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Home My WebLink About01-0263 /6-;2/~-3 REV-1500 EX + (6-00) CAPB HpRL EplO CRAC KOTK ES C P o 0 R N R D E E S N T C o M T C A T X A T I o N REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER OFFICIAL USE ONLY 21-01-0263 D E C E D E N T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBUAG, PA 17128-0601 DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL) Shee1 F. Romaine DATE OF DEATH (MM-DO-YEAR) COUNTY CODE YEAR SOCIAL SECURITY NUMBER 162-36-8324 THIS RETURN MUST BE FILED IN DUPl.JCATEWlTHTHE Copyright (e) 2000 form software only The Lackner Group, Inc. DATE OF BIRTH (MM-DD-YEAR) 02 16 2001 L 06 16 1907 A51,FI ,AN MID NUMBER NITIAl REGISTER OF WILLS SOCIA U tot USE' X 1. Orlglnllll Return 4. Llmltacl Estate X S. Decedent Died Testate (Attach copy of Will) o 9. litigation Proceeds Received 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) X 7. Decedent Maintained II LIving Trust 1 (Attach copy of Trust) 010. Spousal Poverty Credit 0 (date of death between 12-31-91 and 1-1-95) ,.lJRRE$!1!>NQ!!Nel!'lllliNlliENT "IINI'! COMPLETE MAILING ADDRESS NAME James D. Bo ar Es uire FIRM NAME Of Applicable) 3 date 0 death . Remall'ldef Return prior to 12-13-8.2) S. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 1,. Election to tax under Sec. 9113(A) (AUach Sch 0) TELEPHONE NUMBER One West Main Street Shiremanstown, PA 17011 R E C A P I T U L A T I o N 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or So~-Proprietorship 4. Mortgages & Notes Receivable (Schedule 0) 5. Cash. Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabil~ies, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (line 8 minus line 11) 13. Charitab~ and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Sub'eel to Tax (Line 12 minus Line 13) OFFICIAL USE ONLY (8) 461,471.14 (11) 19.859.34 (12) 441,611.80 (13) (14) 441,611.80 (15) (16) (17) (18) (19) 0.00 19,872.53 0.00 0.00 19,872.53 (1) (2) (3) None 200,916.80 None (4) (5) None 34,296.18 (6) 128,980.75 97,277.41 19,830.46 28.88 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(aX1.2) 16. Amount of line 14 taxable at lineal rate 441,611.80 17. Amount of Line 14 taxable at sibling rate 18. Amount of line 14 taxable at collateral rate 19. Tax Due 20. X H.,~IlEii:;ICi'HE!lE' X X X X .0 0 .0 45 .12 .15 Form REV-1SOO EX (Re.... 6-00) Decedent's Complete Address: STREET ADDRESS 517 East Lisburn Road CITY I STATE I ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPaymenls A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 19,872.53 0.00 20,101. 78 993.63 Total Credits ( A + B + C) (2) 21,095.41 3. InterestlPenalty W applicable D.lnterest E. Penalty "";:'j;'''' Hi!! !!!i! TotallnteresVPenalty ( D + E) (3) 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) S. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) I. Enter the total of Line 5 + SA. This is the IALANCE DUE. (51) ...~ake Check Payable to: REGISTER~~'IoI,I~~!),,~c;~,t:I! :::::m:m:::::;: ',,',::: ll'" :,:,::::: ::1 ,::' , : :' '.llii!WilWiiW lW:!i:;:;;;!::HH:~:::::!!t:t::!i:::::l:!:::;::;::::;:::::::;:;;;;:;: ll!llllll!mmml!iiii. ;~::!;:::.,;::::::!mmmmmmlmmlmmm!l!lll !III!I!II:ii!i!i!!!!W!!!::fi!l!,';':::::!::iiiiiiiiii;ilii!!:::;];mm::mm:!i::::l:::::m::!i:;mmm: PLEASE ANSWER THE FOLLOwiNG GUeSTIONS BY pLACING AN ;'X';iN THifAPPROPRIATEBLoCKSq 1. 0.00 1,222.88 0.00 0.00 0.00 Did decedent make a transfer and: a. retain the use or income of the property transferred; . . . . b. retain the right to designate who shall use the property transferred or its income; . c. retain a reversionary interest; or. . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . .. .................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Yes No ~~ m m D D IT! D Under penalties of perjury, I declare that I have examined thIs return, IncludIng accompanying schedules and statements, and to the best of my knowledge and belief, It Is true, correct and complete. Declaration of preparet other than the personal representative Is based on all Information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN Blanche R. Kennedy 517 East Lisburn Road - - Mechanlc-s!:i;:';'- -; - PA - - rioss- - - - - - - - - - - - - - - - - - --- James D. Bogar Esquire One West Main Street ----------------------------------------------------- Shiremanstown PA 17011 DATE LG().~IO( DATE For dates of death on 0 .r July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 9116 (a)(1.1) (j)J. 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. 9116 (a) (1.1) O;)l 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, or a stepparent of the child is 0% [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%, except as noted in 72 P.S. 9116( 1.2) [72 P.S. 9116(aX1lJ. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12"1" [72 P.S. 9116(aX1.3)]. 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. CopyrIght (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Re.... 6-00) ADDITIONAL Personal Representatives Estate of F. Romaine Sheely SS# 162-36-8324 02/16/2001 ****************************************************** Under penalties of perjury, the undersigned declare that they have examined this return, including accompanying schedules and statements, and to the best of their knowledge and belief, it is true, correct and complete. Signature ~12 -Ltd~ John R. Sheely 46 Bourbon Red Drive Name Address Line 1 Address Line 2 City, State, Zip Mechanicsburg, PA 17055 Date l~/~~ / COMMONWEALTH 0' ~NNSYLV"NI" DI!P"ITM!NT 0' R!VeNue INHDfTAHa TAX DtYISlOH DUT.21lO601 HAPJSIUIlG.'" 11121-0001 ".ase Print or Type MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS COUNTY CODE FILE NUMBER SOCIAL SECURITY OR DEATH CERTIFICATE NUMBER f\-\'~~ Q...,. ~ G\~~ ~ 2.1 \ ({i-'l 4~ ~{\-<< o.td.<.tI... ~~ w..;.d ~""OV,l'( ,I 'I!V~I!X.il.921 '*' SAFE DEPOSIT BOX INVENTORY DE EDENT'S NAME (LAST, FIRST, MIDDLE) Sheely, F. Ranaine ADDRESS OF DECEDENT ISTREET) (CJTY) 517 East Lisburn Road Mechanicsbur NAME AND ADDRESS Of PeRSON REQUESllNG THE OPENING Of THE SAfe DEPOSIT BOX II"AME) James D. Bogar, Esquire ISTREET ADDRESS) ICITY) One West Main Street Shiremanstown NAME, ADDRESS AND RELATIONSHIP ('F ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. (NAME) (RELATiONSHIp) James D. Boqar, Esouire None (STREET ADDRESS) (CITY) One West Main Street Shiremanstown b. (NAME) (RELATiONSHIp) (STATE) PA (STATE) PA (STATE} PA (STREET ADDRESS) (CITY) ISTATE) c. (NAME) IRELATiONSHIp) (STREET A.DDRESS) (CITY) {STATE} NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED INAME} Mellon Bank, N.A. (STREET A.DDRESSj 2 West Main Street , NAME OF PERSON MAKING LAST ENTRY F_lU.,~,':f DATE Of CONTRACT TO RENT BOX \ ru..'6 [CITY) {STATE} Mechanicsburg PA DATE AND TIME OF LAST ENTRY "'3W-\\'n TITLE UNDER WHICH BOX IS REGISTERED r,~~~ NUMBER OF BOX 'tl'-\ - JfQ NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. {NAME} b. [NAME} t::.~~ &l.,.~~J. {STREET ADDRESS} ~ {Sn.e:.T ADDRESS} oft, ~t- krlLu'f/"'Y\ (4t (C!TYI ISTATEI {ZIP CODE} (CITY) ~ ~ Lc.Ors" NAME AND TITLE OF EMPLOYE TAKING THE I VENTORY ~~l).~,L~ (STATE] WAS A WILL IN THE BOX? ';t:YES =1'10 If YO', a. Dato.f will, b. Ham. IInd IIdciress of p.rsonal represenfative. if named in the will (NAME) (STREET ADDRESS) (CITY) ISTATEI ~. Nom. und adclr.u of ai10rney I if any (NAME) {STREeT ADORESSI (CITY) jST,ATEj (ZIP CODE) 17055 (ZIP CODE) 17011-637 (ZIP COOE\ 17011-63 1 IZIP CODE} IZIP CODE} (ZIP CODE) 17055 (ZIP CODE) ~1 (ZIP CODE) (ZIP CODE) Page af SAFE DEPOSIT BOX INVENTORY INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificote, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and dass of stock. (3) Obligations of U. S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. ITEM NO. ITEM DESCRIPTION \. \..\e~ 'S~ " " '. <- - -, '- . , <, ~ , -, '. '. '. ~ .. '. " - t\vt q ~1O-<@. a.(;>)S~ e. I n .. .. '. ~ .\ e.. 1. \lot'e> j " ~ -. <, - .1 ...1 .1 I '8.1 'l.. I M,;;, e. of 1.9a~. I :ERTIFY UNDER PENALTY OF PeRJURY THAT THE ABOVE RECORD is PERSON RECEIVING COPY OF CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX iNVENTORY: TURE PQ.:NT TITlE ..k..tv( f). ~ ~~ ~~ G5~et r-'~ Pol' ATE a~x aELOw: '[CHECK APPROPRIATE BOX; o Executor{trix) 0 Administrotor(trix} . Qfstote Representative U Joinl ~wner ,jf safe decosit box ?';(:NT NAM NOTE: Attach additional 81,1::11 x 11" ,Jheet (5) if necessary or use duplicates aT this page of form. REV-1503 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS F. Romaine Sheely SSI! 162-36-8324 02/16/2001 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION 1 share Cumberland Valley Co-operative Association _ Common stock, Certificate No. 5445 2 1 share Cumberland Valley Co-operative Association _ Preferred stock, Certificate No. 12557 3 3,120 shares Hershey Foods Corp, CUSIP #427866108 _ Common stock UNIT VALUE 10.00 10.00 64.39 (If more space is needed, insert additional sheets of the same size) CopyrIght (c) 1996 form software only CPSystems. Inc. TOTAL (Also enter on line 2, Recapitulation) FILE NUMBER 21-01-0263 VALUE AT DATE OF DEATH 10.00 10.00 200,896.80 200,916.80 Form REV-1503 EX (Rev. 1-97) Cumberland Valley Cooperative Association ~ 908 MT. ROCK ROAD POST OFFICE BOX 350 SHIPPENSBURG, PENNSYLVANIA 17257 TELEPHONE: 717 532-2197 FAX: 717 532-4353 April 5, 2001 James D. Bogar Attorney at Law One West Main Street Shiremanstown, PA 17011 RE: F. Romaine Sheely Estate Dear Mr. Bogar Enclosed is a check made out to the F. Romaine Sheely Estate for $20.00. The two certificates that you mailed to us were the only ones that she owned in the Co-op. They were a Common Stock certificate for I (one) share and a Preferred Stock certificate for I (one) share Both common and preferred certificates are valued at $10.00 per/share. Thank you for your time. If you need any additional information, please let us know. Sincerely, 4- K Q.:-~ . U Tena R. Jones Enclosure H Hershey Foods Hershey Foods Corporation 100 Crystal A Drive P.O. Box B10 Hershey, Pennsylvania 17033-0810 Phone: (717J 534-4000 Fax: [717J 534-6760 Internet: http://www.hersheys.com May 14,2001 Mr. James D. Bogar, Esq. One West Main Street Shiremanstown, P A 170 II RE: Estate ofF. Romaine Sheely Dear Mr. Bogar: In response to your letter of May 7, 2001, our records indicate that Mrs. Sheely holds 3,120 shares of Hershey Foods Common Stock represented by at least four (4) stock certificates. The date of death value is $64.39 per share, which is the closing price ofHSY stock on the NYSE on February 16, 2001. To transfer the shares to another name(s), we will require the following: the stock certificates endorsed on the reverse side by the co-executors of the estate with a Medallion Signature Guarantee Stamp affixed to each certificate; a copy of the short certificate and the death certificate; and reissuance instructions including name, address, social security number and number of shares to be issued to each recipient. The stock transfer request should be sent to the following address by registered mail, return receipt requested: Mellon Investor Services PO Box 3310 South Hackensack, NJ 07606-1910 The shares can also be sold through our transfer agent, Mellon Investor Services. The unendorsed stock certificates should be sent to Mellon Investor Services for safekeeping and sale. A letter 8igned by the co-executors (with a Medallion Signature Guarantee Stamp) requesting the sale should accompany the stock certificates. Please also include a copy of the death certificate and short certificate. Indicate how the check should issued (for example to the Estate ofF. Romaine Sheely or to the heirs). If you have any questions or need any additional information, please call me at (717) 534-7530. Sincerely, I ,., i . /:-1 l '#v -'/ -, , J 0,,/[,(,-',[./j"" ., Gay t.< Kaylor Stockholder Relations Representative REV-1508EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS. & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER F. Romaine Sheely SS# 162-36-8324 02/16/2001 21-01-0263 Include the proceeds of littgation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshIp must be diolclooecl on Schedule F. ITEM NUMBER 1 AARP - Refund 10 11 12 13 14 DESCRIPTION VALUE AT DATE OF DEATH 10.00 2 Capital Blue Cross/PA Blue Shield - Premium refund 158.45 3 Guideposts - Refund 9.31 4 Mellon Bank, N.A. - DD Account No. 112-822-0025, date of death balance $14,238.07, accrued interest $0.19 14,238.26 5 Mellon Bank, N.A. - TD Account No. 00728235, date of death balance $5,000.00, accrued interest $1.47 5,001.47 6 Mellon Bank, N.A. - TD Account No. 00922460, date of death balance $10,000.00, accrued interest $47.60 10,047.60 7 Mellon Bank, N.A. - Interest earned in TD accounts prior to date of death 93.18 8 Old Guard Mutual Insurance Conversion Litigation - Pro rata share of net settlement fund 14.18 9 PA Blue Shield - 20% Copayment 13.32 Penn Treaty Network America Ins. Co. - Premium refund 259.52 U.S. Treasury Refund 3,856.00 U. S. Treasury Tax relief 181. 30 Verizon Refund 13.59 Jewelry - as per attached appraisal 400.00 TOTAL (Also enter on line S. Recapitulation) $ 34,296.18 (If more space is needed, insert additional sheets of the same size) CopyrIght (c) 1996 form software on\y CPSystems, Inc. Form REV-1508 EX (Rev. 1-97) ! @ P.O. Box 7899 Philadelphia, PA 19101-7899 Mellon Bank April 04, 2001 James D. Bogar One West Main Street Shiremanstown, PA 17011 Estate Of F. Romaine Sheely Date of Death: 02116/2001 SSN 162-36-8324 Dear SirIMadam: In accordance with your request, the attached information sheet has been provided in the above decedents name as oflIis/her date of death. For 1L or LC accounts, contact our Loan Department at 1-800-537-5591. For all other inquiries, please call (215) 553-1585. / Sincerely, Ll) L'-t-~L t=: IIa;ard Mellon Bank, N.A. Deposit Support Services 199-5355 Page 1 of 2 ~ Mellon Bank Wednesday, April 04, 2001 Account Number Account Title 112-822-0025 F Romaine Sheely Date Opened: 12/06/1972 Account Type: 00 Principal Bal Int from Last Account Bal YTD Int to as of DOD Posting to DOD as of DOD DOD $14,238.07 $0.19 $14,238.26 $11.75 00728227 F Romaine Sheely Or Date Opened: 05/14/1998 Account Type: TO Esther D McFadden Principal Bal Int from Last Account Bal YTD Int to as of DOD Posting to DOD as of DOD DOD $5,000.00 $1.47 $5,001.47 $45.58 OB20791-C F Romaine Sheely Date Opened: 11/05/1994 Account Type: TO Cynthia A Sheely Principal Bal Int from Last Account Bal YTD Int to as of DOD Posting to DOD as of DOD DOD $8,000.00 $3.58 $8,003.58 $74.22 0-A08844-C F Romaine Sheely Or Date Opened: 11/05/1994 Account Type: TO John R Sheely Principal Bal Int from Last Account Bal YTD Int to as of DOD Posting to DOD as of DOD DOD $8,000.00 $3.58 $8,003.58 $74.22 414-36 F Romaine Sheely Date Opened: 04/28/1989 Account Type: SO Principal Bal Int from Last Account Bal YTD Int to as of DOD Posting to DOD as of DOD DOD 00728235 F Romaine Sheely Date Opened: 05/14/1998 Account Type: TO Principal Bal Int from Last Account Bal YTD Int to as of DOD Posting to DOD as of DOD DOD $5,000.00 $1.47 $5,001.47 $47.05 00922460 F Romaine Sheely Date Opened: 08/16/1999 Account Type: TO Principal Bal Int from Last Account Bal YTD Int to as of DOD Posting to DOD as of DOD DOD $10,000.00 $47.60 $10,047.60 $95.20 Page 2 of 2 MfUMM~S I~~.wet,;~ Jto'tE:- (J - 34 WEST MAIN STREET MECHANICSBURG. PA. 17055 APPRAISAL Phone: 766-9422 ~-lsn- w 0 I APPRAISAL ~)~ { 0 ~-e'(V\~\NC ~~~\~ , Appraisal For: \.C) ~ Cict "-" .3 ..sf-o," ..- b:a......J C^7 ~l ~~ (('1 / fZav ~ a. .II-~- e.} ). ru'V 1-' 'l~ re"7 ~? S'hC/<Jj /'Vlvc...~ W.{Qj_ ~ ViiLu-i' dud '"-" q; ) l~ 'i(;1\.1 c~ $~..p )~cu... 5~}- \~ I~ W r vV ei>>& c()~s;) fs 1 4--<f) p/lM ; /'\:::1-.1] 20 pa rYJt" oJ c:= O<\J G -iiV'[ ~.-~- ~\ t~cLa... J 5; n}NC' Lvald., '7 f3 4-dd. CC(tr f\ M' Vl.tMr It{) !~ I?'( hw I .:07' 4. lIMy, 0( yo ~;,,\ s J r0'''''~ S<'U s {---<N<1" --- OV-'p- C1 a~ct .1 C: -Ii i~ <;'. ,Je, f 4 ldt- rJ! uu i d II G.NJ ~ ~ o,,-So ~:JI '; ( ~l",-- ..,;-, , \'I\- " c II vU Q.Ji.)\ . V(\ l.\..~ tOO, tV This appraisal constitutes our carefully studied opinion of [J the retail replacement cosllhrough our facilities :~e diSfress soles nature value of the orficlels) described above insofar as the mounllng{s) have permitted cbser'<lolion. We assume no liability with respect to any action thot may be token an the basis of I a ~, raisa\ orser REV-l509 EX .(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF F. Romaine Sheely SCHEDULE F JOINTLY-OWNED PROPERTY SSII 162-36-8324 02/16/2001 If an ...et was m.de joint within one year of the decedent'. date of death, it must be reported on Schedule G. FILE NUMBER 21-01-0263 A. SURVIVING JOINT TENANT(S) NAME Blanche R. Kennedy B. John R. Sheely c. Cynthia A. Sheely ADDRESS 517 East Lisburn Road Mechanicsburg, PA 17055 46 Bourbon Red Drive Mechanicsburg, PA 17055 7 Longwood Drive Mechanicsburg, PA 17050 RELATIONSHIP TO DECEDENT Daughter Son Widow of Deceased Son JOINTLY-OWNED PROPERTY, 11/05/94 Mellon Bank, N.A. - TD Account No. 0-A08844-C, date of death balance $8,000.00, accrued interest $3.58 12/22/93 PNC Bank, N.A. - Certificate of Deposit No. 21001013447, date of death balance $21,000.00, accrued interest $64.44 12/22/93 PNC Bank, N.A. - Certificate of Deposit No. 21001013446, date of death balance $21,000.00, accrued interest $64.44 ITEM NUMBER 1 LETTER OR JOINT TENANT D DATE MADE JOINT 05/14/98 2 C 11/05/94 3 B 4 A 5 C 6 B 12/22/93 PNC Bank, N.A. - Certificate of Deposit No. 21,064.44 DESCRIPTION OF PROPERTY Include name of financial Institution and bank: account number or similar Identifying number. Attach deed for jointly- held real estate. Mellon Bank, N.A. - TD Account No. 00728227, date of death balance $5,000.00, accrued interest $1.47 DATE OF DEATH VALUE OF ASSET 5,001.47 Mellon Bank, N.A. - TD Account No. OB20791-C, date of death balance $8,000.00, accrued interest $3.58 8,003.58 8,003.58 21,064.44 21,064.44 Tot,l of Contim ation Schedu1e(s) %OF DECO'S INTEREST 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% TOTAL (Also enter on line 6, RecapitUlation) S (If more space is needed insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. DATE OF DEATH VALUE OF ECEDENT'S INTEREST 2,500.74 4,001.79 4,001. 79 10,532.22 10,532.22 10,532.22 86,879.77 Form REY-1509 EX (Rev. 1.97) 128,980.75 REV-1509EX+11-97) '* SCHEDULE F JOINTL Y.OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERlTANCE TAX RETURN RESIDENT DE EDENT ESTATE OF F. Romaine 8heely 88#162-36-8324 02/16/2001 FILE NUMBER 21-01-0263 Wan asset was made joint within one ye.r of the decedent's date of death, tt must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT D. Esther McFadden 126 Diller Road New Cumberland, FA 17070 Daughter JOINTLY -OWNED PROPERTY: LETTER DA1E DESCRIPTION OF PROPERTY %QF DATE OF DEATH ITEM FOR JOINT MADE Include name offinancial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VAlUt:: OF NUM6ER TENANT JOINT deed forjoinUy.neld real estate. VALUE OF A.SSET MEREST DECEDENT'S INTERES1 . TOTAL (Also enter on line 6, Recapitulation) $ (" more space is needed, insert addttional sheets of the same size) Estate of: F. Romaine Sheely Soc Sec #: 162-36-8324 Date of Death: 02/16/2001 Continuation of Schedule F (Jointly Owned Property) Item Ltr for 11 Jt Ten Description of property Date Joint Total Val of Asset Decds X Int Dollar Val of Decds Interest 2100101345, date of death balance $21,000.00, accrued interest $64.44 7 A&B 01/29/99 Waypoint Bank - Certificate Account No. 1800010540, date of death balance $235,000.00, accrued interest $590.08 8 A&B 12/03/99 Waypoint Bank - Certificate Account No. 1800013040, date of death balance $25,000.00, accrued interest $49.21 235,590.08 25,049.21 33.33% 78,530.03 33.33% 8,349.74 86,879.77 " APR-26-2001 08:30 PNCBANK CIF DEPARTMENT 412 705 0057 P.01/02 ~PNCBAN< DecedeDt ReporUnc Firstside Center P7-PFSC-4-F 500 First Avenue Pittsburgh, PA ]5219-3128 ISCP Apri] 25, 2001 James D. Bogar One West Main Street Shiremanstown, P A 17011 RE: Estate ofF. Romaine Sheely, Deceased SSN: 162-36-8324 DOD: 2116/2001 Dear Mr. Bogar: Please find the date of death balances you have requested listed below. CER~CATESOFDEPOSIT #21001013447 Established 12/22/1993 F ROMAINE SHEELY BLANCHE KENNEDY DOD Balance: $21,000.00 + $64.44 accrued interest #21001013446 Established 12/22/1993 F ROMAINE SHEELY CYNTHIA A SHEELY DOD Balance: $21,000.00 + $64.44 accrued interest Page 1 of2 A member of The PNC Financial Services Group PNC Bilnk N.A. Pittsburgh Pennsylvania 15265 . RPR-26-2001 08: 30 PNCBRNK CIF DEPRRTMENT 412 70S 0057 P.02/02 ~PNCBAN< #2100101345 Established 12/22/1993 F ROMAINE SHEELY JOHN R SHEELY DOD Balance: $21,000.00 + $64.44 accrued interest Our omce only provides date of death balances for IRA's, CD's, Checldng and Savtnp accounts. We do!!Q Financial Transactions or Statement Orden. For Further information please call1-800-4-BANKER or your local PNC Branch and ask to speak with a Financial Services Representative. Sincerely, . ~~ Rachelle Sciullo 1-800-762-1775 Page 2 of2 A mcmbt:t of The: PNC Financial Servlen Group PNC Bani< NA Pittsburgh ~nsvlvania 15265 TOTRL P.02 ~l Way~qi!'Kt lOOK FOR US. WE'll GET YOU THERE. MARCH 19,2001 JAMES D BOGAR ONE WEST MAIN ST SIDRESMANTOWN PA 17011 - The information which you requested on the F ROMAINE SHEELY DECEASED (Social Security Number 162-36-8324) is as follows. Account Number(s) 565311119 1800010540 1800013040 CERTIFICATE CERTIFICATE 012999 120399 235000.00 25000.00 590.08 49.21 235590.08 25049.21 JTO JTO Class of Account CERTIFICATE Date Opened 061897 Principal Balance 33000.00 Accrued Interest 93.30 Balance at Date of Death '13093.30 Account Ownership Name of Joint Owner, if any Date Ownership Was Established TRU CYNTHIA SHEEL~ BLANCHE KENNED1 JOHN SHEEL Y BJ.-f\t~l~G. S1\.tN .51-1~C~'1 KGi\:i'c~)1 061897 012999 120399 Additional Information Requested PLEASE COMPLETE W-9 P.O. Box 1711. HARRISBURG. PENNSYLVANIA 17105-1711 Toll FrEE 1-866-WtwPolm (1-866-929-7646) . wwwwaypointbank.com t"l WaYRql!"lt LOOK FOR US. WELL GET YOU THERE. Account Number(s) 7100000769 Class of Account CERTIFICATE Date Opened 071900 Principal Balance 70000.00 Accrued Interest 184.11 Balance at Date of Death 70184.11 Account Ownership Name of Joint Owner, ifany Date Ownership Was Established Additional Information Requested JTO JOHN SHEELY BI-Atv..itf; P&J.J~Y 071900 PLEASE COMPLETE W-9 Si~cerely, ~Nn Kn-rl.J ell"" '7 K~:;:;l Young Senior Services Rep. P.O. Box 1711. HARRISBURG. PeNNSYLVANIA 17105-1711 Tell ,,-~~ '-866-W..Y?'CINT '1-866-929-7646) . www.waypointbank.com REV-1510EX +(1-97) COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF F. Romaine Sheely SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY SSfI 162-36-8324 02/16/2001 FILE NUMBER 21-01-0263 This schedule must be comp~ed and filed it the answer to any of questtons 1 through 4 on page 2 is yes. ~lStRIPTI~N ?,F f,R~PrW %.OF ITEM 'HC H HA.M F T E RA EE THEIR DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE RELATIO~MIlI 0 ECE~ NUNO TH '!lAT o~ TRANSFER. NUMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1 Waypoint Bank - Certificate 70,184.11 100.00% 6,000.001 64,184.11 Account No. 7100000769, date of death balance $70,000.00, accrued interest $184.11. Decedent added names of John Sheely, son of decedent, and Blanche Kennedy, daughter of decedent, to this account on July 19, 2000. Date of Death Value of Asset: $70,184.1l. ($3,000.00 exclusion per transferee in accordance with 72 P.S. Section 9107(C)(3) claimed.) 2 Waypoint Bank - Certificate 33,093.30 100.00% 0.00 33,093.30 Account No. 565311119, date of death balance $33,000.00, accrued interest $93.30. Account Ownership - In Trust for Cynthia Sheely (widow of Roy J. Sheely, deceased son of F. Romaine Sheely). TOTAL (Also enter on line 7, Recapitulation) $ 97,277.41 (" more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Fo.m REV-1510 EX (ROV. 1-97) REV-1511 EX +(1-97) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCET,;x RETURN RESIDENT DECEDENT ESTATE OF F. Romaine Sheely SSiJ 162-36-8324 02/16/2001 FILE NUMBER 21-01-0263 D_ '" _nt muot be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES, 1 James Gringrich Memorials - Inscription 90.00 2 Myers Funeral Home - Funeral expense 7,544.00 3 Pastor Michael Seifried - Honorarium 160.00 4 The Children's Garden - Funeral meal 200.00 B. ADMINISTRATIVE COSTS, I. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip - Year{s) Commission Paid: 2. Attorney's Fees James D. Bogar Esquire 10,500.00 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 Decedent 4. Probate Fees Register of Wills 311.00 5. Accountant's Fees 6. Tax Aetum Preparer's Fees 7. Other Administrative Costs 1 Conunerce Bank - Check printing charge 23.00 2 Mumma's Jewelry Store - Appraisal fee 25.00 3 Register of Wills - Copy charge 1.00 4 Register of Wills - Short certificates 3.00 5 Register of Wills - Certified copy of Will 6.00 6 RESERVES: Costs to conclude administration of Estate including 950.00 filing fee for PA Inheritance Tax Return and Inventory, First and Total of Continuation Schedule{s) 17.46 TOTAL (Also enter on line 9, Recapitulation) S 19.830.46 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. F.,m REV-ISII EX (Rev. 1-91) Estate of: F. Romaine Sheely Soc Sec #: 162-36-8324 Date of Death: 02/16/2001 Continuation of Schedule H-B7 (Other Administrative Costs) Item il Description Amount Final Account and preparation of Personal and Fiduciary Income Tax Returns and payment of possible tax due 7 u.S. Postal Service - Certified mail 17.46 17.46 REV-151Z EX .(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCET/IJ( RETURN RESIDENT DECEDENT ESTATE OF F. Romaine Sheely SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, AND LIENS SSff 162-36-8324 02/16/2001 FILE NUMBER 21-01-0263 Include unreim......... medical .xp....... ITEM NUMBER 1 DESCRIPTION Marlin A. Yohn, Sr., Treasurer - Personal tax AMOUNT 9.80 2 Shepherds town Family Practice - Medical expense 3.32 3 Verizon - Telephone bill 15.76 TOTAL (Also enter on line 10, Recap~ulatlon) $ 28.88 (\f more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97) REV -1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF F. Romaine Shee1v SS# 162-36-8324 SCHEDULE J BENEFICIARIES 02/16/2001 FILE NUMBER 21-01-0263 RELATIONSHIP TO DECI'nl'NT AMOUNT n'l SHARE Do Not List Tru.t~.f'" ... OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (Include ou1rlght spousal dIstributions, ilnd t,ansfenundei' Sec;. 9116(iI)(1.2)] 1 Barbara A. Kaufman 66A N. Old Stonehouse Road Carlisle, PA 17013 Granddaughter One-sixth (1/6) of rest, residue and remainder of Estate 2 Blanche R. Kennedy 517 East Lisburn Road Mechanicsburg, PA 17055 Daughter Specific bequest of rings; one-third (1/3) of rest, residue and remainder of Estate 3 John R. Sheely 46 Bourbon Red Drive Mechanicsburg, PA 17055 Son One-third (1/3) of rest, residue and ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18. AS APPROPRIATE. ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS, A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) Copyright (c) ZOOO form softwilre only The Laclcner Group, tnc. 0.00 Form REY..1513 EX (Re.... 9-00) Estate of: F. Romaine Sheely See Sec #: 162-36-8324 Date of Death: 02/16/2001 Continuation of Schedule J, Part I (Taxable Bequests) Item il Name and Address of Beneficiary Relationship Amount or Share of Estate remainder of Estate 4 Kenneth B. Sheely 14001 Fa1concrest Road Germantown, MD 20874 Grandson One-sixth (1/6) of rest, res idue and remainder of Estate 5 Timothy A. Sheely 13 Nottingham Road Camp Hill, PA 17011 Grandson One-sixth (1/6) of rest, residue and remainder of Estate LAST WILL AND TESTAMENT OF F. ROMAINE SHEELY I, F. ROMAINE SHEELY, of 517 East Lisbum Road, Mechanicsburg, Cumberland County, Pennsylvania, make, ublish and declare this as and for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by . .1 me. FIRST: I give and bequeath all of my rings to my J daughter, BLANCHE R. KENNEDY. Should BLANCHE R. J) KENNEDY predecease me, I give and bequeath all of my rings to her issue per stirpes by representation. SECOND: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, as follows: (A) One-third (1/3) thereof to my son, JOHN R. SHEELY, provided, however, that should he predecease me, I devise and bequeath his share pass unto his wife, SARA D. SHEELY. In the event that both JOHN R. SHEEL Y and SARA D. SHEELY predecease me, I devise and bequeath the share of JOHN R. SHEELY pass unto his issue per stirpes by representa- tion. (B) One-third (1/3) thereof to my daughter, BLANCHE R. KENNEDY. Should BLANCHE R. KENNEDY predecease me, I devise and bequeath her share unto her issue per stirpes by representation. ,1 (C) One-third (1/3) thereof, in equal shares, to the ~ children of my late son, ROY 1. SHEELY, same being J KENNETH B. SHEELY, BARBARA A. KAUFMAN and TIMOTHY A. SHEEL Y. Should either KENNETH B. SHEELY, BARBARA A. KAUFMAN or TIMOTHY A. SHEEL Y predecease me, I devise and bequeath their share unto their issue per stirpes by representation. Given the fact that my grandson, TIMOTHY A. SHEEL Y, does not presently have children, I direct that should he predecease me without being survived by issue, then his share under this, my Last Will and 2 -1 I << u:.. Testament, should pass to his wife, RHONDA SHEELY. THIRD: Should any of my great-grandchildren not have attained the age of twenty-one (21) years at the time for distribution to him or her, I give, devise and bequeath the share of each such great-grandchild to my hereinafter named Trustee or Trustees, IN SEPARATE TRUSTS, to hold, manage, invest and reinvest the shares so received, and to use and apply from time to time such portion of income and principal for the said great-grandchild's education (including college, trade school or other similar training or education), support and welfare as my Trustee or Trustees, in their sole discretion, deem advisable. Any income or principal not so applied shall be dis- tributed to each such great-grandchild when he or she attains the age of twenty-one (21) years. In the event any of my great- grandchildren die prior to the termination of this Trust, the interest of said great-grandchild in said Trust shall cease with any income and principal being divided evenly between or among my other great-grandchildren that are alive as of the date of my death, or the separate trusts established hereunder for 3 their benefit. FOURTH: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all proper- ty, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon ~l such terms (including credit, with or without security) or condi- l lions as are deemed proper. This includes the power to give Q;;: legally sufficient instruments for transfer of the property and to " receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivision, improvement, zoning or management of real estate and to im- pose or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including 4 stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduciaries, as are deemed proper, without regard to any princi- ple of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given by the ederal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named beneficiaries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration ex- penses, to protect or improve any property held under my will, and for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise 5 any other rights which they may have under the plan, in what- ever manner they consider advisable. FIFTH: I nominate and appoint KENNETH B. SHEELY, as Trustee ofthe hereinabove described trusts. In the event of the death, resignation or inability to serve for any reason whatsoever of the said KENNETH B. SHEELY, I nominate and appoint BARBARA A. KAUFMAN, as Trustee of - the hereinabove described trusts. In the event of the death, resignation or inability to serve for any reason whatsoever of the said BARBARA A. KAUFMAN, I nominate and appoint TIM- OTHY A. SHEEL Y, who shall serve without bond and shall receive fair or reasonable compensation SIXTH: I direct that all inheritance, estate, transfer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with respect to property passing under this Will, shall be paid out of the princi- pal of my residuary estate. SEVENTH: I nominate and appoint BLANCHE R. KENNEDY and JOHN R. SHEELY, Co-Executors of this, my 6 Last Will and Testament. I direct that my Executrix or Execu- tor, as the case may be, and their successors, shall not be re- quired to post security or a bond for the performance oftheir duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this \ q-\k day of {\SOU€II.t,OVt..,. ,1999. :~# F. ROMAINE SHEELY (SEAL) Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. ~D~Cb\., ~jL ~? Address Address 7 -. Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS .21 - D' - .:2~3 Estate of F. Romaine Sheely also known as No. , Deceased Social Security No. 162 - 36 - 8324 Blanche R. Kennedy and John R. Sheely Petitioner(s). who isfare 18 years of age or older, apply(ies) for: (COMPLETE 'A' or 'B' BELOW:) [K] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut~ named in the last Will of the Decedent, dated 11/19/1999 and codiciKs) dated None 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: n/a D 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: 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 517 East Lisburn Road, Upper Allen Township (list street, number, and municipality) Decedent, then ~years of age, died 02/16/2001 at City of Harrisburg, Dauphin County, PA (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (If not domiciled in PAl Personal property in Pennsylvania (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania 228,000.00 $ $ $ $ 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 a ro riate form to the unders' ned: Si nature T ed or rinted name and residence Blanche R. Kennedy 517 East Lisburn Road, Mechanicsbur , PA John R. Sheely 46 Bourbon Red Drive, Mechanicsbur , PA 17055 17055 I to - ;;J.//P ..- 3 Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991) Oath of Personal Representative Commonwealth of Pennsylvania County of Cumber land 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, Petitioner(s) will well and truly administer the estate according to law. ~1ARCH ,2001 .,6 t"ArP..h,1/2 . ~~ Blanche R. Kennedy ~L R 4j4~ Jo R. Sheely Sworn to or affirmed and subscribed before me this 8 th day of 'lr]~ C ~w-u eA... p. ,\),~For the Aegister No. 21-01-263 Estate~ F. Romaine Sheely Deceased Social Security No: 162 - 36 - 8324 Date of Death: 02/16/2001 AND NOW, MARCH 9 ,2001 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters []] Testamentary D Of Administration (c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate) are hereby granted to Blanche R. Kennedy and John R. Sheely in the above estate and that the instrument(s) dated 11/19/1999 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters. . . . . . . $ 270.00 /YIOvu< ~. ~w.~. t · ^ P 8.~t, \ Register f Wills ~ Short Certificate(s). $ 18.00 Renunciation. $ Affidavits ( $ Extra Pages (6 ) . $ 18.00 Codicil. . $ JCP Fee. $ 5.00 Inventory. $ Other . . $ TOTAL. . . . . . . . . $ 31100 Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. FILED: March 9,2001 Form RW-1 (1991) 21-01-263 REGISTER OF WILLS OF CUMBERLAND COUNTY OATH OF SUBSCRIBING WITNESS James D. Bogar mdiciI (~ a subscribing witness to the will presented herewith, (eacm} being duly qualified according to law, depose(s) and say(s) that he was present and saw F. Romaine Sheely the testatr ix , sign the same and that he signed as a witness at the request of testat r ix in her presence and (in the presence of each other) (in the presence of the other subscribing witness(es)). Sworn to or affirmed and subscribed before me this 8 day of March M) /001 mn, 1 C: ;;e~, po. ~jl,CJr~ egiSt e) , Shiremanstown, PA 17011 (Address) (Name) (Address) REGISTER OF WILLS OF CUMBERLAND COUNTY OATH OF NON-SUBSCRIBING WITNESS Blanche R. Kennedy and John R. Sheel V (each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that they are familiar with the signature of F. Romaine Sheel v , mdicid testat r i x of (lIa:eoofxth!S::~kscHbdRi{~w~~x~ the will presented herewith and ~ that the y believes the signature on the will is in the handwriting of F. Romaine Sheely to the best of __ the tL knowledge and belief. Sworn to or affirmed and subscribed before me this . ~ day of Ma r ch mL2Jl.D 1 '-rn~JLp~ Register \8~!2. if, Blanche R. Ken,wa1h~ 517 E. Lisburn Rd., Mechanicsburg, PA 17055 (Addrp7i / t~ R ~..,v1_ Johnct: Sheel~Nam~ 46 Bourbon Red Dr., Mechanicsburg, PA 17055 (Address) 11: IS to Lenifv that the information here given is correctly copied from an original cenitlcate of death duly filed with me as l),',\1 ~egisrrar. The original certifIcate will be forwarded to the State Vital Records OHILe for permanent"filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~,+.;;,.gl~~~ 3 'Iif"'~\ 1\-\ OF p'i"';;,;~ /111"", \"'':-------., CII'"",--:..~ if"~~./ "~J'. ---=;.\ /l ~/ "..~\~ \\ (!~i '~.' \~%\ i~C)~ - 3;#, i-~I ....c.-'" .'-l'll" Ih'J \,*~..>,..*t \~ c::3., ..~. " j.~/ \_ r..<)" . ...." " \':::._ -1'~~-__ - /~"~\I\ ~ IMEN11J,~,,'ll. ~{!!!!~' , ., ~ j}(Lj.fj}~ /('!JjjU;; I.octl Rcgisrr", ~ fee for this certifIcate. $2.00 P 7121532 (f:th'U/lJ1l/toUM/ Date Hl05.i4JRItY 2187 COMMONWEALTH OF PENNSYlVANIA. OEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH TYPE/PRINT IN PERMANENT BLACK INK AGE (La.. B<rl"".vl UNDER 1 VEAR Mof1CI1II Days NAME Of DECEDENT If." M_e. La", SEX l. 93 Vro UNDER I D~ _ ! Minur.. 5. COUNTY Of OEArH .... Dauphin Ie. White 17b. County Did --.. M.... Cumberland _na/lIp1 11...0 ~-=":=OI MOTHER'S NAME If." M,ddIe. Maoden5Y<namel MARITAL STATUS. M_ NeYef w.rfied. W~. DM>rced (Spec""l Widowed I JprF!r AIIF!n SURVIVING SPOuSE (If -Mle. gMe ~ f\MT\8l DECEDENT'S USUAl OCCUPRION (G,velund clWOfk done durong"""" OIWOfk"'ll Ho~~make'/ 1&. FRHER'S NAME (f.... M"'dlo. LaSl) 517 East Lisburn Road Mechanicsburg, Pa. 17055 """ <11"/_ II. INFOAMANT'S NAME (T ypelP'1Ol1 John W. Raudabaugh Blanche R. Kennedy Fannie Deitch Feb 20, 2001 Camp Hill, Pennsylvania 17011 LICENSE NUMBER FD-012662-L I : C /1-fl,) i';> (J0 ~ /ft'-ti.t /)- DUE 10 (OR AS ACONsEOUENCE Of): (l1.. 'f./LtJ;'J/~Njlh/.C-I{.Jv DUE 1o(Ofl AS A CONSEOUENCE Of) la. I AppIolllma,. : nerval befwHn I onMI ancI_ I l No~ PART H: OUler SlQI1I~ condiloono conu_ing 10 dealft. DuI noc ......"'9 ..1IMl uncleIlylnQ""" gMn in PART I '-.2...'f'v./ DUE 10 (OR AS A CONSEOUE NCE Of) WERE AUTOPSV FINDINGS MANNER OF DEATH _ILASLE PRIOR 10 COMPLETION OF CAUSE N.'ural [8l 0 Of llEMH1 Hom'clde 0 Pending Inve:lugauon 0 No~ Ves 0 No 0 Swcrde LJ Could not be delermlned 0 DATE Of INJURV (Monlh Day. Veall TIME Of INJURY INJURY ATINORK? DESCRIBE HOW INJURY OCCURRED v.. 0 No [J l... 2.... Cl.RT.fIER lC~tJI(;k DOt)' one) "CERTIFYING PHYSICIAN jPhVSK:tdnc.:~WYln9 cause ul tJedltJ Whtlf1 ,Jllulllef (.)tlV~I<.'odfl has pi OflOlJIl(,;e<.] Ut:d.ltl dflO cO'TllJletoo lI~m 2Jl To &he be.. 0' m, knowledge, de.th occu....ed due kt u.. cau..(s).nd manne,.. .tated. . 3 3Ob. PLACE OF INJURY. AI hom.. farm, Slreel. fadOf)', office building, eU:. ISpec.tll) JOe _.._--_.~-_._-- M. JOe. 1-A/'..Ali;lL o ~ ~ :rl o ~ OJ ~ 2 . PRONOUNCING AND CERTIFYING PHYSICIAN tPh'fSolCldn hoctl ~IOI\OUllC,ng llcalh and CeflllyW"IQ locaus.e 01 dedlhl To th. ~tot my knowledgA, death occurred a_ the time. d.... .and pl.c., .nd due 10 (he cause'l) and manner.. s..ted 'MEDICAL EXAMINERlCORONER On the ba.ia of .)lamination andlor invesligiltlon, in my opinion, death occurred al the lime, date, and place, and due to the cause(s) and manner .s stated.. . . . . . . _ . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . 31. 19) ~(JOI ~ CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: F. Romaine Sheely Date of Death: February 16, 2001 will No. 21-01-0~63 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 May 8, 2001: Name Esther McFadden Kenneth B. Sheely Timothy A. Sheely Barbara A. Kaufman Blanche R. Kennedy John R. Sheely Address 126 Diller Road New Cumberland, PA 17070 14001 Falconcrest Road Germantown, MD 20874 13 Nottingham Road Camp Hill, PA 17011 66 Old Stonehouse Road Carlisle, PA 17013 517 East Lisburn Road Mechanicsburg, PA 17055 46 Bourbon Red Drive Mechanicsburg, PA 17055 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None g r, Esquire One West ain Street Shiremanst , PA 17011 (717) 737-8761 Capacity: Personal Representative X Counsel for Personal Representative Date: May 8, 2001 IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE. Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of F. Romaine Sheely, Deceased, Estate No. 21-01-0263 TO: Esther McFadden 126 Diller Road New Cumberland, PA 17070 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent, F. Romaine Sheely, died on the 16th day of February, 2001, at city of Harrisburg, Dauphin County, Pennsylvania. The Decedent died testate (with a will); or The Decedent died intestate (without a Will). The personal representative(s) of the Decedent is/are: Name Address 517 East Lisburn Road Mechanicsburg, PA 17055 46 Bourbon Red Drive Mechanicsburg, PA 17055 Telephone 717-697-0193 Blanche R. Kennedy John R. Sheely 717-766-6965 If the Decedent died testate, the will has been filed with the Office of the Register of wills of Cumberland County, One Courthouse Square, Carlisle PA 17013. Telephone No. 717-240-6345. If the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the Register of Wills of Cumberland County, 1 Courthouse Square, Carlisle, PA 17013. Telephone No. 717-240-6345. If the Decedent died testate, a copy of the will is attached. A copy of the will or Petition may be obtained by contacting the Register of wills and paying the charges for duplication. , Esquire One West Mai reet Shiremanstown, PA 17011 (717) 737-8761 Capacity: Personal Representative X Counsel for Personal Representative Date: May 8, 2001 IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE. Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of F. Romaine Sheely, Deceased, Estate No. 21-01-0263 TO: Kenneth B. Sheely 14001 Falconcrest Road Germantown, MD 20874 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent, F. Romaine Sheely, died on the 16th day of February, 2001, at City of Harrisburg, Dauphin County, Pennsylvania. The Decedent died testate (with a Will); or The Decedent died intestate (without a Will). The personal representative(s) of the Decedent is/are: Name Address Telephone 717-697-0193 Blanche R. Kennedy 517 East Lisburn Road Mechanicsburg, PA 17055 46 Bourbon Red Drive Mechanicsburg, PA 17055 717-766-6965 John R. Sheely If the Decedent died testate, the will has been filed with the Office of the Register of wills of Cumberland County, One Courthouse Square, Carlisle PA 17013. Telephone No. 717-240-6345. If the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the Register of wills of Cumberland County, 1 Courthouse Square, Carlisle, PA 17013. Telephone No. 717-240-6345. If the Decedent died testate, a copy of the Will is attached. A copy of the will or Petition may be obtained by contacting the Register of wills and paying the charges for duplication Bo a , Esquire One West M 'n Street Shiremanstown, PA 17011 (717) 737-8761 Capacity: Personal Representative X Counsel for Personal Representative Date: May 8, 2001 IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE. Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a Will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of F. Romaine Sheely, Deceased, Estate No. 21-01-0263 TO: Timothy A. Sheely 13 Nottingham Road Camp Hill, PA 17011 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent, F. Romaine Sheely, died on the 16th day of February, 2001, at city of Harrisburg, Dauphin County, Pennsylvania. The Decedent died testate (with a Will); or The Decedent died intestate (without a Will). The personal representative(s) of the Decedent is/are: Name Address 517 East Lisburn Road Mechanicsburg, PA 17055 46 Bourbon Red Drive Mechanicsburg, PA 17055 Telephone 717-697-0193 Blanche R. Kennedy John R. Sheely 717-766-6965 If the Decedent died testate, the Will has been filed with the Office of the Register of wills of Cumberland County, One Courthouse Square, Carlisle PA 17013. Telephone No. 717-240-6345. If the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the Register of Wills of Cumberland County, 1 Courthouse Square, Carlisle, PA 17013. Telephone No. 717-240-6345. If the Decedent died testate, a copy of the will is attached. A copy of the Will or Petition may be obtained by contacting the Register of wills and paying the charges for duplicatio Date: May 8, 2001 ( Ja es D. Esquire One West Mai treet Shiremanstown, PA 17011 (717) 737-8761 Capacity: Personal Representative X Counsel for Personal Representative IMPORTANT NOTICE NOTICE OF ESTATE ADMINISTRATION THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE ANY MONEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE. Whether you will receive any money or property will be determined wholly or partly by the decedent's will. If the decedent died without a Will, whether you will receive any money or property will be determined by the intestacy laws of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of F. Romaine Sheely, Deceased, Estate No. 21-01-0263 TO: Barbara A. Kaufman 66 Old Stonehouse Road Carlisle, PA 17013 Please take notice of the death of decedent and the grant of letters to the personal representative(s) named below. The Decedent, F. Romaine Sheely, died on the 16th day of February, 2001, at City of Harrisburg, Dauphin County, Pennsylvania. The Decedent died testate (with a Will); or The Decedent died intestate (without a Will). The personal representative(s) of the Decedent is/are: Name Address 517 East Lisburn Road Mechanicsburg, PA 17055 46 Bourbon Red Drive Mechanicsburg, PA 17055 Telephone 717-697-0193 Blanche R. Kennedy John R. Sheely 717-766-6965 If the Decedent died testate, the Will has been filed with the Office of the Register of wills of Cumberland County, One Courthouse Square, Carlisle PA 17013. Telephone No. 717-240-6345. If the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the Register of wills of Cumberland county, 1 Courthouse Square, Carlisle, PA 17013. Telephone No. 717-240-6345. If the Decedent died testate, a copy of the will is attached. A copy of the will or Petition may be obtained by contacting the Register of wills and paying the charges for duplication. Date: May 8, 2001 r, Esquire One West Mai reet Shiremanstown, PA 17011 (717) 737-8761 Capacity: Personal Representative X Counsel for Personal Representative Register of Wills of CUMBERLAND County, Pennsylvania INVENTORY Estate of F. Romaine Sheely No. 21- 01- 0263 Date of Death 02/16/2001 also known as ,Deceased Social Security No. 162 - 36 - 8324 Blanche R. Kennedy and John R. Sheely, 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 of 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. l!We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative Name of Attorney: James D. Bogar Esquire Signature: ~J?~2/ .~ Blanche R. ~edY ~ f! ~~ .04/ J n R. Sheely 517 East Lisburn Road 1.0. No.: 19475 Signature: Address: One West Main Street Address: Shiremanstown, PA 17011 Mechanicsburg, PA 17055 Telephone: 717/737-8761 Telephone: 717/697 - 0193 Dated: \.Ol1-rlo ( Description Value (See continuation page(s) attached) (Attach additional sheets if necessary) Total: 235,212.98 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. Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form IfRW-7 (1992) Estate of: Date of Death: County: INVENTORY F. Romaine Sheely 02/16/2001 Cumberland CASH: AARP - Refund Capital Blue Cross/PA Blue Shield - Premium refund Guideposts - Refund Mellon Bank, N.A. - DD Account No. 112-822-0025, date of death balance $14,238.07, accrued interest $0.19 Mellon Bank, N.A. - TD Account No. 00728235, date of death balance $5,000.00, accrued interest $1.47 Mellon Bank, N.A. - TD Account No. 00922460, date of death balance $10,000.00, accrued interest $47.60 Mellon Bank, N.A. - Interest earned in TD accounts prior to date of death Old Guard Mutual Insurance Conversion Litigation - Pro rata share of net settlement fund PA Blue Shield - 20% Copayment Penn Treaty Network America Ins. Co. - Premium refund -1- 10.00 158.45 9.31 14,238.26 5,001.47 10,047.60 93.18 14.18 13.32 259.52 u.s. Treasury - Refund 3,856.00 U.S. Treasury - Tax relief 181.30 Verizon - Refund 13.59 PERSONAL PROPERTY: Jewelry - as per appraisal 400.00 STOCKS/LISTED: 1 shares Cumberland Valley Co-operative Association - Common stock, Certificate No. 5445 10.00 1 shares Cumberland Valley Co-operative Association - Preferred stock, Certificate No. 12557 10.00 3,120 shares Hershey Foods Corp - Common stock 200,896.80 TOTAL RECEIPTS OF PRINCIPAL............... -2- 33,896.18 400.00 200,916.80 235,212.98 ._. __ _. .. .._.. ...._r"'-.... . ,....."......., Ut:t"'AK I Mt:N I UF REVENUE NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN DATE ESTATE OF DATE OF DEATH FILE NO. COUNTY ACN INHERITANCE TAX DIVISION D:::PT. 28DSQ1 HARRISBURG, PA 1712S-06Q1 Raecy'- Re;,' JAMES 0 BOGAR ESQ A 9 :27 '01 O\e 21 1 W MAIN ST SHIREMANSTOWN PA 17011 :~..' Q ~ f" \~- ./ " .. 12-17 -2001 F R SHEELY 02-16-2001 21 01-0263 Cumberland 201 Amount Remitted ~ -:::..? ~. ~~~' nl;"'~i; ~~~ ~~P- REV.423 EX AFI> 103-97) 1;)"J ) &d. O~ MAKE CHECK PAYABLE AND REMIT PAYMENT TO: Register of Wills Cumberland County Courthouse Carlisle, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. CUT AL_C?~~_~~_t~_~~t:J~____.__.__ ~ RETAIN_ LC?~~~.~~~"I~,?N FOR YOUR.RES;ORDS ~ Ct-~r'~< Glnnbe, /("-2/0 --3 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE t NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOHANCE OR DISALLOHANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS REV-l&48 EX AFP (12-00) ESTHER D MCFADDEN 517 E LISBURN RD MECHANICSBURG PA 17055 DATE ESTATE OF DATE OF DEATH FILE NUMBER CO.UNTY SSN/DC ACN 07-30-2001 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 162-36-8324 01122470 F R 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 ~ RE-V=is~8-EX--AFP--[i2-:00)------------------------------------------------------------------------------------ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 07-30-2001 ESTATE OF SHEELY F R DATE OF DEATH 02-16-2001 COUNTY CUMBERLAND FILE NO. 21 01-0263 TAX RETURN WAS: S.S/D.C. NO. 162-36-8324 (X) ACCEPTED AS FILED () CHANGED JOINT OR TRUST ASSET INFORMATION ACN 01122470 FINANCIAL INSTITUTION: MELLON BANK ACCOUNT NO. 00728227 TYPE OF ACCOUNT: DATE ESTABLISHED ( ) SAVINGS ( ) CHECKING ( ) TRUST (Xl TIME CERTIFICATE 05-14-1998 Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions Taxable Amount Tax Rate Tax Due x 5,001.47 0.500 2,500.74 .00 2,500.74 .45 112.53 NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." x TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-05-2001 AA496560 5.63 106.90 TOTAL TAX CREDIT 112.53 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, 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" ( CRl, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX( 11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BOGAR JAMES D 1 W MAIN STREET SHIREMANSTOWN, PA 17011 _nUn_ fold ESTATE INFORMATION: SSN: 162-36-8324 FILE NUMBER: 21 - 2001 - 0263 DECEDENT NAME: SHEEL Y F ROMAINE DATE OF PAYMENT: 12/21/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 02/16/2001 NO. CD 000682 ACN ASSESSMENT CONTROL NUMBER AMOUNT 201 I $26,262.06 I I I I I I I I TOTAL AMOUNT PAID: $26,262.06 REMARKS: JAMES D BOGAR ESQ CHECK#1012 SEAL INITIALS: AC RECEIVED BY: REGISTER OF WILLS MARY C. LEWIS REGISTER OF WILLS / fo ~c2 /0 -- 3 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG I PA 17128-0601 REV-1607 EX AFP (12-00) Recur Hor DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 01-14-2002 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 201 F R .02 JAN 18 P 3 :45 JAMES D BOGAR ESQ 1 W MAIN ST G:,S'(r, SHIREMANSTOWN ~hn~l~~1 Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ HE-V: i6oj-ExAFP--fi'2-:oo.r------...--iNirERI'T):Nc'E-fAx--sTA-fEMEiif-cfF-Accouiff--...--------------- - -- - -- ESTATE OF SHEELY F R FILE NO.21 01-0263 ACN 201 DATE 01-14-2002 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: 12-17-2001 P R I NC I PAL TAX DU E : ........................................................................................................................................................................................................................... 27,234.37 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-15-2001 AA496593 .00 1,222.88 12-21-2001 CDOO0682 224.87- 26,262.06 TOTAL TAX CREDIT 27,260.07 BALANCE OF TAX DUE 25.70CR INTEREST AND PEN. .00 II IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE 25.70CR SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRl, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. 1 I t/;~ ~~ ~ __3 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-16D7 EX AFP U2-00) .02 Vlf\H 1 8 P?:\ 5 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 02-11-2002 SHEELV 02-16-2001 21 01-0263 CUMBERLAND 201 F R JAMES D BOGAR ESQ 1 W MAIN ST SHIREMANSTOWN Allount RellUted PA\.;i1iOll Curne " MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv=i6'ii7'-ix-AFP--fi'2:ooi-------...--INHEiI,.-ANcE'-TAx-si'7rfEME-NT-O-F-ACCouiif--.-i.------------------ --- ESTATE OF SHEELY F R FILE NO.21 01-0263 ACN 201 DATE 02-11-2002 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: 12-17-2001 P R I NC I PAL TAX DUE: ..........................................................................................................,......................................................................,......................................... 27,234.37 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-15-2001 AA496593 .00 1,222.88 12-21-2001 CDOO0682 224.87- 26,262.06 01-28-2002 REFUND .00 25.70- TOTAL TAX CREDIT 271234.37 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 "CREDIP' (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) ~ -\ (') S rn ~ )::> <- ZO'O> :lJ3~ ~ cOm)::> rn1:> 0 ~ ~~(f)() cn:n~ c: tPJJ(f)z .,..--<- ~ rT10~ t,.t) JJrfil ~n iJ ~ tn- -e. 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CD fg .... ~ ." ?2 CJ ::c m :n m fo-':'- ....-'\ 'I J:I m o m <: m o -n J:I o ~ ;t> zo~ cOm;t> sZ(j)o OJ-I(j)z m:Il~ :nOm rz -I .~ ~;~ f'-..... .;",., "'~. ;t> s o c Z -I f :1 ::;~ r:r ,-yO; IOlXlOO )>mc:mo :O"'O;:O"'Os :o--im)>s Ui~)>~o mocsz C"'Om~ :OS"T1zm o z-1)> "'0 ooCi )> :;::-nI 0:00 c:m-n )>~"'O rzm -lCZ )>mZ >< (J) m -< III r < )> Z )> 'j !\) ro 6 '" S z 0 :I: m -n :II 'TI =i - )>"0 0 Zm - (')Z )> mZ r- )>cn Z-< :D C~ m m)> 0 cnZ -1- m )>)> - -I -a m -t -I )> >< Z 0 )> ~ ~ <..0 en (J1 <.0 W JJ m ~ Q) f\) m x cO 2 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE NO. 21 01-0263 ACN 01122470 DATE 05-01-2001 REV-1545 EX AFP (09-00) EST. OF F R SHEELY S.S. NO. 162-36-8324 DATE OF DEATH 02-16-2001 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS o CHECKING o TRUST IX] CERTIF. ESTHER ~MCFADDEN 517 E LIS~N RD MECHANICSBURG PA 170pQ REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE1 PA 17013 MELLON BANK has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, yoU were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by ca~ling (717) 707-6527. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 00728227 Date 05-14-1998 Established PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due To insure proper credit to your account, two (2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". x x NOTE: If tax payments are made within three (3) months of the decedent's date of death, you may deduct a 5% discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. Tax [] The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent's representative. [] The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. If you indicate a different,t~ raiel please state your relationship to decedent: loJM \t 6&& U ~~V- PART @] DATE PAID DEDUCTIONS CLAIMED PART ~ TAX LINE RETURN - COMPUTATION 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF 1 2 3 4 5 6 7 8 x 'z,~" 6 - 1 't TAX ON JOINT/TRUST ACCOUNTS x 465 \ \ 7~ S~ DEBTS AND PAYEE DESCRIPTION AMOUNT PAID I TOTAL (Enter on Line 5 of Tax Computation) I $ Under penalties of perjurYI I declare that the facts I complete to the best of my knowledge and belief. ~ A. JJld-~~ TAXPAYER SIGNATURE have reported above are truel correct and HOME (111) l1'i-~t10 WORK ( ) TELEPHONE NUMBER DATE It; -C:)/b -~? '.. 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-U07 EX AFP (01-02) 1 C) DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 05-06-2002 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 101 F R JAMES D BOGAR ESQ '02 1 W MAIN ST SHIREMANSTOWN 1~::17011 .! 6 Allount Rellitted (~;l.1rl MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ i.f"=i60j-E3f-AFP--(fff:021-------...--INH-ERIr-ANc'E-;:AX--STA-fE~iE-N;:-OF-ACCouirf--."i.--------------------- ESTATE OF SHEELY F R FILE NO.21 01-0263 ACN 101 DATE 05-06-2002 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: 12-17-2001 PR I NC I PAL TAX DU E : .............................................................................................................................................................. 19,872.53 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-05-2001 AA496560 5.63 106.90 05-15-2001 AA496592 73.61 1,398.63 05-15-2001 AA496593 914.39 17,373.37 TOTAL TAX CREDIT 19,872.53 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 PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J \, /(,.. o;./tJ 0' 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-I607 EX AFP (01- 02) JAMES D BOGAR '~~Q lU 1 W MAIN ST SHIREMANSTOW~ PA 17011 Ctr , :; [} DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 05-06-2002 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 201 F R Anount Renitted 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~ subnit the upper portion of this forn with your tax paynent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ R'fV' =iitoj-ix--AFP--fo1-.:o21-------...--iNirERITANc'E-TAx--STjrfEHENT-OF-Accouiff--.-..---------------- - - --- ESTATE OF SHEELY F R FILE NO.21 01-0263 ACN 201 DATE 05-06-2002 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: 12-17-2001 P R I NC I PAL TAX DU E : .................................................................................................... 27,234.37 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-15-2001 AA496593 .00 1~222.88 12-21-2001 CDOO0682 224.87- 26~262.06 01-28-2002 REFUND .00 25.70- TOTAL TAX CREDIT 27,234.37 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 It IF PAID AFTER THIS DATE~ SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1~ NO PAY"ENT 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. J \. /6 -;t/6 "-..3 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG. PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEHENT~ ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX Recorc,~ Re~; " .' .. ,-' i DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-17-2001 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 101 ',':;) .01 OIC 17 Pl2 :01 JAMES D BOGAR ESQ 1 W MAIN ST SHIREMANSTOWN PA CJy~k 1 CLnnbb( ,C,,:' i. \ C~ll I t-\ REY-1541 EX AFP (12-001 F R Amount Remitted CHANGED Cl) (2) (3) (4) (5) (&) (7) .00 200.916.80 .00 .00 34.296.18 128,980.75 97,277.41 (8) MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV:is4-j-E3f-AFP--fi'2-:o0Y-NOTicE--OF--='iNHER-frAifcE-TA;(]rppRA-isEMENi'-,--ALLOWANCE-cfi------------ ----- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SHEELY F R FILE NO. 21 01-0263 ACN 101 DATE 12-17-2001 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 I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 1&. Amount of Line 14 taxable at Lineal/Class A rate (1&) 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 RETURN WAS: (X) ACCEPTED AS FILED 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) &. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets NOTE: (9) ClO) 19~830.46 28.88 NOTE: To insure proper credit to your account~ submit the upper portion of this form with your tax payment. 461~471.14 Cl1) Cl2) Cl3) Cl4) 19.R1i9 34 441~611.80 .00 441~611.80 .00 X 00 = 441,611.80 X 045= .00 X 12 = .00 X 15 = Cl9)= .00 19~872.53 .00 .00 19~872.53 TAX CREDITS: PAYHENT RECEIPT DISCOUNT (+) AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) 05-05-2001 AA496560 5.63 106.90 05-15-2001 AA496592 73.61 1~398.63 05-15-2001 AA496593 914.39 18~596.25 TOTAL TAX CREDIT 21~095.41 BALANCE OF TAX DUE 1~222.88CR INTEREST AND PEN. .00 TOTAL DUE 1~222.88CR * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) /6 ~.2/b -\3 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-16D7 EX AFP (12-00) RecorC!6Ci Registc " DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-17-2001 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 101 F R JAMES D BOGAR 1 W MAIN ST SHIREMANSTOWN .01 ote 27 A10 :14 ESQ C:Efl~'17011 Clunbeija"C PA 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-Ex--AFP--fi'2-:oo1-------.i.--iNifERITANc'E-iAx--STATEMENi-OF-Accouiff--.-..---------------- ----- ESTATE OF SHEELY F R FILE NO. 21 01-0263 ACN 101 DATE 12-17-2001 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: 12-17-2001 P R I N C I PAL TAX DUE: ........m......m..m.....m.................m.........m......m...m..........m.....m........m....m...m............m....umu..........m.n....m..........m.....m....m....m.......... 19,872.53 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-05-2001 AA496560 5.63 106.90 05-15-2001 AA496592 73.61 1,398.63 05-15-2001 AA496593 914.39 17,373.37 TOTAL TAX CREDIT 19,872.53 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 !IIi 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 "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) \, /6-d1/b.~ 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-16D7 EX AFP 112-00) RecorCifh, Regl'JC'f DATE ESTATE OF DATE OF DEATH A. 10 '1 A FILE NUMBER . ,I . \ '4 COUNTY ACN 12-17-2001 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 201 F R .01 Ole 27 JAMES D BOGAR ESQ 1 W MAIN ST SHIREMANSTOWN PA 17UI~rK. CUlnbe\ 12n.~ Amount Remitted PA 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 ~ REY=i6cfj-e:x--AFP--fi'2-:ooj------...--iNifiRITANcE"-TAx--STATEMENT-O'F-AC-COU'Ny--...--------------------- ESTATE OF SHEELY F R FILE NO.21 01-0263 ACN 201 DATE 12-17-2001 THIS STATE"ENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NA"ED ESTATE. SHOWN BELOW IS A SU""ARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAY"ENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 12-17-2001 P R I N C I PAL T A X DUE: ....0000.0000.....00...............................00..........................00......0000......n....................................nu...........u..u..u..................................'0000""""00.......... 27,234.37 PAYMENTS (TAX CREDITS): INT AT REV PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 05-15-2001 AA496593 .00 1,222.88 EREST IS CHARGED THROUGH 01-02-2002 TOTAL TAX CREDIT 1,222.88 THE RATES APPLICABLE AS OUTLINED ON THE ERSE SIDE OF THIS FORM.* BALANCE OF TAX DUE 26,011.49 INTEREST AND PEN. 297.65 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE 26,309.14 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAY"ENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU "AY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOR" FOR INSTRUCTIONS. ) RecO;;-', : Re;). U~~AKIM~NI UFREVENUE NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN DATE ESTATE OF DATE OF DEATH FILE NO. COUNTY ACN INHERITANCE TAX DIVISION DEPT. 28050~ HARRISBURG, PA 17128-0601 /~-02/" ~ JAM ES 0 BOGAR ESQ 12-17-2001 F R SHEELY 02-16-2001 21 01-0263 Cumberland 201 1 W MAIN ST SHIREMANSTOWN PA 17011 CierI Glunbec;cij-' .01 ole 17 PI 2 :04 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: Register of Wills Cumberland County Courthouse 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 Q RETAIN LOWER PORTION FOR YOUR RECORDS ~ -. REV483" EX AFP" (03=97) - u - - -. - -". - u. - - -- -" - - -;; "NO rICe-OF" i)ErERrViINATIO.N -AN DO AS'SE"SS-';'-Ei-ii" -. -"" -. -. -...."." - - - - -. - -. -- - - - - - - -.- OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN ** ESTATE OF F R SHEELY FILE NO. 21 01-0263 ACN 201 DATE 12-17-2001 ESTATE TAX DETERMINATION 1. Credit For State Death Taxes as Verified 46,113.27 2. Pennsylvania Inheritance Tax: Assessed (Excluding Discount and/or Interest) 18,878.90 3. Inheritance Tax Assessed by Other States or Territories of the United States (Excluding Discount and/or Interest) 0.00 4. Total Inheritance Tax Assessed 18,878.90 5. Pennsylvania Estate Tax Due 27,234.37 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 5/15/2001 A.7\..4 9 65 9 3 1,222.88 I I :::::NTREST IS C?ARGED THROUGH 12-25-2001 TOTAL TAX CREDIT 1,222.88 .Zl.T THE P..2\T E S APPLICABLE Jl.S OUTLINED ON THE BALANCE OF TAX DUE 26,011.49 REVERSE SID:S OF THIS FOR!vi* INTEREST AND PEN. 250.57 TOTAL DUE 26,262.06 * IF PAID ~~TER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. (IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOT.AL DUE IS REFLECTED AS A CREDIT (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR /~-02/6~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG I PA 17128-0601 REV-IU7 EX AFP (12-00) RHGOn'c.. of Req;'.t. .01 ESTHER D MCFADDEN 517 E LISBURN RD MECHANICSBURG Ole 17 P12:0 1 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-10-2001 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 01122470 F R Amount Remitted PA U;ms ClIlnbeiiC:: '-"/, 1M 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: i 6o"7-ix-AFP--fi'2-:ooY------...--INifERITANci--TAx- STATEHE-tij-'(fF"-Accouiif--...---------------- ----- ESTATE OF SHEELY F R FILE NO.21 01-0263 ACN 01122470 DATE 12-10-2001 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: 12-06-2001 P R I NC I PAL TAX DU E : ........................................................................................................................................................................................................................... .00 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 Jt 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" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) ./- ( I. .yo BUREAU bl= INDIVIDUAL TAXES INH~ITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER DATE ESTATE OF DATE OF DEATH FILE NO. COUNTY '03 JU!~ -2 J\11 :19 ACN ~~ .~.~ ..:..... " ' " REV-736 EX AFP 103-97) JAMES 0 BOGAR ESQ 1 W MAIN ST SHIREMANSTOWN P A 17011 06-03-2003 SHEELY F R 02-16-2001 21 01-0263 Cumberland 202 L'.~ ; C\illl::;~ Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: Register of Wills Cumberland County Courthouse 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 q RETAIN LOWER PORTION FOR YOUR RECORDS ~ - - REV:736 EX AFP- (03:97) - - - - - - - - - - - - - - - - - - - - - - - -;; -NoT"lce- OF- O-ET-ERNIINA-TIO-N -A-NO AS-SESSpjIE~iT - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER ** ESTATE OF SHEELY F R FILE NO. 21 01-0263 ESTATE TAX DETERMINATION ACN 202 DATE 06-03-2003 1. Credit For State Death Taxes as Verified 46,113.27 2. Pennsylvania Inheritance Tax Assessed (Excluding Discount and/or Interest) 3. Inheritance Tax Assessed by Other States or Territories of the United States (Excluding Discount and/or Interest) 4. Total Inheritance Tax Assessed 18,878.90 o . 00 18,878.90 5. Pennsylvania Estate Tax Due 6. Amount of Pennsylvania Estate Tax Previously Assessed Based on Federal Estate Tax Return 27,234.37 27,234.37 7. Additional Pennsylvania Estate Tax Due 0.00 TAX CREDITS: PAYMENT I RECEIPT DISCOUNT (+) DATE I NUMBER INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * 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 ICR). YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) JAMES D BOGAR ESQ 1 W MAIN ST SHIREMANSTOWN PA 17011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN *' BUREAU OF l~IVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 2~0601 HARRISBURG, PA 17128-0601 . .'\ REY-73' EX AFP 101-02> 06-03-2003 SHEELY 02-16-2001 21 01-0263 CUMBERLAND 202 F R REGISTER OF WI CUMBERLAND CO CARLISLE~ PA HOUSE NOTE: To insure proper credit to your account~ submit the upper portion 0 this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR ILES ~ itEfv;736--EX--AFP--fo~:o2)-----j(i-Noificif-oF--DETifRMIN~fIO-N-Aifn-A-- i5:S-MENY----------------------------- OF PENNSYLVANIA ESTATE TAX BASED ON FEDERA CLOSING LETTER .. ESTATE OF SHEELY F ACN 202 DATE 06-03-2003 ESTATE TAX DETERMI 1. Credit For State Death Taxes as Verified / 19,872.53 6. Inheritance Tax Assessed by Other Stat s or Territories of the United Stites (Excluding Discount and/or Interest Total Inheritance Tax Assessed Pennsylvania Estate Tax Due / Amount of Pennsylvania Est~ Tax Previously Based on Federal Estate T~ Return / Additional PennsYlvani,/Estate Tax Due 18,878.90 2. Pennsylvania Inheritance Tax Assessed (Excluding Discount and/or Interest) 3. .00 4. 18,878.90 5. 993.63 Assessed 27~234.37 7. .00 TAX CREDITS: PAYMENT RECEIpT DISCOUNT (+) AMOUNT PAID DATE NUMB€R INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 -IF PAID AFTER THIS DATE~ SEE REVERSE SIDE (IF TOTAL DUE IS LESS THAN $l~ NO PAYMENT IS REQUIRED FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ~ YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.J Gt/ OiL , , STATUS REPORT UNDER RULE 6.12 Name of Decedent: F. Romaine Sheely Date of Death: February 16, 2001 Will No. 21-01-0263 Admin. No. 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 XX 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 XX 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 XX No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. James D. Bo ar, Esquire Name (Please. type or print) One West Maln St. Shiremanstown, FA 17011 Address Date: 2/19/03 (717) 737-8761 Te 1. No. Capacity: Personal Representative x Counsel for personal representative (MAH:rmf/AM3) ~ Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (71 7) 240 - 6345 ,J Date: 1/06/2003 BOGAR JAMES D 1 W MAIN STREET SHIREMANSTOWN, PA 17011 RE: Estate of SHEELY F ROMAINE File Number: 2001-00263 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 2/16/2003 Your prompt attention to this matter will be appreciated. Thank You. ~;f)~~ DONNA M. OTTO ~~ DEPUTY REGISTER OF WILLS ~ cc: File j Personal Representative(s) Judge