The URL can be used to link to this page

Home My WebLink About01-0340 PETITION FOR PROBATE and GRANT OF LETTERS " ~.. ...:) .,.._-~"--......~. \.C-. No. 21-01-340 To: Register of Wills for ,the . \ .l , Deceased.. County o~vL-"""""""''-.S::.~ lit nr 1& Social Security No. l "'L",,":> -'. \. 0 " '- 4- t.r'[- 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 of.) ,.. in the la~t ~ill of the ab.ov,e de~e~nt, dated t-l " .) 2.--t and codlcll(s) dated \~ ~ ,..,-.........- Estate oj---'-,C<-'""^- ~ r- also known as named ,19x5 (state relevant circnmstances, e.g. renunciation, death of executor, etc.) ?ecendent was d?miciled. at .death i? c: ~ ~ ~_~ J County, pe~nsyJ.v~nia, wi.tl1 h l S ~ I,ast faIl1lly or ,PIlDclpal resldence at ." t'>. ........ ". . .~ .::. ..........\ S ~c.9 \.-...... <..-:> \." .q-. c,::(" .~ <..,. v '=' S..:.~""'- ':>c_\...l.~ _ \" \.-\. . I.\" , "'""''''-- \...... t> \...... (list street, number and muncipality) '-2...... c> 0 \ D~cendent, then. Ci.... "'""S.. years of a e~ died .' ~ . ~ ' ~ at L1. c... ~~ <,;. .':~ <L'~ d.....~ ~........,.....:> ,,-\," \.. \., c--' ~ '-'" c) 1,...... 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: $'z.~cJOc) $ $ $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters ---::"''''' -::.""- A........ LV'- -'C':i -, (testamentary; administration c.t.a.; administration d.b.n.c,t.a.) '" ~~-- ::: '" "O~ .- '" "'~ "''- CX:'" ::: "00 t::'~ ~.;:: ~'" ~p.. '" '- EO '" ::: OIl Vi theron. , \.J....<:A.. ~ )- '-\ Lt.. <,-=-~<~ ':... '- \.< ~\..... - ~ '\'-- "- ~ . 4r- 0 -'L \~ 1..- 'l-- 0.... '='" :S"~ ~~ J.":L~\..''''''~~ 1..=:1 ~ U\.,., OATH OFPERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA I ss COUNTY OF ~UMBERLAND 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) wi~~,~~ tr~~ ad~ist~.r the e~te\acCOrding to law. Sworn to or affirmed and subscribed ~~ ' ---------::::~,-".::::.:--\ en before me tbis 29th day of ~- C"_.. ....- ~ "- clji. ~CH,~ ;; 1..~ ~ //; (I ://L/cj II/I / U ~ ~ ' / Register ~ / ~ -;2;2 / - c:2- - No. 21-01-340 Estate of JAMES D PARK , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW MARCH 2?, 2001 ~_, 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 NOVEMBER 27, 1989 described therein be admitted to probate and filed of record as the last will of JAMES D PARK and Letters TESTAMENTARY are hereby granted to HARRY L BRICKER, JR , ~ 7?J2'7/ (;J ~~<!k~~/A!V A~ R ster of Wills !; FEES Probate, Letters, Etc. ......... Short Certificates( ).......... x-pag~s. RenUnCIatIon ................ JCP $ $ $ $ 5.00 TOTAL _ $ 42.00 " MA~<;~. .ZQ ~ . ?O.Ql. . . . . . " . . . . . . . . 25.00 6.00 6.00 __..u---;:>' ~--\ Co... \.)... - \ ~,"..' -~ \ <:::::-\.<.~'t- _ ~\.~ - - AITORNEY (Sup. Ct. I.D. No.) 4 pi" \~.-~ ~~~ -ST"' ADDRESS \:-\.t>-'l-~-, '" "'"~~~ \c'- D "- PHO E ... -~,.-- '\ \. \. -z... '"3. -<:::, J.... ~ ~ ~ Filed ~ \O4--~ t11U).~U) K.t:V 1}/86 ~-~lis is to certify that the information here given is correctly copied from an original certificate of death dul~ filed with me as Local Registrar' The original certificate will be forwarded to the State Vital Records Office for permanent filmg. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~~i~~CJ-> F Fee for this certificate, $2.00 p 7284657 0)-)3-& ) Date 21-01-340 H105.143 Aev. 2117 COMMONWEAlTH OF PENNSYlVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH ~ .. _T aNI _Of'llECI!DeNr(fq. _... L JAMES D. PARK~ SR. _cu.~ _._ - I 0.,. SEX a. Male .....'U_ SOCIAL SECulun HUYlER L193 10 _ 2448 ~ 0. ~lC4y- SIMI cr FChIG" eoun.yt Brookvil1e" PA 7. NAME (I noI "*"*'". gMt... ancI.....".,." Canp Hill Care Center Sl-..ci IfQlII ..---- IlECEIlENrS - RESIDENCE --- ...-- ,.... CUM8ERLAND .70.0 :...-=-.::'.. _R.S_If...._._s..r_ 'I. Caroline G. Wanner ~~~~ro ~~sra~CPX 17025 1'RClNOUIiCIO__.eo,. ~ -CASE_lO_ 8:3:> plI M. Feb~ 9. 2001 ....29...0 S7.MRrk -"'--"---"'_Do"_"'_"~_._,,__,_,,__, ,_ MRrI: 0000r..-_.......__ ....---..-- !=.."":' ..--.....~__.._L I I , i40J DUE1OIORASACONsEQUENa OF): -Of'llERH DonOf'INJUllY TlWEOf'INJURY _1tl1lloORll7 CE____. _.eo,. -I - l;J.. _ 0 - 0 ......__ 0 ... a- - 0 ~....._ 0 ......,.0f'1NJUllY..._._____ M. -... ;:"""-.....-., -.-0-...._ ~"'nICIM~~~-~.,...---~..cwonauncectdllllft.._.a~.....2:h ..............., ~--..............--..............-........................................................... .~UA~ CIft...-....----.....,-.__....._._..__._.........._OOI.'_ ""~"""""""""""""""""""""""""""""""""""""" .............. -............... REGlST1WI'S~AND ""-R 1~~~AI;;.rj , .--ANDc:uTIPwG"'nICIM__",--O__..........._.._. -..........,......... ...............-..... .......... ........... ...~.......-.................................. )C. 'ii ~ ~ ~ ~ ! ~ 21-01-340 LAST WILL AND TESTAMENT OF JAMES D. PARK I, JAMES D. PARK, of the City of Harrisburg, County of Dauphin and Commonwealth of 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 Wills or testamentary writings by me at any time heretofore made. FIRST: I direct that all my debts, funeral expenses and inheritance taxes be paid by my personal representative, hereinafter named, as soon after my death as may be practicable. SECOND: I give, devise and bequeath all the rest, residue and remainder of my Estate, be it real, personal and mixed, of whatever nature and wheresoever the same may be situate, to my wife, Marian P. Park, providing she shall survive me by a period of sixty (60) days. THIRD: Should my wife, Marian P. Park, predecease me or die on or before the 60th day following my death, I give and bequeath all my United States Savings Bonds to Gary D. Waulters, who presently resides at 18 Pennsboro Drive, Enola, Pennsylvania 17025, per stirpes. FOURTH: Should my wife, Marian P. Park, predecease me or die on or before the 60th day following my death, I give, devise and bequeath all the rest, residue and remainder of my Estate, be it real personal and mixed, of whatever nature and wheresoever the same may be situate as follows: A. Three-quarters (3/4) thereof to Gary D. Waulters, per stirpes. B. The balance thereof to James D. Park, who presently resides at 7747 Northland Avenue, Northwest, North Canton, Ohio 44720, per stirpes. FIFTH: I hereby nominate, constitute and appoint my wife, Marian P. Park, executrix of this my Last Will and Testament. Should my wife, Marin P. Park, fail to qualify or cease to act as executrix of this my Last Will and Testament, I hereby nominate, constitute and appoint Harry L. Bricker, Jr., executor of this my Last Will and Testament. SIXTH: I hereby direct that the personal representatives herein named shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I, JAMES D. PARK, have signed, sealed, published and declared this to be my Last Will and Testament consisting of this and one additional page in the margin of each of which I have also set my hand for greater security and better identification this ~ day of 7l1Yl/.. 1989. G1 da~-IAJ- 'j).? ~_ (SEAL) J a m,e's7D. Par k { / The preceding instrument, consisting of this and one other typewritten page each identified by the signature of the testator was on the day and date hereof signed, sealed, published and declared by JAMES D. PARK, the testator herein naTIed as and for his last Will, in the presence of us, who at his request, in his presence and in the presence of each other have hereunto subscribed our names as witnesses hereto. We further certify that at the time of the execution hereof, ~ the said JAMES D. PARK, was of sound and disposing mind, memory and understanding. J------ ,,<=---.-.7(-;...~~. h... .... . .~. ~ .~~ .'\::-=::-::- '-. '" h....... . ". ::-:~""h~~' "~ ~ l;Me/AI tl0~ ~ 4~1~ \\ of A-L)\.\\'Z..~~~~:X~ .~ ~.~ of -:~ _ _ _ '_~:~ 1JJ. l~h~./.-t1..f.~/@ !Jes-s .6- (.-) 7 'n.:J q d,-, h' tJ ~<AAl' if CL LZ /0 '} of - 2 - j ~ cA 1 D COMMONWEALTH OF PENNSYLVANIA ) ) S S : COUNTY OF DAUPHIN ) I, JAMES D. PARK, Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. PARK, Sworn or affirmed to and acknowledge~ before me by JAMES D. the Testator, this ()..7"tl day of ~-n14.vU 1989. (SEAL) Exp i re s: &! '1/9-d COMMONWEALTH OF PENNSYLVANIA ) ) COUNTY OF DAUPHIN ) NOTARIAL SEAl" AGNES G. NICHtCI. Notary flIui)lIe \ Harrisburg. Dauphin County ~y Commission E~:;lres June 19. 1990 SS: ----~. . c;..~...~n ..,,':.,1 ....... ;P-II~ /J/;; /0,. - P ~ . We, -- . .... ::::-::-:.~.:< '. ..... ':~,<...:~d q/'1o/..'1.Y' ~~J , the w~tnesses who e~.q..E.e s~gned to.,....the attacb:ed or forego~ng instrument, being duly qual-Hied accordi~o law, do depose and say that we were present and saw JAMES D. PARK, Testator, sign and execute the instrument as his Last Will and Testament; that James D. Park, signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time 18 or more years of age, 0 f 'ound mind and unde~~,,~c~=.mai:t:r....u..n =..d.:e ~nf~:ence t... -'''-'.-.~''.'...'.~. ~... . "":'. ...~. - ~~....,., - ~~~ ~ -~ e:;.-- ~ A <~ ./1-' Sworn to and subscr~bed bef9reme this ~1a, day of ~ 1989. ;2 ,,/ jJ >U~ V~ry Publ~c My C ommi s s ion Expi re s: (,,/ f'h t:/ (SEAL) NOT l. q;.~L SEAL AGNES G. N1Ct-i\Ci. Notary F'ublle Harrisburg. Dauphin County My Commission EX:;lres June 19. 1990 > ... - ',.,- -~ CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: James D. Park Date of Death: 02/09/01 No. 2001-00340 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 June 14, 2001: Name Mr. Gary D. Waulters Mr. James D. Park Address 18 Pennsboro Drive. Enola. PA 17025 7747 Northland Avenue. Northwest. North Canton. Ohio 44720 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: No Exceptions Date: ~ - '- k ..- ~ \ \ Harry L. Brick ,Jr., Es 407 North Front Street Harrisburg, PA 17101 (717) 233-2555 Capacity: x Personal representative Counsel for personal representative c/ ~.~..dJ- STATUS REPORT UNDER RULE 6.12 Name of Decedent: James D. Park Date of Death: February 9.2001 No. 2001-00340 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_ No X 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: Hopefully within one year 3. If the answer to NO.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes_ No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes_ No_ d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: (b...... \ cr -0 \.. '~\. 4"'~::':~" ..~'" ~~ Harry L. Bricker, Jr., Esquire 407 North Front Street Harrisburg, PA 17101 (717) 233-2555 ...." "'\\ ~ Capacity: X Personal Representative Counsel for Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND } u: I, Harry L. Bricker, Jr. "-/ being duly sworn according to law, deposes and says that he Executor of the Estate of James D. Park late of --.J?ast Pen_~sbo~_<:?._!_<?wnsh~"p , Cumberland County, Pao, deceased and that the within is an inventory made by me I the said attorney of the entire estate of said decedent, consisting of all the personal prop.trty and real estate, except real estate outside the Cl;)mmonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value es of tbe date of decedent's death. '\ <LA~~ and subscribed before me, ~ 4 C/o J NOTARIAl SEAl. AGNES G. NICHICI, Notary Public . Harri.sb~rg, Dauphin County . My CommISSIon ExpIres June 2002 Dat~~ia .Weelatiot~,~(hlS' .Y is the Harry L. Jr. Encutor . Aclministr 407 North Front Street Harrisburg, PA 17101 Aclelr... February lo4onth 2001 Y..r INSTRUCTIONS I. An inventory must be filed within three months after appointment of personal representative. 2. A supplement inventory must be filed within thirty days of discovery of additional assets. 3. Additional sheets may be attached as to personalty or realty 4. See Article IV, Fiduciaries Act of 1949. ~ o .... z w > Z ~ w a::: ... w < 0.. ... W 0 en a::: W :I: 0.. ... U. ...J o < z o 0 en Z ffi < 0.. ...J LL < 0 W a::: o z 0.. -r-! .c: en s:: ~ o 8 o lo-l o .Q en s:: s:: OJ P-l .jJ en rd j:il -v . .. .. . u . C lo-l t-:> . lo-l ClI' ill ~ .. .!<:: 0.. U" 'r-! 0 lo-l= o::l< - o . A. .i- IC :t c3 ~ IC .. ~ . .A E :t o ~ ..! it oM o o CD tit- .f .. ...J ~nventory of the real and personal estate of James D. Park deceased Refund from Camp Hill Care Center 2,000 00 Payment of Pension to date of death by PSECU 230 26 Wiedeman Funeral Home - Prepaid funeral 600 00 I! 'I " 0/ .., '1,'''] 2,830 26 " \ ~~ .,.. /" ,l c' ., (tK- STATUS REPORT UNDER RULE 6.12 Name of Decendent: James D. Park Date of Death: Februarv 9. 2001 Will No. 2001-00340 Admin. No. 21-01-0340 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 No b. representative's account is: The separate Orphans' Court No. (if any) for the personal c. parties in interest? Yes Did the personal represenatative state an account informally to the X No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. , Date: Januarv 13. 2003 c---"", Cs '. -~ . ..~- '. \ ". (............ - ....,/., Signature' -.-... '" '.. ~~ " .~. Harrv L. Bricker. Jr. Name (Please type or print) .~"'~ 407 North Front Street. Hba. PA 17101 Address ( 717) 233-2555 Tel. No. Capacity: X Personal Representative Counsel for personal representative (MAH:rmf/AM3) Cumberland County - Register Of wills Hanover and High Street Carlisle, PA 17013 phone: (717) 240-6345 ~ Date: 1/06/2003 HARRY L BRICKER JR 407 N FRONT STREET HARRISBURG, PA 17101 RE: Estate of PARK JAMES D File Number: 2001-00340 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 2/09/2003 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, DONNA M. OTTO DEPUTY REGISTER OF WILLS cc: ~File Counsel Judge REV-T!;/IOP(S_OO) . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT 280601 HARRISBURG, PA 17128-0601 I/, -~/-.;Y REV-1500 w ... ::.::$(1) U"'" w"-g x~..... U"-Ill "- '" INHERITANCE TAX RETURN RESIDENT DECEDENT ~ Z W C W (.) W C OECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Park, James D. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) Februar 9, 2001 Ju1 6, 1907 (IF APPLICABLE) SURVIVING SPOUSES NAME (LAST, FIRST, AND MIDDLE INITIAL) pi Of-F\::>b,L ')~:t: ()!\:'_~'{ FILE NUMBER ...2- L - L2 L COUNTY CODE YEAR --~~~ NUMBER [Xl 1. Original Return o 4. Limited Estate o 6. Decedent Died Testate (Attach copy of Will) o 9, litigation Proceeds Receil/ed o 2. Supplemental Return D 4a. Future Interest Compromise (date of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach copy of Trust) o 10. Spousal Poverty Credit (cale 01 cea\h between 12-31-91 and 1-1-95) SOCIAL SECURITY NUMBER 193 - 10 - 2448 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Return (date 01 de.a\1I priof to 11-13-82) o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (AttachSch 0) ... z w C Z o "- Ul w II: II: o U $NCl;~ (:9NflbElli1)Ai..JAj'(ItIiFORW\.Tl6tj$HQiiwJBelli~C1E\:l TO.: COMPLETE MAILING ADDRESS Harry L. Bricker, Jr. Attorney at Law 407 North Front Street Harrisburg, PA 17101 i)ffljlt-fjP'*titU~'f~qQM~:~LLc6~ NAME Harr L. Bricker, Jr. FIRM NAME (If Applicable) TELEPHONE NUMBER (717) 233-2555 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) (1) (2) (3) (4) (5)$ 2,830.26 I ,- OFFICIAL USE ONLY --I I i I i z o ~ ::::l l- ii: <( (.) w It: 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. JOintly Owned Property (Schedule F) D Separate Billing Requested 7. lnter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) B. Total Gross Assets (tota! Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (101al 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) (B) 2.830.26 (6) (7) (9) $159,920.67 (10) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o !C( I- ::::l D. ~ o (.) >< i5 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x.O_ (15} x.O_ (16) x .12 (17) x .15 (18) (19) $ (11) (12) (13) $159.920.67 ($157,090.41) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of L.ine 14 taxable at collateral rate 19. Tax Due 200 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE $IDE AND RECHECK MATH < < (14) ($157,090.41) Decedent's Complete Address: STREET ADDRESS Camp Hill Care Center 46 Erford Road CITY Camp Hill I STATE PA I liP 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InteresUPenaity if applicable D.lnterest E. Penalty TotallnteresuPenalty ( 0 + E ) (3) 4. If Line 2 is grealer than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE, (5A) (5B) Make Check Payable to: REGISTER OF WILLS, AGENT ,!i"ij,".;~~'<t'l1i-"'" :~_r~~:!'-~~Y'V"'_"""~ '~r'-=W"':zr '-ji~'-_,"!iJ 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;.......... ....................m .w......"............................ ',. 0 b. retain the right to designate who shall use the property transferred or its income; ................................... ..... 0 c. retain a reversionary interest; or. ..... ....... ..... .......... ........... ........... .." ................................... .................... ......... ..... 0 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? mm.............. ......................................... ....................... ...................... 0 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? . .."............. ......................... ............................. No KJ KJ Xl !>. Under penalties of pe~ury, I declare that I have ex.amined this return, inciuding accompanying schedules and statements, and to tfle best 01 my knowledge and belief, it is true, COfFecl and complete Declaration of pre parer other than the personal representative is based en all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETU Harr L. Bricker Jr. ADDRESS 407 North Front Street, Harrisbur , PA 17101 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ~-\.."l-<5 DATE ADDRESS 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. ~9116 (a) (1.1) (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 n01 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. ~9116(aJ(1.2)j. The tax rafe 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)(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. ~9116(a)(1.3)j. A sibling is defined, under Section 9102, as an individuaf who has at least one parent ill common with the decedent, whether by blood or adoption. ." -~ REV.'~""'(1."'._ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER James D. Park Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION Refund from Camp Hill Care Center VALUE AT DATE OF DEATH $ 2,000.00 230.26 2. Payment of Pension to date of death by PSECU 3. Wiedeman Funeral Home - Prepaid funeral 600.00 TOTAL (Also enteron line 5, Recapitulation) $ 2, 830. 26 (If more space is needed, insert additional sheets of the same size) "";s,u,"""*' COMMONWEALTH OF PENNSYLVANIA INHER\1ANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ,TFlmp.~ n PFlrk Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: L Wiedman Funeral Home - cremation $ 600.00 2. Woodlawn Memorial Gardens - Death Scroll Vase 380.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (5) Social Security Number(s) I EIN Number of Personal Representalive(s) Street Address City State Zip Year(s} Commission Paid: 2. Attorney Fees Harry L. Bricker, Jr. 185.00 3. Family Exemption: (If decedent's address is nollhe same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wills, Cumberland County 42.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. The Carlisle Sentinel - Advertise Estate 7!1n9 8. Cumberland Law Journal - Advertise Estate 75.00 9. Camp Hill Care Center 107.33 10. Filing Fee - Inheritance Tax Return and Inventory 25.00 for Cumberland County II. Department of Public Welfare 158,431. 95 TOTAL (Also enter on line 9, Recapitulation) $ 159,920.67 (If more space is needed, insert add,tional sheets of the same size) REY'.15.3EX,0(1-S]lW . - '- . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF James D. Park SCHEDULE J BENEFICIARIES NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Gary D. Waulters 18 pennsboro Drive Enola, PA 17025 2. James D. Park 7747 Northland Avenue Northwest, North Canton, Ohio 44720 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Son Son AMOUNT OR SHARE OF ESTATE 3/4 1/4 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 PARTII. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional. sheets 01 the same size) 0. PNCBAN< Decedent Reporting Firstside Center P7-PFSC-04-F 500 First Avenue Pittsburgh,PA 15219-3128 SCP May 01, 2001 Harry L Bricker Jr Attorney at Law 407 N Front St Harrisburg. PA 17101-1296 RE: Estate of James D Park Deceased SSN: 193-10-2448 DOD: 02.09-2001 Dear Mr Bricker Ir: Please find the date of death ballUlces you have requested listed below. CHECKING ACCOUNT #5001884831 Established 07 -Q9-1998 JAMES D PARK DOD BallUlce: $2,000.00 non interest bearing account Our office only provides ute of death balances for IRA's. CD's, Checking and Savings accolUlts. We do NO Financial Transactions or Statement Orders. For Further iDformatlon please uD 1-800-4-BANKER or your local PNC Branch and ask to speak with a FiDancial Services Representative. Sincerely, Cu~~ 1. ~ Erica L. SchlegeI1-800-762-177S A mc:mber of The f'NC Financial Setvices Gropp PNC Bank NA P;t(sbufgn Pt'nn:oylviloia 1Sl6S TnTnJ D Dl1 IUIr\L r.~J. . COMMONWEAl. TH OF PENNSYLVANIA DEPARTMENT OF PUBUC WELFARE BUREAU OF FINANCIAL OPERATIONS EST ATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 June 14, 2001 HARRY L BRICKER JR ESQUIRE 407 N FRONT ST HARRISBURG PA 17101 Re: JAMES PARK CIS #: 810124747 Co/Rec: 21/0072581 Date of Birth: 07/06/1907 SSN: 193-10-2448 Dear Mr. Bricker: please be advised that the Department of Public Welfare maintains a claim in the amount of $158.431.95 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 $18.992.39, was incurred during the last six months of the decedent1s 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 $139.439.56, 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. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available~ Sincerely, iZ U'{J&' /; t4 Nicole L. Early TPL Program Investigator 717-772-6606 717-772-6553 FAX Enclosure