HomeMy WebLinkAbout01-0402
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
No.
To:
-2-/- ~ J .. Vd-~
,---
Estate of ~i!~61f: 1'1. \(c.../.J~'~5r
also known as
Register of Wills for t}1e f\
County of w.~her\an~ in the
Commonwealth of Pennsylvania
Deceased.
Social Security No. _~ :J.. 4- oq~?
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl~_ for letters of administration
___ on the estate of
(d.b.n.; pendente Iile; durante ahsentia; durante minoritare)
the above decedent.
Decendent was domiciled at death in Cu..\A.l\'~r\a\1~ County, Pennsylvania, with. .._ I .
h ~r last family or principal residence at 3.:15" tJE:5 La-'f J>.e.,,,:c, ).( ecll.t7J (~.&\J ~ L4~Jo.: ftu_(; /..I
(list street, number and municipality)
Decendent. I hen
at
'f~
years of age, died ~L" to I
,,4000
Decendent at death owned property with estimated values as folllows:
(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~rYIVania
situated as follows: A
$ -\500
$
$
$
Petitioner__ after a proper search h~ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name
~~~ C ~t..,""a:-o/~.s T
,It r2. 6- J aU A K
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration In the
appropriate form to the undersigned.
l~ ~"'LU&.L C ~..:. ~.: .~
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Vi
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF eLl M~~LM:l)
} ss
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
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law. , ~
Sworn to ,0, r affi,rmed,A ,&fld SUbsc"ribed f-- h~ e...~ ~
before me tijis ~/ day of l>
~~ ~~I E
1 ~ /l a '^ tC;i:; /) . 1.; A 'I ~
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R~~ l ~
No. 21-01-402
Estate of JESSIE M. KLINEDINST
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW APRIL 23, 200 1 ~_, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that JAMES C. KLINEDINST
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
JAMES C. KLINEDINST
are hereby granted to
in the estate of
JESSIE M. KLINEDINST
~ ~Z .'
n7a~ r!. ' ~ <. )t/:J n.L.?- ..<:.? /1. :J.i:':;,r' L u,,) /.(/ ..tLV<.Y!Ct,,,
, I .. / J
Register of Wills
FEES
Letters of Administration $ 25.00
Short Certificates( 2) . . . . . . . . .. $ 6.00
~Wfi~tion ......... 'JCP'" ~ ~: ~~
TOTAL _ $ 42.00
Filed . ~~.~~~. .2.~~. ~.~q~... A.D. ~ 2001
A TIORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
MAILED LETTERS AND ORDERS TO ADMINISTRATOR
21-01-402
RENUNCIATION
In Re Estate of
~ ~_'~ ") i i... (" I ~ '\ L I N ~. D I Ai '") .~
deceased.
To the Register of Wills of
C 1..' \\. j/, ~".k. ,_ t\ NI)
County, Pennsylvania.
The undersigned
\/ }('. "'\
I /'_ '- 'i I f-.1 I ~
\<.. loJ (~- it i.
1'> A.v c: tol ~
of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
be issued to
-l \,:1. \', F ~; c ~(L I 1\1 'c. '\..) J Ai ....) .;---
, /J
WITNESS c=~~{ /v't-a c7<~
L//
hand this / 'JI'I1 day of ~
;19 2001.
(Signature)
'y?CJ,Eox 771
C'j,~"' rL" -a A Is 11 Vi) P>'t nn
(Address)
(Signature)
(Address)
(Signature)
(Address)
l'hi" is to ccrrifv that the intllrt1ution here given is cOITectly u)pied from .\11 original cerritlc.llc uf death dulv filed with me as
ilKal Registrar.' The on'~lIla] ccnificltc \ViII ~hc forwarded [() the SUtl' \'iLll lZeumh OHlce for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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P 8650569
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1 )alt.'
. 2187
COMMONWEALTH OF PENNSVlVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
AGE (Lall Bw1r>oay)
DATE OF BIRTH
.Man'" Oey. ....,
STAlE FilE NUM8ER
SEX SOCIAL SECURITY NUMBER ~DA1E Of DEATH ,McnfI. Oa~. ."eat)
a. Fe.male. 3.193 -24 -0942___ .1.7-6-2000
PlN:E OF DEATH ICt>edo 0IVy IY'e- _",",rUCI.ons-;;;;.~";;';~ ~~~~--~-_._~------~- ~--
HOSPITAL:
InpM_ 0 ER/OuIpal..... 0
y.~thek~b~g,MV k
FACIUTl' NAME (II nol ..........,.... QI" ....... _ numtl8r.
BIRTHPLACE (CIv and
sw. Ql Fa..." CClUfllry)
00\0
~IO
NAME OF DECEDENT (F"S1 M.dc:.e lasl
1. ]e.~~~e. M. Ki~ne.d~~t
METHOD OF DISPOSITION
8uriII 0 C,.......... ~ ~ INlm SlaI.O
~O Ohr~ 0
at... _ ..... .~.~___.~__~_ ._._ ~_______ atll.
::ru~Cu:r ;:;'7E;~PE7Jl~h=H :HSE NUMBER
~ "__~Wr- w.",.,.v .. b.- 01 my k~...alII OQ;W'''' a' u......... dA'. _ pIac;e SIa''''
- P'..- . nac avUablA a. ~ 0'''''" to a and lillel
~_oIdMl11
UNDER I DAI'
Houra : MInulaa
: 12-13-07
r- ak~DEATH
... Cumbekiand.. WOWek Aiie.n _ . ~~thanlj V ~iia,ge.
-~ .[j(CEoEN!'SI.i~Al OCCU~-'---~KIHo oFsuSiHiSSiiNoUSTRY__ J ~DEcEDENt EVER IN MARITAl SWUS. Married
,,~~~i%~:~~~~~~L_~:tJ1t~q~PA~la~S:OD:;jS1 t~ 1.. ;7;:T
~t-;c.5 DEhWaNTe.n.;";c.~;b,Fg..t"~~P(SlrA"',C4yl-fTown7--0'3.s..3-"CoMI J~on-~-~. t7a.SIaM PA :.... 17C.O _.~_ln
Vie ~ /.J loVL -. 17Ia.County Cumbekiand --'7 t7..0 ::"'~':::of
r:TN;~B~7;~~_~nMM)
1Nf'00000rs MAIUHO ADDRESS (SIr.... C4yfTown. ~. Zip Codal
. 302 HallmaAk No~th, Hek~hey, PA 17033
PlN:E OF OlSPOSJ.T1ON . Namf fI C-llf1. c,~. . lOCR1OH . ClIy/IJMl. SIaIa. Zip Coda
OfOhr"'- c~e.ma.[..ton ::iOc...te.-ty 06
ale. PA C~e.mato~y a1.. HaA~L6buJc. , PA 171 09
NAME AND AOORESS OF fi1tlCIUTY C~ e.matio n S g c.~ ety Q 6 P A
22c.4100 ]one~town Road,HaJt~~~ uJc.g~ PA 17109
LICENSE NUM8ER ORE SIGHED . -
(MonIl. Oey. -I
5. ~_2 unu_ v,.
COUNTY OF DEATH u
SUfMVlNG SPOUSE
II _. gnoa..- narnaJ
AZNn
....
. c:iIyIboIo
FRltEA'S NAME (Fnt. MoOdIe L3st)
,.. ]ame.~ Ne.wton. ~e.~~i
_OAMANrSNAMli,.(Ty,*Pnnq-- . . .
M.'l.. Jame.~ c. KlHte.d..tn~t
ORE OF DISPOSITION
.00y._1
7-11-2000
~TE CA~ (Fonal
~or~1Qt'I
_ .-.g." oaath)-
A ( z- ~ t-v\ 4--r
DUE 10 lOR AS A COHSEOUENCE OF):
'b~n4-
X-
I """""'....,.
'--
1__-
nb. Dc.
ow.s CASE REFERRED 10 ...EDICAl EXAMINEAICOAONER?
.....IVFD
..&(
__ 24-2e ""* be complaC'" by
- parwwlwllO pronouncea death
23L
OF DEATH
DATE PRONOUNCED DEAD (Month. Day. 'leal)
a.. 2'. .... 25.
~ 27. '-RT I: EIll.. me disNMs. inJUliaS Of compIICallOlla wIIich c:ause<llhe ...Ilh oil not..... lhe IIlOda 01 dying. such ... cardiac Of r._a'ory .u.... 5hoct< Of heart ,.....
L.. ontt one uuse on .ecII_
7-6-2000
PART .: Ohr IigniIIcanI CClndIIiclN ~ to dutll. buI
_ rauIIinll in... ...-.y;ng __ given in PART I.
e (-f?'.
:: ~... 0llndIIJ0rw
= - ~ 1MdinQ1O_.
;;: ~ Em. UNDIIII..YlHG
: CAUSE (o.s.a. Ql "VY
~"..--
:'-.g"'_llAST
~ . --- --- ---
: Wt.SAH AUlOPSV WERE AUlOPSV FINDINGs
~ PERFORMED? ~~ei.o.. -:; ~USE
OF OERH?
I :
DUE 10 lOR AS A CONSEOUE NeE OF):
DUE 10 lOR AS A CONSEOUE NeE OF):
v.. 0
MANNER OF DEATH
_.... ~ HomOC>de 0
- PendinV _ovalion 0
Suade 0 CotlId _ be determIned 0
DATE OF INJURY
(Monlh. Day. _I
TI...E OF INJ RY
INJURY AT WORK? DESCRIBE tON INJURY OCCURRED.
..... 0 NoD
..... 0 Nof\
Nor$.
M. 3OC.
. .~ SIGNAT~)Nd~
k/,,,-/ / ~ /' c2....t~ ~ :;:_:.,,,,,.,,,
I~ r~, //1
34.
7 ~~
:lea. :no.
CERTIFIaIICheck oniy onel
.CERTIFY.,.. PHYSICIAN /PhySlClan certJlylng ~ d ~aI11 """'" anolher ptwsrcoan has PfOllOUncecl dealfl ana compleled l1em 231
To _ _ of...y knowledQe. de.'" OC:C_ _10 _ eauM(a)and mann.,.. atated. .
29.
PLACE OF INJURY. AI home. farm. SI,..I. factory. oIIIce
~ ecc 1Specd.1
3Oe.
OPAOMOlINCING AND CERTIFYING PHYSIC'AN (Physc.an boIh O"onouncong O.alt> _ ce<1lfyong 10 cay.. 01 <lea"'.
To'" _ oI...y knowlad9a, death Gee...,'" a._ _. data. and plec.. and elualo lIMt caUM(.) and mann.,.. a.a.'"
-MEDICAL EXAMINER/CORONER
On the ba... olaxaminaUon and/or inva.llga.ion. in my op,nion, d..lh occurr... allhe 11m.. da'e, and placa, and dualo lha cau..(.' and
..........a..la1ad.. . ........................... ........
3'a
s
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
----
Name of Decedent:
U~SI~ M. KL.INr=~'N6r
Date of Death:
~ t..'1 6> l t.oo 0
Wi}) No.
Admin. No. 2bO( - 004o~
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 mai led to the following beneficiaries of the above-captioned estate on ~~ IS:. , ~ 1 2. 0 0 t
Name
Address
y,R.G-'.....A K. tJe-1\-L , .10 GA-tl)!;1! Re>~b. 9.o.BoK 774, ~A1JJ)tA ~L(, ~t1 8704-1
TM-1!S C \(L/~E-i)/""~T:" 30:l '{A-LL~A-1tK Alo~rH, N ~~"G11 PA '1033
Notice has now been given to all persons entitJed thereto under Rule 5.6(a) except
Date: ~~!:; ,q, 'ZOO 1
Signature \, ~ t::; ~ \\ "..-0-
---- ~
--.~
Name ..l~~ C; K L.I N. E-n/,.J -s r
Address
3-02 ~~L.L"1 ~~ ,Jol;T1.l
N~H~, PA /7033
Telephone (*111) .3'~" /3 ~ 0
Capacity: /' Personal Representative
_Counsel for personal representative
fl i D . DO
-
~nventory of the real and personal estate of
~~'S\f. n KL\NE.b\NST'
deceased
C A~ \~ o..l r~ A~t)
~t.1C %~~\(., ~~"'Ul&Gr~ Aec:eu",'" 110. 5'o-ooCl" -:It 22-
P'LLF\R.~TI c:.\"\~c.~'Al~ Ac:eb~,..,.. tJb. 005"18-014-1-(."
'a~T\-\A~'( 'JU.Lf\ ~~ ((!Tle.~t"\~, CE~1""E2., R~$' O'EAl r k,~n AC'bu~, ND. 00360
l:~~P\T\CU~ ~t)c.\~T'\ Of"" ~~~~'(L."~lA I ~~E.P""~ FUAl~A-L A ccou",r
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All!) 6Tt\fta- M,~eE l&.ArJc.o~~ ~...~.~ ~\.. (>aO~c.~TY ,$ "~L\A~D "''11&'''00 ill. U~
l6,f\'"
~ to 0.0
14(, 'to
~5 5'&
~C\~ .1
\ ,'11 S 00
'SOD 00
I 3.4Qo gq
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
l
j
55:
~ n e..s C ~ f-,' N E-s) J t\l S ...
being duly ~wt).elJ according to law, deposes and sa:t.!-!hat he i ~ rK ~
~"'-I""'\.sT12-~Qa. of the Estate of 4 ~I ~ Ii t<L/Ilf~i)J^,5T
late of _n~c::."'_~_'_f_~~_~_~_&-.____ , Cumberland County, Pa., deceased and that the
within is an inventory made by ::lIc+lE S c: "'L..II'l ~ I ~t.s f _, the said f+-J)).t, ^" '..fTlZA-f-a R-
of the entire estate of said decedent, consisting of all the personal prop~rty and real estate. except real estate outside
the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value
as of the date of decedent's death.
~ WDatJ
and subscribed before me,
4trt{~ c. ~LIAtE-j)J^,..s T
~
-..l \J lit ~
'8,
I
m-cU'+er . Administrator
~G>~'
,3t) ~ \~A-LLf\~~ Ao eT1~
J+~~PA-
I ;033
Address
Date of Death
~
r--
~ l.l (., ..,
Month
~ooo
Day
Year
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.
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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
JAMES C KLINEDINST
302 HALLMARK NORTH
HERSHEY PA 17033
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
08-06-2001
KLINEDINST
07-06-2000
21 01-0402
CUMBERLAND
101
<)'/(
c
REY-15~7 EX AFP 02-00)
JESSIE
M
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV : is"4-j-EX-AFP--fi'2---00'Y-NO,..-icE--OF-'rNHER-ifAifcE-"-AX-A-PPRA-isEMENT~--Ai:l-owANCE-ifR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF KLINEDINST JESSIE M FILE NO. 21 01-0402 ACN 101 DATE 08-06-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
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
3,490.89
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage liabilities/liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
ClO)
2,540.24
.00
(11)
(12)
(13)
(14)
NOTE:
If an assessment was issued previously, lines
reflect figures that include ~he ~o~al of ALL
ASSESSMENT OF TAX:
15. Amount of line 14 at Spousal
16. Amount of line 14 taxable at
17. Amount of line 14 at Sibling
18. Amount of line 14 taxable at
19. Principal Tax Due
TAX CREDITS:
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
3,490.89
7.&;40 74
950.65
.00
950.65
14, 15 and/or 16, 17, 18 and 19 will
returns assessed ~o date.
.00 X 00 =
950.65 X 045 =
.00 X 12 =
.00 x 15 =
(19)=
rate
lineal/Class A rate
rate
Collateral/Class B rate
(15)
(6)
(7)
(18)
.00
42.78
.00
.00
42.78
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
06-18-2001 AA496733 .68- 43.46
TOTAL TAX CREDIT 42.78
BALANCE OF TAX DUE .00
INTEREST AND PEN. .09
TOTAL DUE .09
* 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.)
RESERVATION: Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
PURPOSE OF
NOTICE:
To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.S.
Section 9140),
PAYMENT:
Detach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side.
--Make check or money order payable to: REGISTER OF HILLS, AGENT
REFUND (CR):
A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an -Application
for Refund of Pennsylvania Inheritance and Estate Tax- (REV-13l3). Applications are available at the Office
of the Register of Wills, any of the 23 Revenue District Offices, or by calling the special 24-hour
answering service for forms ordering: 1-800-362-2050; services for taxpayers with special hearing and I or
speaking needs: 1-800-447-3020 (TT only).
OBJECTIONS:
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must Object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
ADMIN-
ISTRATIVE
CORRECTIONS: Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, HarriSburg, PA 17128-0601
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
DISCOUNT:
If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5Z) discount of
the tax paid is allowed.
PENALTY:
The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time periOd as you would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST:
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (6Z) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after
January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2001 are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
1982 20i: .000548 1992 97- .000247
1983 167- .000438 1993-1994 7"/. .000192
1984 11Z .000301 1995-1998 97- .000247
1985 l3Z .000356 1999 77. .000192
1986 107- .000274 2000 87- .000219
1987 97- .000247 2001 97- .000247
1988-1991 11Z .000301
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUKBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
STATUS REPORT UNDER RULE 6.12
Name of Decedent:~.s' G n. KLIJJ€S)1A95,
Date of Death:
1 ,. a (;. - ~oo 0
Will No.
Admin. No. ~I 01- 0 4-0~
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 V 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. 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 v/ 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: ~.sOC.T~O() \
t\.~.) ~l 0 \.- ~l :~ o~ 1".-LxQ-
~nature
~~E:~ c:: K L. td ~ , 1J..fI
Name (Please type or print)
aO:;t fttrLLH~K ~2rn,I~~f(~\ O~
Address 1703S
(1'1 ) .3l2 -'3 '2 C>
Te 1. No.
Capacity:
,/
Personal Representative
Counsel for personal
representative
(MAH:rmf/AM3)
REV-1500EX(6.00j
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT 280601
HARRISBURG, PA 17128-0601
REV-1500
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OFFIGIM. USE ONLY
FILE NUMBER
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I-
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W
(.)
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C
DECEDENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL)
KL,AlEl),AlSr -~S;SIli.
DATE OF DEATH (MM-DD-YEAR)
o'1-e"-oo
~i - ..Q. .L
COUNTY CODE YEAR
~~4E..':l.
NUMBER
SOCIAL SECURITY NUMBER
1'13 - il.+
- oQ4:l
M.
DATE OF BIRTH (MM-DD-YEAR)
I~. '?J-D1
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[{] 1. Original Retum
D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy of Will)
D g, Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 2. Supplemental Return
o 4a. Future Interest Compromise (date of death alter 12.12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (date of death between 12-31.91 and 1-1-95)
D 3. Remainder Return (date of death prior to 12.13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach $ch 0)
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NAME4f'rn~S C. \(L,,,,e.l),^,:>r
FIRM NAME (If Applicable)
COMPLETE MAILING ADDRESS
3/)'- HII U.M~" Nt) t."'"
AtI&ll~, -PA l"7b33
TELEPHONE NUMBER
111 31-a.-13:to
OFFICIAL USE ONLY
(8) tI 3. 4Ql). M
(11) 1. :("'40.2.4
(12)" 9fo .4'5'
(13)
(14) ~ 1:\5"0. ,of
x.o_ (15)
X .0 4f. (16) ...
x .12 (17)
x .15 (18)
(19) ~
4'1.n
41."&
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5) It 11 ;4q l). 8CJ
19. Tax Due
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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D:
4. Mortgages & Notes Receivable (Schedule D)
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)
\\ 15"40. ~+
(6)
(7)
9. Funeral Expenses & Administrative Cosls (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
(9)
(10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental 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
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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
~ qS'l). (,.S
17. Amount of Line 141axable at sibling rate
18. Amount of Line 14 taxable at collateral rate
20.0
Decedent's Complete Address:
STREET ADDRESS is:l.5' W'1$S Uf!r( h tl ~
CITY ntLc.,u".Ic.s.sue4- I STAT~ ~ I ZIP l'O~5
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1) t 41.16
Total Credits (A + B + C ) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
.(.8
TotallnteresUPenalty ( D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
(3) .4t
(4)
(5) 4'3.44
(5A)
(5B) tl 4!l. 44
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;................................... .......................................... 0
b. retain the right to designate who shall use the property transferred or its income;........ .......................... D
c. retain a reversionary interest; or..................................... .................................................................................... D
d. receive the promise for life of either payments, benefits or care? ............ .................................................... D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .................................................................... ................. D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...........................................................................................
No
~
ill
[tJ
[tJ
~
[tf
Under penalties of perjury, I declare lt1atl have examined this return. including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct
and complete.
Declaration of pre parer other than the personal representalive is ba sed on all information of which preparerhas any knowledge.
SIGNATURE OF PERSON RESPONSIBL
n... ",..) .ll._ C
ADDRESS f\
30"- ~u..l1A-12 ~ N'll enl , I{ :=u."'~ I 1ft
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
~~!. 1& 1&01
170a3
DATE
ADDRESS
For dates of death on or after July 1, 1 994 and before January 1, 1 995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)).
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(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 at least one parent in DOmmon with the decedent, whether by blood or adoption.
REV""""",;r,'~
~
COMMONWEALTH OF Pl::NNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
:Jrssc E M. I< L.IN~1)IAI.s'"
FILE NUMBER
2001 - oo4-()~
Include!he proceeds of Ii/igalion and It>e date the pn>:eeds were recejyed by the estate. All property jolntly.owned _ the right of sUNivo..hlp must be disclosed on Schedule F.
---.-.
ITEM V ALUE AT DATE
NUMBER DESCRIPTION OF DEA T/,
I.
Cash on Hand
$ 10.00
2.
PNC Bank, PO Box 53520, Pittsburgh, PA 15253-5230
Savings Account No. 50-0096-2122
746.70
3.
AIlfirst, 213 Market Street, Harrisburg, P A
Silver Class Checking Account No. 00518-0741-6
65.58
4.
Bethany Village, 325 Wesley Drive, Mechanicsburg, PA 17055
Resident Fund Account No. 00380
893.61
5.
Cremation Society of Pennsylvania
4100 Jonestown Road, Harrisburg, PA 17109
Prepaid Funeral Account
1,275.00
6.
Household goods and furnishings, wearing apparel and costume
jewelry, books, memorabilia and other miscellaneous
items valued at less than $500
500.00
_____ _ ___...1._____
TOTAL (Alsoenleroo line 5, Recap1Iulat/on) $ 3,490.89
(If more soace is needed. insert additional sheets of the same size)
REV-1511 EX+ (12-99)
~~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
'J'ji;~'5IE M. l;(l.IIIIEnIN~T
Debts of decedent must be reported on Schedule 1.
FILE NUMBER
~oo I - 0040:1
ITEM
NUMBER DESCRIPTION AMOUNT
A, FUNERAL EXPENSES:
1. Cremation Society of Pennsylvania Direct cremation, funeral items and services $ 1,175,00
.do- Death certificates 22.00
.do- Cumberland County Coroner cremation fee 25,00
The Rev. Dr. S. Ronald Parks Memorial service (July 2000) clergyman 100,00
Mrs. Elizabeth Kletfel Memorial service organist fee 50,00
BrachendorfMemorials Engraving of tombstone 250,00
Mrs. James Marks Flowers for memorial service 57,77
Bethany Village Retirement Center Refreshments and food after memorial service 160,00
East Harrisburg Cemetery Grave opening 475.00
Rev. Dr. Parks Graveside service (Sept. 2000) clergyman fee 75,00
Pealer's Flowers Flowers for graveside service 8,47
B, ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name 01 Personal Representative(s)
Social Security Number(s)/EIN Number 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. allach explanation)
Claimant
Street Address
City State _ Zip
Relationship of Claimant to Decedent
4, Probate Fees
Cumberland County Register of Wills Letters of Administration and Short Certificates 42,00
5, Accountant's Fees
6, Tax Relurn Preparer's Fees
7,
TOTAL (Also enler on line 9, Recapitolallon) $ 2,540.24
(If more space is needed, insert additional sheets of the same size)
RfV-1513 EX + (1-97)
.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
"J ~~StE. M. KLllllei)II'Il~T
FILE NUMBER
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
,too \ - oo4-o~
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
1. ",~c:..'I'l'A K. NE1IL
'0 GUl>EJol Rofrb I ~.o.Bo~ 114
S~I)IA ~MtK. /111'1 87041
~ 4\ u to It TC-fl.
'5"0 ~o
1.. ~1'1~S c. Kc.,lIIa/"'&s,
30~ ~Au.."'~,," t.\~~n.
I\-G':tLSM~~,?f\ \'l03~
'S01ll
5'l> <<70
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 $
(\f more space is needed, insert additional sheets of the same size)
iii allflrst
JESSIE M KLINEDINST
302 HALLMARK NORTH
C/O JAMES KLINEDINST
HERSHEY PA 17033-2343
1,.,111,"111"",11."11",1.1..11,.1,,1,,11,1,1.,1,1,,,11.,1
Silver Class Checking
Page 1 of 2
JESSIE M KLINEDINST
Acct No 00518-0741-6
January 8, 2000 thru February 7, 2000
Activity Summary
Balance on 01/07
Balance on 02/07
$65.58
$65.58
End of Day Ledger Balance
Account balances are updated in the section below on days when transactions posted
to this account.
Date
Balance
01/07
$65.58
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Balancing your checkbook. Look on the back of your first statement page for a fast and easy
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What your Icons mean
o Customer Service
CI) Credit to your account
o Important reminder
e Charge to your account
o I nternet transaction
~ Other banks' A TM
transaction
026692
0003~9831747B013 050
o 24-hour
Customer Service
1-800-533-4630
For questions about
your statemenr or
change of address
information, please see
page 2.
SaVings Account Statement
PNC Bank
PNClBANK
Primary account number: 50-0096-2122
Page 1 of 1
For the period 04101/2000 to 06/30/2000
Number of enclosures: 0
K
JESSIE M KLINEDINST
302 HAllMARK N
HERSHEY PA 17033-2343
11 For 24-hour customer service or
current rates: Call1-88S-PNC-BANK
t2!SJ Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
a Watch for our new E-Mail address
Visit us at www.pncbank.com
~ TDOterminal: 1-800-531-1648
For bearing impaired clients only
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Savings Account Summary
Account number: 50-0096-2122 Account Link@ number: 0193240942
Jessie M Klinedinst
Balance Summary
Beginning
balance
742.G9
Deposlls. and
other additions
4.01
Checks and other
deducllons
.00
Ending
balance
746.70
Interest Summary
Annual Percentage
Yield Earned (APYE)
Number of days
in Interest period
Average collected
balance for APYE
I nterest Earned
this period
As of 06130, a total of $7 A8 in interest was
earned this year. .
2.18%
Deposits and Other Additions
Date Amount Description
04.- 30 1.29 Interest P,l)'luent
05 '31 1.~15 Interest Panuent
06. 30 1.37 Intel'cst Payment
91
744.07
4.01
There were 3 Deposits and Other Additions
totaling $4.01.
Daily Balance Detail
Dale' Balance
04'01 742.69
Date
0-:1/30
Balance
743.98
Date
05/31
Balance
745.33
Date
06/30
Balance
746.70