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Home My WebLink About01-0177 Register of Wills of CUMBERLANDCounty I Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Geor~e R. Smith No. 21-01-177 also known as , Deceased Social Securjt\! No. 704-01-7101 PelltlOnert'lol, Nf)O f!o/81@ 18 yeAIlI of "'(Je 01 older, 8ppj~(lelll 10f (COMPLETE "A" OR "B" BELOW:) e A. Probate and Grant of Letters and aver that Petitioner(s) isYMe the execut rix named In the Last Will of the Decedent, dated M,qrr n 1 q, 1 qqR and codicil(s~ dated n /,q State r~evant Circumstances, e.g., renunCIation. death of executor, ete 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: none Q B. Grant of Letters of Administration (C.t.8, d,bn C.La. pendenl6 lite, dUI8f'l(e aOSen(IS; tJUtlmle rT\mOfltatel 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 addit:0nal sheets if necessary. Upper Allen Township Decedent was domiciled at death in _ Cllmb~.,..l ::mrl ________ County, Pennsylvania, with his/her last family or pflnclpal residence at 100 Mount Allen Drive, Mprh::mir~hl1rEJ PA 17055 Ilis'SlIeel.<lumoeld<ldlT~'ITICI~""'YI 100 Mount Allen Drive Decedent, then 74 years of age, di~a January 30 , 20QL, at Mechanicsburg, PA 17055 ILocallon) Decedent at death owned property with estlmd1ed values as follows: (If domiciled In PAl All personal property ....... (If not domiciled in PAl Personal property in Pennsylvania. (If not domiciled In PAl Personal property in County Value of real estate in Pennsylvania . . . . . . . Total . . . Real Estate situated as follows: 60,550.00 60,000.00 120,550.00 S225 North Front Street. Harrisbur~. FA 17110 Wherefore, Petltloner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters In the appropriate form to the undersigned: Typed or printed name and residence Ruth M. DeWaelsche 42 Walsh Road Halifax, PA 17032 O'.J_ "? Oath of Personal Representative Commonwealth of Pennsylvania County of Dauphin The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to and affirmed. and subscribed ,,/ 3l ~L,l:ft /1 ~}&i'"t,-Jc; /)/}DL:KJi Ruth M. DeWaelsche before me this 0" lDt day of 1 ( , 01 '-----::f.1,)'LA..,c( ~/~,</ 20 =-- /~ . , D '-V),'1 ': I 0. '~ /,yu;:. / J I a!~~.>~, n rY>0', ~; (-. I ~. --' I Estate of DECREE OF REGISTER GEORGE R SMITH also known as Deceased No. 21-01-177 Date of Death: 204-03-2103 Social Security No: 01-30-2001 AND NOW, FEBRUARY 15 , 20~, in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters rn Testamentary 0 of Administration are hereby granted to (e tA, db Il.r: t . pendenTe Ille. HIJlanre aosenrla, duranft:' mlOorHafc! RUTH M DeWAELSCHE in the above estate and that the instrument{s L if any I dated MARCH 19, 1998 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters.......................... . (4) Short Certificate(s).......... Renunciation................ .. Affidavit ( )................. Extra Pages ( 2)............ Codicil.......................... JCP Fee........................ Inventory & Tax Forms... <0::\ \ \ _, .1\, - '.' Other. .S: .'. L:.').;Q!.... S? :S::~:. ;J..~i;..",_:.:...-<.:,~.#~,-:; 1,~~. TOTAL.............. . RW-7a $ 235.00 12.00 $ $ 5.00 $ $ 6.00 $ $ 5.00 $ $ $ 263.00 \ --/,,-----, //~' 'I ,/ /:') "r,") 7/,r2'/1.1/ (( .r~:.:-.//c.<'j",t~.a ./ ~:'i:: ---- ~/U.t.bj' .'" /'" ,1./ l Re9--i-St:r of Wilis I / /<- - ') /~ ,"r:~ '- ,~ . '7 \. _ k_~/.J: / . //'1 < 1.--:_/ t<//c..':! " .~ .~\. Attorney: Earl Richard Etzweil"er 1.0. No: 06398 Address: 105 North Front Street Harrisburg, FA 17101 Telephone: (717) 234-5600 OA TE FILED: ...."".'\ /' :~)(i.('~-<-~ Lo Ci :<:A<>j'/~ c: ':'.<,,:/, / I ~ I' is lu ,cnih lh;!\ tilL' ll1CUrmJlIU!l hCl"l' [, Rl:;-:[,[LP Th~' UT",li,lIt'Will !\ \.,\:1 t diCit\.. \\lth nl~' !~)l\\'(L-;.ll.'tl ~('1 :hi. .~! H WARNING: It is illegal to duplicate this copy by photostat or photograph. .. t-.. .....' (' r r I ~ Il_.t L t"'~) . on " "l't f ~ I 'f" ,-,; j:~~: ,'. '-;'~~~'-;__.: ." . \ ,ll fl' p,' '" ., I . <. \" . ,1.1.", C1' -'-. .\;, ~;V 4-- {' "" {1-~~~~1 ,;.",~",.t~,; \~" '.,,' ,,,,i>"/ ,~",~'.9!i1[Ni ,',. ~"1"~ ";"~~~:;.;:-:_."l~-=;I~~'~ -~ I !,~: J !1J/Jllf"~"T1'/"~ I .._ ~~ p .__If_.$ 4 21.~--- ..~V'-3/~ c7!-----.- 1 },I:" ,.... \' 21-01-177 H' os, : 4J R... 2117 COMMONWEALTH OF PENNSVLVANIA . DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH ,yHiftAlNT .. EIIIIAHlNT ILACI( lNl( HAMEOfDECEOENT(f... M~-------"------------ SEX ,. George R. Smith J. Male STAlE "lE ~_R SOCIAL SECUR'T't NUt,tBER 3. 204 - 03 2103 DAlE OF OEAJH ._. 0..._1 .. January 30, 2001 AGE (tOOl _.. UNDER 1 YEAR MonIN Days UNDER 1 0/IIIt - ........ IlRTIiI'lACf :C.tv ona "'-"CE Of OEATH .c_. """,.",. -- _ 'ns"uC'''''' on - _I 3tMe 01 fCl~ CClunlIvl HOSPITAl. Harrisburg PA. Inpal_O E~I_ CJ 7. ... FACILITY ,.AUE (II no< ."'",*"" 9""...... ond oumoer. :.no J-,/ Ie. Upper Allen Twp. .... IClNO Of BUSlHESsn,.OUSTRY 1710. Dauphin [);d - ..... . -..ohp7 H~.O :;." "":::' ~ 01 MOTHt:R'S IlAME IF.., _. "'- Sulo_, Martha E. Smith MARITAl. STATUS . ~ _ ........,. w_. Oovcnecl (SpocIyJ u Widowed l~ He!] .....__.. SUSQuehanna SUA\IIVlMG SPOUSE l'_.~"-_ TRW DECEDENT'S ACTUAL AESIOENCE IS. .......... on__1 .... ...,..... ... INfORMANT'S MAIJNQ AOOflESS ISor_ C4y/Tc>0wn. SIoIe. Eop Code. ~42 Walsh Road Halifax PA 17032 ~E Of OISPOSITION - Nome 01 c_...,. C,........., LOCATION. ~ $1M. z;peo. ocou._ o \II II) ~ ~ ::; -< 1100 A.?~~ a. I ApproDftaf. '-- l--- 1 : PART I: 0lIw~_""""'1O_."'" _~in...~-_..I'IIlRTL -::COalY\- I :: d. WERE AU10PSY FINDINGS ~ PflIOR It) COMPlETlOH OF CAUSE ~ DERH7 ow 10 lOA AS " CONSEQUENCE OF); ow 10 COR AS" CONSEQUENCE OF); _R OF DEATH DATE OF INJ\JRV .-. Coy.-. TIME OF INJURY INJURY AT WORK7 llESCAI8E HOW IKIURV OCCURRED. ...0 1100 __ 0 _ 0 _ 0 _ 0 ~............ 0 CouId_becltl_ 0 ... 0 NoD .IIEDtCAL EXAIIINf.RlCORONEII On IIle be~. oI...minallon and/<< In....llg.tion.1n my opinion. de.,h occ..rred o'!he limo. d.,.. ond p1ac.."'" d...,o lho c.....I.'.nd )1.~ II ...,..1.. . . . . . - . . . . . . . .. . - . . . . . . . . . . . . . . . .. . . . .. . . . .. . . .. . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . , . . . . . . . . . . . .. REGlSTRAR'S SlGHA1\JAE AHO NUMBER -. 29. c:eJnYIEA co..c:a llflil, onoI "Cl!RTIf'YlNO ,",,1IClAN(Ph_c~eauMd_ _..- ""...._'-"'~OIa1ft """c~1\wn 23) Te..._....,............... ......,occ......._.._.MIM(.,__....._................................ z l!l \II U III o lis ~ z "J'IIONOUNCING AND CEltTWVINQ ~YSIClAH (Physcoan bolt> "'_...... '""" <__10..... Of ""."'. To ... _.. lilY 1Inowtedge. ....... occ..._.. .... _. da... """ plac.. and _ II .... <<00....1 """ m....... .. 110..... . . . . l<.rd'~L2l? I JJ. DAlE FilE I 3f. 0/ Register of Wills of Dauphin County, Pennsylvania OATH OF SUBSCRIBING WITNESS Estate of , ~.o...'-G R 0~ also known as No. 21-01-177 , Deceased f'n.~ K,-c~ '(1)''1;,..\l ~.~ (each) a subscribing witness to the ~J codicil(s) ~ill(S) presented herewith, (each) being duly qualified according to law depose(s) and say(s) that she/he/they was/were present and saw the above Testator(rix) sign the same and that she/he/they signed as a witness at the request of Testator(rix) in his/her/their presence and in the presence of each other 0 in the presence of the other subscribing witness(es). cflY{jJ - ~ 2:'~ " {1 "', 'C:::~,.~. '9-\ (Signature) I O,J-~.:i7-~~.~ft:---Ch-- f~ ~A.-~.v ~--2/ '2 / (Addre (Signature) (Address) Sworn to or affirmed and subscribed before me this '1' .. OloY- day of cr'~~ ,20~. ~-ru>. CYTi~~\~ N- Pubtr: \. ,I '_ Ml La,11l11;.::),:);UII [^piro.s..:. (Signature and seal 01 Notary OJ other officlol NOTE: To be taken by officer authorized to administer oaths. Please have present the original or copy of Instrument(s) at time of notarization. qualilled to administer oaths Show dall:' 01 eXJJU81lOn 01 NotalV's cummlSSIOJI ) RW-11 Register of Wills, of Cumberland County, Pennsylvania OATH OF SUBSCRIBING WITNESS Estate of GEORGE R. SMITH No. 21-01-177 LISETTE A. CARDEL, now known as LISETTE A. ALT, a subscribing witness to the Last Will and Testament presented herewith, being duly qualified according to law deposes and says that she was present and saw the above Testaior sign the same and that she signed as a ,witness at the request of Testator in his presence and in the presence of the other subscribing witness on the Last Will and Testament, EARL RICHARD ETZWEILER. ,jdt~'d (atd~1 , Lisette A. Cardel, now known as didlva, tll;t; -- Lisette A. Alt 11 East Marble Street. Mechanicsbur€!. P A 17055 (Address) Sworn and subscribed to before me this !c) "1 , day of February, 2001. /1 ./ i.:> }1.4 .'/ :~'~PI/ :f! J,,~~_ Notary Public Notarial Seal Bonita R. Madara, Notary Public 'Jpper Allen Twp., Cumberland County My Commission Expires Nov. 1, 2004 Member, Pennsylvania Association of Notaries (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: To be taken by officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization. 21-01-177 Register of Wills of Cumberland County, Pennsylvania RENUNCIATION Estate of George R. Smith No. also known as , Deceased The undersigned Gail L. Sturm, of 5225 North Front Street, Harrisburg, P A 17110, daughter of the above Decedent, hereby renounces the right to administer the estate and respectfully requests that Letters Testamentary be issued to Ruth M. DeWaelsche, who was named as the substitute Executrix under Item III(A) of the Last Will and Testament of George R. Smith, dated March 19, 1998. WITNESS my hand this 31 st day of January, 2001 1 . -":,) (~-v./' '/)--:)/~~:l__;.-,--- (Signature) 5225 North Front Street. Harrisburg. P A 17110 (Address) Sworn to or affirmed and subscribed before me this 31st day of January, 2001. NOTARIAL SEAL PATTY L. STROHECKER, Notary Public Harrisburg, Dauphin County My Commission Expires Jan. 6, 2003 \ " _ l_ -~~l\ '\, . ."i"'." ' Notary Public I\1y Cormnission Expires: (SignanJTe and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-13 (Rvsd 9/92) 21-01-177 LAST WILL AND TEST AMENT OF GEORGE R. SMITH I, GEORGE R. SMITH, a resident of Camp Hill Borough, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this instrument to be my Last Will and Testament, hereby revoking any and all wills by me at any iime heretofore made. ITEM I: I direct my hereinafter named Executrix to pay all my just debts, funeral expenses, administration expenses and inheritance, estate, succession or excise taxes, which I owe or may become due on account of my death, as soon as may be convenient after my decease. ITEM II: All the rest, residue and remainder of my estate, be it real, personal or mixed, of whatever nature and wheresoever situate which I may own or have the right to dispose of at the time of my decease, I give, devise and bequeath to be divided as follows: A. 1/6 of my estate after payment of all funeral expenses, administration expenses and other lawful debts to the Armstrong Valley Bible Church, of 2041 Armstrong Valley Road, Fisherville, Halifax, Pennsylvania. B. The balance of my estate after taking out the above bequest to be divided as follows: 1. 1/5 to my son, Mark L. Smith, of EI Cajon, California. ./ ':_'>~ '"1;. '~ .' J./rr.:.- (.. i~J (SEAL) v George R. Smith ,., 2. 2/5 to my daughter, Ruth M. DeWaelsche, of 42 Walsh Road, Halifax, Pennsylvania 17032. 3. 2/5 to my daughter, Gail L. Sturm, of 5619 North Front Street, Harrisburg, Pennsylvania 17110. a. If any of my said children should predecease me or die simultaneously with me, then such share shall lapse and be divided between my children named in this item who survive me in the same proportion as herein provided. ITEM III: I hereby nominate, constitute and appoint my daughter, Gail L. Sturm, Executrix of this my Last Will and Testament, with full power in her discretion to do any and all things necessary for the complete administration of my estate, without being required to file bond for the performance of her duties, with full power to sell at public or private sale and without order of court any real or personal property belonging to my estate, and to compound, compromise or otherwise settle or adjust any and all claims, charges, debts and demands whatsoever against or in favor of my estate as fully as I could if living. A. If my said daughter should predecease me, die simultaneously with me, or be unable or unavailable to serve or complete her duties, then I nominate, constitute and appoint my daughter, Ruth M. DeWaelsche, Executrix, with the same power and authority as given my said daughter. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last /- .,//,' Will and Testament this I --">':-:'day of March, 1998. ~ / (' .-._'~>t( ,:) ._....::'/. .-, J /,,~; , " , (SEAL) George R. Smith Signed, sealed, published and declared by the above-named George R. Smith as and for his Last Will and Testament, in the presence of us, who at his request, in his presence and in the presence of each other, we believing him to be of sound and disposing mind, memory and understanding, ha ve hereunto subscribed our ,. ./ names as witnesses this /'/ day of March, 1998. ...:.-,.-4". J, -~/~; t I ) . ! II ; · .. I I; . ;,., ( \ '. ......~ ,/C /" /" /" ~ //< ( <.,J Ii .0 ... (. ~ ". \..- .,- -- CERTIFICATION OF NOTICE UNDER RULE 5.6(a) NAME OF DECEDENT: DA TE OF DEATH: WILL NO.: Geon!e R. Smith January 30~ 2001 2001-00177 ADMIN. NO.: TO THE REGISTER: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans I Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on February 27,2001: Name Address Ruth M. DeWaelsche. 42 Walsh Road~ Halifax. PA 17032 Gail L. Sturm. 5225 North Front Street. Harrisbur~. PA 17110 Mark L. Smith. 1669 Shady Crest Place. EI Caion. CA 92020 Armstron!! Valley Bible Church. 2041 Armstron~ Valley Road. Halifax. PA 17032 Notice has been given to all persons entitled thereto under Rule 5.6(a) except NONE Date: February 27. 2001 / /'/'_:~!"~-:'_' '~'--_"/;',/L' .~-~ , ,1/ /,(. '.' '- . ~----;;.- . Signature Name Earl Richard Etzweiler. Esquire Address 105 N. Front Street Harrisburg. PA 17101 Telephone (717) 234-5600 X Counsel for Personal Representative f "I. L/ Register of Wills of CUMBERLAND County, Pennsylvania INVENTORY Estate of George R. Smi th No. 2001-00177 also known as Date of Death 01/30/2001 ,Deceased Social Security No. 204-03 -2103 Ruth M. DeWaelsche, Personal Representative(s) of the above Estate. deceased. verify that the items appearing in the following Inventory include a/l of the personal assets wherever situate and a/l of the real estate in the Commonwealth of Pennsylvania of said Decedent. that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death. and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I N/e verify that the statements made in this Inventory are true and correct. IN/e understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative Name of Attorney: Earl Richard Etzwei1er Signature:1Mrn. \-\~~Cl~~ {'-fl(!~ Ruth M. DeWae1sche ' 1.0. No.: 06398 Signature: Address: 105 North Front Street Address: 42 Walsh Road Harrisburg, PA 17101 Halifax, PA 17032 Telephone: 717/234 - 5600 Telephone: 717/896-2983 Dated: 3d-I --0 l Description Value CASH: 2000/2001 refund School Tax 8.59 2001 County/Township tax refund 153.26 Geigle Funeral Home - refund duplicate charge for vault. 397.50 New Cumberland Credit Union - Savings Acct. No. 74863 50.00 New Cumberland Credit Union - Checking Acct. No. 74863 5,306.07 TRW - life insurance payable to estate. 7,000.00 12,915.42 ---------------- (Attach additional sheets if necessary) Total: 139,823.27 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. PreFared by the Pennsylvania Sar Association COt::yright IC) 1996 form software only CPSystems. inc. PERSONAL PROPERTY: Gail Sturm - rent for living in property prior to settlement. 1,200.00 Mark and Ruth DeWaelsche - balance due loan. 3,836.99 STOCKS/LISTED: 1,011.16 shares Waddell & Reed Financial Services - Account No.15931850-621. 7,219.65 692.06 shares Waddell & Reed Financial Services - Account No.15931850-627. 5,135.11 3,428.01 shares Waddell & Reed Financial Services - Account No.15931850-629. 37,262.43 1,501.68 shares Waddell & Reed Financial Services - Account No.15931850-630. 12,253.67 REAL ESTATE/PA: Real estate located at 5225 North Front Street, Harrisburg, PA - known as Dauphin County Tax Parcel No. 62-002-039. With said real estate having been sold at private sale for $60,000.00. 60,000.00 TOTAL RECEIPTS OF PRINCIPAL............... 5,036.99 61,870.86 60,000.00 139,823.27 Earl Richard Etzweiler Christian S. Daghir ETZWEILER AND ASSOCIATES ATTORNEYS-AT-LAW 105 NORTH FRONT STREET HARRISBURG, PA 17101 (717) 234-5600 2 West Main Street Elizabethville, P A 17023 (717) 362-8395 HALIFAX LINE (717) 896-3737 Fax Line: (717) 234-5610 August 27, 2001 225 Market Street Millersburg, P A 17061 (717) 692-2519 Register of Wills CUlnberland County Courthouse Hanover and High Streets Carlisle, P A 17013 RE: ESTATE OF GEORGE R. SMITH FILE NO. 2001-00177 Dear Sir or Madmn: Please find enclosed for filing the following: 1. The original and one copy of the Inheritance Tax Return; 2. The original and one copy of the Inventory; 3. A check in the amount of $234.31 representing the balance of inheritance tax due; and 4. A check in the amount of $25.00 representing your fee for filing estate papers. Please also find enclosed a duplicate cover sheet for both the Inheritance Tax Return and Inventory. Please date-stamp the cover sheets and return the same to our office along with the appropriate receipts for payment received. I have provided a self- addressed, stmnped envelope for your convenience in returning the requested documents to our office. Sincerely, '~ -~//"~ " Earl Richard Etzweiler ERE:haf Enclosure /~~ ~ i.t;~~:. ~ ~ ,~".~l 0J ;to c: ~)~ ~: ~ o -t~~\~< ~ "1,' UJ a: 0) C\J Ln lLJ a::: lLJ ::r:: Cl :2 '.", ~~ 0) ~"j- I- < ~ o ~ <;;( o r'::, (.1 q " j '.' ~, ~ ~'(" '\. ' '\ \'. .... \~J ". ,', , " . ~. ~'-~\ '. '~", ',' -";;v., \ ,~ \:~ \ . I"", ,5' o U) ~.J ,J d :c: " .. "'...; ifI )( ~t-- ~~ S ~ LI,J <: C/) (.;) ~ UJ LLI ~~ cr: ~: -Jf ~(J:5 Q. <: (.) ~..... - LI.. mLl.. ::rO ~ I- < LiJ-J <~OCC OU)CCLiJ <;;(U)I-m /" <~ "'-'0.;:) !20< <;;( a ~ I- < ~ o ~ <;;( -J f5 fl ~J' 4. -lQ Q: · La Uf- ... O} .}.....- '-4 Q) t'r 0 aq,-w g; ~ (L' iiJ o LJ.J CC .:! ~ ~ ~ [fj ~IJ.J>< ~:::>~ & ff~-I 9 u...~~ ~ 0/#9 ;:: fEu...::.. ,... -,oiS <:( w!i~ ~ ~1J.Jt5ofE 6~:::>&:::> ~cr~coco ~<(w"!!!2 oa.~tcr () IJ.J :::> IJ.J cr OtlJo!? (J)- -.J ::! $C Ll.. o $- ~ (J) C5 l.JJ. cr' L J6 ff o IJ.J .:> ijj jf#l lLJ a::: lLJ ::r:: CJ o "... -J LiS U) --- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 000204 ETZWEILER & ASSOCIATES 105 NORTH FRONT STREET HARRISBURG, PA 17101 ACN ASSESSMENT CONTROL NUMBER AMOUNT nnn..._ fold ESTATE INFORMATION: SSN: 204-03-2103 FILE NUMBER: 21 - 2001 - 01 77 DECEDENT NAME: SMITH GEORGE R DATE OF PAYMENT: 08/28/2001 POSTMARK DATE: 08/27/2001 COUNTY: CUMBERLAND DATE OF DEATH: 01/30/2001 101 I $234.31 I I I I I I I I TOTAL AMOUNT PAID: $234.31 REMARKS: RUTH M DEWAELSCHE C/O ETZWEILER & ASSOCIATES CHECK# 3946 SEAL INITIALS: SK RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS REGISTER OF WILLS /6- ;2/'{) - 2/ 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 EARL RICHARD ETZWEILER ETZWEILER & ASSOCS 105 N FRONT ST HBG PA 17101 10-22-2001 SMITH 01-30-2001 21 01-0177 CUMBERLAND 101 -l Sv Amount Remitted REY-1547 EX AFP <12-00) GEORGE R 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 ~ iirv = iS4-j-E3f-AFP--fi"2-:ooT -No"-icE--OF-YNHEifi;:AiicE-T-AX-A-PPRA-isEifENT~--Ai:.ioWAtfCE-ifR"----------- - - - - -- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SMITH GEORGE R FILE NO. 21 01-0177 ACN 101 DATE 10-22-2001 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) 60,000.00 61,870.86 .00 .00 10,952.41 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) 7,001.26 7.293.03 (11) (12) (13) (14) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 132,823.27 14.294 "9 118,528.98 19,754.83 98,774.15 NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: .00 X 00 = .00 98,774.15 X 045 = 4,444.84 .00 X 12 = .00 .00 X 15 = .00 (19)= 4,444.84 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-27-2001 AA496529 210.53 4,000.00 08-27-2001 CDOO0204 .00 234.31 TOTAL TAX CREDIT 4,444.84 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.) L 0 ", \")Ec~" \ <10- 0 c_x::, --:, C).J,,'j STATUS REPORT UNDER RULE 6.12 C '/ c. \ I Name of Decedent:?-e --D~~ E"_ K - ~ ...-.., \.L \"\ Date of Death: \ ~ ~ c--- c..; \ Will No. ~cc}' -- 0(.;\11 Admin. No. (YJ O~ 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: YesL 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. V 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~ No. d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Dated: \ c .-- \ \ -(j '2> &:-~~~~tL... / Signature Earl Richard Etzweiler, Esquire 105 North Front Street Harrisburg, PAl 71 01 (717) 234-5600 Capacity: _ Personal Representative X Counsel for personal representative REV- 1500 EX + (6-00) CAPB HpRL EplO CRAC KOTK ES C P o 0 R N R 0 E E S N T C o M P T U A T X A T I o N REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT /ft.-;J./o- Si c.--' OFFICIAL USE ONLY o E C E o E N T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OEPT.2.80601 HARRISBURG, PA 17128-0601 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Smith Geor e R. DATE OF DEATH (MM-DD-YEAR) FILE NUMBER d/ Df COUNTY CODE YEAR SOCIAL SECUAIl'( NUMBER 204-03-2103 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE DATE OF 8IRTH(MM-OO-YEAA} REGISTER OF WILLS SOCIAL SECU ITY NUM8E X 1. Original Return 4. Limited Estate X 6. Decedent Died Testate 2. Supplemental Return 4a. Future Interest Compromise (date of death anar 12.-12.-B2.) 7. Decedent Maintained a LIving Trust (Attach copy of Will) o 9. litigation Proceeds Received ()/77 NUM8ER 3 date of death . Remainder Return prior to 12.-13-82) S. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes {Attach copy of Trust) 010. Spousal Poverty Credit 0 11. Election to tax under Sec. 9113(A) (date of death between 12-31-91 and 1-1-95) (Attach Sch 0) \; ,THIS SECTION MOS11 BE' COMPLETED;' AlL-CclRRESPONDENClt &'/::ONFIDENTIAL, TAX INFORMATION SHOULO:8E;1l1REC11EO, TO:',;~ NAMe COMPLETE MAILING ADDRESS Earl Richard Etzwei1er FIRM NAME (If Applicable) Etzweiler and Associates TELEPHONE NUMBER 105 North Front Street Harrisburg, PA17101 R E C A P I T U L A T I o N - 6 0 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule 0) 5. Cash, Sank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (1) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (1) (2) (3) 60,000.00 61,870.86 None (4) (5) None 10,952.41 (6) None None 7,001.26 7,293.03 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20. 0.00 98,774.15 0.00 0.00 x X X X .0 0 o 45 ,12 ,15 Copyright (c) 2000 form software only The Lackner Group, Inc. OFFICIAL USE ONLY (8) 132,823.27 (11) 14,294.29 (12) 118,528.98 (13) 19,754.B3 (14) 98,774.15 (15) (16) (17) (18) (19) 0.00 4,444.84 0.00 0.00 4,444.84 Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 100 Mount Allen Drive CITY I STATE I ZIP Mechanicsbur~ PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) Z. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 4,444.84 4,000.00 210.53 Total Credits ( A + 8 + C) (2) 4,210.53 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E) (3) 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 (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. {SA} B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58) ~~~~;;7heck Payable to:!"IOGI,~TER ()F~~~~S, AGENT.,; ..... ;U!!;I;UU;I!~~~~~~;i~~~:~~tHE FO~~~:;~~i::~~~~~;b~~;;~~;!~(~t;;~~AN :!i!~!! !ii~!;;~~~i~~~6~~li~~I;~[6~~;~'" 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; . . ~ ~ix b. retain the right to designate who shall use the property transferred or its income; . c. retain a reversionary interest; or. . d. receive the promise for life of either payments, benefits or care? . . 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? . 3. Did decedent own an ~in trust for" or payable upon death bank account or security at his or her death? 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 0.00 0.00 234.31 0.00 234.31 o o o [R] [R] [R] Under penalties of perjury, I declare that I hal/e examined this Teturn, 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. SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN ~~() \.~~~~h- ,~~l('uJ~ REPRESENTATIVE .Y /) ./ <.12"-w.. Ruth M. DeWae1sche 42 Walsh Road --fjaii-fa~~--PA---i70-32------------------'--------- Etzweiler and Associates 105 North Front Street -- -Har;:i~b;;':- ---PA-- -i7io-i- -- - -- - -- --- - --- --- -- - -- DATE g'J7-01 DATE 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) (;)]. 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 exempt 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. 91.16(1.2} [72 P.S. 9116(a)(I)]. 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)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (el 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) LAST WILL AMU'EST AMENT OF GEORGE R. SMITH I, GEORGE R. SMITH, a resident of Camp Hill Borough, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this instrument to be my Last Will and Testament, hereby revoking any and all wills by me at any time heretofore made. ITEM I: I direct my hereinafter named Executrix to pay all my just debts, funeral expenses, administration expenses and inheritance, estate, succession or excise taxes, which I owe or may become due on account of my death, as soon as may be convenient after my decease. ITEM II: All the rest, residue and remainder of my estate, be it real, personal or mixed, of whatever nature and wheresoever situate which I may own or have the right to dispose of at the time of my decease, I give, devise and bequeath to be divided as follows: A. 1/6 of my estate after payment of all funeral expenses, administration expenses and other lawful debts to the Armstrong Valley Bible Church, of 2041 Armstrong Valley Road, Fisherville, Halifax, Pennsylvania. B. The balance of my estate after taking out the above bequest to be divided as follows: 1. 1/5 to my son, Mark L. Smith, of El Cajon, California. / <>} . --.?' . / ' . .~ ,...d ......." //.~ _or!': / t:.) - 0' George R. Smith ~ (SEAL) 2. 2/5 to my daughter, Ruth M. DeWaelsche, of 42 Walsh Road, Halifax, Pennsylvania 17032. 3. 2/5 to my daughter, Gail L. Sturm, of 5619 North Front Street, Harrisburg, Pennsylvania 17ll0. a. If any of my said children should predecease me or die simultaneously with me, then such share shall lapse and be divided between my children named in this item who survive me in the same proportion as herein provided. ITEM ill: I hereby nominate, constitute and appoint my daughter, Gail L. Sturm, Executrix of this my Last Will and Testament, with full power in her discretion to do any and all things necessary for the complete administration of my estate, without being required to fIle bond for the performance of her duties, with full power to sell at public or private sale and without order of court any real or personal property belonging to my estate, and to compound, compromise or otherwise settle or adjust any and all claims, charges, debts and demands whatsoever against or in favor of my estate as fully as I could if living. A. If my said daughter should predecease me, die simultaneously with me, or be unable or unavailable to serve or complete her duties, then I nominate, constitute and appoint my daughter, Ruth M. DeWaelsche, Executrix, with the same power and authority as given my said daughter. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament this /./ ~~~y of March, 1998. ~ Ie' ..-<t" ,__ II ~'J/j I '.' /1 (SEAL) George R. Smith Signed, sealed, published and declared by the above-named George R. Smith as and for his Last Will and Testament, in the presence of us, who at his request, in his presence and in the presence of each other, we believing him to be of sound and disposing mind, memory and understanding, have hereunto subscribed our ~/' names as wimesses this I r- ?-- day of March, 1998. ~~~~ ~ () CQld~SSD REV-1502 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF George R. Smith SS# 204-03-2103 01/30/2001 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, bath having reasonable knowledae of the relevant facts. Real property which is jointly-owned with riaht of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1 Real estate located at 5225 North Front Street, Harrisburg, PA 60,000.00 known as Dauphin County Tax Parcel No. 62-002-039. With said real estate having been sold at private sale for $60,000.00. SCHEDULE A REAL ESTATE FILE NUMBER TOTAL (Also enter an line 1, Recapitulation) $ 60,000.00 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1502 EX (Rev. 1-97) . -, i A B ~(P= ':,;::: _C',-"N 1 U.S. OEPARn..1ENT OF HOUSING & URBAN DEVELOPMENT 1 [J F~A 2.rF'""":,-,":' 3_ i 'C:JNV .....'NI,~lS 40VA 5. i ICONV INS. I 5. FIL= ~~UM8E.~: , LC":',\I .\jUM8E~: SETTLEMENT STA TE~~ENT n1_rn<=:1 I 3. MCRiGAGE: INS :':'2_ .\JlJ;'J16E.~: OM B ~O 2"02 0265 :;';:: C. NeT:=': This form ",5 turn/shed to gIVe yeu a sraremenr or acruai settlement cos(s. ;'~c:J{::s jdld tO,ana by the sa:;;!emenr agent are shown Items marKea "[POct were pale :;urslde the closmg; they are st!OWn here /crnr:'03ucnal pur;oses and are not mciuded in the rota/s. 1 J '/":3 '01"DC53 I:)r1/01-.'C~'I") .. . ... 0 ~jj.,',1E AND AOCR':::S3 CF 3CRRC'N:.'i E. NAME~,~D ACCR=.SS OF .::l:::~_.::.:~: F N;','..tE AND ADDRESS ~c L"NCE'i: Gail , Sturm single George 'i. Smith EState 5225 ~.jcrth Front Street 52:5 North Front Street Harrrscurg, ?A 171 iO Harrisburg, ?A 1i110 G. P.=:CP:.==:Tr LOC~TION' H. SETTL:::'AEN i ).GE:NT ::;.-S77CS:: I. SE: , LE::\llENT DA TE: 52:5 ,'--Jorth Front Street Earl Richard .=:tz'Neiler Hamsburg, ?A 171 ~ 0 June - . 2C01 Dauchln County, Pennsylvania PLACE OF SETTL~.\,iE.I\,JT Tax P~rcel No 52-002~.J39 105 North Front Street i Suscue~ar.na Township Harrisburg, PA 17101 J SL.:MMARv CF '3CPi:lC'I'I,=='S i~:HIS;'C-;-ICN " 3:_ 'AMAP'I - 3",,;;='S -:-~A,'\JS':'C-:-:CN . 1 0 - , , '00 -r " , - -, , " i 101. Contract Sales Pnce 60.0CO.00 4()1 C.::r:~ct Sales ~"":ce 60.0CO'J0 ! 102. Personal ?rooert'l "02. ,=e:s'::~ai P'ooerl 1103. S~!tlerr.ent Charaes to 8orrower rUne 14C01 573.50 403. 1104 4()4 i 105 405 I c'usrmenrs .-or ,'rems 1-']/0 =''1 ::leI er'n <iCV3nCe -=':.:sr!i,:nrs :r/tems -=..'"' .=v :::~,'Ier :n aavanc= . 106. :COQ-01 Scnaal tax 06121/01 to ':6':30.,01 . a.59 406 :CC.:-:~ Sc...~ooi ~~X ,J5.:1..Cl :0 Q6/30/01 a.o;:~ '07 ....('("\. CoJMun. Tax 06/21/01 to ~2!31i01 15325 407 2.:C' :.Jujl,'1un. ' ~;( C5:::.Ql .. 12/31/01 153.25 4_....1 ',J8 .4,ssessments to 4()3. ..l.53essme~15 :0 '09 JG9 ~ La 410 . ~ 1 1 .111 ~ 12. J....., , _. ; 120 GReSS AMCUNT DuE ,=F.CM aCFRC'NEP . 60 , ,..;.c35 420 GFCSS .-i,...ICi....\'- DL/E ~,- -'---:"'-. 60,: is, ,35 '200_ AMOUNTS PAID B'( OR IN BEHALF OF 30RROWER: 500. REJUCTIONS iN ~MOUN7 DUE TC SE!..lE~: !201 Ce!J:Jsit or ~arnes: mone'l 15.CC:".)O 501 _,'<C2:::S _Olees;: 3~e Instr:.::::cr:s !202 ~~:r;::cai ..l..mour.t::f '~ew L:JanIS: '502 SeC:'~~er': :::-:ar:~s :0 Se:!:::"' '_:!"!e .,~.-, iCC!JO ,203 E,lsi''-'a !oan(s\ faKer' scb:eCl :C 303 =-<~s:'-c I car; ~ 5 : :~..e:1 sco:es:::::: !20J. 5C'::' -:::'..-- ::::f 'irs:. \::,-:;:age :205 505 ...:::'.'.-" ::f 5::C:::~C '':orraace !2.06 506 2e::::5 ~'e~alre':: :'. se!ler 15'JOO,00 :207 507 1:08 5G8 i::09 509 I -CIUS,rr;enrs ,-::::r'~ems :...;nr::;aro == v :;,e.'ler ":'c!/.;'s~" e":s or :'(=,'7"'S ",r:C3IC ='/ ::.elier ::10 :':C:":1 Schooi tax to 510. :~::c:-,: ~ Sc~oci ::!.'( :0 1211 :C:: ::::o.Mljn. Tax to 51 ~ -,rr' :.J,Mcn - :::( :0 121': :'s32ssrnenlS to 512. ,~s3e::S::1e";s :0 :213 513 1214 5,J. !215 ::1: [216 5105 I:;; Sl~ 12:8. 518 1219 .., 0'" 1220 TC~..JL ,0.4/0 aYIFOR BORP.CWE.~ 15,CCOCO :520 IC,,-<- R=:;I..IC~,CN ,J,MCI../r'.jT CUE 5Ei...LE.~ 15.1CO.00 :lOa. C,j,SH AT SETTLEMENT FROM/TO 30RROWER: 600. CA-Sri A T SET7L~MENT TQiFROM SELLER: 1301 Gr::ss Amount Cue From Borrower (Line 1201 60.7..:.0,35 601 Gres", ~mcunt ~;.;e To Se!ler (line ..1::0\ 60~61.85 ]30::. Less ),maunt Paid SviFor Sarrower (Line 220) ( 15,OCOCOl 602. Less ==:edL;ctions ~L;e Seiler (Lne 520\ ( 15.1 ao.cO' ,,03 C":5;~1 x '=ROM) ! TO I BORRCWE,= 45.7~'35 603 C":S~ I X Te' , FRG/...1 , SELi...=.=: 45861,35 - I he ",":erslgned herecy acknowleage receipt cr~moleted_ copy of pages: e.: of thiS 51::::=,,:-, e. ~ny a:-:a'':::1mems. ,-e;e:re~e(em. Saccowe: :JJp A./ J..o ~ 52,le: l~;-;-f<_r,~ ~~._'o ~t he Lcd ,I Gali <.., ,:)lurrr. ":""_. ~_ ,', :::", ..\.. ::._".;:,,~ j ~Yp.tJLd;,j" ace_ L. SETTLEMENT CHARGES 700. TOTAL COMMISSION Based on Price . [l) " PAlO FROM PAlO FROM Division of CommIssion (line 700) as Follows: BORROWER'S SE!..lE:~'S 701 S to FUNDS AT FUNDS AT 702. S to SETTLEMENT SETTLE\o1ENT 703. CommiSSIOn Paid at Settlement 704 to 800. tTEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Oriaination Fee % to 802. Loan Discount % to 803. Appraisai Fee to 804 Credit Report to 805 lender's Inspection Fee to 806. Mo~ Ins. AOQ. ree to 807. Assumption Fee to 808. 809. 810 811. 900. ITEMS RE"UIR<=n BY l"NDER TO"-E PAID tN ADVANCE 901. Interest From \0 @ $ Iday ( days %) 902. Mortnane Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 -vears \0 904. 905 1000. RESERVES"E;POS ITEn WITU LENDER 1001. Hazard Insurance $ cer 1002. Mo~ Insurance $ Der 1003. 2000-01 School tax $ Der 1004. 2001 Co.lMun. Tax $ Der 1005. Assessments @ $ per 1006. "" $ er 1007. @ $ per 1008 @ $ "er 1100. TITLE CHARGES 1101. Settlement or Closinn Fee \0 EtzweiJer & Associates I 75.001 1102. Abstract or Title Searcn to Etzweiler & Assoclates I 37500 1103. Title Examination \0 Etzweiler & Associates I 1104 Title Insurance Sinder 10 I 1105. Document Preoaration \0 Etzvveiler & Associates I 1106 Notarv Fees \0 I 1107 Attorney's Fees to I (includes above item numbers. I I 1108 Tille insurance 10 I (inClUdes above item numbers: I I 1109 Lender's Coverage $ I 1110. Cwner's Coverage $ I 1111 I 1112. I 1113. I 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1 ZOi. Recording Fees: Deed S 28.50 . Mortgage $ Releases $ I 28.50 1202. c:tvlCountvTaxJSta~ Deed Mort iaOe I 100.00 i 203 Stale Tax/Stamos: Re'/enue Stamps . Mortoaoe I 100.00 1204 I 1205 I 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Swr'lev to I 1302. Pest Inspection \0 1303. 1304 1305 I 1400. TOTAL SETTLEMENT CHARGES (Enter on lines 103. Section J and 502. Section K) I 578.50 100.00 p By slgr: ng page 1 of this statement, the slgnatones acknowledge receIpt of a completed copy of page 2 of this two page statement ~, /) /) - / /C, .; "-:~ .-A---~.-1!<-~ -<---r 0l.~ _y'? -; (\ Cert.feCl to be a true copy Earl Rlc:1ard EtzwelIer./ -~ Settlement Agent // (01-0053.1 01-00531 ~) AEV.1503 EX + (1~97) ESTATE OF COMMONWEALTH OF PENNSYLVANIA INHEAITANCETAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS FILE NUMBER George R. Smith SSfI 204-03-2103 01/30/2001 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION UNIT VALUE VALUE AT DATE NUMBER OF DEATH 1 1,011.156 shares Waddell & Reed Financial Services - 7.14 7,219.65 Account No.15931850-621. 2 692.063 shares Waddell & Reed Financial Services - 7.42 5,135.11 Account No.15931850-627. 3 3,428.006 shares Waddell & Reed Financial Services - 10.87 37,262.43 Account No.15931850-629. 4 1,501.675 shares Waddell & Reed Financial Services - 8.16 12,253.67 Account No.15931850-630. TOTAL (Also enter on line 2, Recapitulation) I 61,870.86 (If more space is needed, insert additional sheets of the same size) Copyrlght(c) 1996 form software only CPSystems, Inc. Form REV-1503 EX (Rev. 1-97) ;;FP.27, 28C'~ 10: 49+=;{'1 C~F r ~:C2 [,'ICI.'5"75 ~.2/2 e~~ - K"fi, /)Q !.vAl/tie I!/.:I IM:.L, j" Rei f/t1Ii/J'.-X PA 171HZ , Date: P~I 6300 l..Ei.mer Avem:e POS! Office Box 29217 ShiW1'tl!l1! MIssion, KS 66201.9217 Decedent Name(s): a.e()~ l? .sWJ/~ This is ,..,Titten in response 1:0 your request for a date of death valuation for the above person(s). ~'e have no accoun:s On record in the nameisocial security number of the deceased. We show the follo~'ir.g account(s) in the name ofilie deceased /A n!. ([he following shares anq' net asset prices we provided as of tht/ date of death: p!f'QLJ AccountIFund Number ShlU'es Price-per-Share ~stration /~9 31 'S'IJ ./. ':11 g-t, 3/i'S"o - t.a, (t;'"91! t<::n - c, ~I} 1)91IP~O - vSO 2:~~~:: ;~::: :z'RA ~ ~ 7),\9~V::' 5 I ~S. II ::$... '-I;; 8. OO~ 1.':;OI.Q7S' 3,. ;;(f.,.)<.{3 1~..;tS3.b ( Beneficiary of record (if applicable): In ord~ansfer* (chan~:e registration) or redeem these f~r.ds, please provide: ~ Letter of instructior.s from the surviving owner, executor, beneficia.ry Certified copy of 1:11e death certificate Letters Testament~:dAppoimment (cur.ent within 60 days) Inheritance Ta.x Waiver (Consent to Transfer) Stock Certificate fqr shares Copy of Trust document Other: ' QrtWlity to be of service. Additional questions may be directed to our senta,tives at 800-366-5465 'New r~gistration instructions ~ must include the social sec"'Uritv / numbel' and date of birth for new account owner(.s). - REV-1508 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER George R. Smith SS# 204-03-2103 01/30/2001 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 Sehedule F. ITEM NUMBER 1 DESCRIPTION 2000/2001 refund School Tax VALUE AT DATE OF DEATH 8.59 2 2001 CountyjTownship tax refund 153.26 3 Geigle Funeral Home - refund duplicate charge for vault. 397.50 4 New Cumberland Credit Union Savings Acct. No. 74863 50.00 5 New Cumberland Credit Union Checking Acct. No. 74863 5,306.07 6 Gail Sturm - rent for living in property prior to settlement. 1,200.00 7 Mark and Ruth DeWaelsche - balance due loan. 3,836.99 TOTAL (Also enter on line 5, Recapitulation) $ 10,952.41 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rey. 1-97) Earl Richard Erzweiler Christian S. Daghir New Cumberland Credit Union P.O. Box 658 New Cumberland, PA 17070 ETZWEILER AND ASSOCIATES ATTORNEYS-AT-LAW 105 N. FRONT STREET HARRISBURG, PENNSYLVANIA 17101 (717) 234-5600 2 West Main Street Elizabethville. PA 17023 (7] 7) 362-8395 HALIFAX LINE (717) 896-3737 225 Market Street Millersburg. PA \7061 (7] 7) 692-25] 9 Fax Line: (717) 234-5610 February 27, 2001 This office represents the Estate of George R. Smith who died on January 30, 2001, a resident of Upper Allen Township, Cumberland County, Pennsylvania, and whose Social Security Number is 204-03-2103. Would you please complete the bottom portion of this letter for all accounts in which the decedent had an interest in as of the date of death showing the balance in said account(s) at date of death and have the same signed by the appropriate officer or employee of your financial institution. It is my understanding that you already have a Death Certificate and Short Certificate on file. {fwithin \ year of death of decedent, could prior account be traced into a prior joint account in existence over 1 vear prior t death of decedent - (/0 j, v' ERE:hf Account Number(s) Type of Account Date Opened Interest earned during calendar year up to Date of Death Principal Balance as of Decedent's Death Accrued Interest not disbursed as of Decedent's Death Maturity Date Account Ownership Name of Joint Owner Date Joint Ownership was Established Bank Representative (oj' -P ?-G c: C' A.. 1-L.):1""r61.. n Sincerely yours, ~~J Earl Richard Etzweiler ~}_..(%~ ~V;iqLi; 'J;J..}-1Yl' j Q-' r Ii ,j b ~ ()-if: L f."J/v D ,) ')."')1-'11, o 0 ') lOb o~ 5'0 \ co J ) L, ~ d(';.- u'~ ':'IV\;-r.~) (Vr G~DC-(,t.. -~"'" ~ '(',..'\ N;4 ~. REV-1511 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TfV{RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF George R. Smith Debts of decedent must be reported on Schedule I. ITEM NUMBER A. B. FilE NUMBER SSII 204-03-2103 01/30/2001 DESCRIPTION AMOUNT 1 FUNERAL EXPENSES' Gail Sturm - reimbursement for funeral luncheon. 160.68 1. ADMINISTRATIVE COSTS, Personal Representative's Commissions Name of Personal Representative{s) Social Security Number(s) I E1N Number of Personal Representative(s) Street Address City State ZIp Year(s) Commission Paid: 2. 3. Attorney's Fees Etzweiler and Associates Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address 6,312.93 City Relationship of Claimant to Decedent State Zip 4. Register of Wills 263.00 Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Other Administrative Costs Cumberland County Law Journal - advertise Letters Testamentary. 75.00 2 Etzweiler and Associates - notary fee, postage and photocopies. 50.00 3 Register of Wills 5.00 one Short Certificate 4 Register of Wills 25.00 file estate papers 5 The Sentinel ~ advertise Letters Testamentary 87.85 6 7 u.S. Postmaster - postage Dauphin County Register of Wills - take out of county oath 6.80 15.00 TOTAL (Also enter on line 9, Recapitulation) $ 7,001.26 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97) REV~ 1512 EX + (1-97) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, AND LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCETAA RETURN RESIDENT DECEDENT ESTATE OF Georp;e R. Smith FILE NUMBER SS11 204-03-2103 01/30/2001 Include unreimbursed medical expenses. ITEM NUMBER 1 10 11 12 13 14 15 16 DESCRIPTION Eshenaurs Fuels - sewer maintenance. AMOUNT 248.60 2 Internists of Central PA - medical services provided 218.64 3 IRS - 2000 Individual Income Tax due. 964.00 4 Medical Bills (estimated balance due). Waiting for final billings. 200.00 5 Messiah Village - balance due nursing home care 4,542.00 6 Mobile X-ray Imaging - medical services provided. 36.77 7 Nancy L. Blair, Treasurer - balance due prior to death (real estate tax) 289.05 8 Ohio Casual - homeowner's insurance 81.50 9 Paul D. Dalbey, DPM - medical services provided 26.03 Pharmerica - balance due medical supplies 120.55 Pharmerica - balance due medical supplies 256.64 Pinnacle Health Services - medical services provided. 75.71 Quantum Imaging medical services provided. 4.27 Recorder of Deeds - transfer tax due 100.00 Terminix - balance due for pest contract service. 101.76 Waste Management - balance due for services provided. 27.51 TOTAL (Also enter on line 10, Recapitulation) $ 7,293.03 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97) / ii040 ~b,.add""TreII~R~SeNce 20001 u.s. Individual Income Tax Return !Ill lIS u..~1"ICIt IiIIIh IIlI' ...-In.....-c-. For...,..J.n. 1-D1e. 31, 2DOO,OII"''' ~ begIrninQ .2lXlO,_ .2D ~No. 15015<1074 Label r yOU' ftl'1lt name and irilial Laol name '\ V__MCwIly_ l f~..) A George R Smi th 204-03-2103 B If a joint retun. ~'a firs name and inithlll Laol name """'.... .......-'ly- E Use the IRS L label. Home ackt<<Ie ("","**and'-).If'Po' ..,._P,O. boa,_~ I A"''''' ... IMPORTANTI ... Otherwise. H p1ellse print E 42 Walsh Rd You lit.. enter "'type. R City, b:::lw1 or past office. 1Iate. WId 23P code. If you haw. fareiv-~. .. it'l8lr1.lcfJons '/ClUI'SSN\s)_. E Halifax PA 17032 ~ Pre rllal "- You - ===r. Filing Status Checl< only .ne box. Exemptions If mono IhlIn six ~Idelils, see insIructions. Income - FumsW-2 _ W-2G here. Also aIIl1Ch f<lrm(s)108&-R If tax_ _Id. It you did not got a W-2, see inslnJclions. Enclose, b\.t do not aIIach. any payment Also. pIeose use Fum l040-V. Adjusted Gross Income Single Mat:ried flUng jcirt retum (...., W .nly..... had Income) MarTiedtlling _atentum.____...__.__ ~ of ho.-.old (will qualifying person). (See instructions.) If qusllfying _ is . child but not your dependent. enter this child's name h<<e. .. - Qualilying widow(...) will dependent child ()'!lOr spouse _) __ ). (See in&ructions.) lIio Qg YooneIf. It \<lUr psrent (or someone else) can claim you as. depen_ on his or h<<lIIx b 0 Spcua l'fttJm.do~.che<:kboxEB.".:. .... . '.. . . . . . . . . . . . 1 2 3 4 IIote. Chedcing -Yes- \/\Ill not t:hwlge ycutax or reciJce )OII1Wu1d. Do )OJ. or)Utl .... if filing a jointAilln, ~ $3 tD go to tIQ ftnd? . . . X - - - , . . '" -- 0 Yes 129 No s_ DVes ONo s c Dependents: (2)rr .Mh (J)tl'r .....~ #14...~ ... "" I'l-- '--- --- ........PtD)1IU cr.-(_~.) d Total numb..- of """"ptions cl8lmed ... 7 WlIges.satarles,lips.~ AtlachForm(s)W-2 ....... ................ 7 Sa T.....bIe_.AtlachSCheduIeBitrequired ..... ....... '1' ... ...... lIio b T""..._pt __ Do net include on fine 6a . . .. .... I 8b 0 ~:;;,;:' 9 Onlinary dividends. Attach Schedule B it requIred . . . . .. .................. 9 10 T8IllIblerefunds,Credits,oroffselsot_andloc8lincomelal<es\seeinstruclions)..... 10 11 AI/monyreeeived ..... ......... ........................ 11 12 Busir186Sincomeor(Joss).AtlachScheduIeCorC-EZ .... ....... ....... 12 13 CapiaJ gein or ~oss). AIlach Schedule 0 ~ required. If not r"",ired. chsck heno . -- 0 13 14 Qh... gains or (losses). Altach Form 4797 . . . .. '" . . . . . 14 1l1io T_IRA<itllriWions . . . . . . . . . . . ~ 9 bT8IllIbIe.mount(....lnst.) lIb ll1io T_ponoicna&.....-..iti.. ........ ~I q bT_smourt(....inst) 16b 17 Rental""" estate, 1U)1Illles. partn_ips. S corpol1llions. trusts. etc. Atlach Schedule E. ... 17 18 Farm income Or(Ioss). AlIach Schedule F .. ..... . .. ......... .. 1. 19 Unemplo~ compensation .. . . . . . . . . . . . . . . . . . . . . .. 19 20a Social security _ . . . I 20a I 11, 238 i b T....ble.mount (see inst I 2Gb 21 Olher income. Ust!we.nd .mount(.... instructions) _ ~~!; _ .~~t!:ll,.9!.Epu _ _ _ _ _ _ _ 21 22 Add the 8IT1OIJnts in tf1e tar right eoIumn tor lines 7 through Zl. This is your lotallncome ~ 22 23 IRA deduction (see instructions) .. , . . . . . .. 23 0 t:Jii:~ 24 Student loan interest deduclior1 (see instruchonsl 24 :,' ':' 26 Medical sa.;ngs .ccount deduction. Att.ch Form 8853 26 U ',',1 26 MOIling expenses. Attach Form 3OCI3 .... . .. 26 0" 'r1 One-h.if of _...mpioyment tax. Altach Schedule SE 'r1 0 .', 28 Self-<<nplojed heolllh insurance dedUCliOl1 (see instructions) . 28 0 [,!'.' 29 Self-<<nplojed SEP. SIMPLE. and qualified plans . . . .. .. 29 0 30 Penally on ..~y wthdrawel ot ..-,jngs . . .. ...... .. 30 0 1:","1'-, 31. A1imonypsid b Recipienl'sSSN ~ 31. b.,;~; 32 Add lines Zllhrough 31. .. . .. .. .. . .. . .. .. .. .. .. . 32 1 . .. MIl_'" )'DIIctuetDd~ ;..~ -4 - - J A._Ie: ...-- -- r-::-1 =-..:. ~ L2:..J o 91 o o o 'o,UUU 5,519 o 9,552 881 64,043 o I'om1 ,c.oo(2000) George R Smith 34 Amourt from line 33 (ad)U5Ied gross income) ........ '" .. . . . . . . . 35a Check if: 129 You --. ElS or older, 0 BUnd; 0 ~ _ElSor older, 0 Blind. Add the number of """"" checI<ed abrM! and enIw the _ here . . . . . . ~ 311 b If you are married fling sepBratelyand \OUr spouse _ deductions. or you-..a_alien,seei"",n.dionsandcheckhln ... . . . . . ~3lIb 0 38 Enter your itemized _..... from Schedule A,line:lB, a ....- dedudlon shown on the left. BuI see InsIruction& to find your standard _ if you e_ any Ix>>< on line 35a or:l5b a if someone can cfaim "'" os a doJlendenI 37 SuImIa 11ne:l6 from line 34 . . . . . . . 38 If line 34 isSll6,7Cll or less, multipfy $2,lIXlbythe_lIllmber of....,,>tiu'l8claimed on IineEld. If line 34 is ~ SllB,7Cll, see the __ in the Instructions fertile amounlto enIw 38 Tuable Inalme. SUtllraet 1ine:JB from line 37. If 1ine:JB is more than Hne 37, ertIlr .0- 40 To (see insInJetioos). Cheek hny tax is tTam a 0 Foon(s) 8814 b 0 Form 497.2 41 A_minimum tax. Atlach Form6<S1 . . . . . . . . . . . . . . . . . . . 4:! Addllnes40_41 . . . . . . . . . . . . . . . . . .. 43 Foreignlaxcredt.AIlachForm111Sif:requked ....... 43 0 44 Cradt fer child and depondent care _,_ _ """" 2'" 46 Cl1ldIl fertile ~ orlhe _. Allaeh Sch_ R . . . .. 48 Educatlon_AIlachForm8ll63 ................ 48 ~ Chilcllaxcredl(seel_) ~ 48 Adoplion credt. Allaeh Foon B839 . . . . . . . . . 48 48 ~.~=~from :8 :::Ify)bO Form~ i;~ 0 SO AddlinM43throogh41.n-areyourtalal_ ................ SO 51 SUblract tine s:l from line 42. If line 50 is more than line 42. anter.o- ................ 51 52 SeIf......pIoymenl tax. Atlach Schedule SE ............... . .. .. .. .. .... 52 83 ScciaI security and Medic8re lax on tip incane not reported 10 eml*>)v. Altaeh Form 4137 . . . . .. 13 110I Tax on 1RAs. other Idb g,,erf pions, a/.HASAs. A1lach Form 5329 if required . . . . . . . . . 54 51 A_...medlncomeeradtpaymenlsfrnmForm(s)W-2 . . . . . . . . . . . . . 51 51 H~ employmertlaloes. A1lach Schedl.Ie H .. . . . . . . . . . .. 51 S7 AddlinM51 h53. ThIs is tdaltllX . . . . . . . fi1 Payments ll8 FederBlincomelaxwill1h91dfromFormsW-2and1Ql9 51 0 'c 19 = BOlin_lax p8)I11erts and amourt applied from 1 sgj return . 19 0 SOl I3nedlnccmec:ndlIElC) . . SOl 0 b Nonta>abIe earned Income: amount .. .. .1 I andlype ... _____________________________ 61 E>c_ social securilyand RRTA taxwthheld (seeinslructions) . . 61 52 Addlionalcruldlaxcredl.AllaehForm8812 .. .. . . .' 62 63 Amourt paid wi:h request for 8iUnsion to file (see instructions> ... 63 110I ether paymer(S. Cheek if frnm a 0 Form 2_ b 0 Foon 41:l6 110I 65 Add lines 56, 59, 6le, and 61 through 64. These are your loIal paymeRs Refund -ij -. ~ . b Routing number I -- and fill ine7b. .... d Account number ! 1170, - 67d. 88 Amount 01 line 66 you wart applied 10 your 2llO1 ..Im_ tax ... 68 Amount 69 If line 57 is more than line 65, sutllract lineElStTom line 57. This is the amount you...... You Owe Fa _its on how to pay, see instructions . . . .. 7U EsIimaI:ed lax penaty. AJso include on line 69 .... 70 0 Under ,...rti- at perjt.ry, I dedare..' have ~ tt's reIun.,-.d acc:orn~"liI sc:he:U_ ana . . hllllll.. and to.... "-f d my knaWedge.,.;l Wis, 'tIer.re true,. ect, and' c:ompl en pi' ttr (~ taxpayer} is r..ea on aI irlonmltic)l'l fA w-kh ~.., any kncMfedge. ~ v...._ 71f'll v....~"'~ Doyli_"",,""<Unbeo' , . Retired 717-896-2983 Spouse's si~ If a Sp:lu!Ie's oc:cupatiQn _IN IRS~'" NIlm \fIlI1h ~ shIMn 1Mibw('!!!.,.....)1 ny. I INo Tax and Credits Sta_ Iledudlon far Moot Peop/e SIngle: S4,4Xl _of -: $6,4s:l _filing t:Y~ \'IidQw(erj; S7,:l5ll Married filing ~ $3,675 Other Taxes Jfyau....... qo..oaifying -.- SchecUe ec. Sign Here Jaint retI.m? S. UWructiana. !<ooP a ..... lor yQr ......... 204-03-2103 2 64,043 34 54,807 9,236 36 37 38 38 2,800 6,436 964 o 964 o 964 o o o o o 964 66 If lineElS Is more then line 57, sulllTact Iine57tTom 1ine65.This istheamourt you overpaid 67a Amount of line 6B you want refunded to you . . . . . . . o o o . o .. 1 ... c Type: o CheclOng I OS8\ings MESSIAH VILLAGE STATEMENT Resident: GEORGE R SMITH Resident Number Date 000059805 01/31/2001 Page Amount Due 1 4,542.00 100 Mt. Allen Drive P.O. Box 2015 Mechanicsburg, PA 170552015 (717) 697-4666 B I RUTH DEWAELSCHE L 42 WALSH ROAD L HALIFAX. PA 17043.0107 T o Date Description CharQes Credits Total 4,875.33 150.00 5,025.33 4,350.00 9,375.33 42.00 9,417.33 -4,875.33 4,542.00 Beginning Balance 01/01/2001 01/01/2001 RESTORATIVE PRIVATE REHAB ROOM & BOARD - SEMI.PVT 29 DAYS AT 150.00 PER DAY BLOOD TEST PAYMENT RECEIVED. THANK YOU! 01/01/2001 01/31/2001 ~3S ~ &-* r:JO Y i)L\9' \0\ i Lt q \3? Current Past 31-60 Days 61.90 Days 91.120 Days Over 120 Total Due GEORGE R SMITH 4,542.00 I Due 0.00 0.00 0.00 4,542.00 ANCE CHARGE AFTER FEBRUARY 28. 2001 1%FIN REV-1513 EX "(9~OO) COMMONWEALTH OF PENNSYLVANIA tNHERITANCET~ RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF George R. Smith FILE NUMBER 5511 204-03-2103 01/30/2001 NUMBER I. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [Include outright spousal distributions, and transfers under Sec. 9116{aX1.Z)} FELATIONSHIP TO DECEDENT Do Not List Trustee{s) AMOUNT OR SHARE OF ESTATE See attachment ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 1a, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON- TAXABLE DISTRIBUTIONS. A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS See attachment TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) Copyright (c) 2000 form software only The Lackner Group, Inc. 0.00 Form REV-1513 EX (Rev. 9-00) ITEM I. Taxable Distributions: NAME/ADDRESS Ruth M. DeWaelsche 42 Walsh Road Halifax, PA 17032 Gail L. Sturm 5225 North Front Street Harrisburg, PA 17110 Mark L. Smith 1669 Shady Crest Place El Cajon, CA 92020 Schedule J - Beneficiaries RELA TIONSIDP DAUGHTER DAUGHTER SON ITEM liB. Charitable and Governmental Distributions: Armstrong Valley Bible Church 2041 Armstrong Valley Road Halifax, PA 17032 none SHARE/AMOUNT 2/5 RESIDUE AFTER CHARITABLE SHARE IS DEDUCTED 2/5 RESIDUE AFTER CHARITABLE SHARE IS DEDUCTED 1/5 RESIDUE AFTER CHARITABLE SHARE IS DEDUCTED 1/6 RESIDUE PRIOR TO DISTRIBUTION TO ANY OTHER BENEFICIARIES