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'* COMMONWEALTH OF
PENNSYLVANIA
, DEPARTMENT OF REVENUE
DEPT. 2B0601
'. HARRISBURG, PA 1712B-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENTS NAME (LAST. FIRST, AND MIDDLE INITIAL)
Clark vir inia C.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
10/01/2000 06/ /1924
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
N/A
G
OFFtCIAl USE ON':.~1
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FILE NUMBER ~..~.~,.,...
21 -01 00192
COONT'fCOOE y~ - NUMBER- - -
SOCIAL SECURITY NUMBER
196
20
5709
[i] 1. Original Return
o 4. limited Estate
liJ 6. Decedent Died Testate (Attach copy of \0'1111)
D 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise {dsle 01 dealh after 12-12-(12}
o 7. Decedent Maintained a living Trust (Attach copy ofTrusl)
o 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1.95)
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (dale of death prior to 12-13-132)
o 5. Federal Estate Tax Return Required
~ 8. Total Number of Safe Deposit Boxes
o 11. Election to lax under Sec. 9113(A) (Attach Sch 0)
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Keith O. Brenneman
FIRM NAME (If ~kabl8)
SnelbaKer
TELEPHONE NUMBER
717-697-8528
I:JJ.;ll ElIlJl)IREOl.ED1;J:O: ,
P. C.
44 W. Main Street
Mechanicsburg, PA 17055
Brenneman & S are
(8)
15 , 191.95
(1)
(2)
(3)
(4)
(5)
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1, Real Esta\e (Schedule A)
2. Slocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule 0)
S. Cash, Bank. Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter.Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage liabilities, & liens (Schedule I)
11. Total Deduclions (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 elec50n to tax has not been
made (Schedule J)
(11) 4,289.99
(12) 10.901.96
(13)
(14) 10,901.96
490.59
(19)
490.59
15,191.95
(6)
(7)
(9)
(10)
3,859.81
430.18
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON R~V~RS~ SID~ FOR APPLICABL~ RATES
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15. Amount of line 14 taxable at the spousal lax
rate. or transfers under Sec. 9116 (a){1.2)
,,0_ (15)
,.0 45 (16)
16. Amount of Une 14laxable at lineal rate
10.901. 96
17. Amount of Line 14 taxable at sibling rate
, ,12 (17)
18. Amount of Line 14laxable at collateral rate
, .15 (18)
19. Tax Due
20,0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS
CITY
1061-D Allendale Road
Mechanicsbur
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditsJPayments
A. Spousal Poverty Credit
B, Prior Payments
C. Discount
(1)
490.59
Total Credits (A+ 8 + C) (2)
3. InteresUPenalty it applicable
D.lnleresl
E. Penalty
TolallnteresUPenalty ( D + E) (3)
4. It 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.
A. Enter the interest on the tax dUe.
(5)
(5A)
490.59
490.59
8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.."..........................................................................,........... 0
b. retain the right to designate who shall use the property transferred or its incame;............................................ 0
c. retain a reversionary interest; or......................................................,............,...................................................... 0
d. receive the promise for life of either payments, bef\efits or care'? ..............................................."..................... 0
2. If death occumod 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 to~ or payable upon death bank account or security at his or her death?.............. 0
4. Did decedent own an Individual RetirementAccount, annuity, or other non-probate property which
contains a beneficiary designation? ...........,............................................................................................................ D
No
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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 penallies 01 perjury, I declare thai I have examined this return, inclUding accompanying schedules and statements, and 10 the besl of my knowledge and belief, il is true, correct
and complete.
DecJaralionofpreparerolherthanlhepersonal representalive is based on all in rOl!Tlationofwhichpreparerhasanyknowledge.
SIGNATU~ OF PERSON RESPONSIBLE FOR FlUNG RETURN
~ (!., ;/ ~ .. J , Executrix
ADDRESS
39 Grooms pointe Drive, Clifton Park, NY 12065
SIGNATURE OF PR A R THAN REPRESENTATIVE
ADDRESS
DATE
f/I'/al
44 W. Main Street, Mechanicsburq, FA 17055
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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. 99116 (a) (1.1) (i)].
For dates at death on or after January 1, 1995, the tax rete impOSed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and filing a tax retum 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 ot the child is 0% (72 P.S. 99116(a)(1.2)].
The lax rate imposed on Ihe net value of Iransfers to or for the use oflhe decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)1.
The tax rale Imposed on the nel value of transfers 10 or for the use of the decedent's siblings is 12% (72 P.S. ~9116(a)(1.3)]. A sibling is delined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Virqinia C. Clark
FILE NUMBER
21-01-00192
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
DESCRIPTION
1976 Cameron Mobile Home Serial No. 0440J
Miscellaneous furnishings and furniture
Firstrust Bank payment
Joseph Barnes & Sons, Inc. (property management)
deposit refund
Comcast Suburban Cable refund
York Federal checking account i090-848550
MetLife - trust interest payment
VALUE AT DATE
OF DEATH
$ 2,800.00
585.00
.27
269.00
4.60
11,526.08
7.00
TOTAL (Also enter on line 5, Recapnulation) $ 15,191.95
(If more space is needed, Insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Virginia C. Clark
FILE NUMBER
21-01-00192
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Mt. Airy Cemetery - grave opening fee $845.00
2. Honorariwn to Pastor, Rev. Harry G. Souders 100.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative s Commissions
Name of Personal Representative (8) waived
Social Security Number(s) ( EIN Number of Personal Representative(s)
Street Address
City State Z~
Year(s) Commission Paid:
2. Attorney Fees to Snelbaker, Brenneman & Spare, P. C. 2,000.00
3 Family Exemption: (If decedent s address is not the same as c1aimanl s, attach explanation)
Claimant N/A
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills, Cumberland County 73.00
5. A.ccountant s FeeSl notary fees, filing fees and misc.
administration costs 500.00
6. ~~ Cumberland Law Journal - advertise
letters 75.00
7. The Patriot News - advertise letters 93.81
8. The Hutter Agency - Executor's Bond 163.00
9. Cremation Society - death certificate 10.00
TOTAL (Also enter on line 9, Recapitulation) $ 3,859.81
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(If mOle space IS needed. Insert additional sheets oflhe same Size}
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
Virginia C. Clark
FILE NUMBER
21-01-00192
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
DESCRIPTION
AMOUNT
Comcast Cable - payment on
PP&L - payment on account,
account, cable
electricity
27.52
19.85
45.24
Verizon - payment on account, telephone
Internists of Central Pa, Ltd., payment on account
medical expenses
C.S.P. - payment on account
pinnacle Health - payment on account
Internists of Central Pa., Ltd, payment on account,
medical expenses
98.56
10.00
207.43
21. 58
TOTAL (Also enter on line 10, Recapitulation) $ 430 . 18
(If more space is needed, Insert additional sheets of the same size)
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COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
Virqinia C. Clark
FILE NUMBER
?,_n. _nn'Q?
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OFEST ATE
ESTATE OF
I.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
David Clark
P. O. Box 412
Hedgesville, WV 25427-0412
2. Samuel Clark
135 Fagen Road
Bunker Hill, WV 25413
son
1/4 of residue
NUMBER
1.
son
1/4 of residue
3. Douglas Clark
520 Shape Charge Road
Martinsburg, WV 25401
4. William J. Clark, Jr.
460 Beaver Street
Harrisburg, PA 17112
5. Roger Clark
5190 Carlisle Road
Dover, PA 17370
son
West Virginia
trailer
son
1/4 of residue
son
1/4 of residue
II.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II. 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)
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RE\<-l500 EX 1&001
REV-1500
'* COMMONWEALTH OF
PENNSYLVANIA
. DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Clark, Vir inia C.
DATE OF DEATH (MM.DD- YEAR)
10 01 2000 06 27 1924
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITIAL)
N/A
D 1. Original Return
D4.LimiledEstate
D 6. Decedent Died Testate (AtlachcopyofWiIl)
D 9. Litigation Proceeds Received
00 2. Supplemental Return
D 4a. Future Interest Compromise (dale of dealh after 12.12-82)
D 7. Decedent Maintained a Living Trust (AIlach copy of Trust)
D 10. Spousal Poverty Credit (date of death between 12.31.91 and 1.1.95)
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NAME
Keith o. Brenneman Es uire
FIRM NMtE 1"",",,_',
SneiDaKer, Brenneman & S are,
TELEPHONE NUMBER
717-697-8528
P.
44 W. Main Street
Mechanicsburg, PA
17055
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FILE NUMBER
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COUNTY CODE YEAR NUMBER
SOCI^, SECURITY NUMBER
196 - 20
5709
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Return {dale ofdealh pliorlo 12-13.821
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Allach Sch 0)
1ll:!iBlll'Jpal!rll'F. ..llI',<:i8M'ATlQlli~!iI)ji$"'i!!jRetm!;Dil>>,
COMPLETE MAILING ADDRESS
(1)
(2)
(3)
(4)
(5)
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1. Real Estate (Schedule A)
2. Slocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Unes 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election 10 tax has not been
made (Schedule J)
2.009.69
(6)
(l)
(9)
(10)
14. Net Value Subject to Tax (Une 12 minus Une 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable atlhe spousal tax:
rate, or transfers under Sec. 9116 (a)(1.2)
'.0_ (15)
,.O~ (16)
16. Amount of Line 14 taxable at lineal rale
2.009.69
17. Amount of Line 14 taxable at sibling rate
, .12 (H)
18. Amount of Line 14 taxable at collateral rale
, .15 (18)
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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2,009.69
(11)
(12)
(13)
2.00-..2...Ji.9
(14)
2.009.69
90.44
(19)
90.44
Decedent's Complete Address:
STREET ADDRESS
101il-D Allendale Road
CITY . I STATE D1\ I ZIP 17055
.
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2. CredilslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Total Credits (A + 8 + C) (21
3.
InteresUPenalty if applicable
D.lnteresl
E. Penalty
(3)
(4)
(5)
(5AI
4.72
4.
TotallnteresVPenalty ( D + E )
If Une 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
QO.44
4.72
5.
If Line 1 + line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
95.16
A. Enter the interest on the tax due.
95.16
8. Enter the total of Une 5 + SA. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.........,................................................................................ 0
b. retain the right to designate who shaH 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 nin trust for" or payable upon death bank account or security at his or her death? .............. 0
4. Old decedent own an Individual Retirement A.cCOlIl'\t, annuity, or other non.probate property which
contains a beneficiary designation? .,...................................................................................................................... 0
No
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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 pe~ury, J declare thai I have examined this return, lnduding accompanying schedules and slatements, ami to the best of TTtj knamedge and belief. it is lnIe. correct
and complete.
Dedaralion of preparer other than the personal representative is based on all informatiOn of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSI8LE FOR FILING RETURN
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ADDRESS /
39 Grooms pointe Drive, Clifton Park, NY 12065
SIGNATURE F ER OTHE THAN REPRESENTATIVE
, Executrix
DAT~
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ATE
Q.; :r' 11~
ADDRESS
44 W. Main Street. Mechanicsburq. PA 17055
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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 sUPJrving spouse is 3%
[72 P.S. ~9116 (al (1.1) (ill.
For dates of death on or after Janual'll, 1995, \he tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (al (1.1) (ii)].
The statute dop.s 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 sUNiving 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 stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)].
The tax rale .,mposed on the net vaiue of transfers to or for the use of the deoedent's lineal beneficanes is 4.5%, except as noted in 72 P.S. ~9116(1.21 [72 P.S. ~9tt6(al(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)1. 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.
ltEV.1508 EX+ (2.87]
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SCHEDULE E
CASH, BANK DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
Please Print or Type
FILE NUMBER
21-01-00192
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Virqinia C. Clark
(All property jointly-owned with the Right of Survivorship must be disclosed on Sch.dul. F)
ITEM
NUMBER
DESCRIPTION
VALUE AT
DATE OF DEATH
1.
35 shares, MetLife Policyholder Trust
$957.69
2.
Pension payment
324.00
3.
Social Security payment
728.00
TOTAL (Also enter on line 5, Recapitulation) S 2,009.69
(Attach additional 8Y," x 11" sheels if more space is needed.)
PETITION FOR PROBATE and GRANT OF LETTERS
~J-~OOI- J"'~
Estate of Virgi ni:'l ('. CJ ark
also known as
No.
To:
Register of Wills for the
, Deceased. County of Cumber land in the
Social Security No. 196 - 20 - 5709 Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the executrix
in the last will of the above decedent, dated August 22, 2000
and codicil(s) dated N/A
named
, jtk
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in Cumberland County, Pennsylvania, with
h ~r last family or principal residence at 106l-D Allendale Road
Mechanicsburq.Borough, C~rland County PQnnsylvania
(list street, number and muncipality) ,
Decendent, then 76 years of age, died October 1, 2000
at Mechanicshurg, ~ennsylvania
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent: N/A
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows: None
,JI~
$ unestimated
$
$
$
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters testamentary
(testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
theron.
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39 Grooms Pointe Drive
Clifton Park, NY J206S
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~ ss
COUNTY OF CtlMRBFT AND J
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
and
....k/~~ p~ ..,~
, /~Jir~ey 6nTine
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~o. 21-2001-192
Estate of
Virqinia C.Clark
, Deceased
DECREE OF PROBATE A~D GRA~T OF LETTERS
AND NOW February 20th, Jq. 200;tin consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated Auqust 22, 2000
described therein be admitted to probate and filed of record as the last will of
Virginia C. Clark
and Letters Testamentary
. Shir~Y.vanTIne. a/k/a
are hereby granted to Sh~rley Van'1'~ne
FEES
Probate, Letters, Etc. ......... $ 50.00
Short Certificates( 0) . . . . . . . . .. $ -0-
Renunciation ................ $
Bond $ 15.00
x-Pages (1) TOTAL $ 3.00
JCP - 5.00
Filed . February. . 20th. 20Dl. $. . .73..00.
'v.~
MAR C. LEWIS ~
REGISTER OF WILLs( ~
-
47077 ATTORNEY (Sup. Ct. 1.0. No.)
44 W. Main Street, Mechanicsburg, PA
ADDRESS 17055
(717) 697-8528
PHONE
r-~
L.
CALL ATI'ORNEY WHEN LETTER ARE FINISHED
1105.805 REV 9/86
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.
Fee for this certificate, $2,00
p
6763926
No.
21-2001-192
'/
~ //( '/~
Local Registrar
OCT 0 3 2000
Date
. 143ReY. 2187
COMMONWEALTH Of PENNSYLVANIA. OEPARTMENT Of HEALTH. VITAL RECOROS
CERTIFICATE OF DEATH
STAlE FilE NUMBER
SOCIAL SECuRIT'W' NUMBER
DATE OF O€ATH IMcnlIl. 08.,. ......,
LO--L - 0 ()
_. __om ___~ ___ __.
~ -- ------ --- -
- - ---
BlRTHPL.ACE (C,ty ar.c:s PlACE OF OERH fCtoeck ()I'lIy I)f'8 -- ie8 ,nstruclo(.Wl9 00 other- 'SI(Je)
SlaI8Of fereqnCouolIY) HOSPllAL -~ ----
7 :-- 0 ERIo..,.."... 0 OOA 0 ~~ __ ~ :=dylO
FACR..rrY NAME (It nollllSfof\AlOO. QlV8 wHt and numberl ~ \W4 ~C.JDE"'" OF. HISPANIC ORIGIN? fE,........... _.lllKk. Wh.. of<
/ / No ~ 'too 0" _ _CuDon. ISpcdy)
el1~/1!f, OAi :-"","",,,,-Rieon,"< ... _-_~i~~-
SURVIVING SPOuSe
tit _.. QIY8 rnad8n namel
.7..0 ~"":':"~ol Me.c.hatt.ic..6bWlg
MOTHER'S NAME (Fiest. Md<Je. MiIIden Surname)
It. EUa .i
INFORMANT'S MAlllHG AOORESS ISlr.... Cdy1Town. ~. Z.. ~I
460 Beavek Road Hakk~bWl PA 17112
PlACE OF OISPOSmOH. _ ol~, Cr_ LOCAtION. C~, StoI.. z;peo.
orOlhooPloco Cke.maUOtt SOc..iety
sex
., Female.
76
S.
COUNTY Of DERH
v...
CumbM.e.a.nd
...
DECEDENT'S USUAl OCCUPRION
(C:-~~:OO::=~:T
....HOMe.w.i e. 11b. ---------------- '2,
DECEDENT'S MAIliNG ADORESS (SO.... CoIylbon. S\oIo.l"opC_1 DECEDENT'S
1061-V A.e..e.e.ttda.e.e. Road ~~~NCE
Me.c.hatt.ic..6bUkg,PA 17055 ~~
'1.
FRHER'S NAME (First trAiOtIe. lata)
II. W.iU.ia.m A. W.iL60Yl
INFORMANT'S.....ME (l ypolPronl)
M't. W.iU-i.a.m Ciak k
METHOD OF DISPOSITION ...../
O _0 Cr_lY" __5<...0
- ~dy
. 2ta.
_URE
11.. Stale
CumbM.e.aYld
1111.
21c.
DATE PRONOuNCED DEAD 1M"""'. Day. 'marl
... ~', 30 P M 2$. 10 - / - 0 0
21. PART l: En1aIlM diSH..s, Wltyf. Of compkaIions which caused lhe death. Do not enter lhe mode at dying, such as cardaac or respif'afOty arrest. ShOCk Of hean ta~UI.
Lila onty OM cauae on each tine.
..
-e
l :
d.
WERE AUlOl'SY flHDlHGS
~E PRlOfIlO
COMPLETION OF CAUse
Of DEATH?
OUE 10 (OR AS A CONSEClUENCE Of):
UAHNER Of DEATH
DATE OF INJURY
(Monlh. Day, ~arl
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.. 196
- 20
5709
..
CoIIogo
(1.4Of~H
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WAS CASE REfERRED TO ME~ .JICAMINERICORONER?
... ... ~O NoD
. Appro""". PART H: OIIlor~_~lod..\ll,...
: inlerdI between not rHUIting in the undettp\g <<*IN gr,.n in PART I.
I QnMt and dMU\
I
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I
HY}J~~::hA
Tlwe OF INJURY
INJuRY IiI'M)AK"l
DESCRiBE HOW INJuRY OCCURRED.
p.rdng~lion
Could nalI bIi detem\lned
o
o
o PLACE (y INJURY. At horne,larm, st,.." taclofV. orftc:.
bu*Ing. Me. 1$pecIM
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CER'I'If'1ER IChocJ< coly onol
.CERTIF"tIHG PHYStClAN (Ptly$ICtan certlytng cause Of death wh.... anolhet phVSICoan has ptonouncec1 deal'" ana completed lIem 2Jl
To.... MMO'ftI' ktIQwa.ctve. ..thoccurrM due1oIlMcauM(S).nd manner.. _'-teet. .........................
-PftONOUNCING AND CERTIFVINQ PHVSM:tAN (Physc&an both o;lfonounc.tng oealtl and certllYI0910 cause of deathl
To the.... ot tny know&eclgft. death occurred at 1fM........ 4.", .ndplac., and due to the cauM(a) and manner n ..a..-t..
"MEDICAL EXAMINER/CORONER
On th. b..i. ot ..aminatlon andlor Inv.sUgalton. in my opinion, death occurred .. 'heUme, da'.. OInd place. and due '0 'he C8uae(s) and
manner.. .r..ed.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31..
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REGISTER OF WILLS OF
OATH OF SUBSCRIBING WIT
COUNTY
SS
,,"
,,//
/
codicil
(each) a subscribing witness to the will presented here "th, (each) being duly qualified according to
/
law, depose(s) and say(s) that present and saw
Sworn to or affirmed and subscribed be ore
me this ay of
signed as a witness at the
(in the presence of each other) (in the presence of the
the testat , sign the same and that
request of testat_ in h
other subscribing witness(es)).
(Name)
(Address)
(Name)
/
(Address)
21-2001-192
REGISTER OF WILLS OF CUMBERLAND COUNTY
OATH OF NON-SUBSCRIBING WITNESS
Shirley VanTine tiNe/.. (!/ff.< ( K- V-4.A1 /14 is
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
she aAutl. hE tr/l( familiar with the signature of Virginia C_ Clark
OO1tkit
test at rix of (one of the subscribing witnesses to) the will presented herewith and
(!M! K. V"'A171Nc ~;t/~ ooUiX
that Shirley VanTine believeXthe signature on the will is in the handwriting of
Virginia C. Clark
to the best of . her OU/2. knowledge and belief.
Sworn to or affirmed and subscribed before -4...4 ~J/ d1 J~-;;~
me this 31st day of Shirley Van l.I~~ame)
Janua ~ 2001 39 Grooms Pointe Dr.. Clifton
~egiste~ lU IS t!~~
(Name)
Park, NY
12065
11' ~tJw... ~/4fd1f:..ss) Cicfft,A.) ;1~('r ,v r !Lu(;,S
21-2001-192
BOND
REGISTER OF WILLS OF CUMBERLAND COUNTY
BOND AND SURETY FOR PERSONAL REPRESENTATIVE
KNOW ALL BY THESE PRESENTS, That
Shirley VanTine *
as principal(s) and
Ohio Casualty Insurance Company
as surety (sureties) are held and firmly bound unto the Commonwealth of Pennsylvania in the sum of
Thirty Thousand Four Hundred
dollars ($ 30 , 400 ) to be paid to the Commonwealth, for which payment we
do bind ourselves, jointly and severally, our heirs, executors, administrators and successors, the
condition of this obligation being that if
Shirley VanTine, principal
as (state fiduciary capacity)
Executrix
of the estate of
Virqinia C. Clark
, deceased,
or any of them, shall well and truly administer the estate according to law, then this obligation shall
be void as to the personal representative or representatives who shall so administer the estate and his
or their surety or sureties; but otherwise it shall remain in full force.
Signed and sealed this
;3 JSf
day of ...Lti\JUf\-lZ-'1
, 'U( JOO I ,each
intending to be legally bound hereby.
*Identified in the will of the Decedent
as "Shirly VanTine"
(Seal)
(Seal)
(Seal)
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(Seal)
CERTIFIED COpy OF POWER OF ATTORNEY
THE OHIO CASUALTY INSURANCE COMPANY
WEST AMERICAN INSURANCE COMPANY
No. 33-561
Know All Men by These Presents: That THE OHIO CASUALTY INSURANCE COMPANY, an Ohio Corporation, and WEST AMERICAN INSURANCE
COMPANY, an Indiana Corporation, in pursuance of authority granted by Article VI, Section 7 of the By-Laws of The Ohio Casualty Insurance Company and Article VI,
Section I of West American Insurance Company, do hereby nominate, constitute and appoint: Ralph G. Viehman, Jr. or Thomas R. Viehman or D. Jean
Rodriguez of Mechanicsburg, Pennsylvania its true and lawful agent (s) and attorney (s)-in-fact, to make, execute, seal and deliver for and on its behalf as
surety, and as its act and deed any and all BONDS, UNDERTAKINGS, and RECOGNIZANCES, not exceeding in any single instance ONE MILLION
($1,000,000.00) DOLLARS, excluding, however, any bond(s) or undertaking(s) guaranteeing the payment of notes and interest thereon
And the execution of such bonds or undertakings in pursuance of these presents, shall be as binding upon said Companies, as fully and amply, to all intents and purposes, as if
they had been duly executed and acknowledged by the regularly elected officers of the Companies at their administrative offices in Hamilton, Ohio, in their own proper
persons.
The authority granted hereunder supersedes any previous authority heretofore granted the above named attorney(s)-in-fact.
In WITNESS WHEREOF, the undersigned officer of the said The Ohio Casualty Insurance Company and West American Insurance
Company has hereunto subscribed his name and affixed the Corporate Seal of each Company this 30th day of October, 1998.
#""'~~~
I.SEAL'~
A~
4~
Sam Lawrence, ASSIstant Secretary
STATE OF OHIO,
COUNTY OF BUTLER
On this 30th day of October, 1998 before the subscriber, a Notary Public of the State of Ohio, in and for the County of Butler, duly commissioned and qualified, came
Sam Lawrence, Assistant Secretary of THE OHIO CASUALTY INSURANCE COMPANY and WEST AMERICAN INSURANCE COMPANY, to me personally known to be
the individual and officer described in, and who executed the preceding instrument, and he acknowledged the execution of the same, and being by me duly sworn deposeth and
saith, that he' is the officer of the Companies aforesaid, and that the seals affixed to the preceding instrument are the Corporate Seals of said Companies, and the said Corporate
Seals and his signature as officer were duly affixed and subscribed to the said instrument by the authority and direction of the said Corporations.
r!kf J. ~r
Notary Public in and for County of Butler, State of Ohio
My Commission expires August 6, 2002.
This power of attorney is granted under and by authority of Article VI, Section 7 of the By-Laws of The Ohio Casualty Insurance Company and Article VI, Section I of West
American Insurance Company, extracts from which read:
Article VI, Section 7. APPOINTMENT OF ATTORNEYS-IN-FACT, ETe. "The chairman of the board, the president, any vice-president, the secretary or any
assistant secretary of each of these Companies shall be and is hereby vested with full power and authority to appoint attorneys-in-fact for the purpose of signing the name of the
Companies as surety to, and to execute, attach the corporate seal, acknowledge and deliver any and all bonds, recognizances, stipulations, undertakings or other instruments of
suretyship and policies of insurance to be given in favor of any individual, firm, corporation, or the official representative thereof, or to any county or state, or any official
board or boalrds of county or state, or the United States of America, or to any other political subdivision."
Article VI, Section \. APPOINTMENT OF RESIDENT OFFICERS. "The Chairman of the Board, the President, any Vice President, a Secretary or any Assistant
Secretary shall be and is hereby vested with full power and authority to appoint attorneys in fact for the purpose of signing the name of the corporation as surety or guarantor,
and to execute, attach the corporate seal, acknowledge and deliver any and all bonds, recognizances, stipulations, undertakings or other instruments of surety-ship or guarantee,
and policies of insurance to be given in favor of an individual, firm, corporation, or the official representative thereof, or to any county or state, or any official board or boards
of any county or state, or the United States of America, or to any other political subdivision."
This instrument is signed and sealed by facsimile as authorized by the following Resolution adopted by the respective directors of the Companies (adopted May 27, 1970-The
Ohio Casualty Insurance Company; adopted April 24, I 980-West American Insurance Company):
"RESOLVED that the signature of any officer of the Company authorized by the By-Laws to appoint attorneys in fact, the signature of the Secretary or any
Assistant Se<:retary certifying to the correctness of any copy of a power of attorney and the seal of the Company may be affixed by facsimile to any power of attorney or copy
thereof issued on behalf of the Company. Such signatures and seal are hereby adopted by the Company as original signatures and seal, to be valid and binding upon the
Company with the same force and effect as though manually affixed."
CERTIFICATE
I, the undersigned Assistant Secretary of The Ohio Casualty Insurance Company and West American Insurance Company, do hereby certify that the foregoing power of
attorney, the referenced By-Laws of the Companies and the above Resolution of their Boards of Directors are true and correct copies and are in full force and effect on this date.
IN WITNESS WHEREOF, I have hereunto set my hand and the seals of the Companies this '31 day of "JiT /JU It {2.. Y J. DO I
'II "I.. ,1>1"'8."-",,>--
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~,~EALlJ ~. SEA~/l
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ASSistant Secretary
8-4300 (8/98)
-
'S:.-
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CERTIFICATION OF NOTICE UNDER RBLE 5.6(A)
Name of Decedent: Virginia C. Clark
Date of death: October 1, 2000
Administration No.: 21-01-0192
To the Register:
I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned Estate on
February 27, 2001.
Name
Address
Douglas Cla~k
520 Shape Charge Road
Martinsburg, WV 25401
David Clark
P. O. Box 412
Hedgesville, WV 25427-0412
Samuel Clark
135 Fagen Road
Bunker Hill, VW 25413
William J. Clark, Jr.
460 Beaver Street
Harrisburg, P A 17112
Roger Clark
5190 Carlisle Road
Dover, PA 17370
Shirley C. VanTine
39 Grooms Pointe Drive
Clifton Park, NY 12065
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None.
Dated: February 27,2001
LAW OFFICES
SNELBAKER.
BRENNEMAN
& SPARE
~
Keith O. Brenneman, Esquire
Snelbaker, Brenneman & Spare, P. C.
44 West Main Street
Mechanicsburg P A 17055-0318
Capacity: _ Personal Representative
-X Counsel for personal representative
COMMON'../EALTH OF PENN5YL'..ANIA
eouNrr OF CUMBERLAND.
}
STATE OF NEW YORK
55:
SSe
COUNTY OF . :5/j~7V0#
Shirley VanTine
_being duly sworn according to law, deposes and says that she 1S the
Executrix of the Estate of Virginia C. Clark
late of ____ Mecb~nic~.Qurq , Cumberland County, Pa., deceased and that the
within is an inventory made by Shirley VanTine , the said Executrix
of the entire estate of said decedent, consisting of all the personal propo!rty and real estate, except real estate outside
the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value
as of the date of decedent's death.
Sworn to
----_._-~'..-
/==t
Date of Death
and subscribed before me,
, ~ .
_~~~ l&~ ~ ... J
xecutor . Administrator
Shirley VanTine
39 Grooms Pointe Drive
Clifton Park, NY 12065
~ 2002
JANICE E.....ftAItCt1
ry !'vb/Ie in the $tct..<Qt N.. M
te.ldina In _alogQ ~ / ^ ~
..-.., c-........ ~lt.. Cl'i 3D/ Ll'--'
Address
1
2000
October
Month
Y.ar
Day
INSTRUCTIONS
I. An inventory must be filed within three months after appointment of personal representative.
2. A supplement inventory must be filed within thirty days of discovery of additional assets.
3. Additional sheets may be aHached as to personalty or realty
4. See Article IV. Fiduciaries Act of 1949.
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Supplemental~nventory of the real and personal estate of
Virqinia C. Clark
deceased
IO. PERSONALTY
A. 35 shares, MetLife Policyholder Trust
B. Pension payment
c. Social Security payment
$957.69
324.00
728.00
TOTAL APPRAISED VALUE, SUPPLEMENTAL
INVENTORY:
$2,009 9
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
L
J
STATE OF NEW YORK
55:
COUNTY OF ~~-?L
:
SS.
Shirley VanTine
being duly sworn according to law, deposes and says that she J..S the
Executrix of the Estate of Virginia C. Clark
late of ______________~echanicsburg , Cumberland County, Pa., deceased and that the
within is an inventory made by Shirley VanTine "' the said Executrix
of the entire estate of said decedent, consisting of all the personal propclrty and real estate, except real estate outside
the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value
as of the date of decedent's death.
Sworn to
and subscribed before me,
.
d~ /J~~
-Sh' 1 ec:utor - Administrator
J..r ey VanTJ..ne
39 Grooms Point Drive
Clifton Park, NY 12065
p
ry Mile in tIoe State-Qf New .,~
Residin, in Saratoga ~ , _ /. I
.thy C~ b,tirtM : ~ 300
Address
Date of De-ath
1
October
Month
200.0
Day
Year
INSTRUCTIONS
I. An inventory must be filed within three months after appointment of personal representative.
2. A supplement inventory must be filed within thirty days of discovery of additional assets.
3. Additional sheets may be attached as to personalty or realty
4. See Article IV, Fiduciaries Act of 1949.
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Inventory of the real and personal estate of
Virginia C. Clark
deceased
$ 2,800.00
585.00
.27
269.00
4.60
11,526.08
7.00
$15,191 95
NONE NONE
$15,191 95
I. PERSONALTY:
A. 1976 Cameron Mobile Home, serial no. 0440J
B. Miscellaneous furnishings and furniture
C. Firstrust Bank payment
D. Joseph Barnes & Sons, Inc. (property management)
deposit refund
E. Comcast Suburban Cable refund
F. York Federal checking account 1090-848550
G. MetLife - trust interest payment
TOTAL APPRAISED VALUE, PERSONALTY:
II. REAL ESTATE:
TOTAL. APPRAISED VALUE, ALL PROPERTY:
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FR:OM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
SNELBAKER BRENNEMAN & SPARE PC
C/O KEITH 0 BRENNEMAN
44 W MAIN STREET
MECHANICSBURG, PA 17055
~____n_ fold
ESTATE INFORMATION: SSN: 196-20-5709
FILE NUMBER: 2101-0192
DECEDENT NAME: CLARK VIRGINIA C
DA TE OF PAYMENT: 02/08/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 10/01/2000
NO. CD 000836
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $95.16
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$95.16
REMARKS: KEITH 0 BRENNEMAN
C/O SNELBAKER BRENNEMAN SPARE
CHECK#1503
SEAL
INITIALS: SK
RECEIVED BY:
REGISTER OF WILLS
MARY C. LEWIS
REGISTER OF WILLS
LAW OFFJCE:5
SNELBAKEI~.
BRENNEMAN
Be SPARE
2( -0(- OOr? L
RECEIPT AND RELEASE
WHEREAS, VIRGINIA C. CLARK, late of Mechanicsburg Borough, County of
Cumberland and Commonwealth of Pennsylvania, died on the 1 st day of October, 2000, having
first made her Last Will and Testament in writing dated April 22, 2000, which since her decease
was duly probated before the Register of Wills of Cumberland County and Letters Testamentary
were issued to SHIRLEY VANTINE, the Executrix named in the Last Will and Testament of
said decedent.
NOW KNOW ALL MEN BY THESE PRESENTS, that we, ROGER CLARK,
SAMUEL CLARK, DOUGLAS CLARK, WILLIAM 1. CLARK, JR. and DAVID CLARK,
being the residuary legatees and distributees named in the Will of said decedent and the persons
entitled to share in the residuary distribution ofthe Estate of said decedent, do hereby declare and
say that we, and each of us, have examined the attached Account and Schedule of Proposed
Distribution (attached hereto as "Exhibit A" and "Exhibit B", respectively), and find the same to
be true and correct, and in strict accordance with the terms and provisions of said Will, and we
do hereby acknowledge that we, and each of us, this day have, had and received of and from
SHIRLEY VANTINE, Executrix of the Estate of VIRGINIA C. CLARK, the cash and/or
personalty set opposite our names in the above stated Schedule of Proposed Distribution, in full
satisfaction, payment and discharge of all such sum or sums of money, legacies and bequests,
share or shares, purparts and dividends which were due, owing and payable and belonging to us,
and each of us, by any means whatsoever, for or on account of our full share, part or dividend of
the Estate of VIRGINIA C. CLARK, Deceased, and all interests accrued thereon.
NOW, THEREFORE, we, and each of us, ROGER CLARK, SAMUEL CLARK,
DOUGLAS CLARK, WILLIAM 1. CLARK, JR. and DAVID CLARK, do by these presents,
remise, release, quit-claim and forever discharge the said SHIRLEY VANTINE, her heirs,
executors and administrators, of and from our said share or dividend ofthe Estate aforesaid, and
of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever,
for or by reason thereof, or of any act, matter, cause or thing whatsoever, from the beginning of
the world to the day and date of these presents.
AND, desiring to avoid the delay and expense ofthe settlement of said Estate by filing a
formal Account of said administration in the Office of the Register of Wills of Cumberland
County and by having the balance in the hands of the Executrix, as shown by said Account,
distributed by the Court of Common Pleas of Cumberland County - Orphans' Court Division, we,
and each of us, do hereby agree that the foregoing schedule concerning the matter of settlement
may be recorded with the same effect upon me as if the same had been reported upon by said
Court, in a Decree of Distribution made on such report by the said Court of Common Pleas -
Orphans' Court Division.
AND in consideration of the aforesaid settlement being made without the aid of such
Court of Common Pleas - Orphans' Court Division, that we and each of us, the said ROGER
CLARK, SAMUEL CLARK, DOUGLAS CLARK, WILLIAM J. CLARK, JR. and DAVID
CLARK, do hereby agree that if any debts or demands other than those included in the First and
Final Account of the said SHIRLEY VANTINE, Executrix of the Estate of VIRGINIA C.
CLARK, Deceased, as hereinbefore set forth, shall be hereafter recovered against the Estate of
LAW OFFICES
said decedent and be legally payable out of the same, that we will return to the said Executrix
SNELBAKEH.
BRENNEMAN
& SPARE
-2-
LAW OFFICES
SNELBAKER.
BRENNEMAN
Be SPARE
such amounts thereof as may be necessary to pay such debts or demands.
').-<
IN WITNESS WHEREOF, we have hereunto set our hands and seals this cr
day of
fJ1f1(
,2002.
WITNESSED BY:
(SEAL)
Roger Clark
(SEAL)
Samuel Clark
\..Q.t n-f; 2 -----
Douglas Clar
(SEAL)
(SEAL)
William J. Clark, Jr.
(SEAL)
David Clark
,.,
-.J-
LAW OFFICES
SNELBAKER.
BRENNEMAN
Be SPARE
such amounts thereof as may be necessary to pay such debts or demands.
IN WITNESS WHEREOF, we have hereunto set our hands and seals this In- day of
n;
,2002.
WITNESSED BY:
(SEAL)
Roger Clark
(SEAL)
Samuel Clark
(SEAL)
~ Douglas Clark
-'
/"
/
./'~'"
/// ~..----
// .".---..-- ~
/~.. - / 4J!..
~~//
(SEAL)
(SEAL)
David Clark
-3-
LAW OFFICES
SNELBAKER:.
BRENNEMAN
Be SPARE
such amounts thereof as may be necessary to pay such debts or demands.
IN WITNESS WHEREOF, we have hereunto set our hands and seals this J 1A day of
fI(1fle~
,2002.
WITNESSED BY:
(SEAL)
Roger Clark
(SEAL)
Samuel Clark
(SEAL)
Douglas Clark
(SEAL)
William J. Clark, Jr.
~ViJP (~
(SEAL)
,.,
-.)-
LAW OFFICES,
SNELBAKEf;t.
BRENNEMAN
Be SPARE
such amounts thereof as may be necessary to pay such debts or demands.
IN WITNESS WHEREOF, we have hereunto set our hands and seals this Z(P day of
Af~ll
,2002.
WITNESSED BY:
Cf(n:u-dld,. / Q; ,:TJ~~
~
ROge%;-k
/II! I
~-
(SEAL)
Samuel Clark
(SEAL)
Douglas Clark
(SEAL)
(SEAL)
William J. Clark, Jr.
David Clark
(SEAL)
-3-
such amounts thereof as may be necessary to pay such debts or demands.
IN WITNESS WHEREOF, we have hereunto set our hands and seals this ;.. 7 R day of
Irf7R (c-
,2002.
WITNESSED BY:
(SEAL)
Roger Clark
~&---
Samuel Clark
(SEAL)
7U/ (~fft-
/' -
(SEAL)
Douglas Clark
(SEAL)
William J. Clark, Jr.
(SEAL)
David Clark
LAW OFFICES
SNELBAKER~.
BRENNEMAN
Be SPARE
"
-.)-
LAW OFFICES
SNELBAKER,
BRENNEMAN
Be SPARE
STATE OF WEST VIRGINIA
COUNTY OF Bf.A.l<u...,."
)
SS.
)
On this the ~ day of maA-{ ,2002, before me, a Notary Public in and
for said State and County, the undersigned officer, personally appeared DOUGLAS CLARK,.
known to me (or satisfactorily proven) to be the person whose name is subscribed to the within
instrument and acknowledged that he executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
OFFICiAl SEAL
NOTARY PUBLIC
STATE OF WEST VIRGINIA
. , . . SHAWN D, SOWDERS
~ '., ~"': OPEQUON MOTORS, INC.
'.~ ,'" P. O. BOX 1937
. ~ MARTINSBURG, wv 25401-6937
My Commission ExpIres October IS.
Commission Expires: 0bI-. /6, cXOO?
LAW OFFICES
SNELBAKER,
BRENNEMAN
Be SPARE
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF ()AV(J~
SS.
)
--"
On this the J S \ day of N ~ Y ,2002, before me, a Notary Public in and
for said Commonwealth and County, the undersigned officer, personally appeared WILLIAM 1.
CLARK, JR., known to me (or satisfactorily proven) to be the person whose name is subscribed
to the within instrument and acknowledged that he executed the same for the purposes therein
contained.
IN WITNESS WHEREOF, I hereunto set my han~.and official seaL
"'" ............-_r'
/,/" ,,,..,..........,, .
r{~~
Notary Public
My Commission Expires:
Notarial Seal .
Charles Frank Class 111, Notary Public
Lower paxton Twp., Dauphin County
My Commission Expire:s Apr. 30. 2003
Member, Pennsylvania Association of Notaries
LAW OFFICES
SNELBAKER.
BRENNEMAN
Be SPARE
STATE OF WEST VIRGINIA
COUNTY OF Cf3~~'0
)
: SS.
)
On this the ::<11:;11 day of -' l ,2002, before me, a Notary Public in and
for said State and County, the undersi ned officer, personally appeared DAVID CLARK, known
to me (or satisfactorily proven) to be the person whose name is subscribed to the within
instrument and acknowledged that he executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
?
- - f---~-ed~ //1 ~
~ 6) OFFICIAlSEAL ~ Notary Public
Notary Public, State of West Virginia /
JUDITH M. ATWELL ~ I
492 Weaver lane ...
. ~ . Martinsburg.WV 25401 a My CommIssiOn ExpIres:
s._"" MycommissionexpiresMan:h12.2012 a
LAW OFFICEf;
SNELBAKER.
BRENNEMAN
Be SPARE
COMMONWEALTH OF PENNSYLVANIA)
COUNTYOF Y b~k
SS.
)
On this the ~b+h day of If p Y',' J , 2002, before me, a Notary Public in and
for said Commonwealth and County, tlie undersigned officer, personally appeared ROGER
CLARK, known to me (or satisfactorily proven) to be the person whose name is subscribed to the
within instrument and acknowledged that he executed the same for the purposes therein
contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
~) PA / O? 12etM rluff
Notary Public / '
My Commission Expires:
Notarial Seal
Louella R. Deardorff, Notary Public
Dover Twp., York County
My Commission Expires June 24, 2004
Member, Pennsylvania Association of Notanes
LAW OFFICES
SNELBAKER.
BRENNEMAN
Be SPARE
STATE OF WEST VIRGINIA )
: SS. \3B-L..\2-0\Y\
COUNTY OF ~y'"\t-e \00..\ )
On this the 2.1 day of Pipf"'" \ , 2002, before me, a Notary Public in and
for said State and County, the undersigned officer, personally appeared SAMUEL CLARK,
known to me (or satisfactorily proven) to be the person whose name is subscribed to the within
instrument and acknowledged that he executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
~a.~~ q} OJu~
Notary Public
My Commission Expires: Ha..y \lo, 20\ I
OFFICIAL SEAL
. NOTARY PUBLIC
STATE OF WEST VIRGINIA
. TAMllYN H. CLARK
CITY NATIONAl.. BANK
P. O. BOX 1579
· . · INWOOD. WV 25428
-~ My Cl)IIll'IIiISlo elqlires May 16, 2011
ESTATE NO. 2001-00192
FIRST AND FINAL ACCOUNT OF SHIRLEY VANTINE,
EXECUTRIX OF THE ESTATE OF VIRGINIA C. CLARK,
LA TE OF MECHANICSBURG BOROUGH, CUMBERLAND
COUNTY, PENNSYLVANIA
SHIRLEY VANTINE, EXECUTRIX and Accountant herein
avers as follows:
DATE OF DECEDENT'S DEATH:
October 1, 2000
DATE LETTERS TESTAMENTARY ISSUED:
February 20,2001
LETTERS TESTAMENTARY WERE ADVERTISED AS FOLLOWS:
The Patriot News:
March 6, 13 and 20, 2001
Cumberland Law Journal:
March 9, 16 and 23,2001
DATE OF RULE 5.6(A) CERTIFICATION:
February 27,2001
PERSONAL TY - PRINCIPAL ACCOUNT
DEBITS
The Accountant charges herself with receipt of the Decedent's goods and
personalty as more fully set forth in the Inventory and Appraisement
and Supplement filed with the Register of Wills of Cumberland County,
Pennsylvania:
LAW OFFICES
SNELBAKER.
BRENNEMAN
& SPARE
1976 Cameron Mobile Home, Serial No. 0440J
Miscellaneous furniture and furnishings
First Trust Bank payment
Security Deposit refund
Comcast Suburban Cable refund
York Federal Checking Account No. 090-848550
MetLife - interest payment
MetLife - 35 shares of Policy Holder Trust Stock
Pension Payment
Social Security Payment
$2,800.00
585.00
.27
269.00
4.60
11,526.08
7.00
957.69
324.00
728.00
TOT AL. PERSONALTY, PRINCIPAL ACCOUNT, DEBITS:
$17.201.64
EXHIBIT A
PERSONALTY - PRINCIPAL ACCOUNT
CREDITS
The Accountant claims credit for payment of the following items from
personalty principal:
Checks posted to Decedent's account after date of death:
Comcast Cable - payment on account, cable
PP&L - payment on account, electricity
Verizon - payment on account, telephone
C.S.P. - payment on account
Pinnacle Health - payment on account, medical expenses
Internists of Central Pa., Ltd., payment on account, medical expense
Mt. Airy Cemetery, grave opening fee
Honorium to Rev. Harry G. Souders
Cremation Society, death certificates
Register of Wills, Cumberland County, probate fee
Cumberland Law Journal- advertise letters
The Patriot News - advertise letters
The Hutter Agency - Executor's Bond
Snelbaker, Brenneman & Spare, P. C. -legal fees to April 3, 2001
Register of Wills, Agent - payment of inheritance tax
Register of Wills, Agent, payment of supplemental inheritance tax (Advanced)
Register of Wills - filing fee for Inventory and tax return
H & R Block - tax return preparation fee
Reserve for final filing fees, attorneys fees and miscellaneous Estate expenses
TOTAL, PERSONALTY, PRINCIPAL ACCOUNT, CREDITS:
PERSONAL TY - INCOME ACCOUNT
DEBITS
The Accountant charges herself with receipt of the following items of
income from personalty:
LAW OFFICES
SNELBAKEIR.
BRENNEMAN
& SPARE
Interest on Decedent's checking account No. 090-848550, from
date of death to close of account
Interest on Estate checking account to July 9,2001
TOTAL, PERSONALTY, INCOME ACCOUNT, DEBITS:
-2-
$ 487.38
27.52
19.85
45.24
10.00
207.43
21.58
845.00
100.00
10.00
73.00
75.00
93.81
163.00
1,650.00
490.59
95.16
25.00
44.00
1,500.00
$5.983.56
$ 74.58
26.80
$101.38
LAW OFFICES
SNELBAKER.
BRENNEMAN
& SPARE
PERSONAL TY - INCOME ACCOUNT
CREDITS
The Accountant claims credit for payment of the following items from
personalty income:
NONE
TOTAL, PERSONALTY, INCOME ACCOUNT, CREDITS:
NONE
REAL EST A TE - PRINCIPAL ACCOUNT
DEBITS
The Accountant charges herself with receipt of the Decedent's Real
Estate as follows:
NONE
TOTAL, REAL ESTATE, PRINCIPAL ACCOUNT, DEBITS:
NONE
REAL EST A TE - PRINCIPAL ACCOUNT
CREDITS
The Accountant claims credit for payment of the following items
from real estate principal:
NONE
TOTAL, REAL ESTATE, PRINCIPAL ACCOUNT, CREDITS:
NONE
REAL ESTATE - INCOME ACCOUNT
DEBITS
The Accountant charges herself with receipt of the following income
from real estate:
NONE
TOTAL, REAL ESTATE, INCOME ACCOUNT, DEBITS:
NONE
-3-
LAW OFFICES
SNELBAKEFl.
BRENNEMAN
& SPARE
REAL EST A TE - INCOME ACCOUNT
CREDITS
The Accountant claims credit for payment of the following items from
real estate income:
NONE
TOTAL, REAL ESTATE, INCOME ACCOUNT, CREDITS:
NONE
-4-
LAW OFFICES
SNELBAKER.
BRENNEM,o,N
& SPARE:
RECAPITULATION
I. PERSONALTY
A. PRINCIPAL ACCOUNT
Debits
Credits
Balance
$ 17,201.64
5,983.56
B. INCOME ACCOUNT
Debits
Credits
Balance
$ 101.38
-0-
C. NET BALANCE OF PERSONALTY:
II. REAL ESTATE
A. PRINCIPAL ACCOUNT
Debits
Credits
Balance
NONE
NONE
B. INCOME ACCOUNT
Debits
Credits
Balance
NONE
NONE
C. NET BALANCE OF REAL ESTATE:
III. NET BALANCE OF ESTATE FOR DISTRIBUTION:
-5-
$11,218.08
$ 101.38
$11 ,319.46
NONE
NONE
NONE
$11.319.46
SCHEDULE OF PROPOSED DISTRIBUTION
TO: DOUGLAS K. CLARK
Mobile Home, received in kind: $2,800.00
Value of property received: 125.00
Total: $2,925.00
TO: DA VID CLARK
One-fourth (1/4) of residue per Will
Value of property received in kind: 75.00
Cash to David Clark: 2,023.61
Total: $2,098.61
TO: SAMUEL CLARK
One-fourth (1/4) of residue per Will
Value of property received in kind: 220.00
Cash to Samuel Clark: 1 ,878.61
Total: $2,098.61
TO: WILLIAM 1. CLARK, JR.
One-fourth (1/4) of residue per Will
Value of property received in kind: 125.00
Cash to William J. Clark 1,973.62
Total: $2,098.62
TO: ROGER CLARK
One-fourth (1/4) of residue per Will
Value of property received in kind: 40.00
Cash to Roger Clark: 2,058.62
Total: 2,098.62
TOTAL DISTRIBUTION TO BENEFICIARIES: $1 1,319.46
EXHIBIT B
LAW OFFICES
SNELBAKEF1.
BRENNEMAN
8c SPARE
STATE OF NEW YORK
COUNTY OF .sa~0-
)
: SS.
)
SillRLEY V ANTINE, being duly sworn according to law depose and say: that she is the
Executrix ofthe Estate of VIRGINIA C. CLARK, Deceased and the Accountant herein; that the
foregoing Accounting is true and complete; that the attached list or schedule [*] contains the
names and addresses ofall persons who have given notice of their claims, and whose claims
remain unpaid; that the attached list or schedule [**] contains the names of all persons interested
in the distribution of said Estate; and that the facts set forth in the within Account are true and
correct to the best of her knowledge, information and belief.
.
~A~ I/~~
Sl1iey VanTine
Sworn to and subscribed before me this
a.G, day of flVri l , 2002.
~ ~ LOll M. IIONOWICZ
__ ^~~ ~,. .. ,ho ..... of _....
Not Pu lie lfIed In Saratoga ~ I ~
ary . mlttlulo" Explfe. q,.ll ]...lQ.
* Persons having claims against Estate:
None
** Persons interested in distribution of Estate:
Roger Clark
5190 Carlisle Road
Dover, PA 17370
Samuel Clark
135 Fagen Road
Bunker Hill, WV 25413
Douglas Clark
520 Shape Charge Road
~artinsburg, WV 25401
William J. Clark, Jr.
460 Beaver Street
Harrisburg, P A 17112
David Clark
P. O. Box 412
Hedgesville, WV 25427-0412
"\, /6 -(:2//- C
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT. ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
KEITH 0 BRENNEMAN ESQ '02
SNELBAKER ETAL
::C~A:~~~B~~G PA 1~~~,
APR -1
D12 :4 B
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
03-25-2002
CLARK
10-01-2000
21 01-0192
CUMBERLAND
101
'*
REV-1547 EX iFP '01-021
VIRGINIA
C
Allount Rellitted
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-E3f-AFP--foY:02Y-NOYicE--oF-YNHERiTANCE-YAirA-PPRAisEirENT~--ALi-oWAircE-'ifR-------------- ---
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF CLARK VIRGINIA C FILE NO. 21 01-0192 ACN 101 DATE 03-25-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
4. Mortgages/Notes Receivable (Schedule D) (4)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
NO. 01
.00
.00
.00
.00
2,009.69
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
.00
.00
(11)
(12)
(13)
(14)
NOTE: I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
NOTE: To insure proper
credit to your account.
subllit the upper portion
of this forll with your
tax paYllent.
2.009.69
00
2.009.69
.00
12.911.65
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
12.911.65 X 045=
.00 X 12 =
.00X15=
(19)=
.00
581.03
.00
.00
581.03
n~_~_. . l+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
04-20-2001 AA478294 .00 490.59
02-08-2002 CDOO0836 4.67- 95.16
TOTAL TAX CREDIT 581.08
BALANCE OF TAX DUE .05CR
INTEREST AND PEN. .00
TOTAL DUE .05CR
. 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
.& 1ll'I'"IINn 0:::1'1' IlI'UI'Il!::1' !::Tnl' nl'" TItTO::: I'"nllM I'nll TNO:::TllllrTTnNO::: \
Vv'
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Virginia C. Clark
Date of Death: October 1, 2000
Will No.
Admin. No. 21-01-0192
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes X No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date: May 14. 2002 ~
ss.~~
Keith o. Brenneman
Name (Please type or print)
44 W. Main Street
Mechanicsburq, FA 17055
Address
..-
N
(7171 697-8528
Te 1. No.
N
P
-"
"':";~
Capacity:
Personal Representative
x Counsel for personal
representative
( MAH : rm f / AM 3 )
'\, /b-~//- 6-'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
t,.) ,
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
~0UNTY
ACN
05-21-2001
CLARK
10-01-2000
21 01-0192
CUMBERLAND
101
KEITH 0 BRENNEMAN ESQ
SNELBAKER HAL
44 W MAIN ST
MECHANICSBURG PA 17055
~*
REY-15'7 EX AFP el2-DD)
VIRGINIA
C
Allount Rellitted
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 ~
REY=is'4j-EX-AFP--fi'2=oOY-NOYiCE--OF-YNHEiiiiANCE-YAX-APPRAisEHENi:'~--Ai:.rowAiiCE-(rR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF CLARK VIRGINIA C FILE NO. 21 01-0192 ACN 101 DATE 05-21-2001
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)
.00
.00
.00
.00
15,191.95
.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/Governllental Bequests; Non-elected 9113 Trusts
14. Net Value of Estate Subject to Tax
(9)
(10)
3,859.81
430.18
(11)
(12)
(13)
(14)
(Schedule J)
NOTE: I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS.
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
15,191.95
4.?89 99
10,901.96
.00
10,901.96
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
10,901.96 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
.00
490.59
.00
.00
490.59
.
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
PAYMENT MUST BE MADE BY 07-01-2001*. TOTAL TAX CREDIT .00
BALANCE OF TAX DUE 490.59
INTEREST AND PEN. .00
TOTAL DUE 490.59
. 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 RFFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.l
\, /b-.O:)-//- ~
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
)'1: ~
/~
REY-1607 EX AFP <12-00l
KEITH 0 BRENNEMAN ESQ
SNELBAKER ETAL
44 W MAIN ST
MECHANICSBURG PA 17055.\
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
-COUNTY
ACN
05-21-2001
CLARK
10-01-2000
21 01-0192
CUMBERLAND
101
VIRGINIA
C
Allount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV= i60i-i:Y-AFP-fi'2-:ooY------...--iiilHERITANcE-TAY-sTAfEMENT-OF'-Aifcouiff--.-..---------------- - ----
ESTATE OF CLARK VIRGINIA C FILE NO. 21 01-0192 ACN 101 DATE 05-21-2001
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 05-14-2001
PR I NCI PAL TAX DUE: .......................................................................................................................................................
490.59
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
04-20-2001 AA478294 .00 490.59
TOTAL TAX CREDIT 490.59
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
IE
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1,
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT"' (CR1,
vnll MAV RI= nlll= A RFFlJND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. 1
.
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item 4 if R n d address on the re
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SO tt\at we can retU~~e back of the mallplec9.
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or on the fron I
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1. Article Add~
.~ VERNEY, ESQ.
J ACQUELINb M. C\ 'I
NOVER ST "'
44 S. HA P A 17013
CARLISLE,
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4. n<>"
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7005 182 102595-O2"""-154O}
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2. Article NulT\b6I" rvfO& ,ab6/)
(Transfer from se
3811 February 2004
PS Form '
Domestic RetUrn Receipt
.. . .
.
'1PLETE THIS SECTION ON DELIVERY
. Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
. Print your name and address on the reverse
so that we can return the card to you.
. AttacMhis card to the back of the mail piece,
or on;the front if space permits.
1. Article Addressed to;
D. Is delivery ~9ress different ~ item 1?
If YES, enterc~ery add~low:
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ROBERT O'BRIEN, ESQ.
19 WEST SOUTH ST
CARLISLE, P A 17013
byes
2. Article Number
(Transfer from ssfVlce label)
. PS Form 3811, February 2004
7005 1820 0002 4615 4007
Domestic Return Receipt 102595-02-M-1540 :
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