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Home My WebLink About01-0243 REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA PETITION FOR GRANT OF LETTERS Estate of Fern V. Kraly No. 21-01-243 also known as , Deceased Social Security No. 177-16-0970 Connie Bollinger Petitioner(s), who is/are 18 years of age or older, apply)ies) for: (COMPLETE "A" OR "B" BELOW:) GJ A. probate~d Grant of Letters and aver that Petitioner(s) is/are the execut rix Decedent, dated .'"; J 10 197d. and codicil(s) dated named in the Last Will of the State relevant circumstances, e.g., renunciation, death of executor, etc Except as follows, Decedent did not marry, was not divorced and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incapacitated: o B. Grant of Letters of Administration (c.t.a., d.b.n.c.t.a.: pendente lite, durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence I (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence at 100 West South St., Carlisle, PA 17013 (list street, number and municipality) Decedent, then 81 years of age, died February 11 ,2001 I at Carlisle Hospital (Location) Decedent 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 ........................................................................................ $ Total .................................................... ................................................................. $ JOOO ~3oo () Real Estate situated as follows: Wherefore, Petitioner(s) respectfully request(s} the probate of the Last Will and Codicil(s} presented with this Petition and the grant of letters in the appropriate form to the undersigned: Typed or printed name and residence Connie Bollinger 408 Cocklin Street Mechanicsburg, PA 17055 RW-1 Oath of Personal Representative Commonwealth of Pennsylvania County of CUMBERLAND The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate accor& to law.. Sworn to and affirmed and subscribed ~<-p K 5 ~;J/-d before me this e.7 day of FEBRUARY 2001 ':zYlI(V(;~O'~ /t2L/-I//P'f / /a., / / / / / (/ / Estate of Fern V. Kralv DECREE OF REGISTER also known as Deceased No. 21-00-243 Social Security No: 177-16-0970 Date of Death: 2/11/01 AND NOW, MARCH 5 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters ~ Testamentary 0 of Administration ((c.t.a., d.b.n.c.t.; pendente lite; durante absentia; durante minoriate) are hereby granted to Connie Bollinger in the above estate and that the instrument(s), if any, dated described in the Petition be admitted to probate and filed of record as the Last Will of Decedent. FEES Letters................................... . Short Certificates(s) ............... Renunciation......................... . Extra Pages ( ) ............... I.T.R....................................... JCP Fee ................................. Inventory ... .... ..... ..... .... .... ....... Other..................................... . TOTAL............................ .$ $ 25.00 7:/?2;/ (J t~" / I2/W & / A0.1"'/:/ / Regisrt'er of Wills Ii $ $ $ $ $ $ $ $ 3.00 5.00 3.00 Signature 5.00 Attorney: Marielle F. Hazen 1.0. No: 68003 Address: 845 Sir Thomas Court, Suite 9 Harrisburg P A 17109 41. 00 Telephone: (717) 541-5550 DATE FILED: fhis is to certif" that the information here given is correctly copied from an original certitlcate of death d.ply tiled with me as Local ,Registrar. The original certitleate will be forvv'arded to the Slale Vital Records OHlee tor permanent tiling, WARNING: It i:s illegal to duplicate this copy by photostat or photograph. No, _~-jjfili"fi7;;~ . ~;.i<~~l~..QFil~~-~~ .-., " I~\~// "1J'-;,~ Ii '5::J. / .!Il:la... <~. ~ !S~~' '~iir'~'\~ ~~! "-" \'P, ~ <::);- -~, I:~~ ~~\_ .,t.fJ" _ ./h~1 Il *~ . ~., * ' ~ a\' '. ,c~_' --,~ $' ~~, /~/ ~-~ ;y',.?' . '.' / f:<.-~ I" ~,~" 'lME-N"1'r.~ ~ 1.\1,'\ ~~,:'f (11' \l.~.,,!,Y ~. ~. /)';;' , 'J:f}A~ ./Ll!..-UL.-.J {;.- .~j . Local Regisrm ~ Fee for rhis certificate, ~2.00 P 7121480 rfr~l't"/'/; "'-MI Dare 21-01-243 .:JJ-emtt I ~ ~hc4J he- /\/0 fkm#/7 -511O<"J Dc' ~ /I'/''!4.- H1U~_:4JA." 2187 COMMONWEALTH Of PENNSVLVANIA . OEPARTMENT Of HEALTH. VITAL RECOROS CERTIFICATE OF DEATH iYPEJPRINT IN PERMANENT BLACK INK AGE (La.. BoI1May) UNDER' YEAR MonItIo Da~ SEX Female 2. STATE FilE NUMBER SOCIAL SECURITY NUMBER 3. 177 - 16- D"Y E OF DEATH ,McnlI>. Oa,. ....., February 11, 2001 NAME OF DECEDENT If"SI MKl<lIe. lasl 80 v.. BIRTHPl..ACf :C''Y..OO PlACE OF DEATH 4CI'>Eck ~y oPe u ~ ,n$lfucl.or\'S on 0If\et sde~ StaHl 01 fcrtttgll Country) HOSPiTAl: Marysville,. lnpal_ ~ 7. IA. FACllfT"f NAME (II not In!o:l'lutM)O. 01\18 Slreet and number I :=oI'flO 5. COUNTY OF DEA1H Cumberland RACE.Amenc;an InClIan, 8lack. _.. elC (~) White .. Ie. MAAlTAl STRUS."- Ne_ Man"'. W_. ~ (Spe<<y) Widowed SURVIVING SPOuSE lit ..... gMt I'NIden I\AI1\eI DECEDENT'S USUAl OCCUPIa'ION (Gove Iund '" _k -.. dufong__ ell -ing 1!ti:1fflAm~@'rl . U.. lib. DECEDENT'S MAILING ADllRESS (Su"'. Coly~. ~. Zop Codel 100 West South Street Carlisle, Pennsylvania 17013 '" FATHER'S NAME IF'Sl. Mo<ldIe. Lasll II. 1NF000000000'S NAlolE (T ypelf'fontl 17b. Cou Did -- Min. -.-p? 17d.r:1::"'-=-:=", MOTHER'S NAME IF.... M<ldIe. 101_ Sutnamel ,.. Lulu Yingling INFORMANT'S MAll,LHq ADORESS (SIt.... Colyfilwn. SIlIlo. Zip Code) 2GI>. 40l:S Cocklin Street Mechanicsburg, Pa. 17055 PlACE OF DISPOSITION. N..... '" C_ilfY. CI.malOry lOCRION . Ctlyfilwn. SIal.. Zop Code Of ClIheI PIK. Mechanicsburg Cemetery .... Carlisle ~ Harvey Reisinger Connie Bollinger --) "- r.::L. \~ \- Mechanicsburg, Pennsylvania FD-012662-L 2141. M 25. 27. PART I: Enter'he diseases, injuries Of comphcaltons which cause4 lhe dealh Do nol8nl., lhe mode 01 ayi . such as cardiac 01 respiratory arresl, shock 01 heart 'allYle LlSI only ~ causa on each Iirw . 'JULie.;" ltt<->-,/-- dt,,fYlt", ~~t~ b~"CONSEauENCEOF): / I I DUE TO lOA AS "~EauE E OF): - : Jtt~~C~~5uNcEj/,L- /Vl OJ PART N: ClIheI "'III'iIlcenl _ conuobuling 10 a.."'. bill _1ftUIling..1I1e ~ ~ given in IWIT I 7A;;~ tt~ WERE "UlOPSY FINDINGS ""'-'LAlIlE PRIOR TO COMPLETION OF C"USE OF DEA1H? MANNER OF oe"YH DATE OF INJURY (....onth. Day, leal. nME OF I~URY INJURY'" WORK? DESCRJ8E ItCNi I~URY OCCURRED s..c... ~ o o HomICide [] n o ~CE OF INJURV . AI hom.. ta'm~;.."-"dory. otfic. bu~. MC. ISpec.III) _. \'eo 0 NoD Peodu'-.g lnvesugahon ~~/ ;).1/1:4. UtLJ Y.. D NoD Could not be del.fmloed 2... 2.... CEllTIfIER ,neck on. one) .CERTlfYlNG PHYSICIAN IPhy~~n CefllfylOg cause 01 Ot:'alh when .JnOltlef ph~~,an hdS pronounced ded.lh ano COmiJlel~ lIem 2Jl To..... bee' o. my knowMdQe. <teeth oecunlld due __the cau..(I) and maoner I. etated. . . . , . . . . . . . .. . . . . . . . . . . . . . .. . . . ~ ~ ~ o o ~ z . PRONOUNCING AND CERTlfVING PHYSICIAN IPhv~lan tlolt1 ;.l1cJ(lOWIC10Q Ut".Jltl drw1l.:eftllVlflg 10 cause 01 aedlfl) To Ihe beet 0' my knowiNg., de.th OCCUlred .Iu... time. date. ~nd pllce. and due to the cauM(I) and manner.. sl.led. .MEDICAl EXAMINER/CORONER ~~:::::i:I::~~~~.i~~'!~~ ...n.~~ ~~~~~l~~~'.i~~: ~~ ~.y. ~~I.~i~~: ~~~~~ ~~~~~~e.~ ~~ ~~~ ~I~~,.~~I~.' ~~l~.~I~~~: ~~~.~~~ ~~ ~~~ ~~~~~~~).~~~ 0 "a ~/Vlb<.'I(i",j . Register of Wills of tluphin County, Pennsylvania OATH OF SUBSCRIBING WITNESS Estate of ---fer f'I 1/ . ~ '/ also known as No. , Deceased o 'c;c}\. ; 3 , Dca A (each) a subscribing witness to the [J codicil(s) Llwill(s) presented herewith, (each) being duly qualified according to law depose(s) and say(s) that she/he/they was/were present and saw the above Testator(rix) sign the same and that she/he/they signed as a witness at the request of Testator(rix) in his/her/their presence and [] in the presence of each other 0 in the presence of the other subscribing witness(es). .~~,~C? ~. ~ignaturel 1~ to ~~/ U-u~~ "-yJ11 A ; (Addr,ess)!J1 ' (--;y d ., ILK(!A(#,{2/1~M-U7J--.J .t.?/~ ~i-- . (Signature) (Address) Sworn to or affirmed and subscribed before me this J- r;-r-- day of r- ...vt~ ,20 i2t-. C,? ~~ <(f-~' My Commission Expires: (Sign8tUJ€' and seal of Notary or other QI ficlal NOTE: To be taken by officer authorized to administer oaths. Please have present the original or copy of Instrument{s) at time of notarization. qualified to admmiste, oaths Show date of explfBlIon of Notap(s commission) Notarial Sea! , Marttyn E. Wiliams. No*af'1 PubftC ~~O eoro. Cymbenand county My CommissiOn Expil"eS Nov. 6. 2001 Member. PeDnsvNama AlSociatiOO of &tar.ieS RW-11 traM~Ph~: Register of Wills of . County, Pennsylvania OATH OF SUBSCRIBING WITNESS Estate of ----i e ( ^ V K r !J.l 'I also known as No. I Deceased ) J~ 06er'+ Si-au {f~~( (each) a subscribing witness to the [J codicil(s) 1_lwill(s) presented herewith, (each) being duly qualified according to law depose(s) and say(s) that she/he/they was/were present and saw the above Testator(rix) sign the same and that she/he/they signed as a witness at the request of Testator{rix) in his/her/their presence and [J in the presence of each other 0 in the presence of the other subscribing witness(es). v" ) (Signature) (Address) Sworn to or affirmed and subscribed cJ11'- before me this day of :j~ /Vl~~ t~ , ,20~. NOIanal Seal Mart!yn E. WiWams. Notary Public ~Hg.Boro. Cumberland County -, "^,,nTl"S$On Exptr86 Nov. 6. 2001 Mem~r. Pennsylvania A!Socialloo ot Notaries Notary Public My Commission Expires: (SignstUle and seal of Notary or other fJtficlal NOTE: To be taken by officer authorized to administer oaths. Please have present the original or copy of Instrument{s) at time of notarization. quctlilled to admmister oaths. Show date of expifatlon 01 Notary's commisslofl.l RW-11 FROM SMOOTHE JOES In.R.e Estate of Fern To thc Registcr of Wills of The iifidefsigficd A^_~/'\~/'I '---'"~ 1... c....-I \JI I '-"'f FAX NO. 7177374508 Feb. 27 2001 10:56PM P2 RENUNCIATION 'l 1(10" III / r.. .j-~'- --1 "-'u~ n~, J 0 nr County I Pennsylvania. deceased. T J-J ^^ \ f.p r- v. I'~V"""'" of the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters -t e sf 0 Y'>1 @ n t a ,.- v' , / C~nt1J' ~ -L. be issued to WITNESS l~o/I>IlQe 'C J t ~ hand Ibis ~ day of ~et,fL\(i IL! I .wJ.uJ x \L f)'fc1 cJI\~?J\1 ~.~. \~~e{si JUll WID (Address) ) : ~ 1 e:ll 74- 0 ,,~ (SiID8ture) (Address) (Sisnalute) (Ad.duss) .... .. LAST WILL AND TESTAMENT OF FERN V. KRALY I, FERN V. KRALY, of the Borough of Mechanicsburg, County of Cumberland and State of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. I give, devise and bequeath all the rest, residue and re- mainder of my estate, of whatsoever nature and wheresoever situate, to my two daughters, to wit, Connie L. Bollinger, and Barbara J. Hoover, share and share alike. LASTLY, I nominate, constitute and appoint my daughters, Connie L. Bollinger and Barbara J. Hoover, Executrices of this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal / () day of iff/1l'L' , A. D. 1972. this ;d)." -"J'/ j~. 1~r Fern V. Kraly \ (SEAL) Signed, sealed, published and declared by the above named Fern V. Kraly, as and for her Last Will and Testament, in the presence of us who have subscribed our names hereto as witnesses, at the request of said testatrix, in her presence and in the presence of each other. t/ ~, . /'} / fl. Y7~ t ~-d_.J -2- REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA E - CERTIFICATION OF NOTICE UNDER RULE 5.6'a) Name of Decedent: Fern V. Kraly Date of Death: 02/11/2001 Estate No. 2001-00243 SSN: 177160970 File No. 21-01-0243 Date Letters Granted: 03/05/2001 Will or Administration No. To the Register: I certify that Notice of Estate Administration 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 03/29/2001 Name Connie L. Bollinger Address 408 Cocklin Street Meehan icsbu rg 10724 Clinton Avenue Hagerstown PA 17055 Barbara J. Hoover MD 21740 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Personal Representative X Counsel for Personal Representative ~it~ Marielle F. Hazen. Esquire Name (Please type or print) Jan L. Brown & Associates Address 845 Sir Thomas Court. Suite 9 Date: 03/29/2001 Capacity: Harrisburg PA 17109 Telephone No. (717) 541-5550 \ ;Ll. (j ;- a. </3 ORIGINAL e. FAMILY SETTLEMENT AGREEMENT AND FINAL RELEASE IN ESTATE OF FERN V. KRALY, DECEASED KNOW ALL MEN BY THESE PRESENTS, that WHEREAS, Fern V. Kraly late of Cumberland County, Pennsylvania, deceased, died testate on February 112001, having first made her Last Will and Testament, which was duly executed on March 5.2001 , and is duly recorded in Cumberland County Courthouse. Register of Vii lIs. Pa No. 21-01-0243 ; WHEREAS, the said Fern V. Kraly by the aforesaid Last Will and Testament, named Connie Bollinger as Executor/rix of said Last Will and Testament; WHEREAS, Letters Testamentary on the estate of the said decedent were duly issued by the Register of Wills of Cumberland County, and Letters Testamentary were granted to the said Executor/rix, hereinafter called Personal Representative; WHEREAS, the said Personal Representative has gathered the assets of the estate of the said decedent and the assets consist of both real property and personal property, to a total value of $ 39.899.17 as set forth in Exhibit A, which is a statement of account of the said Personal Representative, and which is attached hereto and made a part hereof, and marked Exhibit A; WHEREAS, the balance for distribution as shown in the said statement marked Exhibit A has been reduced to cash and has been distributed as herein indicated in accordance with the terms of the Last Will and Testament of the said decedent; NOW THEREFORE, KNOW YE, that we, Connie Bollinger and Barbara Hoover , being all of the beneficiaries of the said decedent and heirs under the Last Will and Testament of the said decedent, and being those persons entitled to inherit under said Last Will and Testament do hereby, each of us, acknowledge that we have this day had and received from the aforesaid Personal Representative, in full satisfaction and payment of all sum or sums of money, legacies, bequests, and devices as are given, devised and bequeathed to each of us respectively by the said Last Will and Testament, which amounts we have received this day, and which amounts are in the amount set opposite our respective names in the table and schedule of distribution in said statement attached hereto and marked Exhibit A; AND, each of us does hereby stipulate that in order to avoid the expense and time involved in the filing of a formal account and schedule of distribution, we each agree that no account is necessary and we do hereby agree that we do consent to distribution being made without the filing of an account and schedule of distribution, the same to be with the same force and effect as if it had been filed and confirmed by the Orphans Court Division of the Court of Common Pleas, Cumberland County Branch. THEREFORE, we and each of us do hereby remise, release, quit claim and forever discharge the said Personal Representative, Connie Bollinger , her heirs, executors, and administrators and assigns, of and from the said estate and from all actions, suits payments, accounts, reckoning, claims, and demands whatsoever for or by reason thereof, or for any other use, matter, cause or thing whatsoever touching upon the estate of the said decedent, and each of us do further hereby covenant and agree that should any liability come due to the estate of the said decedent after the signing of this agreement, and each of us do hereby covenant and agree with each other and the aforesaid Personal Representative that we will contribute pro rata our share of the estate to satisfy any and all claims, demands, suits, or causes of action which may be successfully prosecuted against the said estate or the aforesaid Personal Representative after the signing, sealing and delivery of this Family Settlement Agreement and Final Release. IN WITNESS WHEREOF, we have hereunto set our hands and seals this day of Dl'J2~ /' o 1 ' 2001. ..1}A-uli1lVO ~lt ess ~j3 Connie Bollinger Witness Barbara Hoover THEREFORE, we and each of us do hereby remise, release, quit claim and forever discharge the said Personal Representative, Connie Bollinger , her heirs, executors, and administrators and assigns, of and from the said estate and from all actions, suits payments, accounts, reckoning, claims, and demands whatsoever for or by reason thereof, or for any other use, matter, cause or thing whatsoever touching upon the estate of the said decedent, and each of us do further hereby covenant and agree that should any liability come due to the estate of the said decedent after the signing of this agreement, and each of us do hereby covenant and agree with each other and the aforesaid Personal Representative that we will contribute pro rata our share of the estate to satisfy any and all claims, demands, suits, or causes of action which may be successfully prosecuted against the said estate or the aforesaid Personal Representative after the signing, sealing and delivery of this Family Settlement Agreement and Final Release. IN WITNESS WHEREOF, we have hereunto set our hands and seals this ./fl day of IX-... /' ~ /7 , 2001. Witness V o'LJ),i ~ r() IY\..U m I1M- Witness Connie Bollinger .--....... ---) ,,- t ~-<-~-Ct~i4 "~.- ~t~ BarEaif Hoover -.---" ,. -.l GOMMO~&H ObF f1~~~ COUNTY OFLt1.\h'l\~ ~ ss: On this the n-tn day of -1nu') , 2001before me, a Notary Public, the undersigned officer, personally appeared Barbara Hoover (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. y ~ ~\Yl(YU' r01LrL Notary Public {)'\~ ~mm,~sL(fnfYPlfes' 8},J~3 . . COMMONWEAL TH OF PENNSYLVANIA SS: COUNTY OF DAUPHIN tj'f\ On this the L day of , 2001 before me, a Notary Public, the undersigned officer, personally appe d Connie Bollinger (known to me/or satisfactorily proven) to be the person whose name is su scribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. ~~1fJ>) Notarial Seal Marielle F. Hazen, Notary Public Lower Paxton Twp., Dauphin County My Commission Expires Sept. 23, 2002 Register of Wills, Cumberland County COpy INVENTORY I Deceased No. 21 01 0243 Date of Death 02/11/2001 Social Security No. 177160970 Estate of Fern V. Kralv also known as Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative: Name of Attorney: Marielle F. Hazen ~ oI! ti+ 1.0. No.: 68003 Address: 845 Sir Thomas Court, Suite 9 HarrisburQ, Telephone: (717) 541-5550 Dated M7J 9 , doC) I PA 17109 Description First Union Bank CD, Account#247412093644363 Value 3,000.00 Total 3,000.00 (Attach Additional Sheets if necessary) NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. RW-4 \ / ~~c2/Y-// BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT * REV-li01 EX AFP el2-00l MARIELLE F HAZEN JAN L BROWN & ASSOCS 845 SIR THOMAS CT 9 HBG PA 17109 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 08-20-2001 KRALV 02-11-2001 21 01-0243 CUMBERLAND 101 FERN v Amount Remitted 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, submit the upper portion of this for" with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ RE-V: i60-j-Ex-AFP-(i2---ol..r------...-iNi..-ERi~fANCE--iAX-STA-fEMftii-OF-ACCOUNY--.-..---------------- -- --- ESTATE OF KRAL V FERN V FILE NO. 21 01-0243 ACN 101 DATE 08-20-2001 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: 06-25-2001 PR I NC I PAL TAX DUE: ........................................................................................................................................................... 1,668.42 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-09-2001 AA496577 83.42 1,611.15 08-06-2001 REFUND .00 26.15- TOTAL TAX CREDIT 1,668.42 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 If IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIP' (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) ~ /6 -~/~"'/J COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES I~HERITi~l."E TAX DIVISION DlPT. Z80601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX MARIEllE F HAZEN JAN l BROWN & ASSOCS 845 SIR THOMAS CT 9 HBG PA 17109 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 5~ (Y .' / 07-02-2001 KRALV 02-11-2001 21 01-0243 CUMBERLAND 101 REY-1547 EX AFP el2-00l FERN v Amount Remitted 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=iS47-i3f-AFP-fi"2-:ocfr-NCfficE--OF-'fNHEifiTANCE-TAX-A-PPRA-isEi.rENT~--AiioWAN-CE-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF KRAlV FERN V FILE NO. 21 01-0243 ACN 101 DATE 07-02-2001 TAX RETURN WAS: ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE 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) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) NOTE: If an assessment was issued previously, lines reflect figures that include the total of ALL ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS. .00 .00 .00 .00 3.224.85 2,674.32 34.000.00 (8) 1,066.05 1.757.23 (11) (12) (13) (14) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 39,899.17 ?A?3 ?A 37,075.89 .00 37,075.89 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. .00 X 00 = 37 , 075.89 X 045 = .00 X 12 = .00 x 15 = (19)= .00 1,668.42 .00 .00 1,668.42 '. PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-09-2001 AA496577 83.42 1,611.15 TOTAL TAX CREDIT 1,694.57 BALANCE OF TAX DUE 26.15CR INTEREST AND PEN. .00 TOTAL DUE 26.15CR * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) REV-1470 EX (6-88) . ~ INHERITANCE TAX EXPLANATION OF CHANGES .t COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG PA 17128-0601 DECEDENT'S NAME Fern V. Kraly Sheila Megonnell FILE NUMBER REVIEWED BY ACN 2101-0243 101 SCHEDULE ITEM NO. EXPLANATION OF CHANGES The value of the estate has been adjusted as the result of the correction of an error in arithmetic. ROW Page 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT No.AA 496577 REV-1162 EX (11-96) RECEIVED FROM: I ACN ASSESSMENT CONTROL NUMBER AMOUNT .~--; (..:_~~ ,:~.' :~- '''1 rii', I L, ._l. [ ,- ~ /\ . ~..f~1111JJ.~:' , j _ J -7-- ~.'J r'; ':~'1 (\ .\".; (: C) L; ~\' ~ '1 f.-"~ r~' ~: ,"-: l~:~: L..i ;'~.' t.::1 " C' ;.', - FOLD HERE FOLD HERE - ESTATE INFORMATION: FILE NUMBER ~ io-' t~,. <.' : .,' .) i.,~' {t ~'.~ :~1 f' ~ _~ (~J () C? ~/ (; NAME OF DECEDENT, ,(L~ST~ , .: ~. :''-., p. . " (FIRST) (MI) DATE OF PAYMENT :~- " -~ / E? ,::i (:i 1 POSTMARK DATE _, . "~'t::.t .. .- COUNTY ~ ~ . ~ ; .~~.: .-: '-_ +<1 :\; ~} TOTAL AMOUNT PAID DATE OF DEATH REMARKS ~~: t..J L,. L- l r< t...;: t~, ~ ...~ j.~1 {..,~ ;~:1 ~.? I L ~_ !,i i) ,~ l, ' E~. ~:; t) tJ I ,:,), f:~. I . RECEIVED BV///I( It i'~'. (1 ;:::: \/ C~:." L. ~.~~~,; ~~ ..~..) .... .-- ." .." '" ..... ~. ,..., !<L.I:)) '::," ":"':.)l' ."; / \........ " \........;:..--/ .f,C /J, .,1,.. ,1_ .{., .,,/," !/,:::~({~,,/ ~~. ,. ':; , .}< (1.<'.1,:/, 1\'~f' SEAL REGISTER OF WILLS ~ --- ------ ( ORIGINAL STATUS REPORT UNDER RULE 6.12 BEFORE THE REGISTER OF WillS, COUNTY OF Cumberland , PENNSYLVANIA Name of Decedent: Fern V. Kraly Date of Death: 02/11/2001 File No. 21-01-0243 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to the completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: YES~ 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 Orphan's Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? YES~_ NO_ d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: ___j_-_~-.J -0 1__ ,iJ~~~'. ____u..__,__ v' ( > Signature Marielle F. Hazen Name (Please type or print) 845 Sir Thomas .court. Suite 9 Address Harrisburg. PA 17109 (717) 541-5550 Tel. No. Capacity: Personal Representative ~_ Counsel for personal representative REV'15oQR, I G Il\J ^ J '* 1~&;:;Mm:ALTHOF , . PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-<1601 I- Z W o W (J W o w :;: ",-co "If'" WO" :rtt:9 ""CO ~ REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL} Kral Fern V. DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DO-Year) OFFICIAL USE ONLY G _L~-:_Id_Ci~_/ I__ FILE NUMBER 21-010243 CDUtffi'CODE -y"EAR---'NiiMiER-- SOCIAL SECURJTY NUMBER 177-16-0970 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Retum (dateofdeathpriorlot2.13-82) o 5. Federal Estate Tax Retum Required _ 8. Total Numberof Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) {Alta::tI Scll 0\ z o 5 ::I I- ~ (J W c::: z o ~ I- ::I Q. ::E o (J ~ I- 02/11/2001 03/15/1920 {IF APPLICABLE} SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITIAL) 00 1. Original Return o 4. Limited Estate 00 6. Decedent Died Testate (AtlachcopyofWiIl) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (date afdeath aller 12-12.82) o 7. Decedent Maintained a Living Trost (Attaeh copy otTrust) o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) COMPLETE MAILING ADDRESS 845 Sir Thomas Court. Suite 9 20. OFFICIAL USE ONLY 3,224.85 2,674.32 \ I 34.000.00 ~___~___I 39.899.17 1 ,066.05 1.757.23 (11) (12) (13) 2,823.28 37,075.89 !Z w " z ~ co ~ " NAME Marielle F. Hazen FIRM NAME (If Applicable) Jan L. Brown and Associates TELEPHONE NUMBER 717 541-5550 Harrisburg, PA 17109 (14) 37,075.89 (1) (2) (3) (4) (5) (6) (7) (8) (g) (10) 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Noles Receivable (Schedule D) 5, Cash, Bank Deposits & Miscellaneous Pe"""al Property (Schedule E) 6. Jointly OWned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Sche<luie G or L) 8. Total Gros. Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgaga Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (LineS minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. NetValU8 Subject to Tax (Une 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfelS under Sec. 9116 (a)(1.2) X _(15) 37.687.81 X ~(16) X .12 (17) X .15 (18) (19) 1.695.95 1.695.95 16. AmountofUne 14 taxable atlinea.lrate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Register of Wills, Cumberland County ORIGINAL INVENTORY Estate of Fern V. Kraly No. 21 01 0243 , Deceased Date of Death 02/11/2001 Social Security No. 177160970 also known as Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears In a memorandum at the end of this inventory. I/We verify that the statements made in this inventory are true and correct. !!We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative: Name of Attorney: Marielle F. Hazen ~ at~+ 1.0. No.: 68003 Address: Dated M7J ~ doC'/ 845 Sir Thomas Court. Suite 9 Harrisburg, Telephone: (717) 541-5550 PA 17109 Description First Union Bank CD, Account#247412093644363 Value 3,000.00 Total (Attach Additional Sheets if necessary) 3,000.00 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. RW-4 JA~1\al~O Decedent's Complete Address: STREET ADDRESS .Iv . . Fern V. Kral 100 West South Street CITY I STATE I ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 1,695.95 1611.16 8479 Total Credits (A + 8 +C) (2) 1,695.95 3. InteresUPenalty if applicable D. Interest E. Penalty T olallnteresUPenally ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enler the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to requesta refund (4) 5. if Une 1 + Line 3 is greater than Une 2, enterthe difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) Make Check to: REGISTER OF AGENT 0.00 0.00 0.00 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a Iransfer and: Yes No a. retain the use or income of the property transferred; ........................................................................... 0 IZI b. retain the right to designate who shali use the property transferred or its income; ........................................ 0 IZI c. retain a reversionary interest; or ...................................................................................................... 0 IZI d. receive the promise for life of either payments, benefits or care? ............................................................. 0 IZI 2. If dealh occurred after December 12, 1982, did decedenl transfer property within one year of death without receiving adequate consideration?.............................................................................................. IZI 0 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. 0 IZI 4. Did decedent own an Individual Retirement Accounl, annuity, or other non-probale property wllich contains a beneficiary designation? ......................................................... .............................................. 0 IZI 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 that I have examined this return, jncrudin~ accompanying schedules and statements, and 10 the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative Is based on alllnformallon of which preparer has any knowledge. SIG~RSON. S~\BLE F.OB F~L1NG RETURN DATE ADDRESS 408 Cocklin Road Mechanicsbura, P SIGNATURE OF PREP RER OTHE H DATE ADDRESS For dates of death on or after Juiy I, 1994 and before January I, 1 995, the tax rate imposed on the net value of transfers to or for the use of Ihe surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)). For dates of death on or after January I, 1995, the tax rate imposed on the net vaiue oftransters to or for the use a! the surviving spouse Is 0% [72 P.S. ~9116 (a) (1.1) (ii)]. The slalule does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disciosure of assets and filing a tax retum are still applicabie even if the surviving spouse is the only beneficiary. For dates of death on or after Juiy I, 2000: The tax rate imposed on the net value of transfers trom a deceased child twenty-one years of age or younger at death to or for Ihe use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)J. The tax rale imposed on Ihe net value of transfers to or for the use of the decedent's lineai beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(I)J. The tax rate imposed on the net value of transfers to or for the use at the decedent's siblings Is 12% [72 P.S. ~9116(a)(1.3)]. A sibiing is defined, under Section 9102, as an individuai who has at leasl one parent in common with the decedent, whether by blood or adoption. ~'~'EX'I'971. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Kralv Fern V 21 01 0243 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. DESCRIPTION First Union Bank CD Account# 247412093644363 VALUE AT OATE OF DEATH 3,000.00 2. Cumberland County Burial Allowance 100.00 3. Refund from PharAmerica 124.85 TOTAL (Also enler on line 5, Recapitulation) $ (If more space Is needed, insert additional sheets of the same size) 3224.85 ~'~~.".,).. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTL Y.OWNED PROPERTY ESTATE OF Kralv Fern V If an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G. FILE NUMBER 21 01 0243 SURVIVING JOINT TENANT(S) NAME RELATIONSHIP TO DECEDENT ADDRESS A. Connie Bollinger B c 408 Coclin Street Mechanicsburg, PA 17055 Daughter JOINTLY -OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINl MADE Include name offlnaocial institution and bank a::cou/l1 numbel or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed for;oinUy-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 9/1986 First Union Checking Account 5,348.63 50. 2,674.32 TOTAL (Also enter on line 6, Recapitulation) $ 2674.32 (If more space is needed, insert additional sheets of the same size) ~""~.".". COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Kralv Fern V. FILE NUMBER 21 01 0243 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT MID THE DATE OF TAANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER ATTACH ACOP'l'QfTHEOEEOFORREAlEe,1ATE. VALUE OF ASSET INTEREST (IFAPPlICABlE) 1. To: Connie Bollinger (daughter), date of transfer June 2000 20,000.00 100. 3,000.00 17,000.00 2. To: Barbara Hoover (daughter) date of transfer June 2000 20,000.00 100. 3,000.00 17,000.00 TOTAL (Also enter on line 7, Recapitulation) $ 34 000.00 (If more space is needed, insert additional sheets of the same size) '~""~.I"'). COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Kralv Fern V Debts of decedent must be reported on Schedule I. SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 01 0243 ITEM NUMBER OESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Funeral Expense- Paid to Myer's Funeral Home 120.05 2. Headstone 90.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) ! EIN Number of Personal Representative(s) Street Address City Slaw Zip Year(s) Commission Paid: 2. Attomey Fees Jan Brown and Associates 800.00 3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Marelle F. Hazen Street Address 845 Sir Thomas Court, Suite 9 City Harrisbuf!:l, PA State PA Zip 17109 Relationship of Claimant to Decedent 4. Probate Fees Register of Wills, Cumberland County 41.00 5. Accountants Fees 6. Tax Return Preparer's Fees Patrick Donley 15.00 7. TOTAL (Also enler on line 9, Recapitulation) $ 1 066.05 .. (If more space IS needed, Insert addltlOl1al sheets of the same Size) "",.",,,,.,,.,, .~- .~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Kralv Fern V. Include unreimbullIed medical expenses. ITEM NUMBER 1. 2. 3. 4. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER 21 01 0243 Sarah A Todd Memorial Home DESCRIPTION Carlisle Imaging Assoc Three Springs Family Practice Sprint AMOUNT 1,650.70 67.86 32.14 6.53 TOTAL (Also enteron line 10, Recapitulation) $ (If more space is needed, Insert additional sheets of the same size) 1 757.23 REV.1513EX+'j-97)~~ ..~ COMMONWEALTH OF PENNSYLVANIA INHERITANCETAX RETURN RESIDENIT DECEDEN1 SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Kr"'/v "',"" V ?1 n1 "?,,~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Connie Bollinger Daughter 50% 408 Cocklin Street Mechanicsburg PA 17055 2. Barbara J. Hoover Daughter 50% 10724 Clinton Avenue Hagerstown, MD 21740 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRiATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX is NOT BEiNG MADE 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 addltlonai sheets of the same Size)