HomeMy WebLinkAbout01-0274
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REV1500EXI6-!JOI..
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
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"FILE NUMBER.-----------------
INHERITANCE TAX RETURN
RESIDENT DECEDENT
o I
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NUMBER
2/
COUNTY CODE
YEAR
I-
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W
C
W
(.)
W
C
DECEDENTS NAME (lAST, FIRST, AND MIDDLE INITIAL)
UMBleE U, PEIfR. L L.
05/fo
SOCIAL SECURITY NUMBER
.;lptf - 0/
DATE OF DEATH (MM-DD-YEAR)
0:2-:('1-/)1
DATE OF BIRTH (MM-DD-YEAR)
0:1..-1;<-/t"9"1
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
AI/A
~ 1. Original Return
o 4. Limited Estate
~ 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise {d~\e of death after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy ofTruSI)
o 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1,95)
D 3. Remainder Return (dale of death prior to 12.13.82)
D 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) {Attacl1Sch0)
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E: S/t'/ELj)S.7ll:
FIRM NAME (If Applicable)
TELEPHONE NUMBER
7/7- 7t.1D - 020 <J
-~
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-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
(Schedule G or L)
8. Total Gross Assets (tolal Lines 1-7)
9. Funeral Expenses & Administrative Cosls (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
1'/5:>, Co;;! 6./1
D
o
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)
(11)
(12)
(13)
14. Net Value Subject to Tax (Line 12 minus Line 13)
- 0-
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15_ Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a}(1.2) NP/vJ: x .0 e..- (15) /VeAle-
16. Amount of Line 14 taxable at lineal rate tJ x .0 'is.. (16) 0
17. Amount of Line 14 taxable at sibling rate AlP;'/: x .12 (17) /lillA/IT
18. Amount of Line 141axable al collateral rate AlPpE x .15 (18) tf/RAlE"
19. Tax Due (19) 0
20. LJ
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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Decedent's Complete Address:
STREET ADDRESS Ci..II-/i?E/J1pNT Ntll(SIN6- ruuI ;eE#AD. &:=Nr&7f
31S" CL/h€EMP;</7 :DIGII/E
CITY eAR-US L~ I STATE ~/f I ZIP /7a/3
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
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(J
p
Total Credits(A+ 8 + C) (2)
o
3. InteresUPenally if applicabie
D. Interest
E. Penally
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TotallnteresUPenally ( 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)
C)
{/
5. If Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE. (5)
8. Enter the totai of Line 5 + 5A. This is the 8ALANCE DUE.
(5A)
(58)
{)
o
o
A. Enter the interest on the tax due.
Make Check Payable to: REGISTER OF WILLS, AGENT
~~n."Zj~~:'~~E,:t;;;k,;,";;":':;;Gfu;nt~''/J~~;;g~t&i~:M:~~~;'~~",~~~".........." f:~~~'BJ~Jd~\iJ;'~ lIII!IJ't!'I~
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;....................... .................................................. . 0 IZI
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 12(1
c. retain a reversionary interest; or.............................................. . ...................................................................... D ~
d. receive the promise for life of either payments, benefits or care? ........................................... ....................... 0 ~
2. If death occurred after December 12, 1982. did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D e8J
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ~
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 penalties of perjury, I declare that I have examined this return. including accompanying schedules and statements. and to the besl of my knowledge and beliel, it is true. correct
and complete.
Declaration of preparer other than the personal represenlalive is based on all information of which preparerhas any knowledge.
DATE
3-1-<!>~
/J1E(!#/f/Y/CfL3wI€'0 AI /7~.5S-
DATE
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ADDRESS (!NA.€L.€$.E; hI'/.Ef'ZL).$-or
.:;. C!.Lt>kS,se /f?I>- J $cC'h'/f/Y/C.f,6uA?6-,;<7,., / 7iP SS""
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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 P.S. 99116 (a) (1.1) (ill.
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)].
The statute does not exemDt 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. 99116(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. 99116(1.2) [72 P.S. 99116(a)(I)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503Ex+{1-971
*'
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
UfI1BteELL, PEltI<L
1-.
FILE NUMBER
.;11- 0 1 - ;aL/
All property jointry.owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
/0 ShartS of lYIeJ-L;Fe ownush;p l{.n;t.s.
(see CDpy or .jfa}ement CUt'; fJNcee.Js cA:d( af/ached)
'+0/.:<,(00
TOTAL(Alsoenteronline2,Recapitulation) $ .51.;'. Go
(If more space is needed, insert additional sheets of the same sIze)
. ................ ......L.... I....U. .....QI'C" r I V,",(;;'C"U" ,"",tCl.ol:\. 1~ ""'....d.Il..:IIt::U
V\ooV'~.-..... ..~
I3r<OKER'S Name, Addre~s. ZIP Code. Federal Form 1099- B Proceeds From Broker and Barter
[dentiJ'ication NUlllber and Telephone Number: Exchange Transactions
copy B FOR RECIPIENT
Mellon Investor Services "'IMPORTANTTAX INFORMATION"" U.S. INFORMATION OMB NO.
85 Challenger Road This is important tax information and IS being furnished to RETURN FOR 2002 1545-0715
Ridgefield Park. NJ Cl?GGO tll" lml'.rna\ Re~enue Service. If you are required to Hie a
2n3G7522 return. a negligence penalty or other sanction may be la Dale of Sale Ib CUSIP Number
]-800-649-3593 imposed on you if this income is t<lXabJe and the IRS
determine:> that it h3snot been reponed. 02/l412002 59156RlO
TO WHOM PAID 2. Stocks, Bonus. etc. 3. Bartering
$312.60
John William Umbrell 4. FEDERAL INCOME TAX WITHHELD
Est. Pearl L Umbrell
cia Charles E. Shields III Esq ~o nn
6 Clouser Rd. } D Gr05spro~....d'lessCOllHlli"ions
Mechanisburg, P A 17055-0000 REPORTED aud oplions premium,
Toms
D Grossproc....ds
5. Description
Metlife, Inc.
Investor 10 RecipJem, ldemificallon Number on file
806791233848 25-6768789
TRANSACTION DETAIL
Date Description Shares Sold Sale Price Gross Proceeds Tax Withheld Net Proceeds Trust Interest Balance
($) ($) ($) ($)
Balance 10.0000
02/20/2002 Shares Sold 10.0000 31.2600000 3 \2.60 0.00 312.60 0.0000
.... IMPORTANT TAX RETURN DOCUMENT ATTACHED ....
YOUR ACCOUNT HAS BEEN CLOSED. THE A TT ACHED CHECK
REPRESENTS THE FULL VALUE OF YOUR ACCOUNT.
Retain this number for future reference:
Investor ID: 806791233848
For information concerning this statement, call MetLife, Inc.'s Transfer Agent,
Mellon Investor Services toll free at 1-800-649-3593
SFULL(8-0!l
PLEASE DETACH ALONG THE PERFORATION
rHE :o,\c:,: OF- THIS DOCUMENT HAS A llLUE BACKGRCUNO ON WHITE PAPF.:R rHE SACK OF THIS DOCUMENT CONTAINS AN ARTIFICIAL WATERMARK. HOLD AT ANGLE TO VIEW.
F 1J219 0000252
.MetlHe'
Description: Sale Proceeds
Check No. 00232926
50-937
2I3
Check Date
02120!ll2
Investor lD
80679123 3848
Pay
....$312.60
Pay 10The
Order of:
John William Umbrell
Est. Pearl L Umbrell
CIO Charles E. Shields III Esq
6 Clouser Rd.
Mechanisburg, PA 17055-0000
Payable at
Chase Manhattan Bank, Syracuse, NY()r
The Chase Manhattan Banl<, New York
/fJJIfl ~~
Authorized OtTicer Signature
lI'00232'12bll" ':021.30'137'11: bOj,S'1200'111"
",,"~"'."':I.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
IA M 13 re. e-u.., (J"/fte L 0
FILE NUMBER
:t./-o 1_ Z7lf
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
Clo.r<''''or\t Nu.t^s;Y1d _d aeh.b;/;f-.../,"P", Center / Gu~st Fund
;4eCbunt l3aJ,."ce as of /tori; do' .do
(see sra.tement atfa&h...I)
De.c..Ju.t cI;e.d :1'] N/J.O'"s;",1 HDrne <W.J ha.d ~f ve;" awcur
at! VIer +CLn3; br.. (JuSona. f1.y IVl'JJ beio ~ 0
VALUE AT DATE
OF DEATH
1T
J/380.7'1
TOTAL (Also enter on line 5, Recapitulation) $ ',3 8'0, 7 q
(If more space is needed, insert additional sheets of the same size)
71 ?;:'43C::,:,r:,3 CLII'\B CT'-( l',jUR;c HiJl'iE
366 POL'{)2 r"lR"'r" 03 ~01 14:26
Claremont Nursing and
375 Claremont Drive
Carlisle, PA 17013-8805
Rehabilitation Center
main (717) 243-2031
Fax (717) 240-1952
FAX
DATE:
S-/3/0 /
TO:
Pot f r i c i c1
ORGANIZA TION:
c.;, 0. r- le.5 c!',
Sh ;-,<-Icls ;:zzr
FAX NUMBER:
7Js- 7Y73
FROM: z VQ-/~6 1/' CLAREMONT NURSING & REHAB CENTER
Oek""""- tf'", ",,01 BUSINESS OFFICE--FAX #717-240-1934
INCLUDING COVER SHEET:
2- PAGES
MESSAGE: c.r.-'II;'" FVhd' //(('"",.--.1 6...1",,,,,,1' 01,)" rl' f?1'{~I-'I;
r..pi r...-r; "'" dI..,rf!,
If there are any questions regarding the material you receive. or you do not receive all the pages, please
call back to sender as soon as possible.
-CONFICENTIALITY NOTICE"'-
This information contained in this facsimile communicCltion is intended only for the personal and
confidential use of the re.cipient named above. This communication may contain confidential or privileged
informCltion protected by law. If the reader of thiS communicCltion is not the intended recipi"nt, or any
age.nt responsible for delivering it to the intended recipient. the reader is hereby notified that you have
receive.d this communication in error, and that the review, dissemination, distribution, oopying of this
communication or taking any action in reliance of the contents of this communication is strictly prohibited.
If you havEl received this communication in error, pl....se notify us immediately by telephone and return the
original message to us by mail.
THANK YOU
A service agency of Cumberland County
717243:',363 eU~1B err' ~IUF5E HonE
366 F'0.2 0.2 11A'i 0.3 'iJl
FolC;
~ldr~mont NUrp~~g ~ ~~~~b Cn~,
R~.!Iic.en!;. 1\'\:".,101 Hi~eory Ro::.port.
p.;:l'l.cajYe.sr FrQm; 0;;:/2001 Period/Y....ii~ T:lr..~ 02/';:001
[PM?:>)
R\ln Di'te 05/:)j/O~ 'Ti.me; ~.::t~ VI<',
Reter~n~o;;
Type T1''''rl.
Y~~r P~r R~n'Diite
JOl.:nl
Number F~~~ Cod~
0\31;;.o1:l1tll r::lpl".....U'Bc:\nelltt:l
Descript.ion
elL Al;'9t-
P.:ltl!l
Umbn~l1, 1",,"-1:1 L.
AOl';'l.Ltlrilion O;;ste; (I1/1,O/l'~'J
355Q
M~dicrd.d tD:
l',o;J8 ID:
E1;o;lOlnce B/f 1, ]l':l~ Z9
'lOOt Cl oM1.'O/2001 ,"0 (J~/1SnOOl 311)-45 G OTHMED BROWNS.W!A $ATTERIES
~OOl 02 03/0:1/2001 RPJ 02/28/2(101 F'EBOl G peA tt.i8I DEN't' CARE ALLOW
2001 " :>3/02/2001 R;&\T 0;:/28/:,001 FEBOl . IN'T'OU'I' INT3RIl:S'1' CUi: TO CNRC
:<:001 02 o:UOS!2001 RFIN"I' 02/::8/':1001 G ~NTER IN't'ER2ST :NC ~o ~,ES
2001 " >)3/05/::001 "J c~l~al.2001. FF.~Ol G OTRP.1,:!l KtIMeORS:: OTHER .EO
f.I.'10
- JO, 00
~ os
.4.'2
~ 8. 50
. Re9~dent Totdla
.42
- ~ 7 , '15
1, 36 ~ ,2 ~
. i~~ility Totals
-:':7 95
1, JQ9. 29
. "
14:27
POlS'''''
~o:d~nG9
~ r ~v9,;::'
(-- ---',
, : I )~O ,7!1 ~
- -'- ~ ~
L,01.10.7'j
.., "OB, 74
1,409.16
1,417.H
1,417 ~G
1,..1"',1\6
'''''''''''','',9''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
UII18JeEU, flEIML
FILE NUMBER
..1.1-01-.:l7<f.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. 13"1,,.c. d~ wer _.l "10,.,, prql"yed """o",,,t '7'15.00
(SlJ.OO .. fir H{)~ )
for Tues. "':Jilt III e(.lJinJ a.J 9:,- .0'0
8. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions .
50h" w. u.... breI! .:J~o, 00
Name of Personal Representative (5)
Social Security Numbe~s) I EIN Number 01 Personal Reprasentative(s)
Street Address (" 1.3 /I Geneva Dr;lIe
City /YJCe-h C&.ni csb""rJ State Pk Zip /70SS-
Year(s) Commission Paid: :200:2..
Char!~s € .5h;e-/e;!S EL fC
2. Attorney Fees 575.00
3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation)
Claimant /Vp",t: /!/tJ,vc
Street Address
City State lip
Relationship of Claimant to Decedent
11
4. Probate Fees -" sl,.~t cerr;h'c,,1e~ $/.')0
5. Accountant's Fees J ~1S'''. 00
R.but t%.rk, PMhl;. fkcount..nt, e/..$<:--1 ren.rn,..ti
6. Tax Return Preparer's Fees [~e~erve&J J.
7. ~ dtI; {,',,/al Jelll{, cer f " (CIA. ms %
7li. tle"h1j,lirs~qte,tf ~ {,IiIlS, R: Slue/cis ~r cuff I1/A//'1J~ azph!S-et ~ 9. Do
8.70
~. Ifdr'ufisin!l a1 &",1. kJ// .);"r".! "
75,DO
'1, ,4t/yerf;SiRJ In /t.fripf 1J1ef1.,-M~f " 7:l.Df
fIT. F./:7 f,,1,. /A)l h4,." ,.
/0_ #&J
II. n /, n., A eJ!o/fllh1/ (,,,/,;,,) "
1/ O. 00
TOTAL (Also enter on line 9, Recapitulation) $ 1, 555. '19
(If more space is needed, insert additional sheets of the same size)
,REV.1SI<EX"{1-97) ~
'~
'~~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF Uh7/3I<ELL, ;1EIf/l L.
FILE NUMBER
;<./ -01- :?7<f
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
Dept. of Pub, toelfare
~
Clo.s 3 ~ 17,8:l1l.9Z
~
C/.ss ,,= J~, ~'1I.Zo
DESCRIPTION
(!J a im.s
AMOUNT
f" foJ
t-
/59,070,1:?-
(see k&r aIfAChea")
TOTAL (Also enter on line 10, Recapitulation) $ /5 </, t! 70. /2-
(If more space IS needed, Insert addltronal sheets of the same size)
*'
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF PUBLIC WELFARE
BUAEAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PAOGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
March 22, 2001
CHARLES E SHIELDS,
CHARLES E SHIELDS,
6 CLOUSER RD
CORNER OF TRINDLE
MECHANICSBURG PA
III
III ESQUIRE
AND CLOU
17055
Re: PEARL UMBRELL
CIS #: 710136109
Co/Rec: 21/0079773
Date of Birth: 02/12/1899
SSN: 204-01-6516
Dear Attorney Shields:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of 5154.070.12 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely 517.828.92 was incurred during
the last six months of the decedent's life; therefore, it is a Class 3 claim
pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20
Pa. C.S.A. 3392(3). The balance of the claim, namely $136.241.20 is to be
entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. rf the estate contains
real estate, please provide copies of the deed and the latest tax assessment.
Sincerely,
'-J\~ I!..L
Linda Price
Claims Investigation Agent
717-772-6741
717-705-8150 FAX
Enclosure
"",,,m,,,.,,,.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
um8/(e<.c.., jJefteL
L.
FILE NUMBER
21 -01 - :2.7,-/
AMOUNT OR SHARE
OF ESTATE
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
.,.),,~t1 W;II;a.M Llmbrell
613A- Geneva Dr.ve, //pI: /p
/J!e~hpl1/t4Ht~, r?/I I7{)SS-
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
NUMBER
I.
50"1
(?iO .-%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET I S
(If more space 1$ needed, insert additional sheets of the same size)
.----r.~
...........~
" -::o-~.;.~..
Register of Wills of CUMBERLAND County, Penn~
Certificate of Grant of Letters
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No. 2001-00274 PA No. 21-01-0274
ESTATE OF UMBRELL PEARL L
lLA::i'l', l'~K::i'l', J.YJ.~U1JL.r.;J
"I' "
e"t,
c
"
Late of
MIDDLESEX TOWNSHIP
CUJ.YJ.tj~KLAl'41J CUU.N'l'Y,
.'-..
Deceased
Social Security No. 204-01-6516
day of March
2001 an ins'
WHEREAS, on the
jated september 20th
13th
1996
Nas admitted to probate as the last will of UMBRELL PEARL L
(LA::;'l', r il(::;'l', MilJlJLt;)
late of MIDDLESEX TOWNSHIP
,
CUMBERLAND County, who died on the
24th day of February 2001 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, MARY C. LEWIS , Register of Wills in and for
the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify
that I have this day granted Letters TESTAMENTARY
to JOHN WILLIAM UMBRELL
Nho has duly qualified as Executor(rix)
and has agreed to administer the estate according to law, all of which fully
appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF,
of my Office the 13th day
I have hereunto set my hand and affixed the seal
of March
2001.
~e.~ jkm
glSter~1ii~'
**NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE)
~J6...-uZ;C;
August 16, 1996
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of Pe.a rl L. Urn hY't-/1 No. :1..1- 0 J - ~ '7 '-f
also known as To:
Register of Wills for the
t Deceased. County of C l.J-<'h luvl Q.k\. d in the
Social Security No. . f , ] ~ 1,:~J e:?tJtf-~/-~S'/1, 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 executor""
in the last will of the above decedent, dated ~ 1'1 bt__ be-r d/O
,
and codicil(s) dated
named
, 19~
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in C (1 m kr-J t:uY1Ll County, Pennsylvania, with
he..; last family or princ~al residen~ at C la....ernDl1t N~~;~ t R~ h.h. Ct!rrk,..
3 S ('JaruvJf);}t .Pr/r!, -br/,'s/e 1?J~'dd/"e,,-x ?;v~) ~ / 013
(list street, number and muncipality)
Decendent, then II) 2 years of a~e, died
at 375 Claremont DRive,Carlis~e, PA 17013
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}? ~ tf.
,)h J.001
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ 'J J ~ S60. ,,-
$
$
$
WHEREFORE, petitioner(s) respectfully reQ}lest(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters -re.~tQ.Menhfrl
(testamen ary; admInIstratIOn c.La.; admInIstratIOn d.b.n.c.La.)
theron.
"""
13 ~~ lilc~ ~/LB(
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA } ss
COUNTY OF c..u ~ I3creLA.A.tP
Mary
ReOl
/~ -~/~ -/3-
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 abov.e decedent petitione.r(s) will well a~d 9flY administe: the estate accjrding to law.
Sworn to or affIrmed and subscnbed 'i/'-~ i~ "''''- ~Au.t{ '"
before me this 9th day of c- - ~.
M h MX 200 1 ~
t=
~
~
~o. 21-2001-274
Estate of
Pearl L. Umbrell
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW March 13, D2001 , 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 September 20th, 1996
described therein be admitted to probate and filed of record as the last will of
Pearl L. Umbrell
and Letters Testamentarv
are hereby granted to John William Umbrell
FEES
'. ~/M
Mary C. Lewis. /
Reg~ster ot Wllls
Probate, Letters, Etc. .........
Short Certificates(3 ) . . . . . . . . . .
Renunciation ................
x-Pages (-0-)
JCP
$ 25.00
$ 9 . 00
$-~
$. 5.00 ___
TOTAL _ $
Filed ~p.~c;l:1..1.3 & 200.1. . . . . . . . S. .39...aO . .
A TTORNEY (Sup. Ct. I.D. No.) 3 RSG
~ ~/{Se.r Rc( /Jfe,d;MI'cd~/1. r'-f' 111 /10S0-
ADDRESS 0
7/l-7~6 ~CJ ZtJ f
PHONE
MAILED LETI'ERS AND ORDER TO A'ITORNEY
21-2001-274
REGISTER OF WILLS OF CUM'(;t;1eL,4AJD COUNTY
OATH OF SUBSCRIBING WITNESS
Cf./I/-JtLEF's e. SHIi:'ZI>S 7lI:
eeaisil.
~) a subscribing witness to the will presented herewith, (~ being duly qualified according to
law, depose(s) and say(s) that IIG" wlf-J present and saw
~19,eL L.. tlA18,fE"L.L.
the testatrix , sign the same and that HE' signed as a witness at the
request of testatrit..-.. in hU'" presence and (in the presence of each other) (in the presence of the
other subscribing witness(es)).
me this
~~//p~~
CJaarks ~ Shield~Name)
, ~It,u.s~r RaI~ /I1~cllIt/1/C.SbU(J " //A /7IJs.r
(Address)
(Name)
(Address)
/,/'/
REGISTER OF WILLS OF CQHNTY
OATH OF NON-SUBSCRIBING WITNESS
to the best of
knowledge and belief.
Sworn to or affirmed and subscribed before
me this day of
19_
(Name)
(A ddress)
Register
(Name)
(Address)
21-2001-274
REGISTER OF WILLS OF COU
OATH OF SUBSCRIBING WITNESS
//
///
//
,
codicil //'
(each) a subscribing witness to the will presented herewith, ~ch) being duly qualified according to
law, depose(s) and saY(s) that // present and saw
//
,/
the testat , sign the same and that / signed as a witness at the
request of testat in h presence and~ the presence of each other) (in the presence of the
other subscribing witness(es)). //
/'
Sworn to or affirmed and subscribed be.f6re
me this -zfy of
/19
/
/
/
//
//
(Name)
(Address)
Register
(Name)
(Address)
21-2001-274
REGISTER OF WILLS OF (] LI h1 t3s ~L'i-/II./) COUNTY
OATH OF NON-SUBSCRIBING WITNESS
JI)I/N W/LL/,4m uhl8te.e7-L
1eacht a subscriber hereto, ~ being duly qualified according to law, depose(s) and say(s) that
fiE: IS familiar with the signature of flMeL L. umL:J/?e:z.L.
"f:odicil
testatr,'x of ~ne of the stlb!Cribiag witats3C5 to) the will presented herewith and
codicil
that IIG believes the signature on the will is in the handwriting of
;2arRL L. Ul1IdR.CZL
to the best of 6.l's knowledge and belief. ! / J , ,. I. ? i ~_ _ J. 1/
Sworn to or affirmed and subscribed be'ore -f f:v,,:, ~~ __ /7'I'YVVIL- '-,
me this 9th day of " W/!/IQ/h /t/hiN-eI/ (Name/
March ~ 2001
(Address)
(Name)
(Address)
This is to cerrit}, rhat the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original cerrificare will be forwarded to the State Viral Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
Ai~t~"otPE~
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~
Fee f()(' this certitlcate. 512.00
,
P 7285106
,;2 ~;)~-~I
Date
21-2001-274
HIO$.:4J fIeof 21117
COMMONWEALTH OF PENNSVLVANIA · OEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
rPIIPfllNT
IN
MAHUfT
LACIt ..
NAME 01' DECEDENT lfor.. _. ._
1. PEARL L. UMBRELL
UNDER' YEAR
- o.ra
SEll
I. Female
S,,",.,..._II
SOCIAl SECURl1't ~8ER
3. 204 - 01
DATE OF OERH ........, 0... ._.
..February 24" 2001
Claremont Nursing & Rehab.
N.
ICINO 01' IUSlNtSS/lNOUSTRY
MS DECEDENT EVER W
U.5. AAIotfO FORCES?
-.0 NoGJ
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UNDER , 01/1/
-- I..........
1lRT~ 1<:..., _ PI.ACE 01' DERH K:l'<<;1o OI"Y """.. _"'UCWM en _ _I
s.-", ."'_ CCJljMY! HOSI'ITAI.:
Shippensburg, P 0 E~ 0
7. ...
FACIlITY NAIoIE (1"",_. ~ ....___,
'2.
17a.S- PA
IoWlITAL SWUS ..........
_Mernecl.~
o-c.cI~
,f.li dowed
17JO -..__
RACE. _ -.llIID. WhIle."
~
,k-bite
SURVMNG SPOUSE
lII-.gooe__
17l>.
':CUMBERI.AND
0llI
......
... II a
"""1
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2t~lawn Mem. Gardens
NAME AHDAOClAESSOl' MClUTY
ER-WlEOEl'JAN FH, 2.%d &
lICENSE NUlil8ER
PA 17109
PAl7lO4
24.. I ~'. 30 1':1"'1... - .;. '4-0 ,
'111. MIlT I: ~..._ ....."'~__........... 00 _....... _ot dyWoo. ..........._01 rupr-v.... _ or...an.....
llaIOIII1f_ _Oft_.....
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DUE lO lOR AS ACONSEOUENCE Ofl:
Lot'QN~"'t" ;O-~\..,.. D')~....!>C
DUE lOlOR AS ACONSEOUENCE Ofl:
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DUE 10 lOR AS A CONSEQUENCE Ofl:
2e.
,~
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MAT ..
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.... r-*'lI ill... ......_.....IaIWrrL
MAE AU1CI'SY I'lNC*GS MANNER a1 OERH
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OI'CAUSE ......... fill
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Acodaool 0 "-" ............
...Q!l -.0 ...11!f ~ 0 CouId......._
DATE 01' IN.lURY
(Uanal.o.,. -I
TIME 01' INJURY
INJURV 111 WORIC1 DESCRIlIE H/CNfIINJUfl't ClCCUMED.
2110.
cmn..-.o-....,_
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..........,~--.....---....caoooacoI-_-_.................,.............. ................. ....
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o PlACE 01' It&JUAy. A1_. _. _.IIlClOly. Olllce M.
llo-.g..... ~
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"MEDICAL DAIIINeJtICOAONEA
On"'''' 0I.._1oft attd/OI......sUgatiM.ln my 0jIIni0n. deetl\ occurred at 1M 111M. dale. ..... pqca. ..... d..e'o .... _Mf.l_
-....-.......... '" ......... .......... .... ........ ........ ..... ......... ...... .... ....... ... ..... .....
31L
REGlSTRAR'S SIGNR\IM AND NUMlIER
I :4..2 ~"A."?! -
l"O~
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,...._.....,-~.-.._.............,..-...... __....c...c..____.,....... .......................
38.
C'I
E
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Pearl L. Umbrell
Date of Death: February 24, 2001
Will No. 21-01-0274
Admin. No.
TO THE REGISTER:
I certify that notice of beneficial interest 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
March 21,2001:
Name
Address
John W. Umbrell
613A Geneva Dr., Apt 10,Mechanicsburg, PA 17055
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: March 21,2001
~~~~
CHARLES E. SHIELDS, III
6 Clouser Road
Mechanicsburg, P A 17055
Telephone: (717) 766-0209
Counsel for Personal Representative
~ / ~c;l/6 - 13
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
CHARLES E SHIELDS III
6 CLOUSER RD
MECHANICSBURG
'02
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
04-15-2002
UMBRELL
02-24-2001
21 01-0274
CUMBERLAND
101
FlPf; 19
: ? :15
'*
REV-1547 EX .FP (01-02)
PEARL
L
PA 1 ~g.!i5
Cllr:~~
Allount Relli Hed
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--fol-':o2j--No;--icE--oF-'rNHEifiTANci-YAX-APPRA-isEiiENT~--ALi-oWANCE-ifR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF UMBRELL PEARL L FILE NO. 21 01-0274 ACN 101 DATE 04-15-2002
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)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
312.60
.00
.00
1,380.79
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subiect to Tax
(9)
(10)
1,555.99
154.070.12
(11)
(2)
(3)
(4)
I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
IS. 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. Allount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
NOTE:
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
1,693.39
155.626 ]1
153,932.72-
.00
153,932.72-
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 =
(9)=
(15)
(6)
(7)
(8)
.00
.00
.00
.00
.00
t"A Tnl:l'fI KI:l;I:~t"1 (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN 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" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
.
n ~,i (
o oY\
..
I
'.
STATUS REPORT UNDER RULE 6.12
Date of Death:
PtALt'1 U I11h r!-II
,9/ d'-l /v I
Name of Decedent:
Will No.
Admin. No. .;LoOI-&027tj
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 )Z 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 X
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes X No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date: /-(3.-/')J
~f'~Jjf-
Signature
C4arks E. S4,'dd>Jit
Name (Please type or print)
~ e/ott5er Rtf /J!echlln'~shu.a,tJA 17pfr
Address
(7/7) 7t?f&, -~?o9
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
.I
-
Date: 1/06/2003
JOHN WILLIAM UMBRELL
613A GENEVA DRIVE APT #10
MECHANICSBURGI PA 17055
RE: Estate of UMBRELL PEARL L
File Number: 2001-00274
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. I, for decedents dying on or after
July 11 1992, the personal representative or his counsell 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: 2/24/2003
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
cc: .1 File
Counsel
Judge
LAST WTI J. AND TESTAMENT' OF PEARL J.,. UMBRP.1.1 ,
21-2DDl-274
~
I, PEARL L. UMBRELL, of Bethany Towers, Mechanisburg, Cumberland County,
Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish
and declare this to be my Last Will and Testament, hereby revoking and making void any and all
former Wills by me at any time heretofore made.
m
'1
"
':#
",
~
~"'.
1.
I':,;
:3,
i
~.
1.-:.'
r
I direct the payment of all my just debts and funeral expenses as soon after my decease as
the same can conveniently be done.
2.
All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and
wheresoever situate, I give, devise and bequeath to my son, John William Umbrell. In the event
he predeceases me, then in equal shares amongst my grandchildren who survive me.
I
,
1:',
,
3.
,-,;
11
i:
r'
~
~,
I nominate, constitute and appoint my son, John William Umbrell, as Executor of my
Estate. In the event that my son is unable or unwilling to act as Executor of my Estate, I nominate,
constitute and appoint my granddaughter, BARBARA UMBRELL, as Executrix of my Estate in
his place and stead. I direct that my Executor shall not be required to file a bond to secure the
faithful performance of his duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 2Pg day of
~.
, A.D. 1996.
(J~;t, ~
PEARL L. UMBRELL
(SEAL)
Signed, sealed, published and declared by the above-named Pearl L. Umbrell as and for
her Last Will and Testament, in the presence of us, who at her request and in her presence, and in
the presence of each other, have hereunto subscribed out names as witnesses.
(?;tAb~ E ~~
~-if"1ALL
August 16, 1996
~.~.""""r'T"~..<'.".;T.""",'_'"
'~~~~-:-'.~--::":"F"'7'_:":~-;:---;'--
, .
.