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IN THE ORPHANS' COURT DIVISION M
OF THE COURT OF COMMON PLEAS OF c-) C,
CUMBERLAND COUNTY, PENNSYLVANIA 51)
ESTATE OF ROBERT A. CIMSTIANSON, DECEASED
No. 201400533
WAIVER, RECEIPT, RELEASE, AND AGREEMENT OF INDEMNITY
The circumstances leading up to the execution of this instrument are as follows:
1. Robert A. Christianson died on April 29, 2014, leaving a Will dated March 7,
2006, naming Sandra S. Christianson as Executrix.
2. Letters Testamentary were granted to Sandra S. Christianson by the Register of
Wills of Cumberland County on May 30, 2014.
3. It is the desire of the Robert A. Christianson heir that the Estate be distributed
without the formality of a court proceeding in order to save the expense, publicity, and delay
incident to such court proceeding, and the Executrix is wining to make such distribution upon
the execution of this instrument.
4. To the best of the Executrix's knowledge and belief, all claims against the Estate
have been paid.
S. In consideration of the foregoing, each of the undersigned hereby:
A. Represents and warrants that she has read and understands this instrument;
B. Represents and warrants that the facts set forth above are true and correct to
the best of her knowledge, information and belief;
C. Declares that she agrees that the Estate should be closed based upon the
information contained on the attached Pennsylvania Inheritance Tax Return;
60
D. Declares that she accepts and approves this action as if it had been
adjudicated and the actions confirmed absolutely by the Orphans' Court Division of the Court
of Common Pleas of Cumberland County;
E. Waives the filing and auditing of the account of the administration of the
Estate in the Orphans' Court Division of the Court of Common Pleas of Cumberland County;
F. Absolutely and irrevocably remises, releases, quitclaims and forever
discharges Sandra S. Christianson, individually and in her capacity as Executrix, from any and
all actions, suits, payments, accounts, reckonings, liabilities, claims and demands relating in
any way to the administration of the Robert A. Christianson Estate;
G. Agrees to indemnify and hold harmless, to the extent of the funds received
by her hereunder, Sandra S. Christianson, individually and in her capacity as Executrix, from
and against any and all claims, loss, liability or damage (including legal fees and costs in
connection therewith) which she may suffer or to which she may be subjected by reason of her
administration of the Estate, the settlement of her Executrix's account and the distribution of
the assets of the Estate without having the formal approval of the Orphans' Court Division of
the Court of Common Pleas of Cumberland County, including, but not limited to, any liability
for any federal estate tax, Pennsylvania inheritance tax or any other death taxes, together with
interest and costs incidental thereto, relating in any way to the Estate; and
H. Declares it to be her intention that this instrument, consisting of two pages,
shall be governed by the law of Pennsylvania and shall be legally binding as an agreement
under sea] upon her and upon her heirs, executors, administrators and assigns.
Executed on:
(Sea])
DAYE S.,)-9flWTIANSON'
-2-
Ex(02-11) � 1505610143 -
Department of Revenue ? OFFICIAL USE ONLY
PA De
p pennsylvania County code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 60x.280601 INHERITANCE TAX RETURN 21 14 00,533
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
04 29 2014 05 07 1944
Decedent's Last Name Suffix Decedent's First Name MI
CHRISTIANSON ROBERT A
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
. CHRISTIANSON SANDRA S
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER.OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ❑ 2. Supplemental Return ❑ 3,Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a.Future Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
C4 6 Decedent Died Testate ❑ 7. Decedent Maintained a Living Trust 0 B.•Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
❑ 9. Litigation Proceeds Received ❑ 10.
between Poverty 1 audit;
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: C H R I S T I A N S O N, ROBERT A
RECAPITULATION
1. Real Estate(Schedule A).........................:.
2. .Stocks and Bonds(Schedule B)............................................................................... 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3.
4. Mortgages&Notes Receivable(Schedule D)...................................................:...... 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 7 , 160 . 36
6. Jointly Owned'Properry(Schedule F). ❑ Separate Billing Requested............. 6.- .292 , 784 . 53
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7. 602 , 3'76 . 4 0
8. Total Gross Assets(total Lines 1 through 7).......................................................... 8. 902 ,321 .. 2-9
'9. Funeral Expenses and Administrative Costs(Schedule H)....................................... 9. 5 ,195 . 87
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............:................ 10.
11. Total.Deductions(total Lines 9 and 10).................. 11. 5 , 19 5 . 87
12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 897 ;.1.2 5 . 42
13.` Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)................................................. 13.
44. Net Value Subject to-Tax(Line 12 minus Line 13)................................................. 14. 89.7 , 125 . 4,2
TAX COMPUTATION-'SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
,at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X..00 .8 9 7 , 12 5 . 4 2 15. 0 ._ 00
16. Amount of Line.14 taxable
at lineal rate X .045 •16.
17.`Amount of Line 14 taxable
at sibling.rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.1
•
19. TAX DUE.......:...........................................................................................................: 19. 0 . 00
r
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21 - 14 - 00533
Decedent's Complete Address:
DECEDENT'S NAME
Christianson, Robert A
STREET ADDRESS
112 Blacksmith Road
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A. .Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest
(3) 0:00
4. 'If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 0.00
Make Check Payable to: .REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.................................................................................. F-1 7x
b. retain the right to designate who shall use the property transferred or its income;....................................
c. retain a reversionary interest;or.................................................................................................................. x
d. receive the promise for life of either payments,benefits or care?.............................................................. 51
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receivingadequate consideration?....................................................................................................................... F-1 O
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?......... F] Fx
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?...................................................................................................................... xx
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of
assets and filing a tax rXim 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 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent,ora stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
•The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in
[72 P.S.§9116(a)(1)]•
•The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.&9116(a)(1.3). A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,wðer by bloo�or adoption.
® pennsylvania SCHEDULE E
DEPARTMENT OFREVENUE
INHERITANCE TAXAXRETURN
CASH, BANK DEPOSITS AND MISC.
RESIDENT DECEDENT PERSONAL PROPERTY
FILE NUMBER
ESTATE OF Christianson, Robert A 21 - 14-00533
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 VALUE AT DATE OF
NUMBER DESCRIPTION DEATH
1 Citizens Bank Circle Gold Checking Account#6100619109 7,160.36
-
TOTAL(Also enter on.Line 5, Recapitulation) 7,160.36
REV-1509 EX+(01.10)
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DEPARTMENT OF REVENUE SCHEDULE F
RESIDENT
EDEN TURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
Christianson, Robert A 21 - 14 -00533
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
Sandra S. Christianson 6 Scott Cove Wife
A East Berlin, PA 17316
'JOINTLY OWNED PROPERTY: pE p p
ITEM LETTER DATE Include name of finanolal Inos itu3io nand bank account numbe DATE OF DEATH %OF DATE OF DEATH
NUMBER FOR JOINT MADE or.similar identi in number.Attach deed for jointly-held real VALUE OF ASSET DECD'S VALUE OF
TENANT JOINT 9 ) y INTEREST DECEDENT'S INTEREST
estate.
1 A 03/20/2006 Charles Schwab Account#8074-1914 585,569:05 50% 292,784.53
TOTAL(Also enter on line 6, Recapitulation) 292,784.53
REV-1510 EX+(08.09)
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DEPARTMENT OF REVENUE SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC, NON-PROBATE PROPERTY
ESTATE OF Christianson, Robert A FILE NUMBER
21 - 14-00533
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH OF EXCLUSION
NUMBER InGude'the name of the transferee,their relationship to decedent VALUE OF ASSET DECO'S TAXABLE VALUE
and the date of transfer. Attach a copy of the deed for reat estate. INTEREST (IF APPLICABLE)
1 Jackson Perspective II IRA#1004848280 602,376.40 100% 602,376.40
i
I
I
' I
I
t
TOTAL(Also enter on line 7, Recapitulation) 602,376.40
REV-1511 Ex+(10-09)
Pennsylvania SCHLEH
DEPARTMENT OF REVENUE FUNERAL SEISES AND
INHERITANCE TAX
RESIDENT DECED NTTURN ADMINISTRATIVE
COSTS�Y� 7IVY W�7
ESTATE OF Christianson, Robert A FILE NUMBER21 - 14 -00533
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER I FUNERAL EXPENSES:
A. 1 Parthemore Funeral Home & Cremation Services, Inc. 3,242.37
B. ADMINISTRATIVE COSTS:
1, Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Debra K. Wallet, Esq. 1,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedant
4. Probate Fees 423.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
Postage, photocopies, etc. 30.00
TOTAL(Also enter on line 9, Recapitulation) 5,195.57
REV-1513 EX+(01-10)
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DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENSCHEDULEJ+EFICIARIES
RESIDENT DECEDENT
ESTATE OF Christianson, Robert A
1 FILE NUMBER
21 - 14-00533
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not Ust Trustee(s)
I. TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and fronsfers,
under Sec.9116(a)(1.2))
I Sandra S. Christianson Wife Residuary Estate
6 Scott Cove
East Berlin, PA 17316
,Enter dollar amounts for distributions shown above on lines.15 through,18 on Rev 1500 cover sheet,as appropriate
NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00