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Home My WebLink About01-0273 PETITION FOR PROBATE and GRANT OF LETTERS ~'-Ol-~' ~ Estate OF 0Yt3-LI--/ ~,. f:TJA/T z..C(,/~ No. 'Ju also known as To: Register of Wills for the . Deceased. County of r'! 1/ .-vt5f-Kt-.I-J A/IJ in the Social Security No. / 72.. - 0 I - y <frO' Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the executJ0tL.'p/f SI-I,v-/ .L'ct/~mer).?' in the last will of the above decedent, dated ~? ~ /1 j-- , 19LL- and codicil(s) dated (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in i? i./ /1'[ I? {f ~ t /1".r-.b h rK last family or principal residence at 6'2 ~ {-', .2 '7 7J.?' /-1 # If'R I [/j?(./~6- / P /7 ' I 7/11 (list street, number and muncipality) County, Pennsylvania, with f'T Decendent, then ? S years of age, died 4~ /9/? C? 1-1 at (1Ii/!?cL /b/"".,/c /1/ ('I1RL. / ['Lc- Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: R- :;2CC7 / ,~ Decendent at death owned property with estimated values as follows: (I f domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania .._. ~ ~ ~ situated as follows: 6' A 71' J, 2r' - J (. ///f!/f?RIS A~t./KrY, ;//'t. 7/// $ .sC?7. - $ $ $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters Testamentary (testamentary; administration c. La.; administration d. b.n.c. La.) theron. VJ ar u c v ~~ VJ '-' v.... 0::: v c -00 c::'= ro -.= 3~ v,- ~ 0 'Cil c 01) Ci3 .--~ c;2-~~7? r/f S; X' rf-6' -2- / "..u- H/V' c! /-/ 6- ..( T C- /<' I yZ/ a. 9' P ;s'" S'- .5'"":> OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA I sn COUNTY OF Olmberland J ~ 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 represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. ~---2? - Sworn to or affirm~tflnd subscribed P' / - '?" ~ before me this day of ~ March ~~2001 ~ ;:: ~ ~ ~o. 21-2001-273 Estate of Evelyn M. Stintzcum , Deceased DECREE OF PROBATE A~D GRA~T OF LETTERS AND NOW March 13th }[~200 1 ,in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated Mav 28th.1981 described therein be admitted to probate and filed of record as the last will of Evelyn M. Stintzcum and Letters Testamentary are hereby granted to Ralph Stintzcum, Jr. FEES $ 25.00 $ 3.00 $ $ 3 . 00 5.00 TOTAL _ $ Filed .. ~?:~c;J:1. .1. ~ 1;:1:1 / ~.o.Q +. . . . $ . . J.q ~ QO. . Probate, Letters, Etc. ......... Short Certificates( 1) . . . . . . . . . . Renunciation ................ x-Pages (I) JCP AITORNEY (Sup. Cr. LD. No.) ADDRESS PHONE EXECUTOR WILL PICK UP LETTERS AND ORDER REGISTER OF WILLS OF COUNTY OATH OF SUBSCRIBING WITNESS //'/ / codicil / (each) a subscribing witness to the will presented herewith, (each) being/duly qualified according to law, depose(s) and say(s) that present and saw ,/'/ ,i'" the test at , sign the same and that request of testat_ in h presence and (in the prese other subscribing witness(es)). // Sworn to or affirmed and subscribed before / / me this day of // '" 19_ ,//' signed as a witness at the e of each other) (in the presence of the (Name) (Address) R~glster (Name) (Address) 21~2001-273 REGJSTER OF WILLS OF Cumberland COUNTY / OATH OF NON-SUBSCRIBING WITNESS ;(1;",c'/I /h -vr Z-{!l/-4?/ JR. ])or:zi<;. ? !tf2E4I4 (each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that thpy arp familiar with the signature of Evelyn M. Stintzcum ~ testat~ of ~x1Ofx~~~~ the will presented herewith and that They believes the signature on the wi~e handwriting of Evelyn M. Stintzcum to the best of the; r knowledge and belief. Sworn to or affirmed and subscribed before .~ ~ me this 12th /~ March /1"- ~ (Na~ 131 fJ;d;;;/1ZH~ (Address) 'h is to cerrify that the information here given is correctly copied from ;1I1 original ce.rrific:He of death du~)~ filed with me as I. l.',: Registrar. The original certificate will be forwarded to the State Vital Records Office for pc rmanent hlmg. WARNING: It is illegal to duplicate this copy by photostat or photograph, No. ~j"""-;;-'7h/~ 4,1i"~~~3'rlQE!tt.::.~ ~I\I~/ '~~\ I~ .~. 1lIb.~' \~ ':. (j~~! . ~ \?~ ~~, -<~' - \~~ ~~\ ::~~" J~~ \\*~>;*! ~~\ "",~,\\ ~... r,<)',. . / /~ " ~-r/l~j;'1m/ ~ ~\:III\/ -"'",,'" ENl \\ III'" '''JI'/:/n''IIIIJIJ Fee for this certifIcate, $2.00 , P 7285509 tV-=; -/~ --~? I Date 21-2001-273 "to!> :~Aew 2117 COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH YHiPAlHT IN UlllAH€NT Uat INK .... STAll ....1_11 SEX SOCIAl. SECUA,n' NU\lII€R I. Female 3. 172 - 01 OAlE Of' DEATH ._. 0... ._, NAME Of' DECEDENT If.... _. co., " 8IRTHPl.ACi :C./y """ ..... '" fa..,. ''''''"'vI I. M. Stintzcum UNDER I YEAR UNDER I D.tlr -.. Oaya - 1 ......... 2001 Harrisburg, PA :"'0 1W:f.",,-- ~.... WNIe. *- ~ White Cumberland Q ! ~ ~ DECEDENT'S USUAL OCC\JfllVlON ~-=:~"='::::.1.:::' "homemaker II'" own DECEDENT'S IoWl.WQ ADDRESS csar_ C4yIbon. ~ rip Coal! 624 S. 29th Street I'" Harrisburg, PA 17111 FRHER'S NAME IF... ...,.".. l.-) IL Norman Heckert -OfIIoWfT'SNAME (T~ Doris Arena ME'THOO OF DISI'OSlT1ON O - fXI c:.-..... 0 --_....0 ~ 00Iw C5t>ocIyt tL ~ N\S DECEDENT EYER IN US. ARMEO FOACES? __O~ I" Penna Did - ... .. . --.., 17...[3:;"'~':::aI MOTHER'SHMlE,F... _._Sul_ ~ Ellie Procnsco IIWORMANrS WAIUNO ADORESS ~... CllIo'bon. ~. liD Codal 127 Bosler Avenue Lemo e PA 17043 PlACE OF llISPOSmON. _ ale-,. c.---, LOCRION -~ $We. Z1pCocla .. 0IIaI_ Pax tang Cemetery Harrisburg, PA 21.. 21.... IoIARItAL swus. __ ---.-. ~l5PKlIVI I..widow 17..0....__.. SUfMYIHG SPOUSE 11__-_ 1"'- Dauphin HarrisburS!: 2001 3125 Walnut L~ DUE lOCOA ASA CONSEOUE I: a .~ !=.-..:= ! l ,."g NRT I: 00Iw........ _-............... .......-.g in........ _...... MIlT L Ml,h~1,L-W~ DUE lOCOA ASA CONSEOUENCE 01'): DUE lOCOA AS ACONSEOUENCE Of): WERlE AU10PSY FlNDWGS AM.AaJ; PflIOA lO COWI.ET1ON OF CAUSE OF llEmf7 MANNER OF DEATH ...0 ......... - Suicide ~ o o ORE OF lNJUflY '-.Day. -I TIME Of' INJUfIY ~1IIW0RK7 DESCAIllE HOW INJURY 0CCUlIIIED. ~ . ., U ,-.- .......... .........-. -- 0 ...0 ~_...- -. a ~.o-anr_ "C8ITM'YlNQ PMYllaAllcPh_carlIfWon9_d_ __ an....,__ 11'__ onoc_.... <.II ......-....,..............---"'..cawe(.I-___.................................................... . .. z ! ~ l!l ~ I 'PIIONOUNCIHGAHOC&RTFfIHG ,"TSIClAN,~ tloIr: ;lIonounl:<no _ M>dC__ID~"'_1 T." _.. My.............. _.. _ at .. _. dala. _ pIac.. _ _ "'.. ca......I_ "'......,.. ........ . . . . . . . . . . . . . . . . . . . . . . . . -..olCAL EXAIIINERICOftONEIl :tl.. =,~":':::::'~.~~~~~l.~~: ~ ~~~: ~~~~~~~ ~~ ~..d.l~: ~.~~: ~.~~ ~~ ~ ~~~~~I.~ REGlSTRAR'S SIGNATURE ANI)_R o ltJlql?l~ 31. DAJEftLEOI_ 0.,._, :N. Jut ViII anb tltsfamtnt It! EVELYN M. STINTZCUM I, EVELYN M. STINTZCUM:, of the City of Harrisburg, COunty of Dauphin and State of Pennsylvania, being of sound mind, merro:ry and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all will or wills by me at any ti.m= heretofore made. As to such estate as it hath pleased God to entrust me with, I dis- pose of in manner as follows: 1. I order and direct my hereinafter naIIEd Executor to pay all of my just debts, legally collectible, as soon as conveniently may be after my decease. 2. I give, devise and bequeath all of the rest, residue and re- mainder of my estate, real, personal and mixed, of whatsoever kind and nature, and wheresoever situate at the t.irre of my decease, unto r~ son, Ralph Stintzcum, Jr., unto him, his heirs and assigns forever. 3. I hereby naninate, constitute and appoint my son, Ralph Stintzcum, Jr., Executor of this my Last Will and Testament, and I hereby authorize, ernpDVJ'er and direct him to sell and convey, by good and sufficient deed, in fee simple estate, any and all of my real estate, at public or private sale, for such price or prices, upon such tenns and conditions, as in his judgment is best for my estate, and to that end to sign, seal, execute, acknOW'ledge and deliver all deeds or other instnnnents necessary therefor, as effectively as I could do if I were personally present. 4. If and in the event that my said son, Ralph Stintzcum, Jr., should happen to be a non-resident of Pennsylvania, it is express direction that he shall be excused fran filing a bond for the administration of my -1- Jasf ViII anb t1rtsfamtnl nf EVELYN M. STINTZCUM estate, for the reason that I have the utrrDst confidence in him, and as authorized under Section 3174(c) of the Act of June 30, 1972, Act No. 164. IN WI'INESS WHEREOF, I, EVELYN M. STINTZCUM, the Testatrix, have to this my Last Will and TestanEnt, typewritten on two (2) consecutively numbered pages, set my hand and seal this 28th day of May, A.D., 1981. (!-t~L:~ ;:/:/ .Id:~~.c::-;~) ,//' Signed, sealed, published and declared by the above-named Evelyn M. Stintzcum, as and for her Last Will and TestanEnt, in the presence of us, WID have hereunto subscribed our naIIES at her request as witnesses hereto, in the presence of the said Testatrix and of each other. .~~ Ii l (' " ~''^Ul l, r~l' ~~~j . ( I \ v DP:ejb 5-28-81 -2- ~ - CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: .)..:: J/ (5 L Y A/ ~ ' ~f I A/' ;- z. (? / / fi/f Date of Death: ~/ /l /? tJ /-1 r L ()O ! Will No. :2 00 I - U 0:2 7 ? Admin. No. To the Register: I certify that notice of (beneficial interest) 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 Name Address 0~. r67 A/' /7' ~ [? /--/ C s /-- C R. / 1~/-7 , 7 rr,.J? S-'J? Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: 0- 14/- () I Signature ~9= Name: ../.~ .7:/ ~ Address ;Z tJ Se7j/ rf62 d/4/(!Ir(C-S'IC-~, ~/1 > , 9 fi,j"?r..j> Telephone ~ ~ r- 7/ - 2 / @- 7 Capacity: ~rsonal Representative _Counsel for personal representative f- ,. - --- Name of Decedent: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) fl/cLr~ /4, ,-(T/~/Tz.eUA'1 Date of Death: 4?' /1/f'e // c/o ) 2coI Will No. ~{-Ul- ;;;)'3 Admin. No. To the Register: I certify that notice of (beneficial interest) 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 Name Address YP/7L ?// , 17-1 ~T2L't://rl J/<" Pv Sox rr62-. ~ /? /1""(.' 17 C J'T ~ *; f'V' /t · 9' r .]:::. s-- -? Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: /~ 4~/ ?)/ ~>~ ~~ Signature Name Address Telephone ( Capacity: _ Personal Representative _Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT,280601 HARRISBURG, PA 17128-0601 ~ I~ ------,~. ..,......"....----.,----.- PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT No.AA 478162 REV-1162 EX (11-96) RECEIVED FROM: I ACN ASSESSMENT CONTROL AMOUNT NUMBER ~.'ALF'il'~ ~::) ~r NT ZCUf'1 JF: 1 (; ~; \ I):S 1 :36 , 1 ,\. , . . '";'i:32 1 - ~'h4F'L E STF?CET f> D BCJ x: f:3 b [! i'"\{~NCHES 1 ER , ~.J{~ q[ra~5~\ FOLD HERE FOLD HERE I - ESTATE INFORMATION: FILE NUMBER (,,;, 1 2 () () 1 (!i~ ~] :-3 ~; ~~; N 1 7(::-0 .t ,.. i.. 88 0 NAME OF DECEDENT (LAST) (FIRST) (MI) "- T NT2CUf"l [VEL Yf'..: !V1 1. DATE OF PAYMENT .~3 / k '~I /eoo 1 POSTMARK DATE 0 /00/ f)OO(, COUNTY % , (-5 i 3c_, . C.UMBEF:Lr~ND TOTAL AMOUNT PAID DATE OF DEATH c.) C~, ~ ..,~ /()8 l i~ I::() .' REMARKS r~(~L.PH ET I NTZCU!~! RECEIVED BY ./' //2'E/~:t;; (~' , ..". ,~~~ /,:.t "'J r--: {\ F~J "l C . p ...... " ,-, ~':: ' . T r ,"r ,"',' r, ~'~'~, .. , .,J;' ~ l~'(.... !, t , ~ ,~ ..:. U.1 ;. '..' SEAL ',LG" '" Lh [j'< '" lI_L:" '':r;{(J".b;~/? J REGISTER OF WILLS \, /6 -r::2/6 - /~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REY-1547 EX AFP <12-00) RALPH STINTZCUM JR 7821 E MAPLE ST PO BOX 862 MANCHESTER WA 98353. DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 09-03-2001 STINTZCUM 03-08-2001 21 01-0273 CUMBERLAND 101 EVELYN M Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv=is4j-E"x--AFP-f12:oi.-r-NoTicE--oF-"rtiHEifiiANcE-TAX-APPRA-isEirENT~--A[l-owANcE-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF STINTZCUM EVELYN M FILE NO. 21 01-0273 ACN 101 DATE 09-03-2001 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN NO. 01 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Stock/Partnership Interest (Schedule C) (3) 4. Mortgages/Notes Receivable (Schedule D) (4) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets . 0 0 NOTE : To insure proper . 00 credi t to your account, . 00 submit the upper portion .00 of this form with your . 00 tax payment. .00 .00 (8) .00 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 .00 (9) (10) 140.188.70 (11) (12) (13) (14) 140 . 1 AA 70 140,188.70- .00 115,595.96- NOTE: I~ an assessment was issued previously, lines re~lect ~igures that include the total o~ ALL ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. .00 X 00 = .00 X 045 = .00 X 12 = .00 X 15 = (19)= .00 .00 .00 .00 .00 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 03-16-2001 AA478162 .00 1,051.36 TOTAL TAX CREDIT 1,051.36 BALANCE OF TAX DUE 1,051.36CR INTEREST AND PEN. .00 TOTAL DUE I,051.36CR * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) /~-~6 -/a. BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT ~~ V REV-16D7 EX AFP el2-00l RALPH STINTZCUM JR 7821 E MAPLE ST PO BOX 862 MANCHESTER WA 98353 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 09-17-2001 STINTlCUM 03-08-2001 21 01-0273 CUMBERLAND 101 EVELYN M 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(fj-Ex-AFP--(i2:oo1-------.u--iNHERI~fANCE--fAx-STA-fE~iENf-OF-ACCouiif--.-..--------------------- ESTATE OF STINTlCUM EVELYN M FILE NO.21 01-0273 ACN 101 DATE 09-17-2001 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: 08-27-2001 PRINCIPAL TAX DUE: ............................................................................ .00 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 03-16-2001 AA478162 .00 1,051.36 08-31-2001 REFUND .00 1,051.36- TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 if IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) ~ 7 f\ l/ . ~J '/6-c..-2/~-/~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP 02-00> 04-30-2001 STINTZCUM 03-08-2001 21 01-0273 CUMBERLAND 101 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ~CN M EVELYN RALPH STINTZCUM JR 7821 E MAPLE ST PO BOX 862 MANCHESTER WA 98353. Amount Remi H:ed 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 ~ irEV; iS4j-E"x- A F p--fl"2:o aT -NcificE - -oF-YNHEifi TANcE-YA";rXpPRXisEi.fENT-,--ALi-owAi,fcE- o-i-- - ------ - - - - - - -- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF STINTZCUM EVELYN M FILE NO. 21 01-0273 ACN 101 DATE 04-30-2001 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) B. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets 25,000.00 .00 .00 .00 5,769.19 .00 .00 (8) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. (1) (2) ( 3) (4) (B) (6) (7) 30,769.00 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 5,123.64 (9) (10) 1,052.81 6.176 45 24,592.74 .00 24,592.74 (11) (12) (3) (14) 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. I~ an assessment was issued previously, lines re~lect ~igures that include the total of ALL ASSESSMENT OF TAX: lB. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: NOTE: .00 X 00 = .00 24,592.74 X 045 = 1,106.68 .00 X 12 = .00 .00 X 15 = .00 (19)= 1,106.68 (1B) (6) (17) (8) PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 03-16-2001 AA478162 55.33 1,051.36 TOTAL TAX CREDIT 1,106.69 BALANCE OF TAX DUE .01CR INTEREST AND PEN. .00 TOTAL DUE .01CR 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.) ~ IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ," (- STATUS REPORT UNDER RULE 6.12 Name of Decedent: E.vt;LY/V 41fiE. efr 1.,1/ T z:. C- {/ A4 Date of Death:,,41 II!<. (!.. H i; 2. 00 I Will No. 200/ -fJ02.'Tf Admin. No. :2.1-O/-02.Z? 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 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 X No b. The separate Orphans' Court No. (if any) for the personal representative's account is: e t/A4t1~ R'- t:/,;"V IJ C?.-oU.II/T 1- C!./9/fLIJ'L<;:) ?~, 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 Cerk of the Orphans' Court and may be attached to this report. Date: /2. .44l'1r 0/ c~~ /C ~ 'Si~ture · ~ R/lLP/I J?T/4/'T ze V"u JR, Name (Please type or print) rCJ 8c7X cf62 /W/JA/(" /-i~.1 T6 /?, yr,/,q, ?~ J>S-..:? Address ' C?6t?) ,I 7/ - 2/6"7 Tel. No. Capacity: X Personal Representative Counsel for personal representative (HAH:rmf/AM3) Rr";1500EXi6-00) w >- ::.::~U) 0."" W"O ",00 0"'-' ..'" .. '" COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT 280601 HARRISBURG, PA 17128-0601 I- Z W C W () W C 001, Original Return o 4. Limited Estate ~ 6. Decedent D'led Testate (Attach copy of Will) o g, Litigation Proceeds Received /6-02/6 -/-:2 REV-1500 OFFICIAL USE ONLY C- INHERITANCE TAX RETURN FILE NUMBER :.:u~ -(1 L RESIDENT DECEDENT CaUNTYCaeE YEAR --'-- -'-~ p..;i NUMBER SOCIAL SECURITY NUMBER 172 - c:J/ 7" <:f'" cr<::, IYc:J '7 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER D 2. Supplemental Return o 4a. Future Interest Compromise (dale of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach copy 01 Trust) o 10. Spousal Poverty Credit {date of ooa\1\ l3eWm.n 11-3'1-91 aruj 1-1-95} o 3. Remainder Return (date 01 death prior to 12-13-82) o 5, Federal Estate Tax Return Required o a. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Attach Sch 0) 1 Real Estate (Schedule A) (I) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedu~e D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) o 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 Liabilities, & Liens (Schedule I) (10) 11. Total Oeduetions (total une~ ~.& 1{)) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental BequestsfSec 9113 Trusts for which an election to tax has not been made {Schedule J) >- z w C z o .. '" w '" '" o o z o ~ :I l- e:: <( () W Ix: 14. Net Value Subject to Tax (Line 12 minus Line 13) rf"7/ -2/6 COMPLETE MAILING ADDRESS jOiJ Fox' ~b2. 7cf':2.1 .E, ~I9PL. C S7 ~/7/f/e/(cS'TcR.) U//1, 7 2 r; C)<:!o. c70 , 7('. <? cr ..? "r:.;> OFFICIAL USE ONLY /' S; 7~"T, / <l (8) ?' 5- /.:?:1. tfi'/ ( CS-2., ,pI" " y~ 7~9,/f' ~ (11) (12) (13) /' /. /7&: Ys- - (14) ~</G'9~, ?-y SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES '.0_(15) '.0_ (16) '.12 (17) , .15 (18) (19) 19. Tax Due CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT z o ~ I-' :I D. ::E o () ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 20.0 Decedent's Complete Address: STREET ADDRESS 7;:.# ~e CITY STATE 'pI? ZIP /7/// Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Pnor Payments C. Discount Total Credits (A+ B+ C) (2) 3. InteresUPenaity if applicable D. Interest E. Penalty TotallnteresUPenalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAVMENT. Check box on Page I Line 20 to request a relund (4) 5. 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. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Ves No a. retain the use Dr income of the property transferred;....".. ...................................................................... 0 0 b, retain the nght to designate who shall use the property transferred or its income; ........,.................................., 0 0 c, retain a reversionary interest; or.., ..................................................... .................................. 0 0 d, receive the promise for life of either.paYfi'lents. benefits Dr care? ....................................................................., 0 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .... .................................................. .................. ................................... D ~ 3. Did decedent own an "in trust for" Dr payable upon death bank account or security at his or her death? .............. 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ... .. ..............., ................, .................... .................................. 0 ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, Under pen ames of perjury, f declare tI1al f have examined this return, including acoompanying schedules and statements, and !o the besl of my knowledge and belief, it is true, correct and complete. Declaration cf preparer other than the personal representative is base donal1informationofwhichpreparerhasanyknowledge. SIGNATURE OF PERSON RESP DATE ADDRESS Pt? ,B'C1X ,?/.;) 7<1".2/ ,E, df: ',:~ S'r., .#/?A/"'fI(fJ'r~'/(, wI?, f'~.i'..j> .,:J SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS For dates of death on Dr after 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) (i)], For dates of death on Dr 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) (ii)], The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and fiUng 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, ~9118(a)(I.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficianes is 4,5%, except as noted in 72 P,S, ~9116(1.2) [72 P,S, ~9116(a)(1)], The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P,S, ~9118(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, C""'~'EJ<''''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE FILE NUMBER All ~~I property owned solely or as a tenant in common must be r . between a wIlhng buyer and a willing seller, neither being compelled to bu e~o:e~ at fair market value. Fair market value is defined as the price at hich survivorshin must be disclosed on Schedul F y or se, at having reasonable knowledge of the relevantfaefs. R I w Property would be e,changed ITEM e , ea property which IS JOlnlly.owned wtth right of NUMBER 1. ESTATE OF DESCRIPTION r ~ S'TC/f't"; ~ ;PC7C?.A1' r/?/'?#C J'T,RVc?rvRc: /1t7~ ..Sf" @.ri)) L eJ(?,4 TC:I!) 14/ /3 Y ft//7 RL) .) tJl- r//6 (! Ir~ <tPr /r"/9IP/?hf' /?t/RGf. j)/lL//,,/I//V" (!'& t/A/Tr.) ?c,/Y'~frL 1/"/9~/RJ !l f/ #' cP ,.f-;::r~ JIY ~ /11' /~ L/ J; (/ T/7' 27>!..-# f2..- __ 7 c.J/;, <"Ct VALUE AT DATE OF DEATH / 2..s; 000'. 00 7/r~c P '?R,e,Pclf'Tl- .J6"C!G pc,4/T V//7 !lOOk ~ YoL 5-~ //1/ T/7' E c:P,c- r"/l:! c ;?o,< We ~ c! cJ .R IN'- ~ t:J,c Pee: OS ~~T";=/1~e.s; C' 'Tc:..> r-c,R .) j);?V P/lI,/1/" (! ot/A/Tr.J /9/V.lJ )Pc?/.fTcA'eO ?;- T#c e/T), ~r- /y/?/?.R1..t'8V/?c0 ?/P., J(//YC 12.J /~7d, t!c? /f/ ye- rc- D /6-6 J;fl?LC j)~cP.) ?,t<J~c /16' ~e~;e';;/(~/) ./ /.:::> . TOTAL (Also enter on line 1, Recapitulation) (If more space IS needed, insert additional sheets of the same size) $ 2S": 000,00' REV-1511 EX+ (12-99) _ ~.I...J:'~'~. . ~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES IItfrlr'e/< r(/,v6/f'/9 L tfoM6. I_e. 1. P{!;'t'r-cr 1'1 "--vt9 L SeR VI(!<f~.; ,eR(!U.! TI~" -I ~ 'l't/IP#1~,y~ ,Z x 0(7 ~,o (!/9.J'KcTJ I/'l9vL.ToI a '-0 THf.-t?.; j/t!'J9Ttf C:6RTIFIf!/lTt:.f {O O,Pc# ftL. t:1S" (5 ?A?J'lVCS'IT6 E/Y'tF-RI9Vc /.,tcHP.rT"""'"6 fY $, <p .; ?/lXr/l~ c:!<5..-<d6r&~J- AS.!'OC!'//1T/O........ rflCjS-; C ~A?/?V6.r /T(f, rc>v-,pt9r/",,~ .A?~_P'/i'//1 (. ~rc?/fCA/ .('o.-:r r~ovvt:A'..r1 ('/1M? 1-I/4L.J p/? / $-:2.6 FI9JTt:11? ) /?,L. eLI"Y~ r!"'A?.4/6JffS'TO ;v", r<5L.L.oWSHJJ'> $-0, a J B. ADMINISTRATIVE COSTS: /lSS'cMt!'Lr of d'-ep" (!/M1f7 Ifu"/-J ,P/? 1. Personal Representative's Commissions Name of Personal Represenlative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City ____~. _ State _ Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City__ State _ Zip Relationship of Claimant to Decedent 4. Probate Fees (! i/.# If (5 t<i' LI? A/ b (!oUft/Tr -;;f6G'IST6'1'i' eJ"" Wli,,-.$' S9- C' /f/?;vo 1/'<5/? ..,. 1f1G'!I ST., C'I9I?LIS"L€, PI?, 17cJ' /.J' 5. .6.~':'')''RtOlRt'B r888 ?/I,X TI9-rC;: /tt:Ir/?J.t> /01 " 1'19, LI/VC'oi,A/ Ir;, /fF1RRI,f/?f..JIUr. 6. Tax Return Preparer's Fees , .3',s-, 0- .EST/! Tc fi/'" T/('c- ?t/.tfL. f(' 19 T/orV 7. TOTAL (Also enter on line 9, Recapitulation) $ .>; 12.3', o C' o $' o o 'C7 ,by (If more space is needed, insert additional sheets of the same size) c_...,.....,._'~ ---~----~- --,-~:::-~~~ ,,' , " ." "" SIiIllJ.IiJ.'tV)IOR!lEMlitit F,ClR '''uN~RAt.: $e~VICE$ ANDIO~ MERCHANDISE, cOntra.Olp.; ~,~1-1€'~,.) ";1 T~;'ct~;=;'~?;~~~'\d".f January., 624:$. 29ths~..3;"'rd~:;,tw;;'i~1~j~"''''! '",,;,:/_,::,-:(CYSI6n1e~NarMt_oIall'bUY9~l (Residence 01 Individual BUY9ror placeolllusliless ileoilliJlltclal8uyer) (ZlllCQdll) anq_1.I8~~$$,il'r'- '-,L;~~lt,>l:'\lrAltra1fJ<l:.met Inc.. of 31Z5 rMllntJJ:St;:....-HaaietJUrgJ:,PA 17109 ":(Cr'fllllor-$.u'!'s1lame} IMdress oI'Sl!ller's plate of business) (llpCllde) AGREEMENT OF SALE SUbjlJct,;:t6';tl\it~rflli:~l1d"c~r'-c1ltIOi'i~~itllfJI,'w;:~iae~0--~lIandprovld" and you' ag{ee to purchase, the ~tof,"$iOn~iervlcea and/or furerel. merchandise speClfiCa'Uy en,umefittedru:ld:o't;l ',- -, " -. ,. , ' ' B~NEFICIARY / ,'j,",-; ;:~J~,];)'- :y~~~i.r~r1IY,"IO.1 ,,(MiIl.Co\ilil rt-firsphtirie,NO.\ ,(Strsel,f4drliss) lMslllng Addt8SS,Jldrllennt Ihsn Strsel Addren) . , , - ' , " , - ',(Cnr1tQW_m ',,:'>>::,',,_: ,',." '''' (81sts)-" ",',' ".,,' , '."-:,, lZijlCOde) ~"~~~Jh:~~~rii:e:u~~:~r;i~~~y~e:[~~!\t;"lh~;ler\:"BlM1ef~:clery" shall m.an t'Mperson upon whoae de~.thsuen,:gOQds a?Qd_rvic'lls"~./o be ~euver$d,. Wh;ttier , , " " STATEMENT'OF FUNERAL SERVIOES ANDIOR MERCHANDIse, SELECTED ,eh~rgf!l:~re~tY_f~~t,tt'~~"I~em,s,t:r\af;.${'~lIHdr)r:wlJ 8t.'."ul~ byIIllW'_!O use an'ynems, we will explaln:lhe rH8:on.I~:'IIrltlngbfatow,':' i.1..YQu'h.l...,.e,d !l~f~n'ledtLwH(c'I'(::~_q~lre~:~b.Ilfmt~g;aUc,h":'8; lun"ai with viewing; )'01,1 mayhavt- 10 pay fo{ emo'almlh-g. You 4o,n_othave to 'P.y'f~t el'\'lbalmlng you dId ,:hot -appi:ove-,U!OU'QI~~',_.r_rjlbg~lme.n'a::~ctl,~"dlteCt,C{SmatICln',or,lmmediate burtai..1f wlch.rged:f~r am~Il'n'na:we Wlll'8){PI'llry':Wh~,btlIO_W. '~E_~~I!:"lti"IS'i'IIfqJlltftJ)t ~1.I"/:P:~I~ltfI,a~e~!,1l'8 with IIYleWlrI,Q',_O Arral'lge/i for 'hl'pment_by_:cc:immone~ler" '. :Dll4l:IM'ed,.~ngemer;ts lhatJequlnldua 10 'hold l~e, bodi10:r:mo,~I~a!l 2'4:,"'o.tliA~P,tov~!1Q:'Tf'fl~{.tlon I, ~valla~e, or a hlJr.MeUe,IIY a~led(lont,ln$l' la not UI~ P!ovitl"'~1i.l ~b4lit1ingdoe8 lIot conlllct\lilth J8l1gI0\l8't)III~fa:or-:frnltjl.~~t:et'lTIl:~etl,ot'l.,,'/ ' .' ':-, ,,-, . ....,' '..,- ,:' Q:. f!Ut4~RALSI:Fi'Vj6~~,:~'eQuESre;9:(I~,cr~~.:til'1' p....Olltsni~-~A'. thlUugh "0" U lndrcsled) F CA8tl:A~VANC&$'f\N~' ~~~~~DAno~,iTEIlI!i: " ,', o'ttadrtlona(~II~fee "-'., . .'-0 Anatornlcal Gift Fo{ your convenlencUnd top'rpvl(:lec'c)nti!'l\.l1W of $etvlce,we ; '~Gr~~Al!lld&'-.ervlc',O"IY OM.morlal servloe will order.~d h~ndle,'paymenl:of;thefOIl~lrig items~ A~Y ...0; imtiifiid'.tltAdre-maUQn_ o Receiving Aemalns omlaslonfj 01 any Item byth'eaupp!l~rof thllHlJ:8fVlceuhall ,:~::'"O<::re(natforl"servl~II.0 ShIpping Flemaina be the suppHer'.aofu.apon.ibIUtY,T-heSellerIS_~i1ev9dOf :"-,::~_:'::'~',[)lreCt:Buri'J '_. .' ,,0 Other.. . -, ... ..' linyllablllty theraforby acting as Y9ur agent (C4Iirtaln Ch.ittgu 0, Fllt.li;.AAl :MIiFll:l~A:NQI,SE REQUEStED ~ncludsdl'" .,."oln.",. ..... through "I"" ul!>d1Wlitl May Be Estimated.) ,A"p'OP~SftI9NA~':S~"'VI~ES ( ) Copie. of Certificate at S~EA.$ ": ~rJ,~,~-~r;f~~~~~q1t4;at~'~',::.~~:,.,,-:\~-:~;.,~.;.;. -$ - so.~OO, '~~-'""'-' ,Sl.Iy".rll uytOH,u...It a~eptanc. fee;pf~:6Dr.(~f.,"\fi npt. ,?(E;Mb.~tIiT!Jlg,:Q(::ie~ijft~'Plepar~lton;and/()(' 200.00 ~"t _00 ,t:.t->,:taros'l\+Ir:' ,,", 3) 'D,~(1itar~~~r.,i'-\~t;,(' .~. '0":01:': . . ... ":",~ ......k. . ",SS W.UU -$ . . .._res~:l"lg.~es,ora' on'~n... . $cel'!"ent,o:eas. ,e\.'. S 4~~n:eral Pr'of~~SJOri~lservlces ,.;, "~,;,. $ 4.U,/.W - , Total SI;'pluneral,Olreetorand'Staff to c,otlduct'and, S 98~OO TOTAL OF APPFlOPRIAtI!ITEMS"A," THRO\JOH':F,i (jrr~ctseirvtces. '.' . "'_' '.-.... .. , .. . ., . . .. .. . ;.... . . &e 00 ClIIEOIT F"9R ITEMS,NOT_I:l~e6 toTAL "A" $ . .... CASH SALE F>FlJCE.:.:.7 ,;..,.... -",",,- ":--",,,' ".'8,FACILlfJ~S-ANtfEQUIF'M'_E,M'r ." , . 1lPrepara1,1,on,rOOfOtI!ld6,!1 t~r_ated_8tippne.& ",: ..'.;~ ',;' 2l. Baste faclllt~e. , .~~.: . ": ". ,"';"" . . ,..) ",",' .~:'~' :.. 3)'Visltat~onp~rlpd-(s), :"" ... ':.,':"" .,i .., ~ ~:'::' .-.- 4) 'Fu,ner~kh()me}or sei'Vlcea~nd/Qt'equtptna:ryt*n.d- :addltlonarumeHnvo1viild .10; 'church-servlces.- iwttfjnd8slred.. ..... ,_, . ... ....... ........ , i2991..~ S . . . .. ~ ~ $ 95.00 ~ . $ ~95.00 s . CASH SAL~-r;.~~ZA110N OF A!olOUNT FINAN.J~Z2.~oi ~DOWNPAYM.NT IP,'.dI",~,",.; by ,_~ 'd, d"" . ,o:_;.f',_~",li --3; UNPAID BAl.ANCr; gfj:C/.SHPRI1;:E(l ittinuall)',,- $; '::.' .... O~Efl()H,6._R(J~..t"CI:JJO,I~t)~MpVNT8 jil-AID:TO 'i;',' OTt'fSAS ON,'(9URl:l~:~:LF:,_',":_:, ,;;': I;, :-8' ~t nfe l"~Ut,al:tct pr......lu_mp'a1dtoo~n. . . ,,'. i-;:;j~ "lneut'lrlC'.c'cimpiny;c,' .: ....... . ,. .... . ' .: c, . '$ If. OfhfltCha't'gll!j! (Sen.eHnuat Id'tm1_lfy ~h!)'Wllll'8C.'YI PlIlyment,nd d'8crll:if purpoae): ' to for to for 5. A~O J'-iT ~1.~A~q!32 ,p.l\!!IAL... '" FtriEAAL tRUtH:IN.LEtlDltlO DISCLO$URlS" ',' . , .' " , . C,;,;,. C .'b' 'MOTOR' ~OUU:iMENT 1j~u.nera'CoaCh.'.. . .. ::t. 95.~ 1.-. !...,f'lIPW/i!r'\'~~la'~""""L'~"I,'''''~''''''_'.:''~;'{'-' ~,~\.,::~;,,- .. .. $ " .. ;t~~AAritftif~t'-rlfg~~::;:Y:'~~iit':~~f:t:~~~~I,~j'~r~%,jtf.t!<~*t~', :: ~~:;;~::~:.~~~::':'~'~:;O~;:;'~~ ::: . , ,., " '.: ,..\lllI' I...a ' TOTAL "0"& "0" ... .. _ $ 170.00- ,....^"", - -1"OT~L "B,">.., .. .. $ $300.00 ..... ,.;,;.\ , ANNUAL . auauftp ,I r - 'is -:'---",' ',:":',-,:: MEACIiIANf)I,$eC ,';O"CASKE1;TyP._-:-- '-~: $upplier-- ;Khid,.; S, Tr."'...'".....,. - ,~ " REV.1512EX<(1-97) ~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER ESTATE OF Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT ;c}?c7,Pcr<TJ- Mx" j)/9f/P/?'/.A/ e"""hvT.J;' ~ P/72- /J4T6D r6/f'..{'t/A/?;- ~ ~OCJ/. )0;J-/JI5'L6' To j)/J VPff/A/ (Jc7V/vT./" / ,li/6/lSUPcC/<' lJ/-J upf//A/ (!tJU /VTJ- (! ou A'I /Iot/JC: I//1R1f/J'CV/?&/ ,P/l, p- I cf'-/ 7"S- :(, .YIO /?/V'I j) /1.41 /!crc ;PC?/1/fl: /) ~~ .J'T/1 7C / /f/ S (/ It> /I /V(? 6- ~.IT / /PI fi JC 6'S'/' <56 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, Insert additional sheets of the same size) /. c:JS 2. cf-I' 2jq!~Le PROPERTY LOSS WORKSHEET Claim No. 5131 :331 15'6 Insured 5rIAJT;!;euf....1 Claimant Page No. Preliminary Estimate I Final Estimate Adjustor IC- L ;:;a,;7.a... Os.e '1:.1- - P. 1 2 3 4 5 6 7 8 9 Quantity Un.. U"'fP<-u Cost fa hem Description ....- . Call R . . ".+i '& ~.. < . 2.g/ 1. tJ l~CJ , , , L 'j "J. ....Ie V/)/ / k7::. SO . < q..- i 5J:1 , , , , .L , , , K.L./t2HM_ . , , , , , : , , , , , , , , , , , , , , , , . , , , , , Z- K&?-AJ:&_ Kn /a l.2 50 5(fJ I (}() b? 3~!e>o , , , , , , , , :k?OCA/lA. , , , , , , , , , , , . . , , , , , , , , , , , , , , , -3 -'? IJl') ......~ -1/ (!lkAf"..:f .3. ?O 5.12.. .1.f2.. !8( ~~~ , , , , , , . , , , , , - , , , , , , , , , , , , , , 4- 1.oR'.1 LJ .b~ I~ .'63 L.F 3 !,g 51:15 , , , , , , , &7 1/ ~{/U .J , , , ( , , , , , , , , , E ~H LMMJJW / e1I- jqc" i/e JCjr,:/o . , , , , , , . , , , , . , , 0 1-<(eR-A.", ~ I~AA L;:::' /139 1-b ~9 . . . KllJ/rF , , , II/JA _M""~/n{)N , , , I -L , ~/, (~-.:;. , , , . , , . , , , . , , : . , , I , I , -L , , -:r b ~/7~ ~ /J Ph M-e.. / ell- /;;0 &10 ,t;;6 J~ , , , , /C..f--c , , , , , , , I , , , , , , , , , . 1;';;J1L1cr ~nM , ff11 !3b , , , , , , , , "'=::-i. J-"n13LEi , , , , I/~ , 6:Jo 1tH> , , , , , , , , INb'/ - , ?71i~ , , 'LIA , , . , , , , , , . , , , . , , , , , , , tJttS71)L (;;'7Z.. < ....0~ q-~ - 5.y-- 5ttJ)? " j . , , I , , , , , , , , , , , '--"~ .JUJu... H~ ~Ol;t.- ~ 'f. {.( .i / 1IVl:? S:S J:1f1! WfJ-t, Y. -. Ie" /.LL/lrV 5"~r CO ., , , , i , , , , , , , , , , , , , , i , , , , INSTRUCT/ONS - Columns 4-9, unshaded column headings are for building or boat loss estimates. Unshaded columns 7. 8 and 9 are available for additional extensions such as deductions %. deductions $, total cost, etc. as required. Shaded headings are for use on contents or boat equipment inventories. WHITE COpy - INSURED YELLOW COpy - FILE PINK COpy - OCR FC1~7.3 PRINTE.D IN U.S.A. ''''''",''''''''. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES NUMBER I. ESTATE OF NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Si"'/4/ / -.z e U~./ J;R. FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) SO/Y AMOUNT OR SHARE OF ESTATE /CJCJ :g: ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS, A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE /Pd~?1-I ,PO 8&?X cr6.:2. 7r:f2~1 ~ /lS'?': Ah''pL <: .# /f'4/(! // e:.J 7C hl..l U/ /7. S'7:' f~3Ss 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space IS needed, insert additional sheets of the same size) ,.,. ''''l REV_1500EX{6_001 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT 280601 HARRISBURG, PA 17128-0601 16 -d.Jfc, - J;Z REV-1500 w "' :t:~U) ,,0:>: w"" ,,00 ,,0:.... ..Ill .. '" INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z W C W (.) W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) r//f/T VELY,A/ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) I?~ ~r:z~ / 'J"'VA/C IS. (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) ?'C'7 OFFICIAL USE ONLY <:!- FILE NUMBER 2L-aL COUNTY CODE . YEAR ~a27:r. . NUMBER /'Y'rt D 1. Original Relurn D 4. Limited Estate D 6. Decedent Died Testate (Attacli copyafWiII) D 9. Litigation Proceeds Received ~ 2. Supplernental Return D 4a. Future Interest Compromise (date afdealli after 12-12-82) D 7. Decedent Maintained a Living Trust (Attach copy alTrust) D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) SOCIAL SECURITY NUMBER /72 - 01 7"rf'tf'o THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER J ""?~ "'" , , r-:z:: C7"'"" , ~/ J>~ CJ (J D 3. Remainder Return (date of death priOf to 12.13-B2) D 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Seh 0) "' Z W o Z o .. Ul W 0: 0: o " FIRM NAME (If Applicable) COMPLETE ~ING AD9l'Eij,S Pe:? .(ToX d"6:2 7rP.2.1 .c. ~/1P~e ('r. #/lA/(! tltE.f'T6.R/ Wrl. ~~.?S-.s 7C' (11) ~/~ ~. 70 (12}<l / ~ 'tJ". 7,:::) (13) - TELEPHONE NUMBER Y 6t:J - <f' 7/ - .2 /6'7' OFFICIAL USE ONLY -0- (14) / ~t:? / crd"" o 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) (1) -0- (2) -0- (3) -0- (4) -0- (5) -0- (6) -0 - (7) -0 - (B) (f 6.?~<t>. s-/) (19) ~ 6S~~. Sf) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) z o ~ ::l I- it <I: (.) w Q: 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter.Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) (9) -0- (10) %'/'7'0. /?tf". # . 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) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o < I-' ::l Q. :iii o (.) ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) (i /'Y'Cl; /tJ>? 7~) ,.0_(15) ,.O't'r (16) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate ,.12 (17) 18. Amount of Line 14 taxable at collateral rate , .15 (18) 19. Tax Due 20.~ CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: STREET ADDRESS .2 .y' CITY I//1RRIS'Ct/.RG Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount ~. ZIP /7/// (1) (i /.?C'd". S-U $ /t::'S/. 3t6' . TotaICredits(A+B+C) (2) ..v ~ C'SI. 3'6 3. InteresUPenally if applicable D. Interest E. Penally (3) _0- TotallnteresUPenally ( D + E ) 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 10 request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes 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; ......... D c. retain a reversionary interest; Of............................ ....................................... .................... D d. receive the promise for life of either payments, benefits or care? ......... . .................... ..... ...................... D 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................. .................. D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ... D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .... ..................................... ..................... ............................... No o o o o o o o 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it;s true. correct and complete. Dec!aration of preparer other than the personal representative is based on all information of which preparer has any knowledge. ADDRESS PC? &x ~,t'A ~A,.t/(!HE.sr€R. 'SIGNATURE OF PREPARER OTH~R THAN REPRESENTATIVE ' W'/T. 9' 1'"$ S- S DATE .:-<~ WL.Y 0 I ADDRESS DATE . I 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 for the use of the surviving spouse is 3% [72 PS ~9116 (a) (1.1) (i)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) (ii)]. 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(a)(I)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblin9s is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ,- ..,:., "~,,~~ -~ S<.:HEDULE H f flH; \1. EX"F.Nf,fS;1. AOI\1INismAfIVC: COSi~ .1>," .....,~j~11d.QF PEN!\S ,_\,\:;~:, 'M~'TAt.Kt TM. RETl.;r.:':'~ ~ ,__ __ ,-,__Rl~~!..[1(C€cf'~~~ ~'-. ESTATE OF S , ____T/~IZC.u~ -, c"~."'-.,-,_.~=",,_o: , -~fILC; N~1IlnFR _ u. 2. ~::<? 1- ~.;z7..? $j/~4XY-A, I\el)l~ of o~denI mU'1 b. "'W.ed on SchQ~"le L -- ITElr -1 - NIJIIBeR -----~~- --- - -~ --~_.._...- p" fU~"RAL EXPoN;c, I , , , I .1~SJ.~Ri~'TIC~; i I '---r-' . I I I ! I I ! Ai~ou~n ti , ADM'i,ii;;f/,ATIYZ CUviS, I p~o..~y f,'~r.'$!;i}r:!;;"ii'i;~ rt)f""'i,,,l:~' '1 ! N"",,,'P,;,,,,,,',"P'","''''''/' _,SilL I'rl_ST l.L1Lr-,!:~C/~,)_!Jk.. ~~.l;,I'''\~h;,,;'h ;.u;;l~bri..: i ::;f\; i.'J!'i:':-_' -,1 ;~, <r: F<;'rl~l,iO' ~-,'j"~<~i L~.I:..:_L~_- ~ 7_.:'42..___ , Srr"11 <,"'~ f"t' L1.o),,--f~-l-..I__ zt2.Ift.~#..e.t. 6 _.r.,....__ ci'i.L!::liJg{fffifr6/f,_ _ _____",," ..J4::"'..I!.. z0_i.~ls-.? -0- Y':(Jjt", " "'S'-~l ?.;,.j~ Rp".:::'~OI1~lLI of (rd:I!1<.l,', 11;' lX':~';i --- I I ..._1 I I I ,I ":nl""f F<'i.',~ , ;"; ;"tr:" ;;~;on: Ii; de~d('1!t ',; "'~'Jit;'~-. 1<;., 'If ,',i; :O;'ll"',~ ~'t' i ,1"'1;1/ '" 3~,"-:;' f;' :i;'I~!il)."-'> .";'7 "':J'! .... ~J~C'; "')\-'--,-~- ~_ ,:>\6:" _... -_ ;"i) ___'" 0','''':'''; ; Au ~_, ,,' '.I~',:, ~to.:,;o '5 Tal( R~l;~ F;(;r.:,n'el .~: ~r.~' I TO~.I\L ';",;"':; '; /,~:-,_:: iil:-.; :).I{~";,;,:, t I I 1---- -,- '";",,c);~ -c:;>- __1.____ ___ ___c'-,,-,-, _,.._,u ;..i'e-. "'>- . ,;;~~:;r!(:~~,: ~>;,;,;"_,:_; ':II ',t' ",_: ~"'~ ~".." """"''''~.h I CQ\",'%W,mHCFPE""SIlVP,"',,\ I DEBTS OF DECEDENT, 1.'Ii',"TA'ICE TAX RUL;;', L' MORTGAGE LIABILITIES, & LIENS ____ R[SI1_(NT D!::CE2ENT - ESTATE OF ' ,. . -- . '-~~"~~"~~~~-"~'~-~~FILENUMBftR _____~)I.E L Y~__~1._,.frlA:'r_~_~(/~____ ___________ SCHEDULE I .2 / - CJ/-cP.<7..f .--.--.--.-. .--.,. Include unteimbursed medical expenses. --~-- - 11 EM f,'JMBER DESCRIPTIOI, A,'QUNT 1 ~cj)/e/-lL. E;r PEA/S'E /r~ /r?? 7~ _____.______ _____. . TOTAL (Aisa [::,"'!!':;r 'Jrl ;:ne ~O, R>2capltufation) (If mt)fe .,pace 1)-;;e('d(:;-in-::;n-2dd:tio~,isr,f:c(~ a/the s'a;r;-s;~'----~----~- ~ $ (~ / <ref>; Zt? .' , COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ~EVENUE BUREAU OF INDIVIDUAL TAXES INH[RITANCf lAX DIV1SION DfI-lT.2a0601 HARRISBURG, PA 17128-U&Ol NOTICE. QF INlIERITJ\NC'"E TAX APPRAIS[f1f::N r J''.[ LO\i'ANCE OR DISAttOWANCE OF DtDUCTIONS AND ASSFSSHENT OF TAX RALPH STINTZCUM JR 7821 E MAPLE ST PO BOX 862 MANCHESTER WA 98353 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04'30,2001 STINTlCUM 03-08.2001 21 01.0273 CUMBERLAND 101 REV-I,,,, H ~fp (,~-CO) EVEL YN M l -~~ _A~ou.n.j R.m'-t.~~d .l 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'; i 54'i' Ej( ',o\Fpu i 1 "':f: (j iif "NoW C E - 'oF' Yl'iHE R Ii' At{CE' YAX - 'iiP" PR/, f sEFEN r'; -A L i'OWAN'C E - OR''' --, -"", -", DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF STINTlCUM EVELYN M FILE NO. 21 01'0273 ACN 101 DATE 0("30-2001 T!.X RETURN WAS: (X J ACCEPTED AS FIl ED ) CHAt~GED ._. 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 Inten'!st (Schedule C) 4. Mortgages/Notes Recaivable (Schodule 0) 5. Cash/Bank Deposits/Misc. Personal Propet'ty CSchadulc f) 6. Jointly Owned Proper-ty (Schedule F) 7. Transfers (SChedule G) 8. Total Assets ll) 25,000,00 l2) ,00 (;) ,00 (4) .00 (5J 5,769.19 (6)._._.--, 00 (71 ,00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Cost$/Misc. Expenses (Sch~dulo HJ 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; N~nelected 9113 Trust~ (Schedule J) 14. Het Value of Estate Subject to Tax (9) l10) 5.123.64 1,052,81 (11] (12) 1I3J 1I4) If an assessment was issued p~eviously, lines reflect figures that include the total of Abh ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rat~ lb. Amou~t of line 14 taxable at Lineal/Cl~ss A rate 17. Amount of Line 14 at Sibling ~ata 18. Amount of line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX Cli.D TS: I" . PAYNENT J VA.TE rOg-l{~200i NOTE: To insure proper cre(fi t to yoUl~ account J submit the upper portion of this for~ wilh you~ tax payment. 30,769,00 (, . I 76-.<t!L 24,592.74 ,00 24,592."/4 l'iOT~: 1~, 15 and/or 16, 17, 1S and 19 will returns assessed to date. ---~T--;~~~:~C~pUE~.~YD .:~) - r' ~___~NOUN~.!~IO_.", 1 -'1 55.33 1,051.36 I . I.. _.... __ __ 'u_ __ _L .__ .._ n" _ J d. .. .... ... 1."._TA.l TAX CRE:DI~.. ".1.".'.6.9 ...1 fB:NL:~~ltDii~:_ .~~=- '. ~-jr::j f If TOTAL DUE IS LESS THAN $1, NO PAYMENT Is REQUIRED. If TOTAL DUf. IS REFLECTED AS A "CREDIt.. (eR), YOU I1AY 8E DuE A REfUND, SEE REVERSE SIDE OF THIS fORN FOR INSTRUCTIONS,! ,00 x 24,592,74 X .00 x ..Jl.Q. x (15) Ub) lln (l8) RECEIPT NUMBER .AA478162 Are N." I . IF PAID AFTER DATE INOICAT(O~ SEE REVERSE FOR CALCULATION Of ADDITIONAL INTEREST. 00 " 045 = 12 0 15 0 119J= .00 1,106,68 .00 .00 1,106,68 <,' . cor,.IMou"V[AI nl or PEN1\SrLVl\r,nA DLPAAll-,'\...~T OF PU()L1C VvELF I\ii.E CUHCJ\1J OF FINA;\CIAL Of-ofRAI IONS r8/ATl: FlfCOVEnY PR(I(;HAM PO GOx 84fl5 1i,"'.ilHISGL'nG, PA 17105'lW~'3 Hay 16, 2001 RAY,PH S'lIN'17,CUN )8~d r: HAVLE ST PO BOX 862 Ml\NCj!r~S'TEF (.'IA 98353 ke; EV.r.:IJYN STINTZCill! CIS *: 49013871-1 Co/Roc: 21/0GBl3?1 Da:::e of Birth: 06/13/1907 SSN: 1-,'7,-01-4880 Dear Vir. Stin~":',~.CLU::\: P1G-Jse be adv~sed tha.t t!J.c LJepa.::'U(U?nt of publjc L',Te] fare maintains 0- claim in '[he amount c)f $140.l_~~~~9.. ,~t9'8.inst: the above.^mentioned estate. Th.'LS cldim is f()r l~(-"stituti(1r1 of rf.edical assistaccc granted on behalf of the dr.:cedeIlc fo;:" 'I,;hich the: Pr-QbaLe EstRto :::3 no,,,, responsibJ.~~ to rClf:'lbut'se the Department. accoLding to Act 49, 62 P.S. ":.41.2, e,ffJ'"clive .7\'ugust 15, 1994, as DfT'endcd by Act ?O..q~, effectiv!::} cJune 30, 199:), Enclosed i_s the Departmellt's .:...te,":lized st{;ltelf.(;nt of claim. P-. po--ction of chis r',f~(hcal eXF',unse, n'):1iely .~--1.....2~_4.~2, was _incurred. ch;~ inv tho L:-lst six months of the decedtc:ut':..~ 2-ife; therefcHc, it is a Class 3 clalol pUr~tlant to St~ction 3192 of the Decedents, Estates, arId ?iduciuries Cod,:, 20 Pd. C.S.A. 339).(3) Th~":! balar.ce of the claim, 1k-lmoly.$_118..593..25., . c- to be entcrerJ d:-.; ;C1 prior-it,y Class 6 cJaim a\]ainst the cst~lte. Pl(~rtse ackncl<....'le,Jge rcc(~ipt 0: t:~i3 ~ettc::.:: and dd\r.ise whether the Cc.)[rJ[\O{I\^J0a)th's claIm lS admittf'd dnd 1,,,h8Tl P:iY'.Tlent ITlo.Y L,~ expected. If the c:state accountinq is c0mpletc;, ple<c;se p~uvide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, If available. c;;y."relY" -1-1 fi~dn "" / C( (.C-'A v Kar'0n 11. PetL~Lson Claims Tnv8stigatic.,rl Agent -;n-!72-6615 717.705 -3150 FAX Ell'. ; 'Jf_:urt; /lr( II: ~