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Home My WebLink About01-0245 Estate of Mary F. Home also known as Register of Wills of CUMBERLAND County, Pennsylvania PETITION FOR GRANT OF LETTERS No. c;)./-O/- JlIS , Deceased Social Security No. 207-34-6961 John G. Home Petitioner(s), who is/are 18 years of age or older, appJy(ies) for: (COMPLETE 'A' or 'B' BELOW:) (!] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut, or the Decedent, dated May 1, 1996 andcodk:iKs) dated .. named in the last WiD of 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 incompetent: 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 that Decedent left no Will and was survived by the following spouse (if any) and heirs: r Name RelationshiD Residence 1 (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in New Cumberland Boro, Cumberland County, Pennsylvania with hislher last family or principal residence at 142 G 15th Street, New Cumberland, Cumberland County, Pennsylvania (list street. number, and municipality) Decedent, then ~years of age, died February 24, 2001 at West Shore Health & Rehab, East Pennsboro Township, Cumberland Co., PA (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (It not domiciled in PA) Personal property in Pennsylvania (If not domiciled in P A) Personal property in County Value of real estate in Pennsylvania $ 30,000.00 $ $ $ 75,000.00 situated as follows: 142 G 15th Street, New Cumberland, Cumberland County, Pennsylvania 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 a ro riate form to the undersi ned: Si n ture 1 John G. Home 789 Null Road New Cumberland, PA 17070 Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems. Inc. /0 -;) I '-/ - 13 Form RW-1 (1991) Oath of Personal Representative Commonwealth of Pennsylvania County of 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 representative(s) of the Decedent, Petilionor(s) will woll and truly administer the 0 0 ccording to Ia,!/. _ / Sworn to or affirmed and subscribed ,~ ~ ".J before me this~ day of Yl?auJ) 2001 '0"'1 (1. XI "L-W flJl, Ii /j ,:;KfdJ'j" / ~ For the Re9iste~..J..G iI 789 Null Road, New Cumberland, P A 17070 N~ 21-01-245 Estate of Mary F. Horne Deceased Social Security No: 207-34-6961 Date of Death: February 24, 2001 AND NOW, MARCH 6, , 2001 , 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.a.; pendente lite; durante absentia; durante minoritate) are hereby granted to John G. Horne in the above estate and that the instrument{s) dated May 1, 1996 described in the Petition be admitted to probate and filed of record as the last Will ot Decedent. FEES Letters. . . . . . . $ 235.00 Short Certificate(s). ~. $ 15.00 Renunciation. $ Affidavits ( $ Extra Pages ( 6 ) . $ 18.00 Codicil. . $ JCP Fee. $ 5.00 Inventory. $ Other . . . . . . . . . . $ 'fT)1J.JJ' fl. ~ fU" f!tl . /J.C'..d;..d J)" /'/dy- Register of Wills / Attorney: Thomas E. Flower, Esquire 1.0. No: 83993 Address: SAID IS, SHUFF, FLOWER & LINDSAY 2109 Market Street, Camp Hill, P A 17011 Telephone: 717/737-3405 TOTAL. . . . . . . " $ 273.00 Prepared by the Pennsylvania Bar AssociatIon CopyrIght (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991) [1 \ is to eertif" thar the information here given is corrcedy copied from an original ce-nitlc~te of death dul~ filed with me as !. )0.; ) Registrar.' The original certificate will be Forwarded to the State Vital Records Otftce tor permanent filmg. WARNING: It is illegal to duplicate this copy by photostat or photograph, No. /-;;fIiiiiH j;~;~~~ 4[~'-'\\ OF pt;;,~ &'~~\.. //~~"'!/If:~ l~// ~~":.~ 1~~... \<-::.~\ /~~i"" \?~ !~c:::J{ --:~_: ":~~ ~'-'~- - -"~,~~..~~ ~ * -{. " ~'; ", * ~ '\ ~~\ - ~-'"-- 0- - ~ /:~./ """ <%'~ ./~/ --..~_-fl;lJ~---j <.. ~'<. "" ~'-'.r,,/" EN1' \\"",,111 ..,-',,/,~!!~ ./?. ;!;(.47-;;;~ !~.:ti/Ii./ .-',F,. c-'l --"I ,.,; L L'-":::~! ~~ v' -,:.9' ~:'" to. Local Reg;srrar d'" -'.-- Fee for this cenitlcne. $2.00 P 7177581 ".,.. -i f' t. LuG' r t '~J (, C- Datt . Ae. 2187 COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH. VITAL RECOROS CERTIFICATE OF DEATH .. Cumberland Ie. E. SEX STATE FILE NUMBER SOCIAl. SECURtrt NUMBER NAME Of DECEDENT IF,;.. Middle. Lasl 76 Mary Frances Horne UNDER 1 YfAIl UNDER 1 OR! . ~ Oaya _ Minul.. a.female 3. 207 - 34 - 6961 t. AGE (La.. Bw1I><laYl Yrs BIRTHPlACE ICoIy iOIld PUlCE OF DEATH ICt>ec~ 0l'Iy /)l'4l -- _ ,nssfUCI,O"," on ome. _I Stal. '" F Cleog<1 COlJnrrYI HOSPITAl Ashland, KY . Inpalienl P ER/Oulpa.ltllll 0 OOA 0 ... . FACILITY NAME (II nol.n5l'I\Jl00n. lilllll SIr"'" ana numoer, ="Y}O 5. COUNTY Of DEAfH RACE. Amen<:an Indian. 8laek. Whil.. ...,. \SpecIIyI white 10. DECEDENT'S USUAl OCCUPRIOH (<:-~~"==~:'f . 11a. Purchasing Agent 1111. Electronics DECEDENT'S MAILING AOOAESS (Skeel. ClIylTOwn. s.-. Zip Codel DECEDENT'S ACTUAl RESIDENCE lSee I/lSlIUCIIOf\I on OIIle, Sldel MS DECEDENT EVER IN US. ARMED FORCES? '1M D NoKl r.v.RITAI. STATUS. Uarried Ne_Manied. W_. ON<<ced (Spec....., 14. Widowed SURVIVING SPOUSE (11.....9""'- namel 17a. SIal. PeBBDylvsBia Did dlIcedanI M"'a ,J J"l Cumberland -ill? 17d~ :....-==~oI J'iEbJ UJM~c.UArJ-A MOTHER'S NAME ,F.... Modclle.l.laKlen Sutnamel 17C.O ~. ~1ll1Ned it> "'P. 142 G 15th Street 1.. New Cumberland, PA 17070 FRHER'S NAME (Firsl. ModdIe. Lastl Ilb. Cou cilylbon:l II. AenxMII.um Sial. 0 Co. Sv I.ICENSEE OR PERSON ACTING AS SUCH 2311. 23c. MS CASE REFERRED TO MEDICAL EXAl.lINERlCOAONER? Yea 0 Nokf PART H: 0Iher si9"illcanl condiliona COIll'ibUling 10 dealh. bul _~in\he~CMMQNeninPAAT I. I: DUE DUE -.s AN AUTOPSY PERFORMED? WERE AUlOPSY FINOlNGS _l.'BlE PRIOR 10 COMPLETION OF CAUSE OF DEAfH? MANNER OF DEATH DATE OF INJURY (Mon"'. Day. 'I\larl TIMe Of INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. Accldenl P.ndong In....ova'ion Could IlOl be det.rmlned o o o PLACE OF INJUFlY. AI home, 'a'm~;a".laclory. offic. ~ ale. ISpec,lvl :JOe. ~ 0 NoD _0 NoDI Yea 0 NoKJ Suicide o o o HomICide NaI...., o , M. 3Oe. 28&. 21b. aRTlFlEA ICheck oniy one) 'CEIITIFYING PHYSICIAN IPhySoC"",, cerldy'og cause 01 <lea1/) whefo anOlher phVSIC"'" has pronounced dealh iIIlO camPleled lIem 23) To _ _ ot Ifty "-wledge. dea'" oc<:,,"" _101 _ cauM(sl and mann.. aa sialOId. . . . . . . . . . . . . . . . . . . . . . . . B. 'PRONOUNCING AND CERTIFYING PHYSICIAN (F'tlySoCoan bolh ;>ronouncong tJedlll andcer1dvono 10 cause 0/ dealhl To 11M _ 01 my looow""9". dea'" occ,,"ed .1 \he lime. dal., and piau. and duo to tho cauM(s)ancl manna' a& slalad.. . . . . o 'MEDICAL EXAMINER/CORONER On lhe baaia 0' ..aminallon and/or invesllgation. in my opmion. dealh occurrod allhe lime, date, alld placa. and duelQ Ihe cause(.) and man"e' .a stated.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :31.. REGISTAAR}'fNATURE AN~ER ..J. . 33 U~,.1 /....( q'/~"'~./-~/7~ ~I 'I..l, "I ~I SAIDIS, GUIDO, SHUFF & MASLAND 2109 Market Street Camp Hill, PA T-- ,1 " . .' LAST WILL AND TESTAMENT OF MARY F. HORNE I, MARY F. HORNE of the Borough of New Cumberland, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any will previously made by me. I - I direct the payment of all my just debts and funeral expenses out of my estate as soon as may be practical after my death. II - I bequeath certain items of my tangible personal property, not including cash and securities, in accordance with a written list made by me during my lifetime. In the absence of such a list or designation on said list, then I bequeath my tangible personal property to those children of mine who survive me, to be divided among them by my executor as he shall deter- mine. III - I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate unto my children, Mary Kay Lenker, Nancy E. Kauffman, Patricia Ann Guy, John G. Horne and Janice L. Mercer, in equal shares, the share of a deceased child to be paid to his or her issue per stirpes. j',FrI , Page 1 SAIDIS, GUIDO, SHUFF & MAS LAND 2109 Market Street Camp Hill, PA I . > '. IV - I appoint my son, John G. Horne, Executor of this, my Last Will and Testament. Should my said son fail to qualify or cease to act as such, then I appoint my daughter, Nancy E. Kauffman, to act in this capacity. Neither of my personal representatives shall be required to post bond in this or any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal on I 'vI this, the day of Yl/1 ~ d , 1996. I }7" ,,' 7 ).'(''''/1' ',' ,,' / . " ,f' / tl t (( , ." t/ J - , Mary F. Horne (SEAL) Signed, sealed, published and declared by MARY F. HORNE, Testa- trix therein named, on this and one (1) other sheet of paper as and for her Last Will and Testament, in our presence, who, in her presence, at her request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. P I, ~'A~ Name r? /r/-o ~ rt-v; rf ..( J-P , if q , / Address r b/Q"l /V~ Address Page 2 SAIDIS, GUIDO, SHUFF & MASLAND 2109 Market Street Camp Hill, PA . . .' ~ COMMONWEALTH OF PENNSYLVANIA) SSe COUNTY CUMBERLAND) OF WE, the undersigned, the testatrix and the witnesses, respectively, whose names are signed to the foregoing instru- ment, being first duly sworn, do hereby declare to the under- signed authority that the testatrix signed and executed the instrument as her Last Will and Testament and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free will and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix signed the will as witnesses and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind, and under no constraint or undue influence. 7,// ,-1./ . I'jt, /(I~ , 1 I lj"-/ .I. . I '." /y,/- ') '} j' ( J Testatrix Subscribed, sworn to and acknowledged before me by the testatrix, and subscribed and sw~~~~ before me by both wit- nesses, this I~ day of ~ ' 1996. ~~.ci:~ }fotary Public (' ."".. NOTARIAL SEAL THELMA S. ~cCAUSLlN, Notary Public Camp ~I"~ CU/}1berland County I MvCorrm'~S:f)nr"Dir~~ ,.J'y3 1Snc ~" _....._::. .;" .....'\. ,,:~~.: out ~ ~) ,1 - 1_ --- REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA CERTIFICATION OF NOTICE UNDER RULE 5.6(A) Name of Decedent: Mary F. Home Date of Death: February 24, 2001 Will No. 21-01-0245 Admin. 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 ~ vk \ '-- ,2001. Name Address Patricia Guy Mary Lenker Janice Mercer Nancy Kauffman John G. Home 333 Evergreen Street, New Cumberland, P A 17070 142G 15th Street, New Cumberland, PA 17070 1924 Southaven Drive, Virginia Beach, VA 23464 1759 Ridge Road, York Springs, PA 17372 789 Null Road, New Cumberland, P A 17070 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except none Date: sf {2 /" ( I ' ~~s.~ Thomas E. Flower, Esquire SAIDIS, SHUFF, FLOWER & LINDSAY 2109 Market Street Camp Hill, PA 17011 (717) 737-3405 Capacity: _Personal Representative X Counsel for Personal Representati ve IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF: MARY F. HORNE, No. 21-01-0245 Deceased Late of the Borough of New Cumberland Social Security No. 207-34-6961 INVENTORY Securities and Investment Accounts: 1. Solomon Smith Barney IRA account # 724-60823-1-2-035, consisting of the following: SB Money Fund SBCX, 95 shares New perspective Mutual Fund ANWPX, 538 shares SB Appreciation Mutual Fund APPRB, 806 shares 24,442.20 2. Solomon Smith Barney account # 724-17780-1-3-035, consisting of the following: 290 shares SBCS Money Fund 554 shares PNVBX Putnam Investors Fund 361 shares APPRB Appreciation Fund 86 shares SBPSB Premium Large Cap Fund 13,663.20 Cash and Bank Accounts: 3. Members 1st Federal Credit Union, savings account # 137117-00 530.53 accrued interest .96 531.49 4. Members 1st Federal Credit Union, checking account # 137117-11 4,359.37 accrued interest 3.90 4,365.27 5. Members 1st Federal Credit Union, certificate of deposit # 137117-41 1,639.65 accrued interest 5.10 1,644.75 6. Members 1st Federal Credit Union, holiday club account # 137117-02 30.28 accrued interest .06 30.34 , . Personal Property: 7. 142-G 15th Street, New Cumberland, 8. 1990 Buick Regal Auto based upon sale price 9. household goods and furnishings 10. Erie Insurance Group - partial premium refund 11. People's Life Insurance - partial premium refund 12. First Union National Bank/Capital One account # 1645885490 - credit balance refund 13. Capital Blue Cross - reimbursement for medical costs paid by decedent 14. Capital Blue Cross - return of premium TOTAL 84,000.00 500.00 5,000.00 53.00 9.15 144.75 92.38 49.12 $134,525.65 . . ESTATE OF MARY F. HORNE NON-PROBATE INVENTORY 1. Mass Mutual variable annuity contract # 09-709-716 2,853.66 . . VERIFICATION I verify that the statements made in the foregoing Inventory are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~ 4904, relating to unsworn falsification to authorities. DATED: _9/~/ 1(L ))~ J~hn G. Horne, Executor of th~ jftate of Mary F. Horne /6'-62-/ y-;<.g COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG~ PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT 1 ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT Of TAX THOMAS E FLOWER ESQ SAIDIS ETAL 2109 MARKET ST CAMP HILL PA 17011 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-05-2001 HORNE 02-24-2001 21 01-0245 CUMBERLAND 101 ~* REY-1547 EX UP (12-00) MARY F Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE1 PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv; ls4j-Ex-iFP--fi"2-:o()r-NoricE--oF--fNHiifiTANci-,.-A"SrA-PPRA-isEifENT-;-iLl-owAirce-o-i------------ - - --- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HORNE MARY F FILE NO. 21 01-0245 ACN 101 DATE 11-05-2001 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) 84,000.00 38.105.40 .00 .00 12,420.25 .00 2,853.66 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS. (9) (10) NOTE: 261628.15 1.010.96 (11) (12) (13) (14) .00 X 109,740.20 X .00 X .00 X NOTE: To insure proper credit to your account1 submit the upper portion of this form with your tax payment. 1371379.31 ?7.63911 1091740.20 .00 1091740.20 00 = 045 = 12 = 15 = .00 41938.31 .00 .00 41938.31 (19)= . PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-23-2001 AA496631 246.92 5,,000.00 TOTAL TAX CREDIT 51246.92 BALANCE OF TAX DUE 308.61CR INTEREST AND PEN. .00 TOTAL DUE 308.61CR . IF PAID AFTER DATE INDICATED 1 SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $11 NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)1 YOU MAY BE DUE A REfUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) /b-~/~- /g ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' REY-1607 EX AFP COI-02> THOMAS E FLOWER ES~~ v_~ SAIDIS ETAL 2109 MARKET ST CAMP HILL ~~ 17011 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 06-24-2002 HORNE 02-24-2001 21 01-0245 CUMBERLAND 101 MARY F ,j 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 form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv:i6'ifj-iY-AFP--c:oY--o2Y------...--iNifERIT-ANc"E--TAY-STAfEMfNT-O-F-AccoiJiif--.-..---------------- -- --- ESTATE OF HORNE MARY F FILE NO.21 01-0245 ACN 101 DATE 06-24-2002 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 10-29-2001 P R I NC I PAL TAX DUE: ............................................................................................................................................................................................................... 4,938.31 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-23-2001 AA496631 246.92 5,000.00 06-07-2002 REFUND .00 308.61- TOTAL TAX CREDIT 4,938.31 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY. PENNSYLVANIA STATUS REPORT UNDER RULE 6.12 r/v Name of Decedent: Date of Death: MaryF. Home 02 - 24 - 01 Will No. 2001 - 00245 Admin. No. 21 - 01 - 0245 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_. that 2. If the answer is No, state when the personal representative reasonably believes 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 Clerk of the Orphans' Court and may be attached to this report. Date: b /2 ?/62- I I ~~~ ignature Name: Thomas E. Flower, Esquire LD. No. 83993 SAIDIS, SHUFF, FLOWER & LINDSAY 2109 Market Street Camp Hill, PA 17011 (717) 737-3405 Capacity: Personal Representative X Counsel for Personal Representative {)M ~ 7/, (iJ .)-- ,~ 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 49S631REv-1162EX(11-96) RECEIVED FROM: ACN ASSESSMENT CONTROL NUMBER AMOUNT I , _ ',',+J EJ., :' t (~ ! fVi,(\ '~") ~',_ s.. ~':.~.. ('_, I',) .:," .. () () (~' .t '. f'".' f'll {:\ ~:~ ,~'. E.. T 'T ~.-\ t, 1:,: .:~ ~ r~ r....l ~-~' ~,' ,:'~ 1. ~/ (~l ,~_ - FOLD HERE FOLD HERE ESTATE INFORMATION: FILE NUMBER ;:'.~: J i~i <.~ (~~"; I .. <:~ :":.; l. :-:~ ~;:~f") ,:::001 ::ii., b<f/.:. 1 NAME OF DECEDEN~. ". .(~AST)_ f', C.i r,' 1\:L 'I i-'1: , , (FIRST) (MI) ',,' DATE OF PAYMENT RECEIVED BY , ~# ".. .., ..,. l>- ot ~ (>(:l<~.. ()() . .. '" .- .,-: :~f~~~~ '. .:/ ~....,"::'"..... . ..,U.u~a/;:2t:",(.. /J;;t~ " t I.)~. )" \~/.< Kl",!' (4"'" , "/ ,,/ ./ ~P: I I .~l '~J ;_-~: (') J_) _; POSTMARK DATE ~) ./ (.t(/ ,/ i,:",'(}:) f"',l COUNTY ~_! t--'1 E1 E ~-~< ~_~ i'~ 1\3 :) TOTAL AMOUNT PAID DATE OF DEATH ;'~1 (\F,~-/ j t~-, C' ~ it I - c~ SEAL REGISTER OF WILLS ~ REV.TOOOEX(&OOj I~-().Ii.f- h3 REV-1500 Cr '* COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 - 01 02 45 COUNTY CODE YEAR NUMBER f- Z W o W () W o DECEDENTS NAME (LAST, FIRST AND MIDDLE INITIAL) Home, Ma F. DATE DF DEATH MM..DD YEAR} THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 207 44 - 5322 DATE OF BIRTH (MM.DD.YEAR) 02-24-01 02-16-25 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL) nla SOCIAL SECURITY NUMBER W I- t!'''' - w!!:u ","0 u~ffi " " < ~1.0riginaIReturn D4.LimitedEstate ~ 6. Decedent Died Testate (A"ach copy otWWj D9.LitigationprOceedsReceived D 3. Remainder Return (dateoldealh prior to 12-13-1l2) o 5. Federal Estate Tax Return Required e. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113{A) attach Sch 00 D2.suPPlementalReturn D 4a. Future Interest Compromise (dale ofduln atler 12.12-62) D7.DecedentMaintainedaLiVingTrustattachacopyotTlUsll D10.SpousaIPovertYCreditldilteofdealhbelWeen12.31.g1and1.1-95) f- Z W Q Z o . " w " " o u THIS SECTION MUST BE COMPLETED ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO NAME COMPLETE MAILING ADDRESS Thomas E. Flower, Es . FIRM NAME (",",,,,,,,.) . Saldls, Shutt, t< lower & Lmdsay TELEPHONE NUMBER 717-737-3405 2109 Market Street earn Hill,PA 17011 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) (1) 84,000.00 (2) 38,105.40 (3) 0 (4) 0 (5) 12,420.25 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) z o i= ~ :J t: a. <l: () w a:: 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (6) 0 6. Jointly Owned Property (Schedule F) DseparateBillingReqUested 7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property (Schedule G orL) 8. Total Gross Assets (total Lines 1-7) (7) 2,853.66 (8( 137,379.31 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 26,628.15 (10( 1,010.96 10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule 1) 11. Total Deductions (tolal Lines 9 & 10) (11( 27,639.11 (12( 109,740.20 (13) 0 12. Net Value of Estate (Line 8 minus line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) {14} 109,740.20 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o f- <( I- :J a. ::; o t) X <( I- 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x.O_ (1S) x.o 45 (16) 4,938.31 x.12 (17) x ,15 (18) (19( 109,740.20 16, Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 1B.Amountofline 14 taxable at collateral rate 19. Tax Due 20 [8J CHECK HERE IF YOU ARE REOUESTING A REFlIND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Complete Address: STmU~D(\Ef~th Street CITY I STATE PA I ZIP 17070 New Cumberland Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (I) 4,938.31 o 5,000.00 250.00 Total Credits (A+ B + C) (21 5,250.00 3. Interest/Penalty if applicable D.lnterest 0 E. Penalty 0 TotallnteresUPenalty ( D + E ) (3) 0 4. If Line 2 is greater than line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 311.69 5.11 Line I + Une 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0 A. Enter the interest on the lax due, (SA) 0 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (513) 0 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS . 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 income; _ _ _ _ _ 0 ~: ~::~j~: t~e::~:i~~:;~~~tl~:ee:~; e~;~~r ~~y~~~t~, -b~~efi;s -o~ ~a~~? -_ -_ -_ -_ -_ -_ -_ -_ -_ -_ - - -_ -_ -_ -_ -_ -_ -_ -_ -_ -_ -_ -. -_ B 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death 3. D:il::~~e:~;V~~na:~~~~t~~~n~~,~~;~:;~ ~p~; d~a;h ba;; ;c~~~n; ~r -s;~u;itya; hi~ ~rh;; de;I;'? ~ 8 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 181 No 181 181 ~ 181 181 D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Und.r p.n.llltt of p.rjury, I d.e1.re ttl.ll h.v. .umln.d ttlil r.tum, Including .ccomp.ny-Ing tch.dulll.nd .lItemenlt, .nd to the bllt of my knowledge .nd b.ll.f, It Is true, cornet .nd complete. Decl'l'IItlonofprep.reroth.rth.nth.peflon.lrepr...nlttlv.ltbll.d nllllnfonn.tlonofwhlchpreptrtrh...nyknowl.dge. ADDRESS Siadis, Shuff, Flower & Lindsay, 2109 Market Street, Camp Hill PA 17011 09/18/01 DATE For dates of death on or after July 1, 1994 and Before January 1, 1995, the tax rate imposed on the net value of transfers to or to the use of the surviving spouse is 3% 172 PS !9116 (al (1.1)(1)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (B)I. The statute does 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 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, ora stepparent of the child is 0% [72 RS. !9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 RS. 99116(1.2) 172 RS. 99116(a)(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. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. "''''"..,,''''''*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESJDENTDECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER MaryF. Home 21-01-0245 All real property owned solely or as a lenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a wjlJing seifer. neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorshjn must be disclosed on Schedule F. ITEM NUMBER I. DESCRIPTION residential condominium located at 142-G 15th Street, New Cumberland, PA 17070 VALUE AT DATE OF DEATH 84,000.00 TOTAL (Also enter on line 1, Recapitulation) $ 84,000.00 (If more space is needed, insert additional sheets of the same sIze) A. U,S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT SETTLEMENT STATEMENT Affiliated Settlement Services Group, LLP 3912 Market Street Camp Hill, PA 17011 (717) 975-7839 FINAL Form Approved OMS No. 2502~026~_ I B. TYPE OF LOAN 1. C FHA 2. C FMHA 4. C VA 5. C CONV. INS. 6. ESCROW FILE NUMBER: i 00001927-001 NJT 18. MORTGAGE INSURANCE CASE NUMBER: I 3. C CONV. UNINS." 7. LOAN NUMBER: - C~-NOTE: This fo;~ i~-iU;:;:;ish~d-to-gi~';yo~a;t-;t~~~;;t-of;~iuaIS~W~~~~t costs. -Amounts paid to and by the settlement agent are shown. Items marked "(P.O.C.)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. D. NAME OF BORROWER: Scott A. Lake ADDRESS OF BORROWER: 5903 Michael Drive Bensalem, PA 19020 John G. Horne Executor E. NAME OF SELLER: ADDRESS OF SELLER: F. NAME OF LENDER: ADDRESS OF LENDER: 'G. PROPERTY LOCATION: 142 G 15th Street New Cumberland, PA 17070 Cumberland County 26-23-0541-218A-U7 rCSETTLEMENTAGENT . .. Affiliated -SeiiiemeriTseiiVTces Group-;- LLP--- PLACE OF SETTLEMENT: 3912 Market Street, Camp Hill, PA 17011 '1. SETTLEMENT DATE: 8/27/2001 PRORATION DATE: J. SUMMARY OF BORROWER'S TRANSACTION I K. 101. 102. 103. 104. 105. Contract Sales Price Personal Property Settlement charges to Borrower (line 1400) 8/27/2001 . ----SUMMARYOF.S'ELLER'STRANSACTION 401. Contract Sales Price 402. Personal Property 403. j=~~~_~=-~__ - I :~~__=-____.___= - ---- - - - ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE' ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: 1, 8 . ---.1- ! +-- I 106. CitylTown Taxes 406. CitylTown Taxes I -- 107. County Taxes 08/27/01 to 12/31/01 110.54 407. County Taxes 08/27/01 to 12/31/01 I .' ------- 108. Assessments 408. Assessments i 109. School Tax 08/27/01 to 06/30/02 I 796.68 409. School Tax 08/27/01 to 06/30/02 i . . --.. - --- 110. AU9uSt Cond 08127/01 to 08/31/01 6.67 410. August Cond 08/27/01 to 08/31/01 , -------- I - .+----- 111. Trash 08/27/01 to 09/30/01 13.71 411. Trash 08/27/01 to 09/30/01 i 112. ~ 412. - ---------------",_._-- ------------ ------------- - 110.54 798.68 6.67 13.71 113. " 413. -1-i4:"-----.==---==--===1=_=.::.::.:::~14.::=.::===__:===__:.==__._. 115. 1415. 120. GROSS AMOUNT DUE FROM BORROWER: 86.614.58 420. . . __--L-____ 201. Deposit or earnest money Excess deposit (see instructions) 202. Principal amount of new loan(s) 502. Settlement charges to Seller (line 1400) 203. Existing loan(s) taken subject to -.------------- ~-.--------1.-553:--ExlS~ng--loan(sjtaken-sljbre-dTo---- ~------------------- .---------. - .L______ I . -.--------- - --T5?4:' Pa9o-WOt fir~fmo-rfg-agelo-a~ -::~::~~~-"'~g----:---- .;:o-~~~~ ~~;:t~,::~~nnrorjgage lo~"-_ __+- :=-:-__m --~=-=-=~__~f=~ ... 'f 209. L=t;~~~_________._ ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: 6,925:25 . --T51J:DO I _.. 210. CitylTown Taxes 510. CitylTown Taxes 211. County Taxes 511. County Taxes ! 212. Assessments 512. Assessments I ----- 213. 513. I - .--- 214. 514. 515. ! .-- 215. - - .. --'--.. -1 ~-=- ~ iji:-:--- I 519. j 220. TOTAL PAID BY/FOR BORROWER ' ---- 5,150.00 , 520. TOTAL REDUCTIONS IN AMOUNT DUE SELLER' .-- 7.075.25 , 301. Gross amount due from Borrower (line 120) - I 86,614.58 6~1. Gross amount due to SeUer ~line 4~0) : -, :1i1l~.llf~!~~~l~\ -302. Less amount paid byifor Borrower ( line 220) ---'--r-' 5,150.00 602. Less reduction in amount due Seller (line 520) - 7,ois.25 ..----.--.-----____-1--_...____. 303. CA~H~~FR()r.1)~9_T()) BORR.C>""~:_~_81~64~L60~CASH (~~~ROrll~~n~....l".~) SELLER ___ .1__-"7~8_5435 216. 217. _nn 218. 219. ___L___.-- PAID FROM BORROWER'S FUNDS AT SETTLEMENT 00001927-001 NJT , "illllillllffillillllifY;;'J"1 , .1~RmTIlh_mWlFMj' PAID FROM SELLER'S FUNDS AT SETTLEMENT BASED ON PRICE$ 84,000,00 @ DIVISION OF COMMISSION (LINE 700) AS FOLLOWS: 701. $ 2,545,00 to Brokersrealty,Com 7U2:$ -' 2,495.00 to a er ea ty 703. Commission paid at settlement 704. 5,040,00 Loan Origination Fee Loan Discount Fee Appraisal Fee to: Credit Report to: Lenders Inspection Fee 806. Mortgage Insura~nce Application Fee to: 857:J\Ssumptior;"Fee----- 808. ---- .------ 809, -~---. ._._-_._--------------_._----~--- 810, __ __________,,____1 _____ 811, , _'~!l1 ~~Jl!llt_ " -OO2-:-Mortgage-jnsu'i--ancePremlLJm for- -Month(s) to-- 903. Hazardlnsurance-Pre-rTlfiJrTlfor- ________n__ Ye-ars(s)1O-- 904, 905, i --------- '---1' ---r-- - I ----T- j 1 01. Hazard Insurance 1002. Mortgage Insurance 1003. City Property Taxes 1004. County Property Taxes 1 05. Annual Assessments 1006. 1007, 1008, Aggregate Acc!. Adj, 26.74 per month per month per month per month per month per month per month per month 1101. Settlement or closing fee 1102. Abstract or title search 11~ Title ex'a-inination 1'1~Tnsurance binder 1105. Documen~ation 1106. Notary fees 1107. Attorney's Fees (includes above items numbers: 1108. Title Insurance ---'-~ AffiliatedSe-ttie-mentSe-rvlces-GroupILP - - -------. . (hlcrudes above' items-numbs-is: ------------ -ffoif.Lenders-coverag-e:- --$- 1110. Owner's coverage $ 1111. 1112. 1113. 1:::--------- 7 _____J_ L_ I .t---- I , ! 5.00 j- ------+------- I 5.00 to Settlement Officer 659,48 84,000,00 I -L 1201. Recording Fees: Deed $ 1202. City/County tax/stamps 1203. State tax/stamps 1204. 1205. 25.50 Mortgage $ Deed $ Deed $ Release $ 840.00 Mortgage $ 840.00 Mortgage $ 840.00 1301. 1302. 1303. 1304. Transaction Fee to M.C. Walker Realty -1305. 2001-2002 School Taxes to Robin Gasperetti 1306. September Condo Fee -~-l5UmJ:iei1ai1dCrosSTngsCondo.As--S------- ------~ ~---------T- 1307. ,o,oSee attached for breakdown l '-91-:32 1400, TOTAL~ETTLEMENT CHARGES (Enteron line 103,SectionTa-ncr:liile562~seCtiOnK) _-:--------:,------==---1,6,<34J)8----- 6,92525 I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, It IS a true and ac;;:curate statement of all receIpts and DIsbursements made on my account or by me In thIS transaction I further certIfy that I hav. received a copy of the Hl.JO-1 Settlement Statement ~ ~ / Scott A L~' _- /. John fipme Exe:;\u ' --, l.-----L ' /' / 1. L~ ~- "'.---- --.... to Home Paramount Pest Control Co 1---------,O.1lIr1 -, ----=-=-50001' 948,93 Setters sed or wilt cause the funds to be Date WARNING: It is a crime to knowingly make false statements to the United States on this or any similar form. Penalties upon conviction can include a fine and imprisonment. For detalls see: Title 18 U.S. Code Section 1001 and Section 1010. Escrow Number: 00001927-001 NJT HUD 1200 DETAILED BREAKDOWN OF GOVERNMENT RECORDING AND TRANSFER FEES 1202. 'City & County Tax/Stamps City Tax/Stamps: Deed $840.00 Total as shown on HUD page 2 Line #1202 1203. State Tax/Stamps State Tax/Stamps: Deed $840.00 Total as shown on HUD page 2 Line #1203 Buyer Amount Buyer Amount $840.00 Seller Amount $840.00 Seller Amount ""'03""""". COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Mary F. Home FILE NUMBER 21-01-0245 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER I. DESCRIPTION VALUE AT DATE OF DEATH SolomonSmithBamey IRA account # 724-60823-1-2-035: SB Money fund SBCX, 95 shares New Perspective Muttual Fund ANWPX, 538 shares SB Appreciation Mutual Fund APPRB, 806 shares 24,442.20 2 SolomonSmithBarney account # 724-17780-1-3-035: 290 shares SBCS Money Fund 3 554 shares PNVBX Putnam InvestorsFund 361 shares APPRB Appriciation Fund 4 86 shares SBPSB Premium Large Cap Fund 13,663.20 5 6 7 8 9 10 II 13 14 TOTAL (Also enter on line 2, Recapitulation) s 38,105.40 (If more space is needed, inse- additional sheets of the same size) SALOMON SMITH BARNEY 71"1-780-1700" 800-237-1700 -. A member of cltlgroupJ March 16, 2001 Thomas E. Flower Said is, Shuff, Flower & Lindsay 2109 market Street Camp Hill, PA 17011 Dear Sir, As requested in your March 8, 2001 letter, enclosed is information regarding the assets of Mary F. Horne as of her date of death, February 24, 2001. 1. A. Mary F. Horne B. Mary F. Horne SSB IRA Custodian 2. A. 724-17780-13-035 B. 724-60823-12-035 3. A. $13,663.20 B. $24,442.20 4. A. 01/31/94 B. 01/06/94 5. N/A Mary requested that Mass Mutual transfer assets held by them to her account, 724-60823-12-035. They have not been received as of this date. Please let me know what will be done with the assets, in order to let you know what paperwork will be needed to do so. --=c 4r-- Fred Peggs Vice President-Investments Financial Consultant Cc: John Horne SALOMON SMITH BARNEY INC 11 [\jorth 3rd Sired 2nd Floor, Harrisburg, PA 1"1101-1702 FAX 717-233-2090 ""'50'''''''''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Mary F. Home FilE NUMBER 21-01-0245 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 I. DESCRIPTION VALUE AT DATE OF DEATH Members 1st Federal Credit Union I. Savings Account # 137117-00............................................................................................. 531.49 Principal...... ..................................530.53 Accrued Interest ................................. .96 2. Checking Account # 137117-11 .......................................................................................... 4,365.27 Principal....... .............................. .4,359.3 7 Accrued Interest ................................ 3.90 3. Certificate of Deposit # 137117-41 ................................................................................... 1,644.75 Principal ......................................1,639.65 Accrued Interest .............................. 5.10 4. Holiday Club Account # 137117-02.................................................................................... 30.34 Principal.......................................... 30.28 Accrued Interest ................................. .06 5. 1990 Buick Regal Auto (reconstructed after accident) (sale price) ..................................... 500.00 6. Household Goods and Furnishings ...................................................................................... 5,000.00 7. Erie Insurance Group - partial premium refund ................................................................... 53.00 8. People's Lifelnsurance - partial premium refund .................................................................. 9.15 9. First Union National BanklCapitalOne - acct. # 1645885490: credit balance refund .......... 144.75 10. Capital BlueCross - reimbursement for medical costs paid by decedent .............................. 92.38 II. Capital BlueCross - return of premium ................................................................................. 49.12 TOTAL (Also enter on line 5, Recapitulation) $ 12,420.25 (If more space IS needed, Insert additional sheets of the same size) Me111.bersJ FEDERAL CREDIT UNION REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner CHECKING ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner HOLIDAY CLUB ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner CERTIFICATE OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Beneficiary VISA CREDIT CARD ACCOUNT: Account Number Date Account Opened Principal Balance at Date of Death Name of Joint Cardholder Estate of: MARY F. HORNE Date of Death: Feburary 24, 2001 Social Security Number: 207-34.6961 INSURANCE DEPARTMENT 5000 LOUISE DRIVE P. O. BOX 40 MECHANICSBURG. PA \7055 1 -800-283-2328 or (717) 697-1161 137117 -00 12/1411993 $530.53 $.96 $531.49 None 137117.11 1211411993 $4,359.37 $3.90 $4,365.27 None 137117 .02 01/0211998 $30.28 $.06 $30.34 None 137117 -41 30 MO 0411411999 $1,639.65 $5.10 $1,644.75 None 41214499933711173 12/23/1993 $.00 None Mb4ER> ," '~n ""'-""_ . ..U~a Denise A. Anders Insurance Products Supervisor March 12, 2001 ""'''''''''"''''',* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Mary F. Home FILE NUMBER 21-01-0245 This schedule must be completed and filed jf 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 DeeaS nEM INCLUDE THE NAME OF THE TRAHSfEREE THEIR RELATIONSHIP TO DECEDENT AN OTHEOATEOFTlWISFER, DATE OF DEATH INTEREST EXCLUSION TAXABLE VALUE ATTACH A CQPV QF THE DEED FOR REAl ESTATE ""M"'" VALUE OF ASSET IF APPlICA!llEl I. MassMutual varriable annuity contract # 09-709-716 2,853.66 100 2,853.66 TOTAL (Also enter on tine 7, Recapitulation) . 2,853.66 (If more space IS needed, Insert additIOnal sheets of the same size) .. MassMutual . The Blue Chip Company'" Massachusetts Mutual Life Insurance Company odnd affiliated insurance companies Springfield MA 01111.0001 Variable Annuity Statement of Payment TRANSACTION DATE PAYABLE TO: AMOUNTS: 04-20-2001 VALUATION DATE JANICE HORNE MERCER 513.83 04-18-2001 JOHN HORNE 513.83 AGENCY NANCY KAUFFMAN Direct 570.90 CONTRACT NUMBER PATRICIA GUY 513.83 09709716 MARY KAY LENKER 513.83 AGENT OF RECORD ANNUITANT Mary F Home REMARKS Fund Accumulation Total Number of Value of Total Number 7 Unit Value Accumulation Units Accumulation Units EQ 3.93691528 118.685145 467.25 BL 3.11307636 161.357122 502.32 OCA 2.30161143 225.776054 519.65 OSB 1.39171756 353.933467 492.58 GPA Guaranteed Principal Account 871.86 Total of Funds 2,853.66 Deduction - Administrative Charge Deduction - Contingent Deferred Sales Charge Contract Value 2,853.66 - Policy Interest 0.84 Federal Income Tax Withheld 228.28 State Income Tax Withheld Net Proceeds 2,626.22 Totals 2,854.50 2,854.50 EQ=Equity MM=Money Market MB=Managed Bond BL=Blend OAG=Oppenheimer Aggressive Growth OGS=Oppenheimer Global Securities OSB=Oppenheimer Strategic Bond In this transaction the Company has acted as principal and as agent for this Variable Annuity fund. Claim Department - C065 Risk Management Division R217t "~A5'''X.''.''"''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Mary F. Home FILE NUMBER 21-01-0245 Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ParthemoreFuneralHome 7,869.77 lnIditionalsetvice 4,299.00 Steel Casket 2,450.00 Steel Burial Vault 789.00 Burial Dress 85.00 Hairdresser 35.00 DeathCertificales 48.00 Olde Towne Florists - flowers and casket wreath 163.77 B ADMINISTRATIVE COSTS: I Personal Representative s Commissions Name of Personal Representative (s) John G. Horne, 789 Null Rd., New Cumberland, P A 17070 4,708.40 Social Security Number{s} I EIN Number of Personal Representative(s) SlreelAddress social security number: City Stale Zip Year(s) Commission Paid: 2001 2. Allorney Fees ISaidis, Shuff, Flower & Lindsay I 6,747.95 3. Family Exemption: (if decedents address is nol the same as claimant s, allach explanation) Claimant Street Address City State Zip Refationship of Claimant to Decedent 4. Probate Fees 273.00 5 Accountant s Fees 6. Tax Return Preparers Fees Advertisement of Estate................ ........................... ...................... ..................... .......... 185.10 7 Costs of Sale of Real Estate Realtor's Commission .............................. 5,040.00 R/E Transfer taxes ...................................... 840.00 School Taxes prorated to date of sale ........ 948.93 Total Settlement Costs................... ........ .................. .......... ............ ..................... ........... 6,828.93 Inheritance Tax Return Filing Fee................................................................................. 15.00 TOTAL (Also enter on line 9, Recapitulation) $ 26,628.15 (If more space is needed, insert additional sheets of the same size) ""'''''''''"''. COMMONWEAL"Tl-i OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF Mary F. Home FILE NUMBER 21-01-0245 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT I. 2. 3. 4. 5. 6. 7. 8. AT&T (phone) Verizon (Phone) PPL Utilities (electricity) Central Medical Equipment Co. Montgomery Wards PA WC (water company) Boscov's Department Store Comcast TV Cable 49.03 69.72 262.82 51.78 425.08 45.75 83.81 22.97 TOTAL (Also enter on line 10, Recapitulation) $ 1,010.96 (If more space is needed, insert additional sheets of the same size) "':""".".,,""w COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF F. t-/-v r"vt ~ JI'laYI/) NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY 1. TAXABLE DISTRIBUTIONS (include outright spousal distributions) I. Patricia Guy 333 Evergreen Street New Cumberland, P A 17070 Mary Lenker 945D Bosler Avenue Lemoyne, P A 17 anice Mercer 1924 Southaven Drive Virginia Beach, VA 23464 Nancy Kauffman 1759 Ridge Road York Springs, PA 17372 John G. Horne 789 Null Road New Cumberland FILE NUMBER '2(-01-0 RELATIONSHIP TO DECEDENT Do Not list Trustee(s) daughter daughter daughter daughter son 1.t/-~ AMOUNT OR SHARE OF ESTATE 1/5 1/5 1/5 1/5 1/5 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET 11. NON.TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1 B. CHARITABLE AND GOVERNMENTAL OISTRIBUTIONS I. TOTAL OF PART 11. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (if more space is needed, insert additional sheets of the same size)