HomeMy WebLinkAbout01-0303
PETITION FOR PROBATE and GRANT OF LETTERS
l3~ffY ~7AI.J~ 1/ Aile, No. rfU-(J 1- 30...3
To:
Register of Wills for the
Deceased. County of ('0;1( ~ EI? I.AItII.l in the
Social Security No. / 8 ~ - IG ~ 0 (.:"> 5 7 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 execut oR.
in the last will of the above decedent, dated 1'2- ~ EM u I') jQ y
and codicil(s) dated
Estate of
also known as
named
,19~
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in
h t;. ~ last family or principal residence at
o t..L c~ /.Up
Decendent, then 77 years of age, died ft) liKe HID , K 2 00 I,
at f'eft~'1 CI/t.I-l<iGc /V()~fllVc; HQ/OfC. A/~W bt-oOrr4P!EJ..d PA..
,
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:
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:
$ ~.~eQ.DO ~
$ /~J O()o. VO
.
$
$
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters TESTAMENTARY
theron.
(testamentary; administration c.La.; administration d.b.n.c.t.a.)
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA t ss
COUNTY OF CUMBERLAND 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 ad inister the estate according to law.
en
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SWom to 0' affitm~ and 'ub",tibed {
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/ Reglst r
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No. 21-01-303
Estate of BETTY JANE HAAG
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW MARCH 20 , 2001 f9C_. 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 FEBRUARY 12. 1982
described therein be admitted to probate and filed of record as the last will of
BETTY JANE HAAG
and Letters TESTAMENTARY
are hereby granted to JOHN HAAG
'-fT)?~ (l. 'i.tJJ~~ 'rh . t!/j .1jCKI-h,,,/iJ? p~~
Register of Wills
FEES
Probate, Letters, Etc. ......... $ 50.00
Short Certificates(~ . . . . . . . . .. $ 3.00
~ ~ArE4\. J'.G.S . . .3.. $ 9.00'
JCP $ 5.00
TOTAL _ $ 67.00
Filed . ~ql. .4Q, . :Z.o.Q t . . . . . . . . . . . . . . . . .
ATTORNEY (Sup. Ct. 1.D. No.)
ADDRESS
PHONE
MAILED LETTERS AND ORDERS TO EXECUTOR MARCH 20, 2001
.......~
HIOS.80S REV 91R6
This is to certifY that the information here given is correctly copied fro~ an original certificate of death dul~ tiled with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
No.
af;~' ,~ ~~
Loca Registrar if
p
7178565
t'iAi~ 1 3 2001
Date
:43 Rev 2/87
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
NAME OF DECEDENT lfltsr, ...-. l_J
..
SWE F'lE NUMeEA
------ SEX--~SECURrrvNU"8ER ---ro.TeOFOEATH....... Do,. ....)
a. ,-L.u.4 - 16 - 005~ /0 Gloor
ORE Of' IIIIlTH 1IIIlT~ lC.... _ PlACE OF DEArH ,0-.... """ n _ _............. _ _I
.-DIy -, SlIfooof",_<:ounuVI HOSPITAl: OTHER:
'-'- 0 :t::" ~ =:...., 0
7. LewL!ltown PA .
FACl.ITV NAME eM not IRSI1UItOn. 0114 SIr", and numblfl
Wh.i.te
SIIRVIV1NG SPOuSE
Ut_.Qn4~~
420 AUendai.e Way
... Carn HiU, PA 17011
FllJHER'S NAME JF"... _. LaoI)
II. EimVt F. ChaJr..f.e-6
INFORMANT'S IloWE (TypoIPriro)
M1t. John Ha.a.
IotETHOO OF llIS1'OS1TlOH
O - 0 c.-.lJ -_SIIl.O
- ou...(SpkoIyI
...
-.vuRE Of' IREAAL SERvICE
......
IV ;Jco/
TIME Of'
INJURY R WORk? DESCRIBE HOW INJURY OCCURRED.
o
o
o PLACE Of' INJURY. AI....... ..'m..............,._ ...
buiIding,.... '-oIy\
:100.
- 0 ...0
plll p( ,/ ,/ I
-PfIONOUNCING AND CERTifYING PHYSICIAN (Phyac.." boIh PfOl'lOuflClOQ lJHIh .00 cen.fVV'IQ 10 cause 01 death)
ro.........of"'.,kno....... .......OCCurre4.IIhe..... .....Met ptec.. .......to....cauHt.).nd m.nner.....Ied............'.....
'IIEDICAl EllAMlNENCORONER
on......... oI..amin..lon and/or Inv..'igation. in my opinton, d..th occ:urred .. the lim., date, and placa, and due to the uu..(a) and
............ "ated.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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REGIST
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21-01-303
LAST WILL AND TESTAMENT
I, BETTY JANE HAAG, of the Township of Lower Allen, County of Cumberland
and Commonwealth of Pennsylvania, being of sound and disposing mind, memory and
understanding, do make, publish and declare this as and for my Last Will and
Testament, hereby revoking and making void all former wills and codicils by me
at any time heretofore made.
FIRST. I order and direct that all my just debts and funeral expenses be
paid by my Executor or Co-Executors, as the case may be, hereinafter named, as
soon as conveniently may be done after my decease.
SECOND. I give and bequeath my automobile and personal effects and such
household goods as may be my individual property and not the property of my
, us band or owned jointly by me with him, and other tangible personalty of like
nature (not including cash or securities), together with any existing insurance
thereon, unto my husband, JOHN HAAG, if he survives me for a period of thirty
(30) days. Provided, hm.]ever. that if my said husband shall not survive me for
a period of thirty (30) days, then I give and bequeath such tangible personalty
""
and insurance thereon unto my two sons, JOHN A. HAAG and CHARLES L. HAAG (or to
the survivor if either is not then living), the same to be divided between them
by my Co-Executors with due regard for their personal preferences in as nearly
equal shares as possible.
THIRD. I giVe, devise and bequeath all the rest, residue and remainder of
my estate, real, personal and mixed, whatsoever and wheresoever situate, unto m
husband, JOHN HAAG, absolutely and in fee simple, if he survives me for a
period of thirty (30) days.
FOURTH. If, however, my husband, JOHN HAAG, predeceases me or fail to sur
LAW OFFICES
SNELBAKER. and bequeath all the rest, residue and remainder of my estate, real, personal
McCALEB 8< ELICKER
vive me for a period of thirty (30) days, then and in that event I give, devise
,.
and mixed. whatsoever and wheresoever situate. in equal shares unto my two sons.
JOHN A. l~G and CHARLES L. I~G. share and share alike. absolutely and in fee
simple.
Should either of my sons not be living on the thirty-first day after
my death but have lawful issue then living. then I order and direct that the
share which any deceased son would have received had he been then living shall
be distributed unto his' said lawful issue per stirpes. said issue to take the
ancestor's share by representation and not per capita.
FIFTH. I nominate. constitute and appoint my son. JOHN A. HAAG. Guardian
of any property which passes to any minor issue of my son. CHARLES L. l~G. and
I nominate. constitute and appoint my son. CHARLES L. HAAG. Guardian of any
property which passes to any minor issue of my son. JOHN A. HAAG. whether such
passes under this Will or otherwise to a minor and with respect to
to appoint a Guardian and have not otherwise specifically
Such Guardian shall serve without bond and shall have the po~rer to us
as well as income from time to time for the minor's education. suppor
and welfare without regard to the ability of said minor's parents to provide fo
uch education. support or welfare; or to make payment for these purposes with-
out further responsibility to the minor. the minor's parents. or to any person
taking care of the minor; or. in the event the funds held by the Guardian for
any minor become. in the opinion of the Guardian. too small for proper and
efficient administration, to deposit such funds in an interest-bearing account
on behalf of said minor.
LASTLY. I nominate. constitue and appoint my husband, JOHN HAAG. Executor
of this, my Last Will and Testament. but if for any reason he shall fail to
qualify as such Executor or cease so to serve. then I nominate. constitute and
appoint my sons. JOHN A. HAAG and CHARLES L. HAAG. Co-Executors, to serve in hi
place and stead. all to serve without bond in this or any other jurisdiction.
LAW OFFICES
SNELBAKER.
McCALEB Be ELICKER
If for any reason either of my said Co-Executors shall fail to qualify as such
Co-Executors or cease so to serve. it shall not be necessary to appoint a
substitute to serve in his place. but in such event the remaining or surviving
,
...
Co-Executor shall serve with full power and authority under this, my Last Will
and Testament.
IN WITNESS WHEREOF, I, BETTY JANE HAAG, have hereunto set my hand and seal
to this, ny Last Will and Testament which consists of three (3) typewritten
pages to each of which I have affixed my signature this /~
day of
:;., ,(7
, A.D., One Thousand Nine Hundred Eighty-two (1982).
~ r~- (SEAL)
The preceding instrument, consisting of this and two (2) other typewritten
pages, each identified by the signature of the Testatrix, was on the date
thereof signed, sealed, published and declared by BETTY JANE HAAG, the Testatri
therein named, as and for her Last Hill and Testament, in the presence of us,
who, at her request, in her presence, and in the presence of each other, have
subscribed our names as witnesses hereto.
/;~'1 ;,
//t~ . /(~
,
f!.~ D.A-., lr In. \?lt~,
LAW OFFICES
SNEJ,.BAKER.
McCALEB' 8: ELICKER
~
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COMMONWEALTH OF PENNSYLVANIA)
SS.
COUNTY
OF
CUMBERLAND)
We, BETTY JANE HAAG, MARLIN R. McCALEB, and JANET M. FORRY, the Testatrix
and the witnesses, respectively, whose names are signed to the attached or
foregoing instrument, being first duly sworn, do hereby declare to the under-
signed authority that the Testatrix signed and executed the instrument as her
Last Will and Testament and that she had signed willingly, and that she execut
it as her free and voluntary act for the purposes therein expressed, and that
each of the witnesses, in the presence and hearing of the Testatrix,
Will as witness and that to the best of his or her knowledge the Testatrix was at
that time eighteen (18) years of age or older, of sound mind and under no
constraint or undue influence.
7~~(
. ~ _1lfUL
ltness
~~~rm~~~
'i-litness
Subscribed, sworn to and acknowledged before me by BETTY JANE HAAG, the Testatr'x,
and subscribed and sworn to before me by 11ARLIN R. McCALEB and JANET M. FORRY,
wi tnes ses, this /,:( rid day of
-,~ .1
d.J.?~"U.t-a/~
, 1982.
/~ (->.-'
( .,-:.' a J-t'.b2.;' q v:;- /~<--.:Lt'-L'y,W ___
Notary Public
CATHARINE E. BOUSUM, NOTARY PUBLIC
MECHANICSBURG BOROUGH
CUMBERLAND COUNTY
!J'r "OMMIS<:!f1N ,YP"H' Ff'R n 19P?
LAW OFFICES
SNELBAKER.
McCALEB a ELICKER
\, /b-crJ/ P- ?
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 (a-I.,
-. I
I
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
05-29-2001
HAAG
03-10-2001
21 01-0303
CUMBERLAND
101
AlIOU"lt R_i Hed
BETTY
J
JOHN HAAG
420 ALLENDALE WAY
CAMP HILL PA 17011
~ j \..
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=isi;j-'EX-AFP-n'2=iioY-NOYic'E--OF-YNH'EifiTANCi-YAX-APPRAIS'EiiENT~--Aii-oWAiici-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF HAAG BETTY J FILE NO. 21 01-0303 ACN 101 DATE 05-29-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APP~AISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
16,004.48
.00
87,137.17
(8)
NOTE: To insure proper
credit to your account,
subBit the upper portion
of this forB with your
tax pay_nt.
103,141.65
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/AdB. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Govern.ental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
.00
.00
(11)
(12)
(13)
(14)
00
103,141.65
.00
103,141.65
NOTE: If an assessment was issued previously, lines
reflect figures that include the total of ALL
ASSESSMENT OF TAX:
15. A.ount of Line 14 at Spousal rate (15)
16. ABount of Line 14 taxable at Lineal/Class A rate (16)
17. ABOunt of Line 14 at Sibling rate (17)
18. ABOunt of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TA C DITS:
PAYHE T REC IPT DISCOU T (+)
DATE NUMBER INTEREST/PEN PAID (-)
14, 15 and/or 1&, 17, 18 and 19 will
returns assessed to date.
103,141. 65 X 00 =
.00 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
.00
.00
.00
.00
.00
AMOUNT PAID
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
.00
.00
.00
.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 HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
~
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CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Will No.
B ~ tt-'1
tv' A t<... c. ).-~
ZOlJ! - d 0 :3 d 3
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\O:J '"'2.60)
:Z}~oJ-()36S
Admin. No.
Name of Decedent:
Date of Death:
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 ft\llilee. to the following beneficiaries of the above-captioned estate on ~ - '2 D - D I
Name
Address
cSO H t'J \-\ A tic;,
L\~ D
~AN\f
RLL~ND AL~ W1\~
r-! l Il, .ph). 17()}1
,
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
/1!OA//f
Date: 0 . ?. D - 0 ,
Signature
Name 3D ~~ ~A6
Address 1/"1.. 0 f),-,-CIJ j) f)Ld" W 1d1
~ ~ M -P---f1i '-L I PA. L 00 it l
Telephone ( ~ '7 - 7' J - 0 '3 65
Capacity: ~ Personal Representative .
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STATUS REPORT UNDER RULE 6.12
Name of Decedent: 13 t: rl ~ ':JArJ ~ t+A A G
Date of Death: -; - l 0 - u l
IBLf-/b- aU 57
Will No.:
"2.. 00 l- u 0 :; 0 ?:>
Admin. No.: 2..j- 0 J - Os 03
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 ofthe estate is complete:
Yes ~ No 0
2. lfthe answer is No, state when the personal representative reasonably believes
that the administration will be complete:
3. lfthe answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes No ~
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the parties
in interest? Yes ~ No 0 :JoHN \-'\'AAG 5 DLe @eNir:IC'Jt4.^i
)
c. Copies of receipts, releases, joinders and approval of formal or
informal accounts may be filed with the Clerk of the Orphans' Court
Date: -2/ ~ 'I :~ may be attached to tlri:i::e ~ ~ rJ {l 0 ~
~() 1-1 N H 1\ AG
Name
/ J 5' IJ iJ 1/ E/i11J e R j)fC c.,j-J,
Address 0 ftJvl P II /1-1-7 P 11 . (7 ()) (
177/7 -76/- U39C;
Telephone No.
Capacity: ~ Personal Representative g, S-PfJ (/5E"
o Counsel for personal representative
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717) 240-6345
.,.
Date: 2/07/2003
JOHN HAAG
420 ALLENDALE WAY
CAMP HILL, PA 17011
RE: Estate of HAAG BETTY JANE
File Number: 2001-00303
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: 3/10/2003
Your prompt attention to this matter will be appreciated.
Thank You.
~~~d'ttl~
DEPUTY REGISTER OF WILLS~
cc:/File
Counsel
Judge
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OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN FILE NUMBER
D2-/-CJI
RESIDENT DECEDENT COUNTY COD' YEAR
--~
NUMBER
SOCIAL SECURITY NUMBER
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DAT OF BIRTH (MM-DD-YEAR)
1()-/8-2~
DATE OF DEATH (MM-DD-YEAR)
3-/0-U/
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
/-1/!1fJ Q. JO)-J ~
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
[YJ 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Retum
o 4a. Future Interest Compromise (date ofdealh after 12.12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (dale ofdealh between 12-31-91 and 1.1.95)
o 3. Remainder Return (dale 01 death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
o P;u
OFFICIAL USE ONLY
(11)
(12)
(13)
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FIRM NAME (If Applfcable)
TELEPHONE NUMBER
'r)7-7t> 1-0385
/I/nu~
(14)
lo3,MI,tS
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
/(/bN$
(19)
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Joinlly Owned Property (Schedule F)
D 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)
(9)
(10)
IVo/Je
N PlV E:
(8)
(7)
11. Total Deductions (total lines 9 & 10)
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-'
~
ll..
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o
u
~
15. Amount of line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
1()3 /4/,,,')
.
,.0_(15)
16. Amount of line 14 taxable at lineal rale
,.0_ (16)
, .12 (17)
17. Amount of line 14 taxable at sibling rate
18. Amount of line 14 taxable at collateral rate
,.15 (18)
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS A
4'20 rILL tZ- IV
CITY
STATE
pp
ZIP
l?iJ /
I~ 11--,,--
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
/l/oNE
(1)
Total Credits (A + B + C ) (2)
3. InteresVPenalty it applicable
D. Interest
E. Penally
TotallnteresVPenalty ( 0 + E ) (3)
4. If Line 2 is greater Ihan Line 1 + Une 3, enter Ihe difference. This is the OVERPAYMENT.
Check box on Page 1 Une 20 10 request a refund (4)
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.
(5)
(SA)
/VtJN;'-
B. Enter the total of Une 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
~llf .- -. mn! I un 1 r ..17. m _111111111 f lmlllm 11111 II! 1111'"'11 ill! 1
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. relain Ihe use or income of the property transferred;.. ................ ...... D [9..-
b. retain the right to designate who shall use the property transferred or its income; .... ................ 0 @'
c. retain a reversionary interest; or............. ..................,..... ...................... ........ 0 G
d. receive the promise for life of either payments, benefits or care?.. ..................... ................. 0 ff
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ... ................... 0 ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ............. B 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................... .................... ...... ............ ....................... .. [M D
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN.
Under penalties of pe~ury, ! declare that I have examined this re!um. including accompanying sched sand statemenls, and 10 the best of my knowledge and belief, it is true, correct and
complete
Declaration of preparer other than the personal represel1tative is based 011 all informatiol1ofwhich re arer has any knowledge
DATE
/-/-f2-0/
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
ADDRESS .q 2 0 If a...,EN O/J4f: ()J If
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
(' f)/Wp ;-J / LL..-- PI4. I 7u/ (
JI )
DATE
ADDRESS
pr- .If '~~IIlIl: _ ~ _ L )1..--. ........JI [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)).
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 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 affer 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 slepparenl of the child Is 0% [72 P.S. ~9116(a)(1.2)J.
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 siblings 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.
"""'~"."'''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DE EOENT
ESTATE OF
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
6Ertl(
:}. 1-\1'1 AG
FILE NUMBER
:.;co C> \ - 00')0".1
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes,
ITEM
NUMBER
1.
T.JG I'll .IlK 1/ 112 /J.6 Mil! v t1 ~ FJ;J /J
lkert If (:,705" 8,/tJ 22 -b WI"'/..) i/?ItP5&<
vp )}raTp r;, ;!US0/1,o/) ...:J;;Jf1J;j1VJ',;:
r, 1"1 PRH E jJlfltl"f. /<eS61"V~ J:>N/J
l)cci"" 7p '1.J. O'7'8kJ.J w/77-) M/JlJsFtfI? 12/~f3j.S:S loe.)
Oft} ,j)j!;'~r.fJ r; /11.I5g;9pJf)" .:LlhJ/-J/YK.
OESCRIPTION OF PROPERTY
INCLUDE THE NAME Of THE TRANSFEREE. THEIR RELATIONSHIP TO OECEOENT AND THE CATEor TRANSFER
ATTACH A COPY' OF THE DEED FOR REAl ESTATE.
TJr.?ff/tk /VPW I}SIFI /"Iv'lvl)/. Nlltf}
t4)./ .IRA II-cc;l iT '" 76 if '5'79 - 3 VV I TlI
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"3
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.
()J i17.J NilS iB;fJ/Jp J(7 HPI /lAtlC
,lis B#r-v, {>CJ In!/
CO)M 1'10 0 1ke-r1t tf'l3 '2~ 76 'f" 371
.r V 11)J ~ olJ/0;J SeL., V/J4J1~ h>d{)
\A.JJr;J /..)v-,,8/JAJtJ :JvHtJ IfAfJG.
/J 5 J.3 Z:}Jj ;::iol9 ~I
OA TE OF OEA TH
VALUE OF ASSET
%OF
OECD'S
INTEREST
EXCLUSION
IF,wPl.ICI.BlE\
TAXABLE VALUE
0li>;r:J8
HIQ.3/:.
/00
o
2. 0 663.(.,2
/
()
7..01 f.63,~'7-
I Uu
<::l
12, 383.~5
/6" '113.8"'1 IOcJ
o
(e" '7'8'>. ~'7
30) '?07,2.3 /0 I>
o
30} q [3 7- '2.'!
(If more space IS needed, Insert additional sheets of the same size)
TOTAL (Also enter on line 7, Recapitulation) $
{? 7) , 3'7, \7
R~V-1511 EX+ (12-99) .
~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
BEn y ::r.~G>
FilE NUMBER
..-z..OOI -Do3IJ3
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
I.
CRGM~T/()N <f'25. ",0
L (J'Ie.M 1.) R.1f>tL- 51.fc- 130,OD
B ADMINISTRATIVE COSTS:
I. Personal Representative's Commissions
Name 01 Personal Representative(s)
Social Security Number(s)fEIN Numoer 01 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 01 Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
!1? ~ fiJllJ 10 [;5, Ou
TOTAL (Also enter on line 9, Recapitulation) $ 0
Debts of decedent must be reported on Schedule I.
(II more space is needed, insert additional sheets of the same size)
REV.1508 EX. (J.l17)
ESTATE OF
'*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
.:J. +L", A G
FILE NUMBER
Z. 00 \ - Goer 0>
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
13 E TI,!
Include the proceeds of litigation and the date the proceeds were received by the estate. All property ;ointfy.owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
.7.....
VALUE AT DATE
OF DEATH
DESCRIPTION
).
SEWc. L- p.~
WEAR ING. ,,,, f( ". R 1:0 L
(AS\-! oN Hf\ND
Co
IJ 00 (.)
) 000
}
'1
9'f'fJ. f~
}
P N<:' BflrJk MON E'I /VlWf f)l"cT 11 5'0 () 32.. I - 112..)
/3
TOTAL(Alsoenteronline5,Recapitulation) $ ItS} eJU if .<r2l
(If more space is needed, insert additional sheets of the same size)