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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
O'BRIEN, Francis A.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD.YEAR)
January 11, 2001 March 23, 1914
(IF APPUCABlE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
n/a
[X] 1. Original Return
o 4. Limited Estate
[X] 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (dale of dt!alll after 12.12.82)
o 7. Decedent Maintained a Living Trust (AlIachcopy of Trusl)
o 10. Spousal PO'l~rty Credit (dale of dealhbelween 12-31.91 and 1.1-95)
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OFFICIAL USE ONLY
Ai - .,:ZJ)S ~ /.:2,
FILE NUMBER
21 01 0113
COUNTY CODE
YEAR
NUMBER
SOCIAL SECURITY NUMBER
116
01
4936
THIS RElURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3,Remal!'\derRetum(daleolda-alhpOOito12.13-82)
o 5. Federal Estate Tax Return Required
1 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (AtlachSchO)
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NAME
Richard L. Place
FIRM NAME (If.Mcable)
PLACt;Y & WRIGHT
TELEPHONE NUMBER
(717) 236-9577
uire
COMPLETE MAILING ADDRESS
3631 North Front street
Harrisburg, PA 17110-1533
1. Real Estate (Schedule A) (1) .00
2. Stocks and Bonds (Schedule B) (2) 18,442.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) .00
4. Mortgages & Notes Receivable (Schedule D) (4) .00
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 137,193.86
Z (Schedule E)
0 6. Jointly Ooned Property (Schedule F) (6) .00
~ D Separate Billing Requested
::l 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) .00
I- (Schedule G or l)
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c( 8. Total Gross Assets (tolal Lines 1-7)
0 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 24,982.13
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0: 10. Debts of Decedent, Mortgage liabilities, & liens (Schedule I) (10) .00
11, total Deductions (total lines 9 & 10)
12. Net Value of Estate (line 8 minus Une 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election 10 tax has not been
made (Schedu", J)
14. Net Value Subject to Tax (lin~ 12 minus Une 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Une 14 taxable at lineal rate
17. Amount of Une 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
129,653.73
1,000.00
x.o_ (IS)
xO~ (16)
x .12 (17)
x .15 (18)
(19)
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OFFICIAL USE ONLY
(8)
155,635.86
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
(11)
(12)
(13)
24,982.13
130,653.73
.00
(14)
130,653.73
.00
5,834.42
120.00
.00
5,.954.42
Decedent's Complete Address:
STREET ADDRESS
13 Dewalt Drive
CITY Mechanicsburq I STATE PA I ZIP 17055
Tax Payments and Credits:
1. Tax Due (Page 1 line 19)
2. CreditslPayments
A. Spousal Poverty Credn
B. Pnor Payments
C. Discounl
(1)
5,954.42
297.72
Total Credits (A< B < C) (2)
297.12
3. InteresVPenany ff applicable
D.tnterest
E. Penalty
.00
TotallnterestlPenalty ( D < E ) (3)
4. If line 2 is greater than line 1 < line 3, enler the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. ff line 1 < line 3 is greater than Line 2, enter the difference. This is the TAX DUE, (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 < 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
5,656.70
.00
5,656.70
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the nght to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or......................................................................,.................................................... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. if death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an 'in trust for" or payable upon death bank account or secunty at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0
No
129
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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 peljury, I declare that I have examined this return, including accompanying sdledules and statements, and 10 /he best of my knovde<1ge and belief, it is true, COffl3Ct
and complete.
Declaration ofpreparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FiLING RETURN
Robert F. 0' ien Executor
ADDRESS
c/o Placey & Harrisburg, PA 17110
SIGNATURE OF PREPARER OTHE
ADDRESS
Place
PA 17110
._,7
N. Front
Harrisbur
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 10 or for the use of the surviving spouse is 3%
(72 PS. ~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 dales 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 stepparenl of the child is 0% [72 P.S. ~9116(a)(1.2)j.
The lax rale imposed on the net value of transfers to or for Ihe use of the decedents lineal beneficianes is 4.5%, except as noled 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 decedents siblings is 12% (72 P.S. ~9116(a)(1.3)J. A sibiin9 is defined, under Section 9102, as an
individual who has at leasl one parent in common with the decedent, whelher by blood or adoplion.
RE"ASQ3~..<l-9n
ESTATE OF
'*
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERJTANCE TAX RETURN
RESIDENT DECEDENT
FRANCIS A. O'BRIEN
FILE NUMBER
21-01-0113
An property jolntly-owned \\rilh right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
VALUE AT DATE
OF DEATH
1.
DESCRIPTION
2.
Exxon Mobil Corporation 80 shares common
Hi: 82.8750; Lo: 81.3750
Valued @ $82.125 per share
6,570.00
International Business Machines 128 shares common
Hi: 94.250; Lo: 91.250
Valued @ $92.750 per share
11,872.00
(See security valuation sheet attached)
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TOTAL (Also enter on line 2, Recapitulation) $ 1 8 , 442. 00
In more space Is needed, insert additional sheets of It1e same sizel
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Total 'J,llue:
Totol J\ccrual:
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01/11/2001
01/11/2001
,j2!H/2fHll
Security
OescTiplion
High/Ask
Low/f.!id
~sti:tte of: Francis "ft. O'Bl"ie.n
Report 'I'y~: Oat..;. ot Daa th
f.'l'umbcJ: of Socul:'iUe-s: 2
Fi.la TD: (Jbl::ien
Mean and/or Di~ and Tnt
Adju5tment~ Acc~uals
SE:CUl:'i1~y
Valtlt.~
1. EXXON MOBIL CORP (302290101)
~YSE
o lIll! ZOOl
82.87500
81. 37500 H/L
82.125000
'lj2.13
1 lUn:RNArlONAL BUSINEAS MACHS (45921]0101..)
NYSE
01(11/2001 94. :t'000
9] .25000 filL
Q2.7500DO 92,7~
;,170.1.. Be
$0.00
This report l-Ja,s p?':oduced \"Lith E;si:ate'lal 2.000, a prouuct of Estat.:=! Valuati:.rm~, ii Pd.cing Sy.stems, Inc. IE YG\.l naVe: qucstjc;nsj
pleaH\i:l c.;ontact" ~VP System,,:,; at !B18) 313--05300. (.r.evi;;ioT1 6.0.3}
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
ESlDENT CEDENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FRANCIS A. O'BRIEN
FILE NUMBER
21-01-0113
Include 1I1e procee<ls of litigation and 1I1e date 1I1e proceeds were received by 1I1e estate. All property jolnUy-o_ wiIllllle right of survivorship must be disclosed on Schedule F.
ITEM VAlUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
2.
3.
4.
5.
6.
7.
Harleysville National Bank and Trust
Checking Account No. 14-3614633
Principal - $5,883.41
Interest - $ 4.33
Company
5,887.74
Harleysville National Bank and Trust Company
Statement Savings Account No. 1406582
Principal - $157.70
Interest - $ .27
157.97
M&T Bank C.D. No. 31003908152091
Principal - $40,000.00
Interest - $ 212.25
40,212.25
Fulton Bank C.D. No. 025-0112610
principal - $90,334.26
Interest - $ 461.47
90,795.73
Chase - credit refund
13.17
AARP - cancellation refund
127.00
Miscellaneous Personal Effects
NO VALUE
TOTAl (Also enter on line 5, Recapitulation) $ 1 37, 1 93. 86
(If more space is needed, Insert addilional sheets of the same size)
RLEYSVILLE NATIONAL
Bank and Trust Company
Ha~eysville. PA 19438-0195
(215) 256-8851 (800) 423-3955
www.ha~eysvillebank.com
February 7,2001
Richard L. Placey
Placey & Wright
3631 N. Front Street
Harrisburg, PA 17110-1533
RE: The Estate of Francis A. O'Brien. Deceased
Dear Attorney Placey;
Our records indicate the following as of January 11, 200 t.
SAFE DEPOSIT BOX
ACCOUNT#
150467
l/N/O
Francis A. O'Brien
& Ruth E. O'Brien
A TM CARD
ACCOUNT#
2616502
l/N/O
Francis A. O'Brien
INTEREST-BEARING CHECKING
ACCOUNT# I1N/O
14-3614633 Francis A. O'Brien
& Ruth E. O'Brien
(Always titled this way)
STATEMENT SA VJNGS
ACCOUNT# l/N/O
1406582 Francis A. O'Brien
& Ruth E. O'Brien
(Always titled this way)
* Figure does not include accrued interest
OPENED SIZE LOCATJON
5/3/94 3 x 5 224 W. Broad St., Quakertown, PA
DATE OF DEATH
OPENED RATE BALANCE*
5/25/93 1.26% $5,883.41
Closed date-2!7101
ACCRUED
INTEREST
$4.33
DATE OF DEATH
OPENED RATE BALANCE*
5/25/93 2.51% $157.70
Closed date-2!7101
ACCRUED
INTEREST
$.27
Enclosed is cashier's check# 139998775 for $1.703.88 representing the closing proceeds of the accounts
14-3614633 and 1406582. You mentioned a Certificate of Deposit Account #331561, but that was closed
prior to date of death on November 10, 2000.
Should YOll have any further questions, please feel free to contact me at 800 423-3955, extension 1338.
Yours truly,
~R~
Carol R. Nice
Customer Support Representative
Harleysville National Bank
Member FDIC
@
--
LENDER
fl:1M&rBank
March 29, 2001
RE:
Estate Search
The Estate of:
Date of Death (D.O.D.)
FRANCIS A O'BRIEN
1111/2001
To Whom It May Concern:
Identified below is the account information requested.
I. M&T Bank accounts in which the decedent's name appears:
CD
3100390&152091
FRANCIS A O'BRIEN
4342
0.0.0. Accrued Interest
Balances
(Includes Acer.
Int.)
$40,212.25 $212.25
Account
Type
Account Number
Account Title
Opening Branch
2. Loans, Mortgages, or other obligations titled in the decedent's name
Account Number
Amount Owed
Account Description
NO Safe Deposit Box titled in the Decedent's name existed at our office.
If you have any questions about the information provided, please contact our Records Department at (716) 635-40 I 0 or 1-&00-724-
2440 outside of the Buffalo, NY calling area. Thank you.
Sincerely,
M&T BANK CORPORA nON
BY:
~dAMA~ ~
Authorized Signature
DATE:
:s- dCJ ~ 0 I
Manufacturers and Traders Trust Company. 1100 Wehrle Drive, Po. Box 767. Buffalo. NY 14240-0767
Fulton Bank
PO. BOX 4887 . LANCASTER, PA 17604
People dedicated to your success. ~
(717)291-2589
WWW.FULTONBANK.COM
]-800-FULTON-4
February 5, 2001
Richard L. Placey
Placey & Wright
3631 North Front St.
Harrisburg, P A 17110
Dear Mr. Placey:
RE: Francis A. O'Brien, deceased
January 11,2001
In response to your recent inquiry concerning the accounts maintained in the name of
the decedent, please be advised that the following accounts were open at the date of death:
CD #025-0112610, open 10/12/99, matures 4/12/02,
balance $90,334,26 and accrued interest $461,47;
paying 6,2%, in his name only,
If you have any further questions, please do not hesitate to contact me.
Very truly yours,
QV\;lG},u f~v~
Christine Putt Smith
Credit Confirmation Processor
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COMMONWEALTH OF PENNSYLVANlA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FRANCIS A. O'BRIEN
FILE NUMBER
21-01-0113
ESTATE OF
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: .
1. Fitzgerald-Sommer Funeral Home 4,145.26
2. Irene Nunn - reimb. post-funeral meal 1,069.94
3. Joseph F. Hevener - gravemarker inscription 145.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative s Commissions
Name of Personal Representative (s) Robert F. O'Brien
Social Seculily Number(s) I EIN Number of Personal Representative(s)
Street Address 13 Dewalt Drive
City Mechanicsburg PA 17055 7,225.00
Slate Zip
Yea~s) Commission Paid:
2. Attomey Fees Placey & Wright 7,225.00
3. Fami~ exemption: (If decedent s address 10 not \he same as claimant s. atlach explanation)
Claimant Robert F. O'Brien
Street Address 13 Dewalt Drive
City Mechanicsburq State PA Zip 17055 3,500.00
Relationship of Claimant to Decedent
4. Probate Fees Cumberland County Register of Wills 267.00
5. Accountant s Fees
6. Tax Return Preparer 5 Fees
7. Robert F. O'Brien - reimb. telephone charges 50.00
8. Chase Visa - debt of decedent 24.98
9. Patriot-News Co. - estate advertising 82.95
10. PA Dept. of Revenue - 2000 PA40 133.00
11 . H&R Block - preparation 2000 individual income taxes 39.00
12. Cumberland Law Journal - estate advertising 75.00
13. Reserve for future costs, taxes and expenses 1,000.00
TOTAL (Also enter on line 9, Recap"ulation) $ 24,982.13
..
(If more space IS needed, lOSer! ooditional sheets of the same size)
.REV-1513EX:ll.gn
.
SCHEDULE J
BENEFICIARIES
ESTATE OF
21-01-0113
NUMBER
I.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FRANCIS A. O'BRIEN
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1.
Francis O'Brien
110 West Wissahickon Avenue
Flourtown, PA 19031
FILE NUMBER
RELATIONSHIP TO DECEDENT
Do Not List Trustee!s)
Sister
Sister
Granddaughter
Granddaughter
Granddaughter
AMOUNT OR SHARE
OFEST ATE
$ 500.00
500.00
500.00
500.00
500.00
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
2.
Rosemary O'Brien
St. Rose Convent, 610 8th Avenue
Belmar, NJ 07719
3.
Chalmarie Fay Powers
3115 Hearn Road
Monroe, GA 30656
4.
Peggy Sue O'Brien Huckaby
c/o 3115 Hearn Road
Monroe, GA 30656
5.
Theresa Louise Willoughby
5988 Maryjo Lane
Norcross, GA 30093
(See continuation attached)
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ . 0 0
(If more space IS needed, Insert additional sheets of the same size)
ATTACHMENT TO SCHEDULE J
BENEFICIARIES
ESTATE OF FRANCIS A. O'BRIEN
21-01-0113
6. John Lewis O'Brien
5988 Maryjo Lane
Norcross, GA 30093 Grandson $500.00
7. Tracy O'Brien
1044 Old Foundry Road
Newton, NJ 07860 Granddaughter $500.00
8. Robert F. O'Brien
13 Dewalt Drive
Mechanicsburg, P A 17055 Son 55% Residue
9. John A. O'Brien
5988 Maryjo Lane
Norcross, GA 30093 Son 45% Residue
LAST WILL AND TESTAMENT
BE IT REMEMBERED THAT
I, FRANCIS A. O'BRIEN, a resident of CUmberland County,
Pennsylvania, being of sound and disposing mind, memory and
understanding, do make, publish and declare this to be my LAST WILL
and TESTAMENT, hereby revoking any and all wills and Codicils
previously made by me.
I
I declare that I am not married, my beloved wife having
predeceased me, and that I have two (2) sons, ROBERT F. O'BRIEN and
JOHN A. O'BRIEN, and five (5) grandchildren, FAY POWERS, PEGGY SUE
O'BRIEN, THERESA O'BRIEN, JOHN LEWIS O'BRIEN and TRACY O'BRIEN.
II
I direct that all my just debts and funeral expenses shall be
paid from my residuary estate as soon as practicable after my
decease.
III
I direct that all taxes that may be assessed in consequence of
my death, of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate as a part of the expense of
the administration of my estate.
IV
I give and bequeath FIVE HUNDRED DOLLARS ($500.00) to my
sister, FRANCES O'BRIEN. If she fails to survive me, then I give
this money to my sister, ROSEMARY O'BRIEN.
V
I give and bequeath FIVE HUNDRED DOLLARS ($500.00) to my
sister, ROSEMARY O'BRIEN. If she fails to survive me, then I give
this money to my sister, FRANCES O'BRIEN.
VI
I give and bequeath any automobile which I may own to my son,
ROBERT, provided that he survives me.
. .
VII
I give and bequeath the sum of FIVE HUNDRED DOLLARS ($500.00)
to each of my grandchildren, FAY, PEGGY, THERESA, JOHN, and TRACY.
If any of my grandchildren should predecease me, then that money
shall be divided equally among my surviving grandchildren.
VIII
I deeply appreciate the care that has been given to me by my
son, ROBERT. I give, devise and bequeath FIFTY-FIVE PERCENT (55%)
of the rest, residue and remainder of my property, whether real or
personal, wherever situate, including any property over which I may
have a power of appointment, to my son, ROBERT.
If ROBERT should
predecease me, then this portion of my estate shall be divided
equally among my surviving grandchildren.
IX
I give, devise and bequeath FORTY-FIVE PERCENT (45%) of the
rest, residue and remainder of my property, whether real or
personal, wherever situate, including any property over which I may
have a power of appointment, to my son, JOHN.
If JOHN should
predecease me, then this portion of my estate shall be divided
equally among my surviving grandchildren.
x
I nominate, constitute and appoint my son, ROBERT F. O'BRIEN,
as Executor of this LAST WILL, to serve without bond. If ROBERT is
unable or unwilling to act in that capacity, then I nominate,
constitute and appoint RICHARD L. PLACEY as Executor of this LAST
WILL, to serve without bond.
IN WITNESS WHEREOF, I, FRANCIS A. O'BRIEN, have set my hand to
this LAST WILl, this c.... '7 day of )/fl~r ' 1998.
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FRANCIS A. O'BRIEN
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Signed, sealed, publiShed and declared by the above-named
FRANCIS A. O'BRIEN, as and for his Last will and Testament~ in the
presence of us, who, at his request and in his presence, a tl in e
presence of each other, have hereunt subs ribed our na s as
witnesses. I /J ;,,/'1/...
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ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
I, FRANCIS A. O'BRIEN, Testator, whose name is signed to the
attached or foregoing instrument, having been duly qualified
according to law, do hereby acknowledge that I signed and executed
the instrument as my LAST WILL; that I signed it as my free and
voluntary act for the purposes therein expressed.
;:J!;,/,-;,'--v.c;" A i.r~,~..'\.
FRANCIS A. O'BRIEN
Sworn or affirmed to and acknowledged before me
o I BRIEN, Testator, this ;27-ff... day of /) 7CM-y
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ALc4"'- 'h,.
Notary Public
by FRANCIS A.
, 1998.
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Notarial Seal
Diane M. Smith, Notary Public
Mechanlcsburg Boro, Cumberland County
My Commle.lon Expires June 22, 2000
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
we, Il)urr< I /2, tt.loJ'f.e(S :L2Tand H/1/11/Z (::"'NJlocL:1 ,
the witnesses whose names are signed to the attached or tbregoing
instrument being duly qualified according to law, do depose and say
that we were present and saw Testator sign and execute the
instrument as his LAST WILL; that FRANCIS A. O'BRIEN signed
willingly and that he executed it as his free and voluntary act for
the purposes therein expressed; that each of us in the hearing and
sight of the Testator signed the will as wit esses; and that to,th~
best of our knowledge, the Testator was~t e time.18Lyears o:f.>a:ge
or more, of sound mind and under no con,t/r in.. t or/,~i;/rf7ri~/.
V/i(;/ flll/[/
I?f-'--'- (b".U.f t-
Sworn or affirmed to and acknowledged be re me
this ,2 '7 o.f<.-. day of I} )Cl7 ' 1998.
DILt'J~ })\. ,~hU~
Notary Public
Notarial Seal
Diane M. Smith, Notary Public
Mechanlcsburg Boro. Cumberland County
My Commissfon Expires June 22, 2000
4
PLACEY t6 WRIGHT
RICHARD L. PLACEY
ATTORNEYS AT LAW
363 I NORn-l FRONT STREET
HARRISBURG, ~ENNSYLVANIA 17110-1533
WILLIAM K. WRIGHT
(lQ43-'9991
(717) 236-9577 FAX (717) e36-0843
April 6, 2001
Register of Wills
CUMBERLAND COUNTY COURTHOUSE
One Courthouse Square
Carlisle, P A 17013
RE: Estate of Francis A. O'Brien
Estate No. 21-01-0113
Dear Madam/Sir:
We enclose herewith for filing, in duplicate, Pennsylvania Inheritance Tax Return for the
captioned decedent, together with check in the amount of$15.00 to cover the cost of the filing
fee and check in the amount of $5,656.70 in payment oftax due.
Please send your receipt for the filing of the same to the undersigned in the enclosed,
stamped, addressed envelope.
Thank you.
~
RLP:hsk
Enclosures
cc: Robert F. O'Brien
Register of Wills of Dauphin County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of
FRANCIS A. O'BRIEN
No. dl-Of
J 1-3
also known as
, Deceased
Social Security No. 116-01-4936
Petitioner(s). who is/are 1 B year. 01 age or older. apply lies) tor:
(COMPLETE" A" OR "B" BELOW:)
~
A. Probate and Grant of Letters and aver that Petitioner(x) is/MR the execut~ named in the Last Will of the
Decedent, dated May 27, 19 98 CDOKxodX:X(x)xdetm
State rele',/ant circumstances. e.g.. renunciation. death ot 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:
~
B. Grant of Letters of Administration
le.La.. d.b.n.c.t.8.: pendente lite; durante absentia; durante minOlitalel
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:
I Name Relationship Residence I
(COMPLETE IN ALL CASES:) Attach additional sheets ,f necessary.
Decedent was domiciled at death in Cumber land County, Pennsylvania, with hlsltlKr last family or principal
residence at 13 Dewalt Drivel Mechanicsburq, Silver Spring Township, Cumberland
(list stleet, number and municipality) County, pennsy 1 vanla
Decedent, then 86 years of age, died. January 11 , 20~, at Holy Spiri t Hospi tal
(Locationl
Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property .............................. $ 130 , 0 0 0 . 0 0
(If not domiciled in PA) Personal property in Pennsylvania. . . . . . . . . . . . . . . . . . . . . . $
(If not domiciled in PAl Personal property in County. . . . . . . . . . . . . . . . . . . . . . . . . . $
Value of real estate in Pennsylvania ............................................... $
T ota' .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 13 0 , 0 0 0 . 0 0
Real Estate situated as follows:
Wherefore, Petitioner(~ respectfully request(s) the probate of the last Will aftl(XOCflCiKM presented with this Petition and the grant of letters in the
appropriate form to the undersigned:
Typed or printed name and residence
Robert F. O'Brien
13 Dewalt Drive
Mechanicsburg, PA
17055
RW-7 1(, - ~ [).S - j~~
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Dauphin
The Petitioner (x) 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(x) and that, as personal representative(~ of the Decedent,
Petitionerb$) will well and truly administer the estate according to law.
f. ,At?,.:! If' (f[)jj , / ~
Robert F. O'Brien
Sworn to and affirmed and subscribed
before me this
25th
day of
January
20 -lL1
DB \\ -~
0;-, . '. ..1T'\,
I
7'Y~ll
'.../- '
c... c}...Q~C~J).
DECREE OF REGISTER
Estate of
FRANCIS A. 0' BRIEN
Deceased
No. 21-01-113
also known as
Social Security No: 116-01-4936
Date of Death: Jan. 11,2001
AND NOW, JANUARY 26 , 20 Ol-, in consideration of the Petition
on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters ~ Testamentary 0 of Administration
fc,l.a.; d.luu;l.; pendente lite; durante absentia; durante minonlatel
are hereby granted to
Robert F. O'Brien
in the above estate and that the instrument(s), if any, dated
described in the Petition be admitted to probate and filed of record as the last =Will of Decedent.
FEES
Letters........................... $ 235.00
"I)
'-rYYl h1 c.. ~u_....., . '). r () \)
Reg"'" 01 W,"sf~ P I) ~~
Short Certificate(s).... ~.... $ 18.00
Renunciation................. . $
Affidavit ( )................. $
Extra Pages ( )............ $ 9.00
Cod i ci I. . . . . . . . . . . . . . . . . . . . . . . . . . $
JCP Fee... ... .. .... . . . . . . . ... . . $ 5.00
Inventory & Tax Forms... $
Other......... .. ................. $
Attorney:
I.D. No:
Address:
Richard L. P1acey
07232
3631 North Front Street
Harrisburg, PA 17110-1533
(717)236-9577
TOTAL................. $ 26700
Telephone:
DATE FILED:
Jan. 26,2001
RW-7a
~~~ etL.~) ~~ Q~ 1 - d.L '-0 I
LAST WILL AND TESTAMENT
BE IT REMEMBERED THAT
I, FRANCIS A. O'BRIEN, a resident of Cumberland County,
Pennsylvania, being of sound and disposing mind, memory and
understanding, do make, publish and declare this to be my LAST WILL
and TESTAMENT, hereby revoking any and all wills and Codicils
previously made by me.
I
I declare that I am not married, my beloved wife having
predeceased me, and that I have two (2) sons, ROBERT F. O'BRIEN and
JOHN A. O'BRIEN, and five (5) grandchildren, FAY POWERS, PEGGY SUE
O'BRIEN, THERESA O'BRIEN, JOHN LEWIS O'BRIEN and TRACY O'BRIEN.
II
I direct that all my just debts and funeral expenses shall be
paid from my residuary estate as soon as practicable after my
decease.
III
I direct that all taxes that may be assessed in consequence of
my death, of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate as a part of the expense of
the administration of my estate.
IV
I give and bequeath FIVE HUNDRED DOLLARS ($500.00) to my
sister, FRANCES O'BRIEN. If she fails to survive me, then I give
this money to my sister, ROSEMARY O'BRIEN.
V
I gi ve and bequeath FIVE HUNDRED DOLLARS ($500.00) to my
sister, ROSEMARY O'BRIEN. If she fails to survive me, then I give
this money to my sister, FRANCES O'BRIEN.
VI
I give and bequeath any automobile which I may own to my son,
ROBERT, provided that he survives me.
VII
I give and bequeath the sum of FIVE HUNDRED DOLLARS ($500.00)
to each of my grandchildren, FAY, PEGGY, THERESA, JOHN, and TRACY.
If any of my grandchildren should predecease me, then that money
shall be divided equally among my surviving grandchildren.
VIII
I deeply appreciate the care that has been given to me by my
son, ROBERT. I give, devise and bequeath FIFTY-FIVE PERCENT (55%)
of the rest, residue and remainder of my property, whether real or
personal, wherever situate, including any property over which I may
have a power of appointment, to my son, ROBERT.
If ROBERT should
predecease me, then this portion of my estate shall be divided
equally among my surviving grandchildren.
IX
I give, devise and bequeath FORTY-FIVE PERCENT (45%) of the
rest, residue and remainder of my property, whether real or
personal, wherever situate, including any property over which I may
have a power of appointment, to my son, JOHN .
If JOHN should
predecease me, then this portion of my estate shall be divided
equally among my surviving grandchildren.
X
I nominate, constitute and appoint my son, ROBERT F. O'BRIEN,
as Executor of this LAST WILL, to serve without bond. If ROBERT is
unable or unwilling to act in that capacity, then I nominate,
constitute and appoint RICHARD L. PLACEY as Executor of this LAST
WILL, to serve without bond.
IN WITNESS WHEREOF, I, FRANCIS A. O'BRIEN, have set my hand to
this LAST WILL this c.... '7 day of ~ ' 1998.
~Ar~
FRANCIS A. O'BRIEN .
2
signed, sealed, published and declared by the above-named
FRANCIS A. O'BRIEN, as and for his Last Will and Testament, in t
presence of us, who, at his request and in his presence, a in
presence of each other, have hereunt subs ibed our na s
witnesses.
~ ~cjt
3
ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA
SSe
COUNTY OF CUMBERLAND
I, FRANCIS A. O'BRIEN, Testator, whose name is signed to the
attached or foregoing instrument, having been duly qualified
according to law, do hereby acknowledge that I signed and executed
the instrument as my LAST WILLi that I signed it as my free and
voluntary act for the purposes therein expressed.
:;;-~~ A ~
FRANCIS A. O'BRIEN
Sworn or affirmed to and acknowledged before me by FRANCIS A.
O'BRIEN, Testator, this :27"-f'^. day of 1Y7, ' 1998.
~)n.~
Notary Public
Notarial Seal
Diane M. Smith, Notary Public
Mechanicsburg Bora, Cumberland County
My Commluron Expires June 22, 2000
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SSe
COUNTY OF CUMBERLAND
We, fY7u.rrtJ /2, WoJf-eI5 .ill and A/V/lI~ r!a.rmodt. ,
the witnesses whose names are ~igned to the attached or- ~regoing
instrument being duly qualified according to law, do depose and say
that we were present and saw Testator sign and execute the
instrument as his LAST WILLi that FRANCIS A. O'BRIEN signed
willingly and that he executed it as his free and voluntary act for
the purposes therein expressedi that each of us in the hearing a 7
sight of the Testator signed the will as wit essesi and that to
best of our knowledge, the Testator was t e time~~years 0
or more, of sound mind and under no con r int or~; flu
~ ~Au~dd--
Sworn or affirmed to and acknowledged be~e me
this ;1'7 V-c- day of /}/Ii ' 1998.
D~ n~. ~
Notary Public
4
Notarial Seal
Diane M. Smith, Notary Public
Mechanicsburg Bora, Cumberland County
My Commission Expires June 22, 2000
f-; 1 (\~ Qn~
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
"" ,tI""""''''''''",,,
",1'<.. ,,\.\H OF PE';'---__
\II.~\,. 'f"p -
'1I.:::.;:o~. . tr~-:"':.
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f~_~' ~\
$ ~~ .... . . .. ~ ~
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--"--.:'"IAfENl \\\" ,Ill
""'''" "//",,,,,,11//""
I20J~
21-01-113
Fee for this certificate, $2.00
y
70783:19
No.
\JAN 1 5 2001
Date
TYPE/PRINT
IN
PERMANENT
BLACK INK
o \ -0 ~
COMMONWEALTH OF PENNSYLVANIA · OEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
Hl05.143 Rev. 2/87
1.
AGE (Las! alrlMay)
FRANCIS
SEX
STATE FILE NUMBER
SOCIAL SECURITY NUMBER
NAME OF DECEDENT (Firs!. Middle. LaSl)
UNDER 1 YEAR
Month. D.VS
UNDER 1 D,;y
Hccn ~ Mlnllles
2. male 3. 116 - 01
BIRTHPI.ACE (C,ty and PlACE OF DEATH fCt>eck Ol"y 0I'e - <ee .nSlruc,oOffl on ~ Sldel
Slale Of Fcre.gn Counlly) HOSPITAl:
Jersey C:l. ty, NJ Inpal~ ERIOutDa.i.nt 0
7. ...
FACILITY NAME (11 not.ns!ofUl1on. gM! street and
86
Y...
5.
COUNTY OF OERH
Clunber1and
lit.
white
11.
F~ER'S NAME (First. ModdItt. LaSl)
11.
INFORMANTS NAME (T ypelPrinll
17b. Coo
Old
dececlent
.... in .
Clunber1and -ip? '7d.o ~~'=of
MOTHER'S NAME (First. Middle. Malden Surname)
MARITAL ST/IJ'US . Married
N._ M.rried. Widowed.
Divon:.cl (Speedy)
,.. widowed
811 ver
SURVIVING SPOUSE
(K WIfe. !:lIVe matden name)
lWp.
cllylboro.
-.bhn A. 0' Brien
~.
METHOD Of' DISPOSITION
BurIal 0 Cr._lion~ R-..rrom Slal.:f9C
Other ($pecolyl
Ib bert F. 0' Brien
19. ELizabeth Me M10 h
INFORMANT'S MAILING AOOAESS (SlIeer. CityfTown. Slate. LIP Code)
2Gb. 1 Lewa1t Drive Mechanicsbur PA 17055
PlACE OF DISPOsmON - N.me of Cemetery. Cr.malory LOCATlON . CityfTown. State. Z1Il Code
or OIher Place
~
z
w
o
w
:rl
o
lL
o
W
~
<(
Z
21c.
EMing Crema tory
EMing 'IWp., NJ 08628
21d.
LICENSE NUMBER
22b. 011607-L
To lhe baSI of my knowledge. dealh occurred al Ihe I'm.. dale and place stated.
(Signature and Tifle)
NAME AND ADDRESS OF FACILITY
22c.FltzGerald-&:lDuner 17 S.De1aware Ave. Yardley, PA
LICENSE NUMBER DATE SIGNED
(Month. Day. Yearl
23b. 234:.
WAS CASE REFERRED TO MEDiCAl EXAMINERlCORONER7
Yes [iJ'"'" No 0
2S.
I Approximate
: inl_ bal\IWeen
I onset and dealh
I
l
PART II: Other significant conditions conlributing 10 death. but
not ",suRing in the undat1ying cause given in PART I.
\'
j
lb.
c.
d.
DUE lO(OR AS A CONSEOUENCE OF):
.,<
~_J
WERE AUlOPSY FINDINGS MANNER OF OE/IJ'H
A~ll.ABLE PRIOR lO Q('
COMPLETION Of' CAUSE 0
OF DE.ATH? Nalural Homlcid.
Acadenl 0 Pending Investigallon 0
Yes 0 No 0 Suicid. 0 Could not ba delennlned 0
DATE OF INJURY
(Month. Day. Year)
TIME OF INJURY
INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED.
:\
~.
1
Yes 0 NoD
308. 3Gb. M. JOe.
PLACE OF INJURY. AI home. tarm. Slreel. factory. orne.
build1ng. .'C. ISpec,1v}
.2". 28b. 29. 30e.
CERTIFIER IC~eck only one)
'CERTIFYING PHYSICIAN (PhySICIan cerlrlyrng cause of death when an01her phVSIC.an has pronounced dealh ana compleled lIem 231
To the ....t of my knowl.clg., du'h occurred d.... to the cause(s) and manner aa staled. . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . .. . . . .
I~ ,91/,<2'.jQI
/-t~
70~, \..- .
'PRONOUNCING AND CERTIFYING PHYSICIAN (Physlclan both "ronounclng dealh and certIfYIng 10 cause 01 dealhl
To Ih. t..s1 01 my knowledg.., death occurred at the lime, dale, ~nd place, and du. 10 Ih. cause(s) and manner as staled.. . . . . . . . . . . . . . . . . . . . . . . . .
.MEDICAL EXAMINER/CORONER
~~~~:~::i:t::::.~~:~~'.I~~ .a~.d:~~ ~~~~~t~~~t:~~: i.n. ~.Y.~~i~.i~~: ~~~~~ ~~~~~e.~ ~~ ~~~ ~i~~,.~~t~: ~~~.~I~~~: ~~~,~~~ ~~ ~~~ ~~~~~~~).~~~ 0
31a.
If, 0
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~
INVENTORY
Estate of
Francis A. O'Brien
21-01-0113
, Deceased
No.
Date of Death January 11, 2001
Social Security No. 11 6-01 -4936
also known as
Personal Representative($) 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 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. I/We understand that false statements herein made are subject to the
penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Personal Representative:
Name of
Attorney:
1.0. No.:
Richard L. Placey
07232
Robert F. O'Brien
fi~/~~tf1 '
Da;ed _ h. ---~
Telephone:
3631 N. Front street
Harrisburq, PA 17110-1533
(717)236-9577
Address:
Description
Harleysville National Bank Checking 143614633
Harleysville National Bank Savings 1406582
M&T Bank CD 31003908152091
Fulton Bank CD 025-0112610
New York Life Insurance Co. - life ins. proceed
Chase - credit refund
AARP - cancellation refund
Exxon Mobil Corporation 80 shares common stock
IBM 128 shares common stock
Value
5,887.14
157.97
40,212.25
90,795.73
10,613.81
13.17
127.00
6,570.00
11,872.00
T atal
$166,249.07
(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.
RW-4
~
E
~
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Francis A. O'Brien
Date of Death: January 11, 2001
Administration No.: 2001-00113
To the Register:
I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court
Rules was given to the following beneficiaries set forth on the attached list on February 6, 2001.
Notice has now been given to all persons entitled thereto under Rule 5.6(a).
- ,/ ) k
/_/'/ ~
Ric Placey, Esquire ~
ttomey for the Estate
3631 North Front Street
Harrisburg, P A 17110
(717)236-9577
Date: February 6, 2001
\
NOTICE GIVEN TO:
ESTATE OF FRANCIS A. O'BRIEN
Frances O'Brien
11 0 West Wissahickon Avenue
Flourtown, P A 19031
Rosemary O'Brien
St. Rose Convent
610 8th Avenue
Belmar, NJ 07719
Chalmarie Fay Powers
3115 Hearn Road
Monroe, GA 30656
Peggy Sue O'Brien Huckleby
c/o 3115 Hearn Road
Monroe, GA 30656
Theresa Louise Welloughby (formerly Theresa O'Brien)
5988 Maryjo Lane
Norcross, GA 30093
John Lewis O'Brien
5988 Maryjo Lane
Norcross, GA 30093
Tracy O'Brien
1044 Old Foundry Road
Newton, NJ 07860
Robert F. 0 'Brien
13 Dewalt Drive
Mechanicsburg, P A 17055
John A. O'Brien
5988 Maryjo Lane
Norcross, GA 30093
PLEASE FILE TillS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF
THE STATUS OF THE EST ATE. IF EST A TE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY
UNTIL COMPLETION Cr /
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Francis A. O'Brien
Date of Death: January 11, 2001
Will No.:
2001-00113
Admin. No.:
21-01-0113
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 x No
B. The separate Orphans' Court No. (if any) for the personal representative's account
IS: n / a
c. Did the personal representative state an account informally to the parties in
interest? Yes No
D.
Copies of receipts, releases, joinders and approvals of formal or informal accounts
may be filed with the Clerk: of the Orphans'G urt an~,e. .attached to this
~~. i
).. /-7
L---v.'~_"_-'-
//Signature
~hard L: ~laCey
Name (Please type or print)
3631 North Front street
Harrisburg, PA 17110-1533
Address
Date: 9 / 2 3 /02
(717)236-9577
(MAH:rmtlAM3)
Telephone No.
Capacity:
Personal Representative
x
Counsel for Personal Representative
RW. - 27
/ ~ - c:2,Oo-- /' d
\
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
05-21-2001
OBRIEN
01-11-2001
21 01-0113
CUMBERLAND
101
RICHARD L PLACEY ESQ
PLACEY & WRIGHT
3631 N FRONT ST
HBG PA 17110
q~/*
REY-1547 EX AFP (12-00)
FRANCIS
A
Amount Remitted
CHANGED
(1)
(2)
(3)
(4)
(S)
(6)
(7)
.00
18,442.00
.00
.00
137,193.86
.00
.00
(8)
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV=is4-j-EX-AFP-fi'2-:oo1--NOT-fcE--OF-i-NHEiffTANCi-TAi-APPRAfSEMENY-,--ALrOWAifci-oR'-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF OBRIEN FRANCIS A FILE NO. 21 01-0113 ACN 101 DATE 05-21-2001
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
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
24,982.13
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
155,635.86
24 . Q82 . 13
130,653.73
.00
130,653.73
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
IS. Amount of Line 14 at Spousal rate (IS)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 = .00
129,653.73 X 045 = 5,834.42
1,000.00 X 12 = 120.00
.00 X 15 = .00
(19)= 5,954.42
.00
(11)
(12)
(13)
(14)
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
04-06-2001 AA478259 297.72 5,656.70
TOTAL TAX CREDIT 5,954.42
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
IN THE ORPHANS' COURT DIVISION OF THE
COURT OF COMMON PLEAS OF DAUPHIN COUNTY
COMMONWEALTH OF PENNSYLVANIA
NO. 21-01-0113
FIRST AND FINAL ACCOUNT OF
Robert F. O'Brien, Executor
For
Estate of Francis A. O'Brien, Deceased
Date of Death:
Date of Executor's Appointment:
First Date of Advertisement of Grant of Letters:
Accounting for the Period:
January 11, 2001
January 26, 2001
February 6,2001
February 7, 2001 to
August 28, 2001
Purpose of Account: Robert F. O'Brien, Executor, offers this Account to acquaint interested parties
with the transactions that have occurred during his administration.
The Account also indicates the proposed distribution of the estate.
It is important that the Account be carefully examined. Requests for additional information or
questions or objections can be discussed with:
Richard L. Placey, Esquire
PLACEY & WRIGHT
3631 North Front Street
Harrisburg, PA 17110-1533
(717)236-9577
SUMMARY OF ACCOUNT
Page
Proposed Distribution to Beneficiaries
7
Principal
Receipts
3
Net Gain on Sale or Other Disposition
3
Less: Disbursements:
Debts of Decedent
Funeral Expenses
Administration Expenses
Federal and State Taxes
Family Exemption
Fees and Commission
Reserve
4
4
4
4
4
4
4
Balance before Distribution
Distributions to Beneficiaries
5
Principal Balance on Hand
5
Income
Receipts
6
Income Balance on Hand
6
COMBINED BALANCE ON HAND
2
$ 24.98
5,410.20
4,881.12
5,828.70
3,500.00
14,450.00
1 ~OOO.OO
$132,731.76
$166,249.07
2~ 145.01
$168,394.08
35~095.00
$133,299.08
3~500.00
$129,799.08
$ 2~932.68
$ 2,932.68
$132.731.76
RECEIPTS OF PRINCIPAL
1 Assets Listed In Inventory
(Valued as of Date of Death)
Cash:
Harleysville National Bank and Trust Company - checking
Harleysville National Bank and Trust Company - savings
M&T Bank - certificate of deposit
Fulton Bank - certificate of deposit
New York Life Insurance Co. -life insurance proceeds
Chase - credit refund
AARP - refund cancellation
$ 5,887.14
157.97
40,212.25
90,795.73
10,613.81
13.17
127.00
$147,807.07
Stocks:
Exxon Mobil Corporation 80 shares common stock
ffiM 128 shares common stock
$ 6,570.00
11 ~872.00
18~442.00
Total Receipts of Principal
$166.249.07
GAINS AND LOSSES ON SALES OR OTHER DISPOSITIONS
Gain Loss
06/20/01 80 shares Exxon Mobil Corporation
Net Proceeds $ 7,048.70
Fiduciary Acquisition Value 6~570.00 $ 478.70
06/20/01 32 shares ffiM Corporation
Net Proceeds $ 3,594.27
Fiduciary Acquisition Value 2~968.00 626.27
07/24/01 96 shares ffiM Corporation
Net Proceeds $ 9,944.04
Fiduciary Acquisition Value 8~904.00 L040.04 .00
Net Gain $ 2.145.01
ISee copy of inventory attached.
3
DISBURSEMENTS OF PRINCIPAL
Debts of Decedent:
02/12/01 Chase Visa - credit card bill
Funeral Expenses:
02/08/01 Fitzgerald-Sommer Funeral Home
02/08/01 Irene Nunn - reimbursement funeral food
02/08/01 Robert F. O'Brien - reimbursement funeral deposit
and telephone expenses
02/08/0 1 Joseph F. Hevener - gravemarker inscription
Administration Expenses:
03/20/01 Fulton Bank - check order charge
03/08/01 Patriot-News Company - estate advertising
04/06/01 Cumberland County Register of Wills - filing
inheritance tax return
Fulton Bank - certified check fee
Placey & Wright - reimbursement costs advanced
Cumberland Co. Reg. of Wills - probate
and short certificates $ 276.00
Cumberland Law Journal- estate adv. 75.00
Allfirst Bank - stock valuation charge 40.00
Notary Fee 2.00
Reproduction 12.40
Harleysville National Bank and Trust Company -
checks cleared after date of death
07/13/01
08/07/01
Federal and State Taxes:
03/29/01 PA Department of Revenue - 2000 PA40
03/29/01 H&R Block - preparation 2000 tax returns
04/06/01 Cumberland County Register of Wills, Agent -
payment of inheritance tax
(discount of$297.72 taken)
Family Exemption:
To Be Paid
Robert F. O'Brien - family exemption
Fees and Commissions:
To Be Paid:
Robert F. O'Brien - executor's fees
Placey & Wright - attorney's fees
Reserve:
Reserve for future costs, taxes and expenses
Total Disbursements of Principal
4
$
24.98
$ 3,490.26
1,069.94
705.00
145.00
21.25
82.95
15.00
15.00
405.40
4~341.52
133.00
39.00
5~656. 70
3~500.00
7,225.00
7~225.00
$ LOOO.OO
$ 24.98
5,410.20
4,881.12
5,828.70
3,500.00
14,450.00
LOOO.OO
$ 35.095.00
02/20/01
02/20/01
02/20/01
02/20/01
02/20/01
02/20/01
02/20/01
Cash
DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES
Frances 0 'Brien - specific bequest per Item IV
Rosemary O'Brien - specific bequest per Item V
Chalmarie Fay Powers - specific bequest per Item VII
Peggy Sue O'Brien Huckleby - specific bequest
per Item VII
Theresa L. Willoughby - specific bequest per Item VII
John Lewis 0 'Brien - specific bequest per Item VII
Tracy O'Brien - specific bequest per Item VII
Total Distribution of Principal to Beneficiaries
PRINCIPAL BALANCE ON HAND
5
$ 500.00
500.00
500.00
500.00
500.00
500.00
500.00
$3.500.00
$ 129.799.08
RECEIPTS OF INCOME
Dividend
03/23/01 ffiM Corporation - dividend 34.56
03/23/01 Exxon Mobil Corporation 70.40 $ 104.96
Interest
02/12/01 Harleysville National Bank and Trust Company -
post-death interest earned savings .29
02/12/01 M&T Bank - post-death interest earned C.D. 183.93
02/12/01 Fulton Bank - post-death interest earned C.D. 494.84
08/28/01 Fulton Bank - interest earned on Estate Checking
Account 3621-86062 from 02/07/01 through 08/28/0 11.86
08/28/01 Fulton Bank - interest earned on Estate Fulton Fund
Account 9904-78814 from 02/12/01 through 08/28/01 2J36.80 2~827. 72
Total Receipts of Income $ 2.932.68
INCOME BALANCE ON HAND
Cash
$ 2.932.68
6
PROPOSED DISTRIBUTION TO BENEFICIARIES
Combined Balance for Distribution
per Summary of Account
All In Cash
$132.731.76
Per Item VIII of Will- 55% of Residue:
To: Robert F. O'Brien
$ 73~002.47
$ 73.002.47
$ 57,829.29
1 ~900.00
$ 59.729.29
Per Item IX of Will- 45% of Residue:
To: Johnny A.O'Brien
Plus: Advance Cash Distributions
Total
$ 132.731.76
ROBERT F. O'BRIEN, Executor under the Last Will and Testament of FRANCIS A.
O'BRIEN, deceased, hereby declares under oath (penalties of perjury) that he has fully and faithfully
discharged the duties of his office; that the foregoing First and Final Account is true and correct and
fully discloses all significant transactions occurring during the accounting period; that all known
claims against the estate have been paid in full; that, to his knowledge, there are no claims now
outstanding against the Estate; and that all taxes presently due from the estate have been paid.
Rak~ l' ~4.d'V'
Robert F. O'Brien, Executor
Subscribed and sworn to by
ROBERT F. O'BRIEN before me this
30 Mday of (')JJqlM1i , 2001.
~-><J I{w<
N tary Public
I~OTARIAL SEAL
HOLLY S. KJRK, Notary Public
Harrisbury, Dauphin County 7
My Commission Expires Feb. 15, 2003
INVENTORY
Estate of
Francis A. O'Brien
21-01-0113
, Deceased
No.
Date of Death Januarv 11, 2001
Social Security No. 116-01-4936
also known as
Personal Representative~) 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 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 made are subject to the
penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Personal Representative:
Name of
Attorney:
1.0. No.:
Richard L. Placey
07232
Robert F. O'Brien
Da~~~1f!j~UO)
Telephone:
3631 N. Front street
Harrisburq, PA 17110-1533
(717)236-9577
Address:
Description
Harleysville National Bank Checking 143614633
Harleysville National Bank Savings 1406582
M&T Bank CD 31003908152091
Fulton Bank CD 025-0112610
New York Life Insurance Co. - life ins. proceed
Chase - credit refund
AARP - cancellation refund
Exxon Mobil Corporation 80 shares common stock
IBM 128 shares common stock
Value
5,887.14
157.97
40,212.25
90,795.73
10,613.81
13.17
127.00
6,570.00
11,872.00
Total
$166,249.07
(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.
RW-4
~~A(l1( t
THE
THE < PATRIOT NEWS
. ~
SUNDAY PATRIOT NEWS
Proof of Publication
Under Act No. 587, Approved May 16, 1929
Commonwealth of Pennsylvania, County of Dauphin} ss
Michael Morrow being duly sworn according to law, deposes and says:
That he is the Asst. Controller of The Patriot News Co., a corporation organized and existing under the laws
of the Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market Street, in
the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot-News and The
Sunday Patriot-News newspapers of general circulation, printed and published at 812 to 818 Market Street, in the
City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th,
1854, and September 18th, 1949, respectively, and all have been continuously published ever since;
That the printed notice or publication which is securely attached hereto is exactly as printed and published in
their regular daily and/or Sunday/ Metro editions which appeared on the 6th, 13th and 20th day(s) of February
2001. That neither he nor said Company is interested in the subject matter of said printed notice or advertising, and
that all of the allegations of this statement as to the time, place and character of publication are true; and
That he has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this
statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and
adopted severally by the stockholders and board of directors of the said Company and subsequently duly recorded in
the office for the Recording of Deeds in and for said County f Dauphin in Miscellaneous Book "M",
Volume 14, Page 317.
NOTICE IS HI;REBV GIVEN that Let-
ters Testamentary Of the Estate of Fr'ancls A.
O'Brien, lot, of the Township of Sliver SprIng,
Cumberland County, PennsylvanIa, de-
ceased, hove been granted to the under.
signed. '
All persons .knowlng themselves to be In-
debted to sold estate wUl make payment Im-
mediately, and thoSe havlna claims will Pre-
sent them for settlement to:
Robert F. O'8r1en, Executor
c/o Richard L. Placey, EsquIre
PLACEY & WRIGHT
3631 North Front Street
Harrisburg, PA 17110
Notarial Seal
Terry L. Russell, Notary ubli
Harrisburg, Dauphin Co
My Commission Expires June 6, 2002
Member, Pennsytvania Association ot NotariesMy commission expires June 6, 2002
ry 2001 A.D.
PUBLICATION
COPY
PLACEY & WRIGHT
3631 NORTH FRONT STREET
HARRISBURG, PA. 17110
Statement of Advertising Costs
To THE PATRIOT-NEWS CO., Dr.
For publishing the notice or publication attached
hereto on the above stated dates $
Probating same Notary Fee(s) $
Total $
81.45
1.50
82.95
Publisher's Receipt for Advertising Cost
The Patriot News Co., publisher of The Patriot-News and The Sunday Patriot-News, newspapers of general
circulation, hereby acknowledge receipt of the aforesaid notice and publication costs and certifies that the same have
been duly paid.
Ft:A1h,1
By....................................................................
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16,1929), P. L.1784
STATE OF PENNSYLVANIA :
SSe
COUNTY OF CUMBERLAND :
Roger M. Morgenthal, Esquire, Editor of the Cumberland Law Journal, of the County
and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland
Law Journal, a legal periodical published in the Borough of Carlisle in the County and State
aforesaid, was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
VIZ:
FEBRUARY 9, 16, 23, 2001
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
O'Brien, Francis A., dec'd.
Late of the Township of Sllver
Spring.
Executor: Robert F. O'Blien, c/o
Richard L. Placey, Esquire, Pla-
cey & Wlight, 3631 North Front
Street, HarIisburg, PA 17110.
Attorneys: Richard L. Placey.
Esquire, Placey & Wright, 3631
North Front Street, HarIisburg,
PA 17110.
.Jl
SWORN TO AND SUBSCRIBED before me this
23 day of FEBRUARY. 2001
NOTAL
LOIS E. SNYDER, Nota '1' Pvbfk
Carl_ Bora, Cumb..-tand County, PA
My CommtueOl1 Expires March 5, 2001
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FIRST CLASS MAIL
PLACEY t3 WRIGHT
ATTORNEYS AT LAW
363 1 NORTH FRONT STREET
HARRISBURG. PENNSYLVANIA 17110-1533
TO:
REGISTER OF WILLS
CUMBERLAND COUNTY COURTHOUSE
ONE COURTHOUSE SQUARE
CARLISLE, PA 17013
. '""-.,....,.!(~ . :.:~::."=...hlr
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FIRST CLASS MAIL
.
~
PLACEY ~ WRIGHT
ATTORNEYS AT LAW
363 I NORTH FRONT STREIT
HARRISBURG. PENNSYLVANIA 17110-1533
TO:
~
REGISTER OF WILLS
CUMBERLAND COUNTY COURTHOUSE
ONE COURTHOUSE SQUARE
CARLISLE, PA 17013
"
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