HomeMy WebLinkAbout06-24-15 (2) 1505610143
� REV-7500�"°�,,,
ly� OFFICIAL USE ONLV
PA�epatlmentofRevenue p¢nnsylvania �o�mycoae vear reerv��,ve,
Bureau oflndlvitluelTaxes ���•a�ME^�=�^F.�'�F
Po eox.zeosai INHERITANCE TAX RETURN 2 1 15 0 17 3
Harrisburg,vA nt28-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
. Social Sewrity Number Date of Oea�h Date of Bltlh
12 17 2019 02 10 1933
DecetlenfsLas[Name Suffix DecetlenfsFlrslName MI
DEIVERT GARY N
Qf Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Sacial Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. OnglnaiReWm ❑ 2. Supplemen�alReWm � 3 RemamJerReNm(Dateolpeath
� PnOt�o 1&19-82)
� a LimiletlEstate � na �°�°ram�aresiComo�omise � 5. FetleralEs�ateTaxRewrnRequiretl
iaa�e oi aeain ane.+2-i2azi
� 6 oa�eeemmeoies�aie � �. oe�oemMamumeaa�i.mai��s� � e. roUlrvum�erorSaleDeoosltBoxes
(A�Iec�CopYolNAli� I�ac�Copyo��nsl�
� BLitigationProCBetlsRecelvea ❑ ���beWeenl&3191zntl�1�0ateotDeatM1 ❑ �� �q�ryacM1�6che0ule0)�� �� ����
CORRESPONDENT�THIS SECTION MUST BE COMPLETED.ALL CORRESPON�ENCE AN�CONFI�ENTIAL TA%MFORMAiION SH W LO BE�IRECTE�TO:
Name Daytime Telephone Number
GARY A DELAFIELD ESQ . 614 237 6278
REGISTER OF WILLS US�:(}NLY
� �
Firet Line of Atltlress - . � (-'�
i
916 9 ATHERTON STR&ET �- `�� � �-'
— ��
Sacontl Line of Atltlress � � '��
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OATEFILH� � � ;:�
City or Post Office Stale ZIP Gotle
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STATE COLLEGE PA 16601 . ,�� � "'�
corresponaenPs e-mail aaaress: 9 d e I af i e I d@d mj k I a w.c o m
unaerp9naltiesolperjury.ItleclaretnatlnaveexaminMinisreWrn.inclueingacmm�panyingscnMulesandstatemenis. natolneCeslolmyxnowietlqeanaoelrel.
�.11stm .torrectanOco �e.Dedarabono�pre0arero1�erl�anNepersona.represnlaliveis0ase4onalllnforma0onolwhicM1prepdRrM1asanyknowletlge.
SI6N UAE Of PER50 N P 51 E FOR FlLING RETORN OAiE
Denise A. Dickerson � a
Pp RE55
1479 E. 14th St et, Clevel d, OH 44114
scuaruaEo�vaEa EaorHE H aa rv� nnre
Gary A Delafield Esq G
nooaess
Delafield, cGee Jone P.C.
916 5. Ath rtqn reet, ate College, PA 16801
Sitle 1
L 1505610143 150561�143 �
�
ADDITIONAL Personal Representatives
Deivert, Gary N. SS# 12/17I2074
Under penalties of peryury, the undersigned declare that they have examined this return,
including accompanying schedules and statements, and to the best of their knowledge and
belief, it is true, correct and complete.
2 Signature
%aM.� Zti-ce C!*--/��,G(.c–e,,—.
Name Tamara A. Nichici
Address 3644 Derry Street
Ciry,State,Zip Harrisburg PA 1711 L1919
Date ��01_5.
3 Signature
Name
Atltlress
City, State,Zip
Date
4 SignaWre
Name
Atltlress:
Ciry,State,zip
Oate
5 Signature
Name
Address:
City, State,Zip
Date
6 Signature
Name
Atltlress:
CiTy,Sfate,Zip
Date
� 1505610243
REV4500 EX
Decedenfs Social5ecurity Numbet
oe�ee��.sNama DEIVERT� GARY N.
REGAPITULATION
1. RealEs[a[e(SchetluleA}_. _._._. ____. .._.. ___ 1.
2. SlocksandBontls(Schetlule8) ..._.... ..__._ .__._... 2.
3. Closely Heltl Corporalion, Partnership or Sole-Proprietorshlp(Schetlule C)._. ._. 3.
4. Mohgages&No�esReceivable(SchetluleD) .._.._. .____ .... 4.
5. CasM1, Bank Deposits 8 Miscellaneous Personal Property(Schetlule E�._ _..._ .. 5. 13 0 , 3 7 3 . 9 7
6. JoinOy Owned Property(Schedule F) ❑ Sepa�a[e Bllling Requestetl....._. ._. 6.
]. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(SchetluleG) ❑ SeparateBillingReques�ed.. ._..._. �.
g, Tolal Gmss AssetsQo�al Lines 1 ihrough]� ....... _ _._. ._.. e. 1 3 0 � 3 7 3 . 9 7
9. Funeral Expenses antl Atlminishative Cosis(Schetlule H).._. _.__..._........ ...__ 9. 9 � 8 9 9 . 7 5
10. Debts of DecetlenL Motl9age Liabilities and Liens(Schetlule I)..._ ._._..._. _..._.. 10. 12 � 1 8 5 . �4
n. Total Detluc[ions(total Lines 9 and io).._.. .... ._.. .._..._ �� 2 2 � 0 8 4 . 7 9
��� NetvaiueofEstate(LineeminusLinell).. ..._.._ .._ ._..... t2 106 � 289 . 18
13. Charitable and Govemmental Bequesis/Sec 9113 Tmsts(or which
an eleclion�o tax has not been matle(Schedule J)_____.. ._..._.._.__.. ._...._.. 13.
14. Net Value Subject to Taz�Line 12 minus Line 13) __._.. _.._.._. �4. 1�B � 2 8 9 . 1 8
_ . . _ .. . __. .
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amounl of Line 14 taxable
at I�e spousal tax rate,or
transfers underSec.9116
(a)f12)X_00 15.
16. Amount of Line 14 taxa�le
auineairatex Aa5 108 � 289 . 18 �6. 4 � 873 . O1
1]. AmountofLineiataxeble
atsi�lingrateX .�p ���
18. Amoun�o(Line 14[axable
at rollaleral ra�e X .15 �B�
19. TAXDUE .. .. .._. ___.. ......... _.._..._ 19. 4 � 873 . O1
20. FILL IN THE OVAL IF YOU ARE REOUESTING A REFUNO OF AN OVERPAVMENT. ❑
Side 2
L 1505610243 1505610243 J
REV-15oo Ex Page 3 File Number $� - 15 - 0173
Decedent's Complete Address:
DECEDENT'SNAME
Deivert, Gary N.
STREETADDRE55
Messiah Lifeways
100 Mount Allen Drive
QTV STATE ZIP � � �
Mechanicsburg PA 17055
Tax Payments and Credits:
t Tax Due(Pa9e Z, Line t9) (1) 4,87J.01
2. Creeits/Paymen�s
A. PriorPaymenls 4,6�0.��
B. oiscount 242.11
TotalCratlns(A «g) 12) 4,842.11
3. In[eres[ (3) 0.00
q, If Line 2 Is grea[er than Line 1 a Line 3,enter t�e tlifference. This Is theOVERPAYMENT (4)
Check boz on Page 2,Line YO ro request a retuntl
5. If Line 1 «Line 3 is grealer Ihan Line 2,enter ihe difference This Is theTA%DUE (5) 3�.9�
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING �UESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Ditl deceden[make a Iransfer and Yes No
a. retain t�e use or income of Ihe pwperty transferretl __._ _ ..._ .._ _....... .__. x
b. re[ain ihe rigM1l�o tlesignate who shall use lhe pmperty lransierred or I[s income'........................ ....... x
c. retainareversionaryin�erest oo ......... ..._._. ._.__. _ ....._.._.... x
tl. receive the pwmise for life af either payments,benefits or care� .....__ . .. a
2 If tleat� occurretl aRer Dec. 12 1982, dltl aeceCen� Vansfer property witM1m one year of Eeath wi�M1wt
receivingadequateconsitleration9 _._.._ ..__.... .__.... _.............. z
3. Dld tleceden[own an"in tmst for" or payable upon tleath bank account or securiry at his or her tleatM._.... z
4. Did decedent own an indlvidual re[irement accoun�,annuiry.or other non-pmbate pmpetly which
containsabeneficiarytlesi9na�ion'+ ._.__. ......._ __.._. _....... .._ .. z
IF THE ANSWER TO ANY OF TME ABOVE�UESTIONS IS YES,VOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF iHE RETUR
For tlates of tleatM1 on or afler July 1, 1994 antl before Jan. 1. 1995,[he tax�ate imposetl on�he ne�value o!Vansfers[o or for��e use ot IM1e surviving
spouse is 3 percen�[2 P-S§9116(a)(i])(iJ].
For tlales of tleath on or afler January 1, 1995,�he[ax rate imposed on[he ne�value of Iransfere b or for Ne use of Ihe surviving spouse is 0 percenl
�]2 P.S.§9116(a)(1 1)Qi)]. T�a s�a1Ne doas no[axampf a Irens/ar to a surviving spouse fmm lax,entl Ue s�aNtory requiremen[s for tlisclosure of
assels antl filing a tax reNrn are s[ill applicable even if Ihe surviving spause is�he only beneticiary.
For dates of Oeath on or afler July 1, 2W�:
•The tax re�e imposetl on Ihe ne�value of�rensfers fmm a deceased chiltl 21 years of age or younger a�tleath to or for the use of a na�ural parent, an
atloptive parent, or a stepparen[ot t�e child is 0 percen��]2 P 5.§911fi(a)(12)j.
•The tax rale imposetl on the ne�value ot iransfers�o orfor the use of the tlecetlen�'s lineal beneficiaries Is 45 percenp exwpt as notetl in
[]2 P8.§9116(a)(i)�.
•The�ex ra[a imposetl on ihe net value of�ransfers to or lor the usa ol�he tlecedenfs slblings Is 12 parcen[�]2 P.S.§9116(a)p 3) A
sibling is tle(netl untler Sec�ion 9102. as an intlividual who has a[least one parenl ln common with the tlecedenl,whether Oy bloo or adoption
ae.-�soe�.p�-ru�
� �. pennsylvania SCHEDULE E
� °""aT`�E"'°`aE�`"�` CASH, BANK DEPOSITS AND MISC.
NMERITANCE TM RETURN
aesioeuroeceoeNr PERSONAL PROPERTY
� �� � � �� � FILE NUMBER
ESTATE OF Deivert, Gary N. zi - is-ona
Include the pmceeds of liligation and lhe date the proceetls were received by ihe estate111 property jointly-owned with Ihe right of
survivorship must be tlisclosed on schetlule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 CitizensBank- CheckingAccoun[- Number6100178307 75,941.05
Date of Death Balance: $75,940.80
Accrued Interest: $25
To[al Date of Death Balance�. $75,941.05
2 CitizensBank- CheckingAccount- Number6218591682 13,287.81
� Da[e of Death Balance� $13,287.68
Accrued Interest $.13
Total Date of Dealh Balance: $13,287.81
� 3 CitizensBank- SavingsAccount- Number6140050146 39,673.11
Date of Dealh Balance�. 539,672.93
Accrued Interest: $.18
Total Date of Death Balance: $39,673.11
4 PennsyNania Treasury Department- Bureau of Undaimed Pmperty - Prudential Financial 56.94
Dividends
5 Centre Daily Times-Subscription Refund 38.18
6 PSERS- Ne[Payment for December 1.376 88
TOTAL(Also enter on Line 5, Recapitulation) 130,373.97
PFV-1511 E%�I�0 09�
� pennsylvania p��p��� ��pHCp ^,^ ��
� DLPARiMENTOFREVENUE ry��y�w��/��/y��y{v�
0.E610ENT�EGE�ENTT'Rry �I�"YC�,J �
� � � �.FILENUMBER
ES�ATE OF Deivert, Gary N. � 21 - 15 - 0173
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER FUNERALEXPENSES: DESCRIPTION AMOUNT
A. 1 Koch Funeral Home - Funeral Expense 4.570.16
2 Grace Wtheran Church - Pos[Service Reception & Food 350.00
3 Pastor Steve Lynn -Honorarium 150.00
4 Pastor Alison Bowlan - Honorerium W.00
5 — See Attached Continuation Page-- 75.00
B. ADMINISTRATIVE COSTS:
1, PersonalRepresentative'sCommissions
Name of Personal Represenlalive�s)
SlreetAddress
Ci�y S�ate Zip
Vear(s)Commission Paitl
2. Anomey's Fees Delafield, MCGee& JOnes, P.C. 3,500.00
3. Family Exemp�im�. Ilf decedenCs atldress is no[ihe same as claimanfs,atlach explanalion)
Ciaimant
Street Atldress
Ciry S�a�e Zip
Relationship of Claimant[o Decetlent
a. Pwbate Fees RegiSter of Wlls 450.00
5. Accountanl's Fees
6. Tax ReWm Preparer's Fees 300.00
y. OtM1erAtlminisire[ive Costs
1 Postage 25.00
� �TOTAL(Also enter on line 9, Recapitulation) � 9,89975
ScF�cktle H �
. . Fu�eral E�er�es&
LOMMONWEAITHOFPENNSYLVPNIA wy��Nr��_.�-J
INHERITFNLFTMRETIIRN FyJ11�lOYQYYOI�w\7 IM.L
aEsioErvl oeceoeNr .
�� � � - - FILE NUMBER
ESTATE OF DeiVerf, G2ry N. p1 - 15-0173
2 �. Document Pmcessing � 50.00
3 � Co-Exew[rix Mileage (Denise A. Dickerson) -490 miles x$.56 . 268.80
4 Co-Executrix Mileage (Tamara A. Nichici) - 180 miles x$.56 100.80
5 � Miscellaneous Bank Charges �, 9.99
Page 2 of Schedule H
'Che F.state of Gary N. Deiverl
DOD: L2/17/2014
SCHEDULE A (FUNERAL EXPENSESI
CONTINUATION PAGE
Line 5
June Miller - Organis� Honorarium $ 25.00
Koch Funecal Home- lnternment Costs $ 50.00
Total: 75.00
�� pennsylvania SCHEDULE I
�y nePAarMeuroraeveHue DEBTS OF DECEDENT� MORTGAGE
NXERIiANCE iAL RETORN
ResiocN.oecEoeHr LIABILITIES & LIENS
�� FILE NUMBER
ESTATE OF Deivert, Gary N. 2� - �5 -on3
Report debts incurred by ihe tleceden�prior�o death that remained unpaid at�he date of death, inclutling unreimbursed medical expenses.
. . _______ .
ITEM DESCRIPTION AMOUNT
NJMBER
1 Thompson Pharmacy Ltc. -Check-in-Transi[ � 14887
2 Allegheny Wtheran Social Ministries -Check-in-Transit 1,246.94
3 Holy Spirit Hospital - Final Balance Due 194.39
4 Pleasant Gap Fire Company Emergency Transport(Ambulance)- Check-io-Transi[ 681.05
5 Alert Pharmacy Services, Inc. - Final Balance Due 113.45
, 6 Messiah Lifeways - Final Balance Due 7,452.00
7 Geisinger- Final Balance Due 31.54
8 H&R Block -2014 Income Tax Return Prepara[ion 175.00
9 United States Treasury -2014 Federel Income Tax Due 2.142.00
TOTAL(Also enter on Line 70, Recapitulation) 12,185.04
REV-15ll E%�(41A0)
� pennsylvania SCHEDULE J ���.
� EVARTMEMOFRCVENVE '
,„„eA„aHoe.n„Ae,�A� BENEFICIARIES �
AesioEHr oECEoeN*
ES7ATE OF Deivert, Gary N. � ����FILE NUMBER
21 - 15 - 0173
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAMEANDADDRESSOFPERSON(S) DECEOENT (Words) ($$51
RECEIVINGPROPERTY oorvoioc�max.iq
�, TAI(ABLE DISTRIBUTIONS}include outrigh�spousal
tlisVibutions,antl transfers
. untler Sec. 9118(a)(12)�
1 Richard G. Deivert Son 1/5 Residue
4259 Berritt Sheet
Fairfax, VA 22030
2 . Tamara A. Nichici � Daughter 1/5 Residue
3644 Derry Street
�. Harrisburg, PA 17111-1919
3 ' Merris D. Schutjer Daugh[er V5 Residue
I 2 Fairfeld Lane
�'. Mechanicsburg, PA 17050
Enter tlollar amounts br dis�ribWions shown above on lines 15[hrough 18 on Rev 1500 wver sheet,as appropriate. .
II. NON-TN(ABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELWTION TO TPJ( IS NOT TAKEN
B.CHARITAeLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE�ISTRIBUTIONS ON LWE 13 OF REV4500 COVER SHEET 0.00
RE0.15ll EX��Ot-10�
�� pennsylvania ', SCHEDULE J
/� oePnarMeHroraEvcrvue .
��HER�.A��E.A.aE.�aN BENEFICIARIES continued
aEsioEHr occeoeN* �..
ESTATE OF DeiVZR, Gafy N. FILE NUMBER
21 - 15 - 0173
� REtATI0N5HIP TO SHARE OF ESTATE AMOUNT OF ESTATE
4UMBER NAMEHNDADDRESSOFPERSON(5) pECEDENT (Words) (5$$)
RECEIVINGPROPERTV ooxo�ue<rmmeqe�
__.
�� � �TAXABLEDISTRIBUTION$inclu0eoutriqhtsoousal
tlisiribu�ions,and transfers
untler Sea 9�t 6(a)(12)]
4 DeniseA. Dickerson Daugh[er 1/5 Residue
1419 E. 14th Street
Cleveland, OH 44114
5 Dawn E. Deivert Daughter 1/5 Residue
307 E�izabeth Drive
Kennett Square, PA 19348
Page 2 of Schedule J
REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
o �M
`� � � � No. 2015 00773 YA No_ 27- 75- 0173
'� `��� eF
1
� � � �
Q 1 bc' y Estate Of: GARYNDENERT _ _
� r � . � u�.vsu
Ci ��� � I�Ifj ZO �
�f
�v� �� y� � Late Or CUMBfRLAND COUN7Y��
i�
-����� Deceased
Socza� Security Nc:
1750
WH5REA5, on �he 13th day of February 2G'S an instrumenz dated
January 19ch 2005 wzs admitted �o probate as the las� wi11 of
GARYNDENERT __ _
��„�,.m;em,.,insn
late of UPPER ALLEN TOWNSH/P, CUMBERLAND CouMy,
who died on the �7th dav oP December 2014 and
WHEREAS, � �rue copy of the u�ill as proba`_ed is anner.ed hereto.
T�?ERcFORE, �, LISA M. GRAVSON, ESQ. , Register of W-11s in and
for CUMBERLAND ^_ounrv, in the Commonwealth of Penn5ylvania , nerei>y
_�-ri`y tnat I have this day granted :,ette-s TESTAMENTARYto:
DENISE A DICKERSON and TAMARA A NICHICI
who 1:ave dul}� qualified as EXECUTOR(R/Xl
a.�d have agr�cd �o admir.ister the estate acrording tc law, a_1 of which
�u71y appears or record in my office at CUMBEFLAND COUNTY CDURT HOUSE,
CARLISLE, PE/VNSVLVANIA.
_TN PL'STIMON� WHF,REOF, I have hereunto set my hand and afiixed che eea2
of mt� office on ffie 93thdayofFebrua�y2015.
j ' Y�� �'��J'C �
�
/ e9atei� �lls�.
^/ i, / / /
F�f �- / �� r
e�yv
`*NOTE** ALJ NF.MES P�OVE F1PYY.9R (FIRS'P, MYJDLE, LASTJ
�� �_ '��� ���� � :�6F ` �
o'_
GARY N. DEIVERT ;-�
, '''
^ --
�
, 0?LR}' ID , DF.IVEF,T, of Sta`e �ollege, C�nLre ^_osnty', �
_'e�nsylvar.!a, revoke al� nror N�ii1s and Cocici=_s T_ nay �:�a�P made�
i
and oeclare th_s to pe my Lasc Wi_1 and Tes�ament .
i
i . __S,H?.7:7'.OiVS . I d_c�a,-c Lk:a' = am a �Nidowe,- ;�nd
'_hat ; nave `ive ;5; c_�__dre,:, TAMARA �.. I�iCHICI , RICI:ARD 3.
DEiVERT, DAWN E' . DEIVERT, DHNISE A. DiCKERSON, and M�RRT_S K.
..7=UT,7Fk. TY_is Will �hal_ be interpre�e3 using these
dsc;.a-at.i::::e .
__ . OT_FT OF PERSONAL_ngOPT_'RTY . I make che followinQ
_ ='s o` my persolal proper[?�:
A. ' give any remain:nc shop toole, eou;pmer.t or
re]a[ed -[ems I r.may own Lc FICHp2� G. DL'IV�RT, orovided chaC
the ��alue o`_ thie distribuLion sha�l be enarged agaL.s- my
_ _.. . ._ �..� . '�_,.. . e� tn. resi::. _ __ ::iy es�a��e;
ar,d
B. � give my ieTacninc _a�ig�:.�le pe�sonal
pxcUar_y L � my cr�1d-cn, Gbo ; �amcd, tc be :ivided among
-�._�ne�.n as �i;c-d �I-,r�ll aqre.�_ .
. T= . g*'=_Di:�.?Y L;S'Pf-TE. ; give �i,e residue c� my
es_ate to ny c�- '�dren, he�-ein nam�d, _r, eonal snares, or, _� any
:t::.�_� snou-d p_=.9ec�as-. m=, tha= crllc' s s'r.a_e co t:�:at c]�iid' s
�ss��e. Shou��_d any child oredecease me w'_thou� leav�ng i�sue, -
d'_r_ect z}�at �ha� cri'_n' s share b=_ d_aided a*nong mp remaining
_ ;sue .
�n mak'_ng [�e distr_buYions an.icioated uacer this
sectio�, my personal reoresentative sha?1 observe tl�e followinq :
1 . Dcstribu`ions to issue sha=1 be on a per
;t_roes basis ; aad
i . Distr'_bu[ions co any benefic-ary who has not
t:hea attacned age twe.�y-one i21) may be to che bene_`iciary
directly, Co a trus�� es�ablisned =or the bene�it o�� such
nenef;ciary where �hat =rust wonld prov_de educalional
asscsta�ce for L}ie benefie-ary, or -o a cusLodial accourt
�or such beneficzary unde- the ?ennsylvania Unifox¢
Transters to Kir.o�-s Ac_, as my ncreonal repreeenTative, _.,
'�er sole discretion s-��11 cle�t . If distribuT�, o:s are n-,ade
Co a c��s[odi�1 aceount, my personai representative sha7.1
3esiq;iate the custodian �hereof.
iV. ?E:RSJ[Gz�L F.�PtESEN'_l;l'i\iPs . S appoint m'Y
ciauqhters, J�N15L A. DLCK3RSON and TAKARA A. N:CHEC1 , Lo act
2
jo:nt�y aa my ocrsone.= renresel_ative, �_ �.._ ....:�-vivor o� th� =wo
o_ znem [c aat znasPe_zden[1v .
V. WAIV3R OF BON7. _.; the e>_�nn� such requisemen�s
legal'_v can be waived, S d_recc that nc fidu�cary namec _n �h'_s
W'_'_1 or an}� successor fiduciaxy shall be requirec to oost any
bond cr gire zny secur_ty in connection with his du�ie�, whether
ir, the Commonweal�il of Pennsy�van_a, or e�sewhere .
VI . SURVIVAL PRRSllMPT=ONS . 1'_ any �enefic_arp shall
3ie simultaaeous'_y wa�h me or ��nder sner circums�aaces as to
Yen3er i� daf`icu=t or -rr_possi�-_e to d�terrz�ne who preveceased
ehe ether, I :-erebv declare Lha'_ I shz11 �e deemed to '�zve
snrviv�d such nene`_iciary anc tnat t:ni� N;iil and all o- its
p��ovisione shall be construed �apor Lhat assumn�ion an� basi� .
�'L . C�'NERAL� ?OW^R5, My nersona- represeetaCivc sha_1
have �ne pow�r to leaSF, sell at punLc o;r private eale,
morCgaqe, `_raisfer a=.d convcy, _n sti:ch manner and on such terms
as ne may deeni adcisable, any and al1 property, real or personal ,
b�:ionq � �ig _o mg estaLe, without t�� necessitv of obt- ining leave
ef any ccurt . No pn�c];a6ers s_lail be lia?�-e Co sec to the
appl=c..Cion o` any nurch �e money. My pE��so:ial rei eacr.tai.'_ve
>
ma}', w n-� : -- �b ,'.i '_y, _ _-a-n a.r� poir-on of sa�d oroner'�y in
___ �arz�. ' __ ..`_ i.vestmen� -n w"_ch the ��me is Laken over bv
__�i,�, _..- pe=iod of such ^-�ce�tio� tc rest ia his judgment . My
pe-sonal reoresencative may =11e _.ncomc tax returns (federal and
state? on mp nena'_�, and may elec_ to d_scla_m any interest in
p�operty whic� I ;o- my estatei may etherwise n=_ entiLled to
rece_ve, wz�hout :eave of Cocrt .
IN I�IITN�SS WHEREOF, I h�ve hereunto set mv hand and sea�
this 14th_ dav�a� January 2008 .
Witnesses : -' ���)
/�
. /// ,
i
� / � � . � , � � _ �
Garp N. Deivert
-•*:-�•� � GARY A. DEI.AFIELD , and
WH, GFRY ti . _... , crl9 ' _ .._�
KRISTIN M. McKEE , tk:� �'estator arid t_= W==ness�s ,
res�ec_�velv, w'.�.osc :ames are s=g�ec �o t'rie -aetacned or foreaoino
�nstrume�t, being `__�t Ga'�.y sworn, do hereby dec-are tc the
uad��=ig:iec a�.iti:ority crat �_he T�scG_o.. sig�e3 and =xecuted .he
instrument as Y.i� '_ast Wz�l and tha�� ne rac siqn?d wilLng-y, and
�ha� he executed it as his '_-ee and volaatary ac�_ for Che
p�irposes tterein exn�-essed, and tnat eaoh o= the Witnesses, in
the presence azd hea=ing of the Tes'_ator, sigried cne Wi'__ as
V;itness and that �o �he bes� o' t.7e_r knowledge �he ^esta�or was
at that cime eignteen (lE? years o� age or cide_, of so�nd mind
a�id u�der ❑c constrai:: or undue ir_-luence.
�'
� I�
.arv��N;'De�vpY
�
�
G7i.tness � �µi j —�
{ � /
Witnesc _' . .
Subecribed, sworn `o and acknowle3ged befo�e me by GAR=' f.
j„ �, � p_ �..Ct �PC c ..�� , u�� SUDSCY D�C{ d1C'1 bWOYA L� bU'OTC ((IC DV
G9P.Y A. DELAPIELD and KRIST?N N.._ McKE�_..__. ,
WiLne �es, t]�is 14th d�. t .f Janua:y __ . , Ao08 .
� ., , _.._._.
� � , r
NoCary Pai:li.r
F.'G. ';. 2f'. _�. ,7P�6' 1'C. E�'i F. d
,� ��fi��eC�S �'r-�t�� "
Account Number 6100178307
Account Title GARY N DEIVERT
i Da[e Opeaed r 12/1/1972
Account T e Checking
Princi alBalanceasofDOD 575940.50
� Interest from Last?ostino to DOD , g ,25
Account Belance as of DOD $?5941.05
YTD Interest to DOD 54.59 �
l,�E. lc 2P�'F _ o,�� . � NC. �" F. .
� �t�t��'t'35 ��!?�-.
AccolmtNumber I 6218�91682 .
I Account Tide GARY N DEIVEP.T
1 Daze Ooened 6/li/2007 i
Accovn2 e Checkine
Princi al Belaace as of DOD I 513287.68
I Inteiest from Last Postine to DOD $ .li
Acwunt Balanct az of DOD $li287.S1
� I'TD Interest to DOD 56.56
��:.. :. ."�'�i e�.�7°N. � VC. Oi"-0. :
� �������5 ��1"E�C"
Acwunt Number 614005014E
Account Tifle GARY N DEIVERT
I Date ened 4/28/1980
LAccouat 2ype Savin�s
� � Pnncipa]Balance as ofDOD 539672.9;
Interes�from Last Postino to DOD 5 1 S
AccouutBalanceasofDOD I $3967311
� ITD Interestto DOD $7 35
t.umnw�nrcu�ui v� i cini.� �� nu�n r.r.-_ . .. ,
Rcmitfance A4.�ice ���o�:, < <,e ,�<o:_ _..
Pennsytvania Treasury - Bureau o{ Unciuimed Property Paymeni
-- CLFIM F 98159139
____________. .____________________ ..
- Paope_Cy ID Holdex Name n=sciiption Amount
120']'1 oPO1JrLV'f . �_NPNC1 ➢� nl�'LCLVI]b' -'•_ -
aoLaa . ���-'�
� opYGE INFORAfATIDF: NOTEe Diiect Fayment ia4uiiiBS Lo.
_ ;.. 1 L�T°TLI Oc . 1.1C - .Ggd _ - P='���' -__J_..
3e4-. JS'RF:Y $T F.C. Boz :.fl3�
I 2F.LS3U4G L�. _'-ll-04'9 kiaiiisbur9. P _^105-183']
FOLD ON�[RfOflNTIJk THEN DP�HCF CNHLPULLY
oearm3 N�nertnNr0000�a3aai oaoa,a ,so3i3s� Q598 500013339',
— � . � ��� CHECK NO.'. ���
_ � SOVEREIGN BANK . . .. . ". � . . .
PHILADELPHIA f'Fl � � � ' . . � p4/1d1201:5 ..
_ = VERIFIGATIONAVAILA6�E-"POSITNEPHV"PROTECTt��.pfi/, /`J �. � . �
_ 5�. 94 � ,.� :;.,. ,w,..., oATE
=PAY E � crscrs � � � voionF,eR,eaoa,
�C THE ORDEFl OF � � � � � . �
— ��..�*��.��56_9
�CIVB T GhRY N ESTATE Of �
– 3644 DERR�ST � � /J���
HARRI F3JRGPA1�11���9�v n �y`��
__ '- /.y�Y �:;��Pn��s.cr:,�y . .
— miil�ulluid��u�illPdih��p�Idl,��i�ip���lulP�l�l�ln , � =, s � A ����n� PENN=.�� . � „
ii• 500D133392��' �:03i375979�: 7680950598ii'
VEqIFV THE GIITHENTICI'Y OF TH!$MU_T4TON=S=COPITY OOCVMENT CHECK 9<CKGNOON�APEL CHANGES COLOP GRBOOPLLV FROM TOP TOHOTfOM. 1�
a o�soz so 98 'sPaa=�s.iNc . e'`��"¢ � ,p-.�,, � �. , ioo�a2oaz5� �
LIVONIF INI48 �3069G �J y,L Novemoe{U 20t4
TEL 30S �A( 422 '}"' . . . . .a�_� »ren-.. .
. . . . .. . ���� ..p �' �� ... voioa�cvizoonrn
N
t
H�,o��-. _.rnm�-�ra�.i aona�_s,�,d as���s•� . � �
� �xS36 .18*=
Pay�to Di;lV'LItI. GP.�1- . . .
the 200�2ACHELUR4P;000211
ordero� PLE.4SANTGAYP,4 1G8�3�i62'_ �J,/"-
K��--:��---
-�i
BanM o(Amerlca NA. � ��'
NHan�a,Oekalb Coun[p,GH
FUTHDR2ED SIGNATl1F.0
�i' 1�� �4 204 25ii' �:06 L i L 2 ?&&�: 3 3 5 900444Dii'
COMMONWEALTH OF PENNSYWANIA
' PUBLIC SCHOOL EMPLOYEES' RETIREMENT SYSTEM
C ' PSERS ToIF/ree: iB88773.7748 (1.888.PSERS4U)
'11� 5 N Sth Stree[ Loca/: 7177878540
�"�""��M""""i Harrisbur PA 17101-1905 www-psers-stafe.pa.us
,, ,�v 9
January 14, 2015
MEP.RIS SCHOTJER
L FAIRFIELD LN
MEry�ICSRORG, PA 17050
RE: Gary Deivert .
SSN: XXX-XX-9058
Dear Ms. Schutjer:
The Pubiic School Employees' Retirement System (PSERS) is processing the benefit of Gary
Deivert. Please accept our condolences for your loss.
PSERS issued the following monthly retirement benefit(s) prior to processing the death benefit:
--_ _. .__ ... ._Hheck�Month—_ —. __ __ - _—. -Checkkmom�Y—__ . . .._—_— __.
December, 2014 $2,76525
Gary Deivert was entitled to a prorated amount of$1,685.88 for the month of December.
Federal Withholding in the amount of$309.00 was deducted from the above payments made
in a prior tax year. Sfnce this amount was already reported to the IRS, it must be retumed to
PSERS.
Theretore, please reimburse PSERS $1.388.37, which represents the total of the monthly
benefit payments and debts (if applicable) listed above, minus the prorated amount. Please
make your check or money order payable to Public School Employees Retirement
System and remtt payment by February 13, 2015.
Please retain this infortnation for preparation of the members final tax return.
If you have any questions, please contact the PSERS Member Service Center by calling
toll-free 1-888-773-7748 (7-888-PSERS4U). Harrisburg local callers, please use
717-787-8540. To contact PSERS by email, use the following address:
ContactPSERS@pa.gov. For your convenience, the Member Service Center is staffed each
business day from 8:00 a.m. [0 5:00 p.m. For more generai information, you may visit PSERS
online at www.psersstate.pa.us.
Sincerely,
�UZC[G SC(xooZ �HvjrFocyCCd� �etixe�e�tt Sy�teHs
� �
DELAFIELD, McGEE & JONES, P.C.
ATTORNEYSATLAW
GARY A. DELAFIELD 916 SOUTH ATHERTON STREET TELEPHONE
DANIEL McGEG STATE COLLEGE,PA 16801 �814�237�278
Courvs�,m vieF1[uf FACSIMILE
ALFRED JONES IR. www.�njklaw.com (814)237-3660
gdelafield n,dmjklaw.com
June2'_. '_015 0 - �
'_ o "' iJ:� rn
r_" o
CumbedandCounryRegisterofWills - — -
I Courthouse Square, Suite 102 N �
Carlisle, PA 17013 �� _ -��
Re: The Es[ate af Gary N.Deivert,Deceased rv - `�'
FileNo: 21-15-0113 -�- � ��'
Inheritaoce Tax Return aud Inventory �" 05 -� -�
Dear Siror Madam:
Enclosed please flnd eopies of[he following documents to be filed in the above referenced
hstate:
I. Original Inheritance Tax Return (two originals plus one copy—please da[e stantp
and return the copy to me);
2. Imen[ory (one original plus one copy—please dare stamp a�d remm [he copy to
me);
3. Sffi[us Report; and
4. Tmst check No. 302, for the Inheritance Tax di �n the amount of$30.90.
I am enclosing n self-addressed, stamped envelop or the re �rn of the above Iisted items ro me.
Thnnk you fur your nttcntion Lo Lhis maticq and if you iould nccd �nything (urthcr to proces's, pleas'e let
me know.
� Respectf -yours,
I
Garv A. Del e , L'squire
GAD/kjb
Enclovures
cc: Denise A. Dickerson,Co-F,xecutris (w/o enclosures)
Tamara A.Nichiei. Co-Cxecutrix(w/o enclosures)
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