, PA 1712S.ll601 / h -r--:)(,;;6-- 6 REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT ')It 1(;1..\1 use orJI" FILE NUMBER 21 01 00106 COUNTY CODE YEAR 1- SOCIAL SECURITY NUMBER I 277-07-2857 , THIS RETURN MUST BE FILED IN DUPLICATE WITH THE --t SOCIAL SEC~~~I~~~~ OF WILLS_ o 3. Kemalnaer Kefum (aate Of death pnor to '12.1 J-B2) NUMBER ~ ~<!:1 u"'" ~:Sg ulfUl ~ ~ Z W C w u w C DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) Boomershine, Marjorie A. DAle UI- UCArH (MM-UU-YCAH)'" I UAII: UI- BIKIH (MM"=UU-VCAK) 12/16/2000 105/21/1917 (IF-ApPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND tviTDDLE INITIAL) 1. Original Retum -i'- Supplemental Return 6. Decedent Died Testate (Attach copy of Will) 9. Litigation Proceeds Received 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) D 5. Federal Estate Tax Return Required o 8. Total Number of Safe Deposit Boxes 4. Limited Estate .~ ~z &!~ CZ ,,~ IRM NAME (If applicable) 11.Election to tax under Sec. 9113{A) (Attach Sch 0) 35 E. High Street, Suite 203 Carlisle, PA 17013 n,: FI<.I^I I !:_~! 'Jr~L v (1) None _u (2) 15,444.0~: I (3) None~ (4) None (5) 20,763.27 (6) 2,001.99 (7) None ELEPHONE NUMBER 717/241-4311 (8), 38,209.26 (9) (10) 1. Real Estate (Schedule A) Z C ~ => ~ ~ ~ w ~ 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 1 Q. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 12,689.82 4,650.29 (11) 17,340.11 20,869.15 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (13) (14) 20,869.15 Copyright 2000 form software only The Lackner Group, Inc. SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 939.11 939.11 120. 0 15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) -- Z 16. Amount of Line 14 taxable at lineal rate 20,869.15 x .045 (16) c g 17. Amount of Line 14 taxable at sibling rate .12 (17) ~ x '" 0 " ~ 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Form REV-1500 EX (Rev. 6.QO) Decedent's Complete Address: STREET ADDRESS CITY -~"-"-----c7i---- [STATE PA [ZIP 17013 Carlisle Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 939.11 892.15 46.96 Total Credits (A + B + C) (2) 939.11 3. Interest/Penalty if applicable D, Interest E. Penalty (3) 0.00 (4) (5) 0.00 (5.0.) (5B) 0.00 Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 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 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.............."...................................,......................... 0 a b, retain the right to designate who shall use the property transferred or its income;,..,.",.......,..,..,.......... 0 1m. c, retain a reversionary interest; or.,.....................................................,........,........................................... 0 0 d. receive the promise for life of either payments. benefits or care?.....................,................................... 0 a 2. If death occurred after December 12, 1982. did decedent transfer property within one year of death without receiving adequate consideration?.............................,................ .................................................................. 0 a 3. Did decedent own an ~in trust for" or payable upon death bank account or security at his or her death?...... 0 a 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?...............................................................................................,............... 0 a 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 retum. including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all Information of which preparer has any knowledge. ~~~~:~lEFORFIL GRETURN ". ::::::: ~~~~i~~o~~~al~~~~c1e=-y J ~~_Qi s~ - AVVH.l:::SS 35 E. High Street, Suite 203 Carlisle, PA 17013 VAll:: For dates of death on or after July 1. 1994 and before January 1, 1995. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January 1. 1995. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% (72 P.S. ~9116 (a) (1.1) (ii)}. The statute does not exemot a transfer to a surviving spouse from tax. and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P .S. ~9116 (a) (1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116 1.2) [72 P.S. ~9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (72 P.S. ~9116 (a) (1.3}l. 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. '* SCHEDULE B STOCKS & BONDS .~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DEceDENT ESTATE OF I FILE NUMBER 21 - 01 - 00106 Boomershine, Marjorie A. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ..... . DESCRIPTION . ~NIT VALU~- VALUE AT DATE OF DEATH 400 shares, .Carlisle Companies, Inc., value. per attached report from Tuckei- --38.61 - 15,444.00 Anthony, per share 38.61 ITEM NUMBER 1 _J_ TOTAL (Also enter on line 2, Recapitulation) 1 , 15,444.00 . TUCKER ANTHONY 111 u ,~,. "N 1 Il IJ I '" I _, I [J fJ 95 Alexander Spring Road Carlisle. PA 17013 Phone 717.241.3055 February 22, 2001 Dale F. Shughart, Jr. 35 East High Street Suite 203 Carlisle, PA 17013 RE: Marjorie A. Boomershine Dear Dale, Listed below is the date of death value for 400 shares of Carlisle Companies that was held in the above-mentioned account. December 15, 2000 High Low Close 39.83 37.62 38.12 December 18, 2000 High Low Close 38.87 38.12 38.43 If I can be of further assistance, please give me a call. Sincerely, 4' U':,:;7C;::/\r George A. Sneed Senior Vice President . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY L COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I FILE NUMBER 21 - 01 - 00106 ESTATE OF Boomershine, Marjorie A. Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshIp must be disclosed on schedule F. ITEM NUMBER I DESCRIPTION VALUE AT DATE OF DEATH 100.00 Furniture and furnishmgs at Nursing Home, value based upon sale price. 2 Freedom Cash Management Fnnd #DSH-008503-21, Tucker Anthony Principal 513.94 Accrued interest 1.69 515.63 3 IBM Southeast Employees' FCU, Membership Account #183829102 Principal 16,392.02 Accrued interest 64.82 16,456.84 4 Carlisle Tire & Rubber, fmal retirement pay 177.34 5 Resident Fnnds of Thomwald, balance in resident's account 24.26 6 Unity Financial Life Insurance Company, refund 184.04 7 Bankers Life & Casualty, reimbursement 242.00 8 U.S. Treasury, 2000 income tax refund 2,983.47 9 Bankers Life, refund of premium 79.69 20,763.27 TOTAL (Also enter on Line 5, Recapitulation) IBM Southeast Employees' Federal Credit Union MEMBER STATEMENT MEMBER NUMBER TAX 1.0. NO. PAGE 183829102 .**-**-**"'* 1 OF 2 I FROM :08 DEC 00 I TO: 07 JAN 01 00020C1700;: MARJORIE A 800MERSHINE 7023 SAN SE8ASTIAN CIR BOCA RATON FL 33433-1014 1.,11",11"1.,1"11".11",,1111,,,,,,11,1,,1,,1,1.,;1",11,1 TRANSI TRANS I DATE I EFF DATEI DESCRIPTION I DEBITS I CREDITS I NEW BALANCE You've got the Gold! As a result of your account relationships December 1-31. you have earned GOLD REWARDS benefits through January 31. .. .. . pEC8 DEC17 DEC16 DEC17 DEC16 DEC1€ DEC16 Previous Balance T'FER TO 183829102S50 VR ATM WITHDRAWAL IBM SE CU-790 PK OF C BOCA RATON FL 00010402 80CA-HDQ 12/16 ~ 13:04 T'FER TO 183829102S50 VR DIVIDEND CREDIT Annual Percentage Yield Earned: 2.82% For the Period from 10/01 through 12/31. ClOSing Date.. .New Balance 5000.00 500.00 16382.02 11392.02 10892.02 I , DEC18 pEC29 DEC31 pEC29 pEC29 JAN7 2300.00 77.45 8592.02 8669.47 8669.47 550 SHARE A C - CHECKING ACCOUNT I (Joint with ROBERTA A SLAYBAUGH) -----------------------SUMMARY----------------------- Previous Balance 85 of 08 DEe 00.... 4003.98 Total of 2 Checks for. Total of 2 Deposits for........ Total of 1 Other Credits for.... 3270.44 - 7300 . 00 + 177.34 ... Ending Balance as of 07 JAN 01.... 8210.88 DEC17 DEC18 DEC18 DEC28 JAN2 DEC16 T'FER FROM 18382910251 VR CHECK 11 487 T'FER FROM 18382910251 VR CHECK II 488 Trace#OOOOOOOO*020366490 RETIREMENT PLAN/PAY-DDA-l/010101 2300.00 5000.00 2300.00 177.34 9003.98 6703.98 9003.98 8033.54 8210.88 970.44 * "'''''''..'''*''' RATE PORTION $ BALANCE THRU 999.99 DEC08 0.000% SUMMARY ABOVE 999.99 0.000% FOR S50 . '" '" '" '" '" '" LAST YEAR TO DATE DIV/INT and FINANCE CHARGES S 1 Total 412.95 412.95 Paid off L6 Total 257.14 257.14 No money for a mortgage down payment? No problem! ...J 003413 Client Statement Till, ,,!!I !IIIO('I'Urrl''-'', (If I -TUCKER ANTHONY BE R V IN GIN V EST [] R S BIN eEl 892 A TUCKER ANTHONY Sun<l1 CDMPANY Securities Account For The Penod December 1 . December 31, 2000 _....i..I;U'.W"'tllllllltlll1Ji \i!i':'e;,.i!<','/ .. M"U"ll..!.".~e,~,: .' .",:":'__F'~*~;_~~P;4' Priced Securities Value $16,925,20 Money Markel Funds $373,94 Account Number DSH-008503-21 Page 1 of 2 ,', .' _,:' ..it;::."-: :'., :~.>:" 'lc:l.,oq<o;~, '$17,175,20 $517,22 Your Investment Executive: GEORGE A SNEED TUCKER ANTHONY MIDATLANTIC 95 ALEXANDER S 'RING ROAD CARLISLE PA 17013 E~mail Address: gsneed@tuckeranthony.com Phone 717.241.3055 Total Net Worth $17,299,14 $17 ,692.42 .' . m!"'l "r' . '..". ~~' !,---~ '--~' -- ,=, . "11'" I~ ,~.t:1 't; :!' J> ,"'..,/.. ......1 ' ,bl , ,'Ii ,l '..iJ", 0 ' \' .' , < ", \.. 1 Money Fund Dividends DMdends $3.28 $140,00 $43,56 $280.00 MARJORIE A BOOMERSHIRE C/O ROBERTA SHAYBAUGH POA 7023 SAN SEBASTIAN CIR BOCA RATON FL 33433-1014 I"II",II.,I"I..!I.,.II",.IIII,.""II.I"I"I,I"I1",11.1 Total Income $143.28 $323.66 . .' -,' ';, . ". ,'-.."..iOl'Ji .-- <".ll":","';~-I;'i'l!,,n"t, 'I ,,1''' 1'1 ';'jl{: ,It ':.!',"l't ~\I':'l 'T,iV"i~, , " ' ',_ J.l ""1 j hl~,' ",," ' , ' QUANTITY CURRENT PRICE CURRENT VALUE ESTIMATED ACCRUED INTEREST ESTIMATED ANN:JAlIZED CURRENT INCOME YIELD COMMENTS CARLISLE COMPANIES INC 400 42,938 $17,175.20 $320 1.86% PRICED SECURITIES VALUE $17,H5.20 $320 FREEDOM CASH MANAGEMENT FUND 517,2~0 1.000 $5,7.22 $517 .22 $31 6.02% 7-Day Yield MONEY MARKET FUNDS $31 , li":k"'" ",'"'7 ~~:r<-ym\ , "1i'/^1..,1 Ij ~-" "~, ". "."'.."'. ':M'~~"~(fJ 0~:1!~~~ DATE TRANSACTION QUANTITY PRICE/COMMENTS AMOUNT DEBITED AMOUNT CREDITED DlV ON 700 CARLISLE COS INC ............................,.......,........,.."",........................................... FREEDOM CASH MGMT FD AUTO SUBSCRIPTION ................................................ FREEDOM CSH MGMT DIV REIN 11/16. 12/15 .................................... ..............,.............. FREEDOM CSH MGMT DIV REIN 12/16 - 12/28 12101 Dividend ....,.................... 12104 Purchased Inco,ne $140.00 ............................ 140 100 $140.00 12/18 Dividend ....................... 12/29 Dividend 2.150 ...................... 1.130 Money ~;lInd Mane I::l'nd !> , % . o 5 ~ z r>]P;I<:P .;:pr. rp,..'pr~" .:::idp \'.'uf~"j r<~..;P" .-~".."~. r~.~"r'''''ft I .~ ! FILE NUMBER- ~.~l - 00106 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. '* I L SCHEDULE F JOINTLY -OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Boomershine, Marjorie A. SURVIVING JOINT TENANT(S) NAME A Roberta A. Slaybaugh .. ADDRESS 7023 San Sebastian Circle Boca Raton, FL 33433 RELATIONSHIP TO DECEDENT Daughter JOINTLY OWNED PROPERTY: ITEM LETTER NUMBER FOR JOINT TENANT DATE MADE JOINT r... DESCRIP liON OF PROI'I=H I Y. . ... .~v. OFI .. DEA ,Incl~d~ n~me ,?f ~nancial institution and bank .a~unt number DATE OF DEATH DECO'S" DA'0~~~E OF TH or similar IdentifYing number. Attach deed for JOintly-held real VALUE OF ASSET ,INTEREST DECEDENT'S INTEREST ~. " IBM Southeast Employees FCU 4,003.9l 50% Checking Account #183829102S Statement attached to Schedule E A 2,001.99 I TOTAL (Also enter on line 6, Recapitulation) 2,001.99 '* SCHEDULE H FUNERAl EXPENSES & ADMINISTRAT1VE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIOENT DECEDENT I \ FILE NUMBER 21 - 01 - 00106 ESTATE OF Boomershine, Marjorie A. Debts of decedent must be ....ported on Schedule I. 'ITEM NUMBER A. DESCRIPTION AMOUNT FUNERAL EXPENSES: Hoffman-Roth Funeral Home -,--- 6,880.00 2 Margie Blumenthal, reimburse flowers, honor.nums , burial clothing, and family meal 970,44 B. ' ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Year(s) Commission paid Attorney's Fees -- Dale F Shugbart, Jr. Esquire Zip 2. (estimated) 2,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address State Zip City Relationship of Claimant to Decedent Probate Fees Register of Wills 81.00 4. 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. I Other Administrative Costs Register of Wills, Short Certificates Register of Wills, filing inheritance tax return and Inventory 12.00 25.00 2 Total of Continuation Schedule(s) 2,221.38 TOTAL (Also enter on line 9, Recapitulation) 12,689.82 " . SchecIuIe H Funeral Expenses & AdninistratNe Cosls continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF h' M" A Boomers me, arJone . i-R:;;berta A. Slaybaugh, reimbur;~o~t of pocket expenses: U.S. Air, two round trips to PA 703.50 Avis, car rental 158.00 . Budget, car rental 240.60 Days Inn, room 313.28 Gas, phone, postage 12.86 Total 1,428.24 4 5 Tucker Anthony, broker's commission on sale of stock Reserve for preparation of fiduciary income tax returns and accounting. I FILE NUMBER 21 - 01 - 00106 1,428.24 --~ Page 2 of Schedule H 293.14 500.00 .' . SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONVo/EAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN __,_ RESIDENT DECEDENT l ESTATE OF .. . Boomershme, Mafjone A. L_ I FILE NUMBER 21 - 01 - 00106 Include unreimbursed medical expenses. AMOUNT -2,352.51 ITEM NUMBER 1 Thomwald Home, final bill. DESCRIPTION 2 Thomwald Home, medical bill. 242.00 3 Phannerica, prescriptions 1,341.15 4 PA Department of Revenue, 2000 income taxes 714.63 TOTAL (Also enter on Line 10, Recapitulation) 4,650.29 . . . SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ----L. I FILE NUMBER' 21 - 01 - 00106 ESTATE OF Boomershine, Marjorie A. I --J RELATIONSHIP TO -LAMOUNT OR..SHARE - NU~BE;--' NAME AND AD~RESS OF PER~~N(S) RECEIVING PROPERTY' DECEDENT OF ESTATE Do Not list Trustee/51 ~ _ " I. ' TAXABLE DISTRIBUTIONS (include outright ~p~usal distributions) ...- , .. Roberta Slaybaugh Daughter one-fifth 7023 San Sebastian Circle Boca Raton, FL 33433 2 'James W. Boomershine 117 Landing Drive Rehoboth Beach, DE 19971 Son one-fifth 3 J. Douglas Boomershine Son ,one-fifth 1401 Meeting House Road Knoxville, TN 37921 4 David S. Boomershine 3975 Sharp Road , Glennwood, MD 21738 Son one-fifth , ,Enter dollar amounts for distributions shown above on lines 15 through 17, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHE T *' SCHEDULE J BENEFICIARIES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Boomershine, MaDone A. NUMBER I.. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. ~BLE DISTRIBUTIONS (include outright spousal distributions) 5 . Margie L. Blumenthal 265 South College Street Carlisle, PA 17013 I FILE NUMBER 21 - 01 - 00106 I ~ RELATIONSHIP TO DECEDENT I D~ Not list Trustee(s) _ , Daughter I AMOUN~ OR SHA~ OF ESTATE one-fifth , _l__~l_ Page 2 of Schedule J PETITION FOR PROBATE and GRANT OF LETTERS ~\- 0\- I~ Estate of MarjD't'ie A. Boomershine also known as Register of Wills for the Deceased. County of C'1 m b '" r 1 ::l n c1 in the Social Security No. 277 - 0 7 - 2 8 ~ 7 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/ are 18 years of age or older an the execut r j y in the last will of the above decedent. dated J a nu a r y 30, and codicil(s) dated No. To: %ared , 19_ (slatc rclevant circumstances, e.g. rcnunciation, death or executor, etc.) Decendent was domiciled at death in C 1) 111 bE' r 1 <l n n County, Pennsylvania, with her lastfamilyorprincipalresidenceatThornwald Home, 442 Walnut Bottom Road, Carlisle. FA 17013 (list street, number and muncipality) Decendent.then 83 years of age, died December 16, ,:l1J 2000, at Thnrm.J;:11n Home 44? W;:11mlr Bottom Road. Carlisle. FA 17013. Except as follows, decedent did not marry. was not c;iivorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (I f domiciled in Pa.) All personal property (I f not domiciled in Pa.) Personal properly in Pennsylvania (It not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situared as follows: 30,000.00 $ $ $ $ \\HEREFORE. petllIoner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters r P R 1"" ;:1m P n t ;:1 r y (testamentary; administration c.I.a.; administration d.b.n.c.t.a.) theron. 1\~Kjq,(}~. Roberta A. Slaybaugh 7021 SAn Sebastian Cir~ -.B-o.ca RatoI1, FT 33433 r :; " ~Z '".J '- =:c::~ ~:~ 7~ ", ;:, OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PEN;\/SYLVANIA I ,~ COL;\iTY OF CUMBERLAND J :s:s The petitioner(s) above.named swear(s) or affirm(s) that the statements in the foregoing petition are true anJ .:orrect to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sw~rn to ~r affirmed and subscribed ~Q ~H ~ belon? me thiS 25th day of ~ .. ~~ir{,g ctf:.,~ Roberta A. Sla augh ~ m _' o~ pl-'. " ~ M Y CLEWIS Ref!,lster ~ j ~ - ;;)05 - U:> No. (1 - U1 - 1U6 Estate of MARJORTF. A. BOOMF.RSHTNF , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW JANUAR Y 25, WX 20 0 ~ 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 J an u a r y 30, 1 989 described therein be admitted to probate and filed of record as the last will of MRrjorie A. Boomershine and Letters T f' R t R men t Ii r y are hereby granted to Roberta A. Slaybaugh ~ffJ (>,~~~. ~ Register of Wills MARY CLEWIS FEES Dale F. Shughart, Jr. Probate, Letters, Etc. ......... Short Certificates( LI) . . . . . . . . . . Renunciation ................ X-Pages JCP $ 60.00 $ 1 2 . 00 $ $ 6.00 5.00 TOTAL _ $ 83 00 .... .~f\NW~~X. .~5,. .2.QQJ........... ATTORNEY (Sup. Ct. I.D. No.) 19373 35 East High Street, Suite 203 ADDRESS Car 1 i s 1 e, PAl 7 0 1 3 Filed (717) 241-4111 PHONE . .: ~, c..~- . Called attorney on 1-25-01 H !O),~O') KEV 9/86 i 1115 is to certify that the information here given is correctly copied from an original certificate of death duly filed with Local Registrar.' The original certificate will be forwarded to the State Vital Records Office for permanent filmg. WARNING: It is illegal to duplicate this copy by photostat or photograph. me as No, """"(~(~",otpl,t---_,_,, \\~~~J""':. ~\ ~. ......-::;- l~~- ~\ ~~I'..~ ~.. ~:E:( '.,. I~~ ~ 8\ --~~.- .,.i:~ l*'Lc '~Ii...._ ',.'1*1 .. <::2 ".' /~" \.~ . ~\l "'- ,,/p -i.\.Y-".\ "-..,:t1MfN1 \\~ "".., "''''''''''''0'1111111//11'1 1i~ {:\. ~e.u..~~'b.~ Local Registrar Fee for this certificate. $2.00 P 6960297 DEe 1. 9 2000 Date / H105.:<tJRev, 2/87 COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH. VITAL RECOROS CERTIFICATE OF DEATH 'RINT t. Marjorie A. Boomershine AGE (Lasr ~Y) UNOEA 1 YEAR UHOER , DAY Mont.... Oays Houra MinuI., SEX 2. Female SlAU FILE NUMBER SOCIAL SECUJ'l"ry UUM8ER 277 _ 07 2. 2857 OATEOF DEATH,MCfI1fl. 0.". '''UtI .. December 16, 2000 KENT ; INK N...ME Of DECEDENT fh;;;:l<<... laSll ~I o,ue OF BIA1t-l 'Monln, [Ry. '1e8l'l P~E OF OEATH ICf>toclt (W1ly 1Y'e~. ift '''SlructoOf19(ln~ ~I HOSPITAl; InpaliWltO 7. ... FAClllTY NAME <" nQllnsN\J.IOfl. g....e S1feef and oumt:lclfl BIfl'THPLAC.E (C,ry ar.d 31a'801 FCfeoQflCounlfy) .. COUNT't Of OERH 83 V<s. g:;""o CITY Cumberland ... Ie. '0, White "'''''I TAL STATuS. M.med N...,.. Man*,. WIdowed. """""(5pocIyJ Widowed SURv1V\NQ SPOUSE (t! ""'e. IJI'4 maden namel ,.. FR'HER'S NAME (Fit.., MOodIe. Lasr) II. Nye A. Schofield INFORMAN'T.S NAME (T YPWPrIn'1 _. Mar ie A. Blumenthal ME"THOO OF OtSPOSITION .......@ C'_ion 0 _....51...0 Olho< (Sooc>Iy DECEDENT'S ACTUAl. REStOEHCE tsee.nItl'UC..ons OflOfflerSlCleI 17.. $Ia.. 17b. Cou Q;d --.. We.... Cumberland _7 170.c:J:::"'''":''.:;.'ot MOTHER'S NAME jf"il's!:. M.adIe.1od3lden Sutn.,...., Jane Stone 17c.O v.., dKedenc w.cr in >WO. Carlisle c.1y-' II. INFORMANT'S MAIUNG .&.OOf!;ESS ts.teet, City/lown, $&ate, LIP Codel MO. 265 South ColI e Street, Carlisle, . 17013 PlACE (y OtSPO$CTKlti. Name ot c.m.1~ CremllOfy LOCATION. CiIyITown, Stat., ~ eoc. Of'OI:herPlac. ~rland Valley Mem Gdns N.....E AHO AOOAESS OF FACILITY 219 >t. I Approxima.. : intervtl bMWftn I 0t\Ml and death , l""T\ ...e: 2.. M, 25, 27. ~ I: Ent., If\oe disease-s, inluries or c.c>mpb'iotIs .hieh ~used ,he dea,"_ Do no' enler!he mode 01 dymg, SuCh.s cll'ltiac or respir.ilIOry ann.. St'IOCf( or ne.rl failure Lila orrI'f one C8.UH on eech J;ne, '''Mil: OUIet$ignitlcanf:~conIribuI:ingloduth. buI: not tHUt\'"9 ir\1M ~ atuM given in PNn" I. ~~~n OUE 10 (()A AS A CONSEOuENCE OF)' { : 'NERE AUlOPSY FINOtNGS A\.tUl.A8l..E ,f\tOf\ 10 COMPLETION OF CAUSE OF DERH? DUE 10 (OR AS A CONSEOUENCE OF): DUE TO(OA AS A CONSEOuENCE Of) MANNER Of DEATH OATE OF INJUAY \Monlh, Day, Yearl TihilE OF INJURY INJURY 1CJ WORK? OESCRIBe HOW INJURY OCCURAED NallMal -fiI.:; o o HOtniCide -"'nt Per'ding I"vesliga'jo" o o o PLACE OF INJURY - Al ~.lat~~;"l.laClory, Qlfic:e M. buildln9.etc.tS~\ .... ,.. 0 ...0 "..0 ...0 Suicide Covld fIOIl>e Oe..rmlned He. 2111I, CE:IITIFtEA \Ct-ec'" Qf'l\)o ~l "CVlTIFYING PHYSICI"'N fPh~l"I c.f!nI4yw.g cause 01 C4l'alh ....tlef'o a"04"er ptIv$oC,an has P1onOUr1Ci!'(J dear" ar'lQ comCllele<! !lem 23\ To "'" t... of "" IUIOW~, de.'" occ:urntd due ~ the e."'"<~1 aM "'ann,., a. stated, ,.. 3.1. SIGNATIJRE.(fO TITLE OF .....fEAT IE~ III 31.. ~ (..I. ,",^-,,--- ~ UCENSE NUMBER :UE SKlNED\MonIl->. Day. 'fear) o 31.. ",,-t) b \ \. :t. '-/ I (, "d. "tlllc:.. I 'a , ~o" NAIlo4E AND AODRESS Of PERSON WHO COMPLETED CAUSE Of DEATH (ITem 27\ TypoaOf P,int <;,.'c::.r.,..... (;J, 6r;~.~<..u.... ..;~ o 22, 'OS~ Lu~ -\t~ 'Pf'OMO\JNCING AND CERTIFYINQ ~HYSK:IAH IF'tlysoc..-,, bort' ;.llO/'1OUflG'''9 Ue;l.lh andcentlV'r'lQ 10 cause 0' dea."l To the blHt of my k(loQwl~';Jfl, cs.'lh DCcurrH at IN lime, dale, and pl.c., Ind duel€' the c.US*(Il)and m.!'.nu.. s\alltd., OMEDtCAL EXAMINER/CORONER 01'1 the b..is 0' e:laminallon and/or inveslIgation, in my opinion, dltath occurred at the lime, dat., and pl'c!!, and due to the e.uu(~) and m.nn"f .S "'.'eO.. Jl.. REGISTRAR'S SIGNATURE A BER ~. ~eu..&.~ ",\) G\.J) c..,'1.('l..p... 6'1 I~\I~IOI DATE FILED (MOIllh Day. ~.q ~ - \0.. d.e%\) 34. I I appoint my daughter, Roberta A. Slaybaugh, Executl~ix of thi s my last Wi 11 and Testament --f'1-<7CrC ~T /c'-:' te--c'JL~ ~/~~/Y-K--"'>:?" ) ~:.A-<--<> ;-i~L.-I- /'-7l-'~/7:!-~ _~j(<- ,e> I direct that my personal representati ves.as, well f~'//~~1~ 7/<<( };3 I <[; '-> 'v.. LAST WILL AND TESTAMENT OF MARJORIE A. BOOMERSHINE I, Marjorie A. Boomershine, of 7023 San Sebastian Circle, Boca Raton, Florida 33433, declare this to be my last Will and Testament and revoke all Wills and Codicils previously made by me. ITEM I: I direct that my just debts, funeral expenses and the expenses of the administration of my estate, including any state, federal or other death taxes payable because of my death, shall be paid from my residuary estate as soon as practicable after my decease, as a part of the expense of the administration of my estate. ITEM II: I devise and bequeath all of my estate of every nature and wherever situate in equal shares to my five (5) children, provided, however, that the share of any child who predeceases me or dies on or before the thirtieth day following my death shall be distributed to his or her issue, per stirpes, living on the thirty-first day following my death, and ill_default of such then living issue, such share shall be added to the shares for my other children. ITEM III: ITEM IV: as their successors, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 7?k,t:r~- {/ 6r-;1~;A/$~ . I ... ,} "". \. STATE OF FLORIDA 5S COUNTY OF I=b!ry-., ~C\r') We, Marjorie A. Boomershine, ~I~ f-t'""'ICt'I(DC""( and f\h~t\ 3' .6~\c:'nKI'11 , the Testatrix and the wi tnlsses, respectively, whose names are signed to the attached or foregoing instrument, having been sworn, declared to the undersigned officer that the Testatrix, in the presence of thE? IN.i tne.sse~, signed.: th-e C...'.i' c f" c\.t H'lC'cI -I- I ,'y)("" \-,dO t::c~" Il~U:l1 ~ i t'"cJ . l::>", instrument as her last Will '/\ that she signed, and that each of the VHC "--el, '~I.:., ) wi tnesses, in the presence of the Testatrix and in the presence of 'j ";L '<.((;""7/<'''1 CJ< C"':: " . -It: ' .~ f.:; ({AI 7//d Z5 each other, signed the Will as a witness. j' '. It. "., ' ,} Ii>, itd:teJLj...... r;~~~ J (J .~ d'-' '...... t '~tb(1 JJL-th t. jJLUtJ{v~ /) ......-1'./ . 7?p-/-I'-1.U--- ( /l -<-.~ / X/; 1 ..l ~.-:7'c.L--- v Sworn and subscribed before me by Marjorie A. Boomershine, the Testatrix, and by V--..e--\I'--'f ~-tC"ICII>15C";"( and tLI~0\-JL"'1~) :J . ~.~ ,I K"(') , the wi tnesses on this 3c) day of VA/)/u/J-nl/ , , 1989. .,7 // . "//. // f;.p{/t~ / /y c /~"Z/. c....-'----. i/ - NOTARY SEAL My commission PAUL NOlARY P\J8UC SlATE Of ~ IIr CIfl i1 'r-1qJiM Ikt.It, llllll E - CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Marjorie A. Boomershine Date of Death: December 16, 2000 Estate No. 21-01-106 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 2, 2001. Name Address 1. Roberta L. Slaybaugh 7023 San Sebastian Circle Boca Raton, FL 33433 2. James W. Boomershine 117 Landing Drive Rehoboth Beach, DE 19971 3. J. Douglas Boomershine 1401 Meeting House Road Knoxville, TN 37921 4. David S. Boomershine 3975 Sharp Road Glennwood, MD 21738 5. Margie L. Blumenthal 265 South College Street Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except None Date: February 2, 2001 clJeMz ~ ~ Dale F. Shughart, Jr. 35 East High Street, Suite 203 Carlisle, PA 17013 Telephone (717) 241-4311 Capacity: Counsel for Personal Representative IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of Marjorie A. Boomershine, deceased Estate No. 21-01-106 TO: Roberta A. Slaybaugh 7023 San Sebastian Circle Boca Raton, FL 33433 Please take notice of the death of decedent and the grant of letters to the personal representative(s} named below. The Decedent Marjorie A. Boomershine, died on the 16th day of December, 2000, at Carlisle, Cumberland County, Pennsylvania. The Decedent died testate. The personal representative of the Decedent is: Roberta A. Slaybaugh 7023 San Sebastian Circle Boca Raton, FL 33433 The will has been filed with the Office of the Register of Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA 17013. Phone No. 717-240-6345. A copy of the Will or petition may be obtained by contacting the Register of Wills and paying the charges for duplication. Date: February 2, 2001 ~ Capacity: Dale F. Shug t, Attorney Supreme I.D. #19373 35 East High Stre t, Suite 203 Carlisle, PA 170 3 Telephone (717) 241-4311 Counsel for Personal Representative IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of Marjorie A. Boomershine, deceased Estate No. 21-01-106 TO: J. Douglas Boomershine 1401 Meeting House Road Knoxville, TN 37921 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent Marjorie A. Boomershine, died on the 16th day of December, 2000, at Carlisle, Cumberland County, Pennsylvania. The Decedent died testate. The personal representative of the Decedent is: Roberta A. Slaybaugh 7023 San Sebastian Circle Boca Raton, FL 33433 The will has been filed with the Office of the Register of Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA 17013. Phone No. 717-240-6345. A copy of the Will or petition may be obtained by contacting the Register of wills and paying the charges for duplication. Date: February 2, 2001 Da e F. Shu hart, Attorney Supreme urt I.D. #19373 35 East High Street, Suite 203 Carlisle, PA 17013 Telephone (717) 241-4311 Counsel for Personal Representative Capacity: IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE ~EGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of Marjorie A. Boomershine, deceased Estate No. 21-01-106 TO: James W. Boomershine 117 Landing Drive Rehoboth Beach, DE 19971 Please take notice of the death of decedent and the grant of letters to the personal representative(s} named below. The Decedent Marjorie A. Boomershine, died on the 16th day of December, 2000, at Carlisle, Cumberland County, Pennsylvania. The Decedent died testate. The personal representative of the Decedent is: Roberta A. Slaybaugh 7023 San Sebastian Circle Boca Raton, FL 33433 The will has been filed with the Office of the Register of Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA 17013. Phone No. 717-240-6345. A copy of the Will or Petit10n may be obtained by contacting the Register of Wills and paying the charges for duplication. Date: February 2, 2001 ale F. Sh ghart, Attorney Supreme I.D. #19373 35 East High Stre t, Suite 203 Carlisle, PA 17013 Telephone (717) 241-4311 Counsel for Personal Representative Capacity: IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of Marjorie A. Boomershine, deceased Estate No. 21-01-106 TO: David S. Boomershine 3975 Sharp Road Glennwood, MD 21738 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent Marjorie A. Boomershine, died on the 16th day of December, 2000, at Carlisle, Cumberland County, Pennsylvania. The Decedent died testate. The personal representative of the Decedent is: Roberta A. Slaybaugh 7023 San Sebastian Circle Boca Raton, FL 33433 The will has been filed with the Office of the Register of Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA 17013. Phone No. 717-240-6345. A copy of the Will or Petition may be obtained by contacting the Register of wills and paying the charges for duplication. Capacity: ~~f~ Attorney Supreme Court I.D. #19373 35 East High Street, Suite 203 Carlisle, PA 17013 Telephone (717) 241-4311 Counsel for Personal Representative Date: February 2, 2001 IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of Marjorie A. Boomershine, deceased Estate No. 21-01-106 TO: Margie L. Blumenthal 265 South College Street Carlisle, PA 17013 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent Marjorie A. Boomershine, died on the 16th day of December, 2000, at Carlisle, Cumberland County, Pennsylvania. The Decedent died testate. The personal representative of the Decedent is: Roberta A. Slaybaugh 7023 San Sebastian Circle Boca Raton, FL 33433 The will has been filed with the Office of the Register of Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA 17013. Phone No. 717-240-6345. A copy of the Will or Petition may be obtained by contacting the Register of Wills and paying the charges for duplication. Dale F. Shug art, J . Attorney Supreme Co rt .D. #19373 35 East High Street, Suite 203 Carlisle, PA 17013 Telephone (717) 241-4311 Counsel for Personal Representative Date: February 2, 2001 Capacity: C!~ STATUS REPORT UNDER RULE 6.12 Name of Decedent: Marjorie A. Boomershine Date of Death: December 16, 2000 Estate Will No. ~n. No. 21-01-106 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 port. Date: 0-/0-01 Dale F. Shughart J Jr. Name (Please type or print) 35 East High Street, Suite 203 Address Carlisle, PA 17013 (717) 241-4311 Tel. No. Capacity: Personal Representative x Counsel for personal representative (MAH:rmf/AM3) \'/6'- c2 ()~-- 6' 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 ~ ~~ CV/J r./" REV-1547 EX AFP el2-00) DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN DALE F SHUGHART STE 203 35 E HIGH ST CARLISLE JR ESQ P~ ~p013 04-30-2001 BOOMERSHINE 12-16-2000 21 01-0106 CUMBERLAND 101 MARJORIE A Amount Remitted (ll (2,) (3) (4) (5) (0) (7.) (9) nO) CHANGED .00 15,444.00 .00 .00 20,763.27 2,001.99 .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 nll (12) (13,) (14) (15) (10) (17) (18) 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': 15'47-E>CAFP--C12':-ooY-NoYicE--oF--fNHERiTAifce-YA"x-APPRA-iSEHENT-,--ALToWAt.fcE-cfri----------- - - -- -- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BOOMERSHINE MARJORIE A FILE NO. 21 01-0106 ACN 101 DATE 04-30-2001 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) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E') o. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets If an assessment was issued previoUSly, lines reflect figures that include the total of ALL ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 10. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: NOTE: 12,689.82 4,650.29 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 38,209.26 17.340.11 20,869.15 .00 20,869.15 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. .00 X 00 = 20,869.15 X 045 = .00 X 12 = .00 X 15 = (19)= .00 939.11 .00 .00 939.11 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 03-15-2001 AA478158 46.96 892.15 TOTAL TAX CREDIT 939.11 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.) Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of Boomershine, Marjorie A. , Deceased No. 21 - 01 - 00106 Date of Death 12/16/2000 Social Security No. 277-07-2857 also known as Roberta A. Slaybaugh The 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 located 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 the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. l!We verify that the statements made in this Inventory are true and correct. l!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. 1.0. No.: 19373 Personal R.P~ Signature: Q e . y aug Signature: ~14 Attorney: Dale F Shughart, Jr. Esquire Signature: Address: 35 E. High Street, Suite 203 Address: 7023 San Sebastian Circle Boca Raton, FL 33433 Carlisle, PA 17013 Telephone: (717) 241-4311 (S(,J ) Telephone: 7 $"0-7 & l./f. Dated:.x 3-7-Z00 1 Personal Property 400 shares, Carlisle Companies, Inc., value per attached report from Tucker Anthony, per share 38.61 15,444.00 Furniture and furnishings at Nursing Home, value based upon sale price. 100.00 Freedom Cash Management Fund #DSH-008503-21, Tucker Anthony Principal 513.94 Accrued interest 1.69 515.63 IBM Southeast Employees' FCU, Membership Account #183829102 Principal 16,392.02 Accrued interest 64.82 16,456.84 Carlisle Tire & Rubber, fmal retirement pay 177.34 Resident Funds of Thotnwald, balance in resident's account 24.26 .(Attach additional sheets if necessary) Total Personal Property and Real Estate $36,207.27 Register of Wills of Cumberland County, Pennsylvania INVENTORY continued , Deceased No. 21 - 01 - 00106 Date of Death 12/16/2000 Social Security No. 277-07-2857 Estate of Boomershine, Marjorie A. also known as Unity Financial Life Insurance Company, refund 184.04 Bankers Life & Casualty, reimbursement 242.00 U.s. Treasury, 2000 income tax refund 2,983.47 Bankers Life, refund of premium 79.69 Total Personal Property $36,207.27 .~.....\ r , \.. -.; 2 -n i2 0 :r: m " m I :tl :r:OalOO )>mc:mo CJ (J) lW \.:1 m JJ"lJ:rJ"lJ;;;: D C en '0' 0 JJ:-im)>;;;: C m iJi[;5>::jo :J) ...... <: cooc:;;;:z , r:1 W m C())Om~ ,..., 01 1) c ~S"'zm t.r"! m D "Tl . Z --l)> ,- ru -4 :::) :tl "lJ co~ I 0 )> <"T1:r: fT1 <:'l ---I ~ ::1 6JJo lJJ ,.. c:m"T1 .J- I\) >rii"lJ ;..... t:;l (Xl ~ [! D 6 ~zm ()) -ICZ D ..I.. r S ~mti5 rr; m -< r..J,) en r < .- --j "T1 )> '-J ;:u Z 0 m L... j; ...,.;. fl1 :t1 GJ '-4 (f) m )> r nn ::r "'. rn 0 r~ , J -r 0 0 "lJ 0 Z "T1 m )> 0 0 )> )> r= en -I C (fJ -I ;;;: m --j m Z -I m m Z 0 (1 :! ;;;: 0 m~ C )> ....... "T1 )> "T1 iu ;;;: -t ru 0 C c.:rJ (;.J "lJ 00 .... co m -;:<; ..... m 3: '-~ 0 -.."., )> am i m Z )> -< JJ ::( ,- -I (II 0)> ,- ;;;: ..0 ru " t :r: o~ -m (~. r>1 lH ~ rn 0 -:-:1 0 (I "- :D '. 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