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Home My WebLink About01-0342 PETITION FOR PROBATE and GRANT OF LETTERS Estate of - ~0r~~ '1M e '5 S I'l &. also known as No. To: 21-01-342 Register of ~r ~-S I . , Decea$ep. County of -.. - cc:,:::s::Lm the Social Security No. \, \ \ - 1 ~ - -'1 (, 01? Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: \ Your petitioner(s), who is/are 18 years of a~ or older an the execut~ in the last will of the above decedent, dated ~~~ \ ~ J l C1 cr "2- and codicil(s) dated Ii. 0 N e~ ' named ~~ (state relevant circnmstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in "'" ~ h l,/\ last family or principal residence at \ (list street, number and muncipality) J--~ years of age, died ~D':'tC k <;/ .~ 2.-<.7 0 l", -, "\ 'v\.. \.- t-.l-{.\-<l~ l ~ I Q ~y-, r. \--l~ (G-'~ l.-- V-::R/vvv,",)'lP~'-Lv kUP/ Except as foll ws, ecedent did not mahy, was not dlvorced and (itd 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: Oecendent 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: $ <.nOQ,'- $ $ 'D. WHEREFORE, petitioner(s) respectfully presented herewith and the grant of letters will and codicil(s) theron. .; administration d.b.n.c.t.a.) ~ " OJ C " ~3 "... 0<::" c -00 c';:: ~.;:: 3~ " .... 90 c;; c 00 Vi PH-~lLIS F, ME5sNER ~\ oJIve ~'<.d. ~a/v'V'f \~J{ . PQk,lLs ~~\e s.. N-L--.--- , OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 1-- S8 COUNTY OF c..{._vv~" ~-J.Ovv-. cL- ) The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. af:fff~d alid {) t-\. 'Y L L l S F, Nt iES'S MERen ~ t' E\ ~. - A..~ 1)<). '"' _ ~}1/'\e. s <S 0i~!:a ~ ~ ~ ~ ~o. 21-01-342 Estate of JOHN MESSNER , Deceased DECREE OF PROBATE A~D GRA~T OF LETTERS AND NOW MARCH 30 Ji~200 1 ,in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated MAY 18. 1992 described therein be admitted to probate and filed of record as the last will of JOHN MESSNER and Letters TESTAMENTARY are hereby granted to PHYLLIS F MESSNER ~. .""(if1f..,-.J/,,uMctt?,Q.uY " glster of WIlls / FEES Probate, Letters, Etc. ......... Short Certificates( ).......... x-pag~s . RenunCIatIon ................ JCP $ 200.00 $ 6.00 $ 15 . 00 $ 5.00 TOTAL _ $ 226.00 ... ~~~. .3.Q,.. ?9.Q~............... AITORNEY (Sup. Ct. LD. No.) ADDRESS Filed PHONE ryd/ 6-) Ck-CL<<-~~/ H 105.805 REV 9/86 This is to certify that the information here given is correctly copied from an original certificate of death du!~ filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent hlmg. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~cliZ,~ Fee for this certificate, $2.00 p 7294412 MAR 1 ~ 2001 Date 21-01-342 .143 Rev. 2187 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH NAME Of DECEOENT IflfSl. MldcIle. Las) .. AGE Ilallllw1l>aoy) UNDER . YEAR MonIha Oava DAlE OF OEATH IMcNn. 0..,. ....) 5.75 Vra. COUNTY OF DERH UNDER I OM -l-" DATE OF llIRTH ~MOfM". Day. '., BIRTHPlACE IC.Iy..... SlaM: or fcre.onCoontry) ~ :,).. 0i::I I cnv. BOllO. ~Io Cumbvr.la.nd DECEDEHT'S USUAl ClCCIlI'RION (aI"'=:~"=''::~:r ilL Me.c.han.i.c.al En .i.ne.vr 11. AMP DECEDENT'S MAIUNG AllOAESS (51<.... c..~. _. Z",Codel 41 Gale. Road Camp H.i.ll, PA 17011 ... _'l~Elf'l'l-lalll . Jotm Me.-6-6nvr 1Nf0000000'S_(J~.., ~-6. Phyll.i.-6 Me.-6-6nvr METHOD OF DISPOSITION _ 0 c.......... 00 _~..._.o OU"'~I Inc.. DECEDENT'S ACTUAl RESIDENCE tSoe"*"""">nl on ohN Sldel 17.. SIaM PA lAARlTAl SWUS._ ...-....... -. ~~ '0. Ma)lIt.i.e.d 170.O....._.._in Wh-i.te. SUIMV1NG SPOUSl! I' wHo QNe"'-*' NmeI tn.. Cou Cumbvrland DMI - he... _? ..... d1y_. 21c. 171 09 171 09 NoD , respiratOfy .".... Shock 01 heart failur.. .-....... I inIentaI between : onMI: and dnd'l I I I PART I: OIIIor~_C>lInlrIluIing.._.bur rw::JI rMUIling in the UftdIrto;inQ '*- given in PART I. ~ rQJ./J~. 4.r...&:- DuE 10 (OR AS ACONSEOUENCE Oft. ~ L...d:t. ~ lb. <. d. WERE AUTOPSY FINDINGS -...aLE PRIOR 10 COMPlETION OF CAUSE OF DEATH? DUE 10 (OR ASA CONSEOUENCE OF), DUE 10 (OR AS ACONSEOUENCE OF), MANNER OF DEATH ........ Acctdenl [3-"'" o o DATE OF INJURV lMonlh. Day, 'ltirl TlWE Of lNJURY INJURY IJ WORK? DESCRIBE HOW INJURY OCCURllEO. Nofjj3 ....0 No~ $uic;do HomiCide Pendtng Inveatigalion CoWd noli be dellmulled o o o PlACE Of INJURY. AI home. I"m, sa,.... factor" officii Y. butIdIng, etc. ISpeclfvl _. '1M 0 NoD aIL a... CUT.... ,Chock .".., onol -C8I1'IFYING PHYSICIAN (Phy5Ctiln Cefllytng cause d death when another phYSlC.aft has Pl'onoonced death ana canpleted Item 2Jl To............,know'-dge. dedloccvnedduelolhec.uM(.~ and m.nner...tIItacI. ......................... _..... .... lOCAl'ION (51<...~. SIaIoI I-+/~/.( I o 3lb. lICENSE N DIn SIGNED I""""'. 00.. ~ 0)1<. NJ) O'-{I')ol.L ). ~I-. Il 1.0l> NAME .....0 _SS OF PERSON WHO COMPlETED CAUSE OF DEATH (hom 27) Typo Of Print TOiC-f"'''' ~... An Li>1 l-\oul~ ~ :12. , I DATE FILED ~MQn#t. Day, Yeafl -PRONOUHCtNG AND CERTlfYtNQ PHYSICIAN (PhYSCIan bolh ;)fOl'lOUOCI09 dealh and cer1dV'"O 10 cause 01 dNth~ T.......... otmy knowledQ., de.lhoc:currlld .......... d.... andplec., .nddullo lttec.u~.)aftd m.nna' .............. "IIEDlCAL EXAMINER/COAONER On the t... of ...min.lIon and/or inv,slIgation, In my opinion, death occurred .t the time. dat., and pl.c., and due to the causa(e).nd ......ner.. .t.,~.. . . ... . . . . . . . . . ... . _ . ... ... . . " ... . . .... . .. ... ... ..... ....... . . .. . ............... _. . ... ....... ... 318. REG o (.1 )0. " 1fiasf ~iIl anb ~estament of JOHN MESSNER JI-O/--Sy~ I, JOHN MESSNER, of Cumberland County, Pennsylvania, do make, publish and declare this to be my Last will and Testament, hereby revoking all Wills and Codicils by me at any time made. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my estate or by any recipient of any property, shall be paid by the Executor out of the property passing under ITEM III of this Will, as an expense and cost of administration of my estate. The Executor shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this Will. ITEM II: I direct the Executor to pay the expenses of my last illness and funeral expenses from the property passing under this Will as an expense and cost of administration of my estate. ITEM III: (a) I devise and bequeath all the rest, residue and remainder of my estate of whatsoever nature and wherever situate, together with any insurance policies thereon, to my spouse, PHYLLIS F. MESSNER. In the event my spouse predeceases me or does not survive me by thirty (30) days, I make said devise and bequest equally to my issue, KATHLEEN M. GOSS and JOHN DAVID MESSNER. In the event any of my children should predecease me, his or her share shall be paid to his or her issue, per stirpes. ITEM IV: In the settlement of my estate, my Executor shall possess, among others, the following Page I <y;i)~ powers: (a) To retain any investments I may have at my death, as long as the Executor may deem it advisable to my estate to . do so; (b) To sell either at private or public sale and upon such terms and conditions as the Executor may deem advantageous to the estate, any or all real or personal property or interest therein owned by the estate; (c) To pay all costs, taxes, expenses and charges in connection with the administration of my estate; (d) To compromise controversies; and (e) To do all other acts in the Executor's judgment deemed necessary or desirable for the proper and advantageous management, investment and distribution of the estate. have ITEM V: died at the same time I Any shall person have, or who shall as in a common disaster with me, or under circumstances that the order of our deaths cannot be established by proof, or within thirty (3D) days of my death, shall be deemed to have predeceased me. ITEM VI: consti tute and appoint Executor of my Estate. my wife, In the I PHYLLIS hereby F. MESSNER, nominate, to be the event my said wife cannot act or refuses to act as Executor for any reason, I nominate, consti tute and appoint my daughter, KATHLEEN M. GOSS, to act Page 2 ~ as Executor in her place. The Executor is specifically relieved from the duty or obligation of filing any bond or other security. IN WITNESS WHEREOF, I have set my hand and seal to this, my Last wi 11 and Testament, consisting of this and the preceding two (2) pages, at the end of each page of which I have also set my initials for greater security and better identification this ;f~ day of ~~ . 1992. ~SEAL) JO MESSNER Page 4 We, the undersigned, hereby certify that the foregoing Wi 11 was signed, sealed, published and declared by the above- named Testator as and for his Last Will and Testament, in the presence of each other, have hereunto set our hands and seals the day and year first above written, and we certify that at the time of the execution thereof, the said Testator was of sound and disposing mind and memory. ~~~~~ ~~/ ,?1f7 oea:(c~ Residing at II ,;5:~t1 / Residing at oP~d ~ ~ ?}uJ ~~~~ ~ /7p]d Residing at // /~~K~/ J/J EJl)oU ?4- 1701' r . ;fbJhf/~ A J //r /'/aX Page 5 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND I, JOHN MESSNER, 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. "~~/~uJSEALJ JO MESSN R Sworn to and subscribed before me this (J~ay My Commission Expires: (SEAL) Notanal Seal . Bamara~n NotarvPubrIC NewCumber1and 80m. Cumberlal'1d ~ My CommISSIOn Expires Q:t. 9. 1995 W1ia~ of Notail8i Page 6 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SSe COUNTY OF CUMBERLAND We, /)7~R'/J PJ#5~Y , J~~ ;;M;:y and the Witnesses whose names are signed to the attached foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator, JOHN MESSNER, sign and execute the instrument as his Last will and Testament; that Testator signed willingly and he executed said will 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 eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. 4~ .c::4~~ Wltness Sworn to and subscribed before me this /~ day My Commission Expires: Notarial Seal New~~PtbIic My CornmtseJOn exp,,., Oct. 9. 1 ~ Page 7 \: /6-.;:)r!!:2 /- Y COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE 5'1 ~. u' '* 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-15~7 EX iFP (12-DDI DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN PHYLLIS F MESSNER 41 GALE RD CAMP HILL PA 17011 1'1, 05-21-2001 MESSNER 03-08-2001 21 01-0342 CUMBERLAND 101 JOHN Allount Rellitted 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-Ex-AFP--fi"2-:ooY-NoTicE--oF-YN'HErfiTANcE-TAX-APPRAisEifENT~--Ai:.U)WANCE-iri----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MESSNER JOHN FILE NO. 21 01-0342 ACN 101 DATE 05-21-2001 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 Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax TAX RETURN WAS: (X) ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) S. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets I~ an assessment was issued previously, lines re~lect ~igures that include the total o~ ALL ASSESSMENT OF TAX: IS. AlIOunt of Line 14 at Spousal rate 16. Allount of Line 14 taxable at Lineal/Class A rate 17. AlIOunt of Line 14 at Sibling rate 18. Allount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: PAYMENT DATE NOTE: R CEIPT NUMBER DISCOUN (+) INTEREST/PEN PAID (-) ~ IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. CHANGED (1) (2) (3) (4) (S) (6) (7) .00 17,168.00 .00 .00 .00 76,500.00 .00 (8) 93,668.00 NOTE: To insure proper credit to your account, subllit the upper portion of this forI! with your tax paYllent. (9) (10) 1,401.00 .00 Ul) (12) (13) (14) 1.401 00 92,267.00 .00 92,267.00 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. (1S) (16) (7) (18) 92,267.00 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 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.) .- " ~ Name of Decedent: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) ()e-.e/"l/) '---vYJ e- 5 s-' /It f?~ '7YLc~~ 3: ~ () I Date of Death: Will No. ~ 01 ~ 00 l~ 4-2-- Admin. No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on Name Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: Signature /LfVI.-~ Name P-i:II)l'Cr::'-m~5<~.?-z Address ifl G ~ R. 0 V\. cL ~rtJ,"j PAtlol1 Telephone Cl/~ 7 3 7 - I:z. 41 Capacity: $- Personal Representative _Counsel for personal representative , Rrv. ~j:~~ .."",,- SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~O/,ry '7Vle. 'S"S"rtev FILE NUMBER ".2- 0 0 /- 0 0 3 'I- L RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. ('J 0 f'l -e.- 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. f\I D f\l~ B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. N ()N~ TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ ~ (If more space is needed, insert additional sheets of the same size) . /: oK- v .'" STATUS REPORT UNDER RULE 6.12 Name of Decedent: ":r- () h IV (Y}e:..ssrv e~ Date of Death: rn OJ). c-. "'- r? I :2-0 0 I Will No.: -2-- c' C' J - 0 0 "3 4 L- Admin. No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State ~hyther administration of the estate is complete: Yes 10" No 0 2. Ifthe 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 ~sentative file a final account with the Court? Yes _ No M 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 0 No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk ofthe Orphans' Court and may be attached to this report. Date: ~ ~ 15/ ").-0 0 "3 ir6-hAvt / II ~ F. ~rvl e '). <; F't..L___ Signature I P&+YLLI5 FJ (lIlE5SrvEI( Name 41 Address .~~ RJ _C?VvnpfW~ 17011 71r - 73,- /24/ Telephone No. Capacity: [J11>ersonal Representative 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 PHYLLIS F MESSNER 41 GALE ROAD CAMP HILL, PA 17011-2623 RE: Estate of MESSNER JOHN File Number: 2001-00342 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: 3/08/2003 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, [)~'mflt&r-/~ DONNA M. OTTO DEPUTY REGISTER OF WILLS cc: t/ File Counsel Judge REV-1500EX(6-00) w ,., :ll::!!;cn 0"':< W"O ",00 0"'.... ..'" .. <( COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 OFFICIAL USE ONLY e- 1?- INHERITANCE TAX RETURN RESIDENT DECEDENT __~~:: ,;J.iii=-!i____~___ FILE NUMBER ~ L - t2 L _ _.L i.. d COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) ME 5'51\1 E R. ~CJ t+N 5!a 1. Original Return o 4. limited Estate IZ1 6. Decedent Died Testate (Attach copyafWill) o 9. litigation Proceeds Received SOCIAL SECURITY NUMBER \l\ C(Qo8' - I I.f I- Z W C W o W C DATE OF DEATH (MM-DD-YEAR) U30g-:;2..001 (IF APPLICABLE) SURVIV NG SPOUSE'S NAME (LAST, FIRST, ANO MIOOLE INITIAL) MEss l::J<. ~rt'lLll'5 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER ~ "is <+ - \ -:L - (" i.{- 3 S- >- Z W o Z o .. "' W '" '" o o 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) or DATE OF BIRTH (MM-OO-YEAR) Iq:2-- 6 'FI o 2. Supplemental Return o 4a. Future Interest Compromise (date of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Altacf1 copy alTrust) o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G orL) 8. Total Gross Assets (total Lines 1-7) z o ~ ::l l- ii: <I: o w 0:: 14. Net Value Subject to Tax (line 12 minus Line 13) o 3. Remainder Return (date of death prior to 12-13-82) o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) z o !;( I- ::l a. :E o o g 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage liabilities, & liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 4- \ G- ~ i< c, o~cL. c:.C\..--vv-.. f' \,--\:" l \ P A- q 0 l \ (1) (2) (3) (4) (5) OFFICIAL USE ONLY Ii l(ll<O~, ~ (6) '1(,:" :<-'00. (7) ~ (B) -tq3)~<O~.~ (9) (10) l L4 0 I. ) (11) (12) (13) I, '-lO ( , Q2.7-io1. , (14) S,L.. "2<0(, SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES o <:::\"2...,'")..(,,1. - , ,.0 n.. (15) 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17, Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due '.0_ (16) , .12 (17) , .15 (18) 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT (19) o Decedent's Complete Address: STREET ADDRESS ~ CITY c~ Ii- ZIP/70tt Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Paymenls A. Spousal Poverty Credit B. Prior Payments C. Discount (1) o Total Credits (A + B + C) (2) 3. InteresVPenalty if applicable D.lnlerest E. Penalty TotallnleresUPenalty ( D + E ) (3) 4. If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 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. (5) A. Enter the interest on the tax due. (5A) (5B) B. Enter the total 01 Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property Iranslerred;.............................................. ................ .......................... 0 0 b. retain the right to designate who shall use the property transferred or its income; ................. .......................... 0 IZI C. retain a reversionary interest; oc......................................."............................ ................................m.. 0 ~ d. receive the promise lor life of either paymenls, benefils or care? .......................... .................................... ...... 0 ~ 2. If dealh occurred after December 12, 1982, did decedenl transler property within one year of death without receiving adequate consideration? ... ................... ................................. ................................ .............. .. 0 ~ 3. Did decedent own an "in trust lo~ or payable upon death bank acoount or security at his or her death? ............. 0 IB 4. Ok! decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designalion? ........ ................ ......................... ................ ........... 0 IXJ 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 01 perjury, I declare that 1 have examined this return, including accompanying scheiJules and statements, and 10 the besl of my knowledge and belief, it is lrue, correct and complete. Declaralionofpreparerotherlhanthe personal represenlative is based on all inlormation of which preparerhas any knowledge. SIGNATURE OF PERScY9l'PON I L.E FOR E RIQU!!('J '\ 1\ i:I' I S -. - V ~ Ie.. S S ('\ .t-? ADDRESS DATE I vi:' 1'2- 00 J >-b \ ~CC~ K~. ~f\~~\ r 0".- \1 \) I I SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE 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) (i)]. For dates 01 death on or after January 1, 1995, the tax rate imposed on the net value 01 transfers to or for the use 01 the surviving spouse is 0% [72 P.S. ~9116 (al (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty~one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a slepparenl of the child is 0% /72 P.S. ~116(a)(1.2)J. The tax rate imposed on the nel value 01 transfers to or for the use 01 the decedent's lineal beneficianes is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has al leasl one parent in common with the decedent, whether by blood or adoption. REV-l~"'."-071 '*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT E~E~ ~I ME:5St\ER \--::S-Or--tl'i All property jointly-owned with right of survivorship must be disclosed on Schedule F. SCHEDULE B STOCKS & BONDS FILE NUMBER ITEM NUMBER 1. VALUE AT DATE OF DEATH 1ltl lb~~ TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV.''''EX''''"* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTL Y.OWNED PROPERTY FILE NUMBER If an asset was made joint within one year of the decedent's date of death, ft must be reported on Schedule G. SURVIVING JOINT TENANT{S) NAME ADDRESS RELATlONSHIP TO DECEDENT A.lPh~ l\; ':> V', ('{\<2.SS~e.JL t.\\ G *- k<l '~C;\.~f~"\.1 I(Q 1\ SrC\~ B. c. JOINTLY-OWNED PROPERTY: lETTER DATE DESCRIPTION OF PROPERTY %0' DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and ba'lk account number or similar identifying number. Atta:;h DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed for jointly-held realestate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. /4-/30) , b/P4 4/G~Q..~~I:'~\\r~ ;\\(51,000. iJ7 (;, So 0 . SD/, \/0 II / TOTAL (AlsD enter Dn line 6, RecapitulatiDn) $ - (If mDre space is needed, insert additiDnal sheets Df the same size) REV.1511 EX+- (12-99) " ~ SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVAN1A INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF N\ E -5"5 N E ~ '--.::rO M \'\. Debts of decedent must be reported on Schedule I. FILE NUMBER ITEM NUMBER A. DESCRIPTION FUNERAL EXPENSES . 1. ~ ,v-e c \r- ~^"^ ~, ""'" '2-. ffi..Q ch.''''-D- \ <h. ~ -€"A...-ts '?>. ~-t,'~\~d.. ~'(l;-<Y1 "'~ *C'L~ ~~\ r:cevT"..Q.--l3 S-) I-t, ~'-l-vv~ '-'\ Q..c \r ~"-'L... ~ iY\ ~ \ ~ ""1' 'f V">-V-J< ~..J<...z.... B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City Slale __ Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is nol the same as claimant's, attach explanation) Claimant Street Address CllY State ___ Zip Relationship at Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets 01 the same size) AMOUNT \ ,OL.5'. 00 S::,-, - io. - :)..5.- 11 "2.. 2-10. \ L{-O \ . -