HomeMy WebLinkAbout01-0408
PETITION FOR PROBATE & GRANT OF LETTERS
ADMINISTRATION C.T.A.
Estate of HARRY EDWARD BAILEY No. 21-01- 4D8'
also known as To: Register of Wills for the
, deceased. County of Cumberland
Social Security No. 284-16-7632 Commonwealth of Pennsylvania
The Petition of the undersigned respectfully represents that:
Your Petitioners, who is 18 years of age or older and the Executrix named in the Last Will of the above
decedent dated February 17 , 1976, and codicils dated none , 19~ The Executor
named none died . Renunciations for Melvin L. Resnick. Karen Lee
Walker, Edward Lee Bailey and Reba Lou Bailey (now known as Reba Kinoston) attached hereto.
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his last family or principal
residence at 503 Quail Court, Hampden Township. Mechanicsburo
Decedent, then .2L years of age, died February 26 . 2001, at Thornwald
Home, Carlisle. 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:
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property
(If not domiciled in PA) Personal property in PA
(If not domiciled in PA) Personal property in County
Value of real estate in Pennsylvania, situated as follows:
$35.000.00
$
$
$
WHEREFORE, Petitioners respectfully requests the probate of the Last Will and Codicil(s) presented
herewith and the grant of letters administration c.La. hereon.
Signature( s) and Residence( s) of Petitioner( s):
, '\ .... . . i\
,-.t lU/IY\i~ ~ ~ ' .~~ · '\ t. (), '
Norma Jean. avhurst
P.O. Box 177
Waverlv. PA 18471-0177
570-563-2995
OATH OF PERSONAL REPRESENT A TIVE
COMMONWEALTH OF PENNSYLVANIA
ss
COUNTY OF CUMBERLAND
Sworn to or affirmed and subscribed
b~'" this 2.. ~ day of
J .2001.
'11J1:ft'. fd,//!V> 11i.J.f1 /J. ~"'? j]vp/~
/ RegIster -- r
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 of
the above decedent, petltioner(s) will well and truly administer the estate according to law.
',- \ \'1'lI Y'''~'~1( II \ ( \ b \\. \ " .(f-
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Norma Jean Hayhurst
/e:, -) A):' I ~
No. 21-01- 408
Estate of
HARRY EDWARD BAILEY , deceased.
DECREE OF PROBATE & GRANT OF LETTERS OF ADMINISTRATION
C.T.A,
AND NOW, April 24th , 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
February 17, 1976 described therein be admitted to probate and filed of record as the
Last Will of Harry Edward Bailev ; and Letters of Administration c.La. are hereby
granted to Norma Jean Havhurst
YI1],~.t~;. ;f~LrG.1I/tU. (/ t7. #)~/~ /2;fV~
Registe:- of Wills
IRWIN Mcr,Nl(~HT & HUGHES
FEES
Probate. Letters, Etc. . . . . . . . $ 70.00
Short Certificates( -2- ) . . . . $ 6.00
Renunciation(s) .. . . . . . . . . . $20.00
JCP .. . . . . . . . . . . . . . . . . . . $ 5.00
Other Will Paqes (1 ) . . . . $3'!OO
TOTAL: .... $lQ4. 00
Filed. . . ~~~~~. .2.~'. . ?99 ~. . . ~~ ~
James D. Huqii~S. Esauire (58884)
ATTORNEY (Sup. G. 1.0. No.)
60 West Pomfret St., Carlisle. PA 17013
ADDRESS
717 -249-2353
PHONE
CALLED ATTORNEY APIRL 25, 2001
21-01-408
REGISTER OF WILLS OF COUNTY
OATH OF SUBSCRIBING WITNESS
/'
/~/
codicil
(each) a subscribing witness to the will presented herewith, (each) being duly qua' ed according to
law, depose(s) and say(s) that present and saw
the testat , sign the same and that signed as a witness at the
request of testat_ in h presence and (in the prese.nce/ of each other) (in the presence of the
other subscribing witness(es)). ~//
////
Sworn to or affirmed and subscribed before ,/'/
me this ~ --
/
/
(Name)
(Address)
Register
/~
~.
/
,
(Name)
(Address)
REGISTER OF WILLS OF CUMBERLAND COUNTY
OATH OF NON-SUBSCRIBING WITNESS
NORMA J. HAYHURST
and
JACQUELINE L. DRAWBAUGH
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
each is familiar with the signature of Harry Edward Bailey
2t~~
testat~ <WC~one:xofCXtJlex~~~~XWif~~o) the will presented herewith and
~tt:tlX
believes the signature on the will is in the handwriting of
each
that
Harry Edward Bailey
to the best of the iL_ knowkdge and belief.
"'--
Sworn to or affirmed and subscribed before
'1 &-/ C1L
me this ;:x' 7 day of
April ~2001
Y'xil(j e, Xu u~ 'f"' . t. 6..-. :JtC~~
Register
(Name)
St.; Carlisle',
(Address)
17013
6
21-01-408
RENUNCIA TION
In regard to the Estate of
HARRY E. BAILEY
, deceased.
To the Register of Wills of
Cumberland
County, Pennsylvania.
The undersigned daughter of the above deted nt hereb
the right to administer the estate and respectfully ask(s) that Letters er · iY/16
be !8sued to ____'---'-~orrngtL Havh:urst .._.____._,._.__
WITNESS my
hand(S)this~dayOf (~~
, 2001.
/ ) I
e:::A1~ \ f f!
/ IWJVI}!1 \1 CC .LJ]1fJUl)
. \ Karen Lee Walker
(SEAL)
7461 Summerfield Road
Lambertville, MI 48144-9601
21-01-408
RENUNCIA TION
In regard to the Estate of
HARRY E. BAILEY
, deceased.
To the Register of Wills of
Cumberland
County, Pennsylvania.
The undersigned son of the above decedent hereby renounce( s) the right
to administer the estate and respectfully ask(s) that Letters Testfunc'lItM drfAdwWll51r~M tk
he issued to
N OrlTla J. Havhur~t
WITNESS
my
/if
hand(s) this ~6-
day Z ' ' 2~01.
Edwar~
(SEAL)
23 Woodwind Drive
Spartanburg, SC 29302
21-01-408
RENUNCIA TION
In regard to the Estate of
To the Register of Wills of
Harry E. Bailey
Cumberland
, deceased.
County, Pennsylvania.
The undersigned daughter of the above decedent hereby renounce( s)
the right to administer the estate and respectfully ask(s) that Letters of Administration
c.t.a
be issued to
Norma Havhurst
WITNESS
my
hand( s) this
, 2001.
21-01-408
RENUNCIATION
In regard to the Estate of
Harry E. Bailey
, deceased.
To the Register of Wills of
Cumberland
County, Pennsylvania.
The undersigned
attorney
of the above decedent hereby renounce( s)
the right to administer the estate and respectfully ask(s) that Letters
of
Administration
c.t.a
be issued to
Norma Hayhurst
WITNESS
my
hand(s) this -7..-A day of
Aoril
, 2001.
~'t -vL- ~ ~. · ~Jl.,
Melvin L. Resnick . t
2407 Edgehill Road
Toledo.OH 43615
1 . .. 1 1 III I I f I .1 \vi t h t11l' as
i) tu \..LTtity th,lt the int~HmatjOn here given IS correctly (opiclt Iron.1 .Ill OrIf:lll;l Cl'.I~li le,lll' (, . l (';1;', (:u,~~i, LL
RcsistLll. Thl' urig.il1.l1 certifIcate will he f()rw<nded ((\ the \tdle VILd Recurds Offill.' tur pCnll,lIh'lll 111111!,.
. )
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~~u.
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H'OS'43 R8't 2187
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
INT
AGE !La.. BW1hC3y)
UNO€R 1 YEAR
Month. Days
UND€ R 1 DI<Y
SEX--
2.lVlal e
STATE ~ILf ~UM8EFl.
SCC'Al SECURrN ><UM9ER
,NT
..,1(
NA-..E Of DECEOENT !Flrsr, M~. laSI
Harry E. Bailey
3.
284 - 16
7632
DATE OF OU.TH ,MC"",. Day."""
2/26/2001
5.
COUNTY OF ()E,(TH
76
Y~
HouB ! M;nul"
BIRTHPLACE ,c.ry aM PVoCE OF DEATH IC~ec. ""'y OI'e -- """ ,nSllLe'''''''' on O!t>e< -I
3\a1601 FCfi!'l(}l"I CounUvl HOSPITAL
Inpatient 0 ERJOutpAflent 0
"'.
F"AClllTV NAME III no! tn~'tutlOro. gl~ 'i(feet and nymoe.\
~::dyl 0
:.:~ \ . ...
Cumberland
O€CEDENT'S USU,t.L OCCUP;UION
(GNe Iund cJ ""'. <lOne durong"""
of wortunrg lit.; do not use rellled )
_ l1L Major l1b. U . S. Air Force
OECEO€NT'5 MAIUNG AOOAESS ($I..... ClIy/TooHl. s.-. Z",Cooe\ O€CEDENT'S
ACTUAL
RESIDENCE
(See If"lSlfUChOt\S
on omer SKJel
I(IND OF BUSINESS/INDUSTRY
WAS DECEDENT EVER IN
U S AR~D FORCES?
Yes lz;. No 0
12.
MAAllAL STATUS . !.lamed
N.....r Maniea. W~.
OM>rced (Spec"Yl
I.. Divorced
10. White
SUfMVING SPOUSE
l" NIle. ~ ma.oen rwTle)
11.. $tate
PA
l1C.l8l Yes. ,*,-nlliYed in
Hampden
twO
503 Quail Court
,..Mechanicsburg, PA 17050
17b. County
[);d
~
M"'.
CUmberland '-'SI\i!>1 17d.o :h~=~ot
MOTHER'S NAUE ,FeSI M,ddIe. M.-. Sutname)
lva Marie Crabill
Cllylboro
FRHER'S NAUE {Fest. MoOdIe. Lastl
Not Kncwn
".
INFORMANT'S MAILING ADDRESS (Street. C,ty/Town, SlaIe. lip Code)
2~. P.O. Box 177, Waverly, PA 18471
PLACE OF DISPOSITION. Nome 01 Cemetery, Cremolory LOCATION. CilylTown, Stote. Zip coo.
Of OItwf Placo
21c~rlington National Cemete 21d. Arlington, VA
LICENSE NUM9Efl , 219 L NAME AND ADDRESS OF FACILITY
22b. OO~ - EWing Brothers Funeral Home, Carlisle,
LICENSE NUMBER DATE SIGNED
(MonIII. Day. _,
11.
IHFOf\IoIANT'S NAME (T ypelPnntj
2010. Norma J. Ha hurst
UETHOO OF D4SPOSIT~
. 0 8unat Iti Cremahon 0 R.....-. bom SII'. 0
eon..oon 01"'" 1Soec"Y'
. 21..
SlGNIlTURE
2'.
27. PART I: Ent., me> diseases, l"fUrieS Or compkahOflS wf'lKh caused the
LiSt 0tnPf one U~ on eaCh tine
~.:~r~\'r\~~ <)~
DUE TO (OR AS A CONSEOUENCE Of)'
Lul'\
\ :
WERE AUTOPSY FINDINGS
AWlJ.91E PRIOR TO
COMPlETION Of' CAUSE
Of' OEIlTH1
DUE TO (OR AS A CONSEOUe NCE Of)
DUE TO (OR AS A CONSEOUE NeE Of)
MANNER OF DEATH
OATE OF INJURY
(MonTh, Day. ~arl
TIME OF INJURY
INJURY AT WORK? O€SCRIBE HOW INJURY OCCURRED.
y.. 0
NoD
Suoeode
~ HomICide 0
D P",ndi"'9ln~t'9atlOn 0
D Could not be determined 0
o NoD
-. 21b.
CERTIFIER IC~ec. ""'y""'"
-CERTIFYING PHYSICIAN (Pt'tysw;.an Cp'(llfytoq cause d Math .....t'ler> anott'ter onvSlCoan has Pl'onounceo dealh ana completed Hem 23\
1'0 ~ be<at ot "'v 'U~'IIt'-dge. de.th occurred due 10 the eau.e(s, and manner~. Itated. .
29.
30e 3Ob.
PLAC€ OF INJURY. At home. tarm. slre.,t, factory, ol1k:.
buttdin9, etc. l$PfJGllvl
300.
o
.PAONOUNCIHG AND CERTIFYING PHYSJeIAN iPhVS'Cl3n oort'. O>fonounc:.ng uedth and Cet1.IYIOQ 10 cause 01 oeal/"il
To the beofl of my knowtedQfI!'. death occ:urred at th.e tl"'., date.,a~ place, and due to the e..use(s) and manner as stated.
"MEDICAL EXAMINER/CORONER
~:~~:,b::i:t:::O~~~.i~~',I~n..,~dJO~ .i~~e~t.i~~t.i~~: ~~ ':',Y. ~pi.n.j~~: ~~~~~ ~~~~r.e.~ ~~ I.~~ ~l~~. ~~t:: ~~~.~I~~~: ~~~.~~~ ~~ ~~~ ~~~~~~~)...~~ 0
31..
"EGISTRAR'SSIGNATURE~~BER "'. ~... . I t\--'- \ .a...
~r\ ~\...--CX\.~_ ~\I~~IOI
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21-01-408
LAST WILL AND TESTAMENT
-OF-
HARRY EDWARD BAILEY
I, HARRY EDWARD BAILEY, of the City of Toledo, Lucas County,
Ohio, being of full age and of sound and disposing mind and memory, do
make, publish and declare this to be my Last Will and Testament hereby
revoking all Last Wills and Testaments by me heretofore made.
ITEM I
I direct that all my just debts and funeral expenses
be paid out of my estate as soon as practicable after
the time of my decease.
ITEM II
A!;;>/ ~
I give, devise and bequeath to my wife, BETHA ALLENE
BAILEY, an amount equal to her intestate share pur-
suant to her right of election under the laws of the
State of Ohio or any state I may be domiciled at the
time of my decease. If at any time before my decease
JI:~u my wife, .LETHA ALLENE BAILEY, and I become divorced,
the above provision in Item II becomes null and void.
ITEM III
All the rest, residue and remainder of my estate, real,
personal and mixed, of every kind and description and
wheresoever situate, which I may own or have the right
to dispose of at the time of my decease, I give, de-
vise and bequeath to my children, NORMA JEAN HAYHURST,
KAREN LEE WALKER, EDWARD LEE BAILEY and REBA LOU BAILEY,
and any other child or children born or adopted from
my present marriage, share and share alike, subject
only to this provision that, if anyone or more of
my said mentioned children shall die previous to my
decease, leaving issue surviving, the issue of such
deceased child or children shall take the estate
herein devised and bequeathed to its parent or parents,
as the case may be, per stirpes.
ITEM IV
I make, nominate and appoint my Attorney, MELVIN L.
RESNICK, to be the Executor of this, my Last Will and
Testament. I hereby request that he be permitted to
serve as such without giving bond.
I hereby authorize and empower my said Executor to
settle, compromise and adjust all claims due to or
owing by my estate at such times and upon such terms
and conditions as he may deem best.
I further authorize and empower my said Executor to
sell, trade, deliver, assign and convey any part or
all of my estate, real, personal or mixed, at such
-I
, ,
... " ......"
r .
,. .
times and upon such terms and conditions and for
such prices as he may deem best, and to such ends
I authorize him to execute, acknowledge and deliver
all necessary bills of sale, instruments of trans-
fer, deeds or other papers of conveyance as he may
find necessary or convenient in the premises. I
hereby exempt him from the necessity of obtaining
any court order for such purposes.
IN WITNESS WHEREOF, I have hereunto subscribed my name to
.-, ...:.~
this, my Last Will and Testament this. / day of February,
1976.
.,/ ~_._~. )' ../"' d"/
--/'/ .' ~.. . i ~
~~~Ed~:t~:f~ (~,d:zL (T---\\
~/ -
f
The foregoing instrument was signed, published and declared
by HARRY EDWARD BAILEY, as and for his Last Will and Testament, in our
presence, who at his request and in his presence and in the presence
of each other, have hereunto subscribed our names as attesting witnesses
o~ythe day and year ab~jre wri tten.
\
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residing at
,
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- 2 -
11
s
----
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent:
HARRY E. BAILEY
Date of Death:
FEBRUARY 26. 2001
Estate No.:
21-01-0408
To the Register:
I certify that notice of the beneficial interest required by Rule 5.6(a) of the Orphan's
Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate
on May 23. 2001
Name
Address
Norma Havhurst
Karen L. Walker
Edward L. Bailey
Reba Kingston
P.O. Box 177. Waverly. PA 18471
7461 Summerfield Road. Lambertville. MI 48144
22 Woodwind Drive. Spartanburg. SC 29302
1812 East Ramble Court. Decatuar, GA 30033
Date:
OS/23/01
Carlisle, PA 17013
Notice has now been given to all persons entitled thereto under ule .6(a) except none.
Telephone (717) 249-2353
Capacity:
Personal Representative
x
Counsel for Personal Representative
COMMONWEALTH OF PENNSYLjANIA
COUNTY OF ~~laV\L'
5S:
__~ORMA_~I~_HAYJIDR.ST _n_____ __u_
being duly __~nrn--- according to law, deposes and says that g,e is the Admil1istratrix
_~~~~____ __ _______ __ ~__n of the Estate of Harry E. Bailey
late of ---
Hampden Townshi.J>
Cumberland County, Pa., deceased and that the
within is an inventory made by____heL-_______________ --- -----------, the said Ar1mini~t"r;:!t"rix r.t.a.
of the entire estate of sa id decedent, consisting of a II the personal prop~rty and real estate, except real estate outside
the Commonwealth 0+ Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value
as of the date of decedent's death.
1
I i-:[L<t',y'("Q.,-1t:,~J~h~~ \'\Lt '1 ~'t
I ~j.cu'o, . Adm\~0"'o,
r
I
I
I
J
n~"--Q~_~~x__t~______
Sworn
and subscribed before me,
Waverly, PA
18471
Address
Date of Death
2001
Month
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.
aJ
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I nventory of the real and personal estate of
HARRY E. BAILEY
deceased
Cash on hand
Allfirst Financial Center
2000 Buick automobile
Coin/paper money collection
Personal property sold
TOTAL:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HUGHES JAMES 0
60 WEST POMFRET STREET
CARLISLE, PA 17013
___n___ fold
ESTATE INFORMATION: SSN: 284-16-7632
FILE NUMBER: 2101-0408
DECEDENT NAME: BAILEY HARRY EDWARD
DA TE OF PAYMENT: 02/25/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 02/26/2001
NO. CD 000885
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $184.72
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$184.72
REMARKS: JAMES 0 HUGHES ESQUIRE
CHECK# 18273
SEAL
INITIALS: VZ
RECEIVED BY:
REGISTER OF WILLS
MARY C. LEWIS
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HUGHES JAMES D
60 WEST POMFRET STREET
CARLISLE, PA 17013
fold
ESTATE INFORMATION: SSN: 284-16-7632
FILE NUMBER: 21-2001- 0408
DECEDENT NAME: BAILEY HARRY EDWARD
DA TE OF PAYMENT: 1 2/ 2 1 / 200 1
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 02/26/2001
NO. CD 000681
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $1.83
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$1.83
REMARKS: ROGER B IRWIN ESQ
CHECK# 18131
SEAL
INITIALS: VZ
RECEIVED BY:
REGiSTER OF WILLS
MARY C. LEWIS
REGISTER OF WILLS
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 260601
HARRISBURG. PA 17126-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
Reel<,
Re"
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
12-17-2001
BAILEY
02-26-2001
21 01-0408
CUMBERLAND
101
.01 0 I C 27
JAMES D HUGHES ESQ
IRWIN ETAL
60 W POMFRET STCiBlh
CARLISLE CAftlilWIl13
Al0 :11
REY~1547 EX AfP 02-00)
HARRY
E
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 = iS4-j-EX--AFP--f i'2:0oY-NlfficE--Or=-YNtiEifiTAifcE-YAjr A -PPRjrisEMENT~--A[i-oWANCE-OR------------ -----
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BAILEY HARRY E FILE NO. 21 01-0408 ACN 101 DATE 12-17-2001
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
n)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
35,811.62
.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)
nO)
7,690.99
15.619.31
Ul)
(12)
(13)
(14)
NOTE: If an assessment was issued previously, lines
reflect figures that include the total of ALL
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
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.
35,811.62
:;i'3 310 30
12,501.32
.00
12,501.32
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
12,501.32 X 045=
.00 X 12 =
.00 X 15 =
(9)=
.00
562.56
.00
.00
562.56
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
05-25-2001 AA496648 26.32 500.00
INTEREST IS CHARGED THROUGH 01-01-2002 TOTAL TAX CREDIT 526.32
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 36.24
REVERSE SIDE OF THIS FORM INTEREST AND PEN. .32
TOTAL DUE 36.56
· 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.)
'\ /6-c:2~~
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
REV-1607 EX AFP (12-00)
Race
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
12-17-2001
BAILEY
02-26-2001
21 01-0408
CUMBERLAND
101
HARRY
E
JAMES D HUGHES ESQ .01 ole 27 mo :07
IRWIN ETAL
60 W POMFRET ST CIS~rK
CARLISLE ~UlTlLOd3,
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
iffv: i 6(fj-E3f-AFP--(i2:0(ff------...--iNirERI'~..-ANCE--fAX--STA-fEMENf-o-F'-AC-coutif--.-i.--------------- - - - - --
ESTATE OF BAILEY HARRY E FILE NO.21 01-0408 ACN 101 DATE 12-17-2001
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 12-17-2001
PRINCIPAL TAX DUE: ............................................................................................--.....
562.56
PAYMENTS (TAX CREDITS):
INT
AT
REV
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
05-25-2001 AA496648 26.32 500.00
11-05-2001 CDOO0483 .00 34.43
EREST IS CHARGED THROUGH 01-02-2002 TOTAL TAX CREDIT 560.75
THE RATES APPLICABLE AS OUTLINED ON THE
ERSE SIDE OF THIS FORM.* BALANCE OF TAX DUE 1.81
INTEREST AND PEN. .02
., IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE 1.83
SIDE 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. )
I (P-;;';;"6 - /3
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
'0.2
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
04-01-2002
BAILEY
02-26-2001
21 01-0408
CUMBERLAND
101
JAMES D HUGHES ESQ
IRWIN ETAL
60 W POMFRET ST
CARLISLE
*v
REY-1547 EX AFP 101-02)
HARRY
E
\..J
Amount Remitted
r.~l:t ("
PA 17013
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--fo1-:02-r-NoYicE--oF--ZNHEifiTANCE-"-A)C-A-ppRAisEMENT-,--AL1-oWANCE-cfi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BAILEY HARRY E FILE NO. 21 01-0408 ACN 101 DATE 04-01-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL
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
NO. 01
RETURN
(I)
(2)
(3)
(4)
(5)
(6)
(7)
.00
4,297.50
.00
.00
.00
.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
265.00
(9)
(10)
.00
(II)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
4,297.50
265 00
4,032.50
.00
16,533.82
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
NOTE: I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 =
16,533.82 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
.00
744.02
.00
.00
744.02
r". II;"" KCl,C.L1"'1 II (+ J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
05-25-2001 AA496648 26.32 500.00
11-05-2001 CDOO0483 .00 34.43
12-21-2001 CDOO0681 .00 1.83
02-25-2002 CDOO0885 3.24- 184.72
TOTAL TAX CREDIT 744.06
BALANCE OF TAX DUE .04CR
INTEREST AND PEN. .00
TOTAL DUE .04CR
. 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.)
,.- ' '--;>
/ (;; . dd:::'-- /~
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
~-'
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-liD? EX AFP elZ-DDl
'02
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
[)? .r~UNTY
, '- .l
ACN
01-22-2002
BAILEY
02-26-2001
21 01-0408
CUMBERLAND
101
HARRY
E
Rf.
JAMES D HUGHES ESQ
IRWIN ETAL
60 W POMFRET ST
CARLISLE
JAN 25
Amount Remitted
G:C\I
PA17 0 Lt~LUnL~
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLEI PA 17013
NOTE: To insure proper credit to your accountl submit the upper portion of this form with your tax payment.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV = i 6cfi-EX--AFP--f r2=offf------...-iNifERIYANCE-;:AX--STA-YEME-N;:-OF-AC-Cou'Nf--..-..--------------- - -- - --
ESTATE OF BAILEY
HARRY
E FILE NO.21 01-0408
ACN 1 01
DATE 01-22-2002
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUEl APPLICATION OF ALL PAYMENTS I THE CURRENT BALANCEI ANDI IF APPLICABLE I
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 12-17-2001
PRINCIPAL TAX DUE: .......
562.56
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
05-25-2001 AA496648 26.32 500.00
11-05-2001 CDOO0483 .00 34.43
12-21-2001 CDOO0681 .01- 1.83
TOTAL TAX CREDIT 562.57
BALANCE OF TAX DUE .01CR
INTEREST AND PEN. .00
., IF PAID AFTER THIS DATEI SEE REVERSE TOTAL DUE .01CR
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $11
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJI
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J
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(-'
STATUS REPORT UNDER RULE 6.12
Name of Decedent:
HARRY E. BAILEY
Date of Death:
FEBRUARY 26. 2001
No. 21-01-0408
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
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 X 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? X Yes No
d. Copies of receipts, releases, joinders and approvals of formal or informal
accounts may be filed with the Cle of rphan's Court and may be
attached to this report.
, McKNIGHT & HUGHES
Date: 6/3/02
James D. Hughes. Esquire
Name (please type or print)
60 West Pomfret Street
Address
Carlisle. P A 17013
City, State, Zip
(717) 249-2353
Telephone Number
Capacity:
X
Personal Representative
Counsel for Personal Representative
1o~
REV-1500 EX + (6-00)
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
D
E
C
E
D
E
N
T
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Baile Harr
DATE OF DEATH (MM DO-YEAR)
OFFICIAL USE ONLY
I (P . 225 I
21-01-0408
YEAR
NUMBER
COUNTY CODE
OATEOFBtRTH(MM-OD YEAR)
SOCIAL SECURITY NUMBER
284-16-7632
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITYNUMBEA
James D. Hu hes Es .
FIRM NAME (If Applicable)
IRWIN McKNIGHT & HUGHES
TELEPHONE NUMBER
X 1. Original Return Z. Supplemental Return 3. date of death
. Remainder Return prior to 12-13-82)
CAPB 4. Limited Estate 40. Future Interest Compromise (date of death after 12-12-82) 5. Federal Estate Tax Return Required
HpRL X 6. Decedent Died Testate 7. Decedent Maintained a living Trust 1 8. Total Number of Safe Deposit Boxes
EplO
CRAC (Attach copy of Will) (AttaCh copy of Trust)
KOTK D 9. Litigation Proceeds Received 010. 0 11. Election to tax under Sec. 9113(A)
ES Spousal Poverty Credit
C
o
M
P
T U
A T
X A
T
I
o
N
02 26/2001 07/24/1924
IF APPLICABLE SURVIVING SPOUSE'S NAME lAST, FIRST. AND MIDDLE INiTIAL)
(date of death between 12-31 ~91 and 1-1-95) (Attach Sch 0)
THIS SECTION MUST'BE COMPLETED. ALL CORRESPONDENCE & CONFIDENTIAL TAX INFOl!lMATION'SHOULD liE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
60 West Pomfret Street
West Pomfret Professional Bldg.
Carlisle, PA 17013
R
E
C
A
P
I
T
U
L
A
T
I
o
N
1 249-2353
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)
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 (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
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)
C P
o 0
R N
R D
E E
S N
T
(1)
(Z)
(3)
None
None
None
(4)
(5)
None
35,811. 62
(6)
None
None
7,690.99
15,619.31
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(a)(1.2)
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
ZO.
12,501. 32
x
X
X
X
,0 0
,0 45
,12
.15
Copyright (c) 2000 form software only The Lackner Group, Inc.
OFFICIAL USE ONLY
(8) 35,811.62
(11) 23.310.30
(IZ) 12,501. 32
(13)
(14) 12,501. 32
(15)
(16)
(17)
(18)
(19)
0.00
562.56
0.00
0.00
562.56
FormREV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
503 Quail Court .
CITY I STATE I ZIP
Mechanicsbur~ PA 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
562.56
500.00
28.13
Total Credits ( A + B + C) (2)
528.13
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
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. (SA)
B. Enter the total of Line S + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
:!I~!:!$~j~!!~~!~~~!~jl~$!~jj~t~!8~:~mj
0.00
0.00
34.43
0.00
34.43
.... : PLEASEAN~WER'j+HE FOLL6~ING QJESTIO~~ 'BY PLACING:~N'
1.
"X"
Did decedent make a transfer and:
a. retain the use or income of the property transferred;
b. retain the right to designate who shall use the property transferred or its income; .
c. retain a reversionary interest; or .
d. receive the promise for life of either payments, benefits or care?
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .
3. Did decedent own an "in trust fo( or payable upon death bank account or security at his
or her death?
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property
which contains a beneficiary designation?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Yes No
~~
o
o
o
[]]
[]]
[]]
Under penalties of perjury, I declare that 1 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 preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN
Norma J. Hayhurst
P.O. Box 177
- - ~ - - - - - - ~ - - - - - - - - - ~ - - - - - - - - - - - - - - - - - ~ ~ - - - - - - - - - ~ ~ - --
Waver 1 , PA 18471
IRWIN McKNIGHT & HUGHES
60 West Pomfret Street
- - -Ca;:'i-i~ ie- - - PA- - - i "'i6i3- - - - - - - - - - - - - - - - - - -. - - - - - --
DATE
or dates 0 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
urviving pouse is 3% [72 P.S. 9116 (a) (1.1) (i)].
r d s 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%
[7 .5.9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets
and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's tineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116( 1.2)
[72 PS. 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(aX1.3}]. 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.
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
REV-1508 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Harry E. Bailey SS# 284-16-7632 02/26/2001
Include the proceeds of litigation and the date the proceeds were received by the estate.
survivorship must be disclosed on Schedule F.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21-01-0408
All property jointly-owned with the right of
ITEM
NUMBER
1 Cash on hand
DESCRIPTION
VALUE AT DATE
OF DEATH
46.85
2
Allfirst Financial Center NA - relationship with interest
checking
9,812.77
3
2000 Buick
22,000.00
4
Coin/paper money collection
3,422.50
5
Personal property sold
529.50
TOTAL (Also enter on line 5, Recapitulation) S 35,811.62
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97)
REV-1511 EX + (1-97)
ESTATE OF
Harry E. Bailey
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
SSlf 284-16-7632
02/26/2001
FILE NUMBER
21-01-0408
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES,
1 Ewing Brothers Funeral Home 4,110.00
2 Toledo Blade Newspaper, ob i tuary 263.90
B. ADMINISTRATIVE COSTS,
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) I EIN Number af Personal Representative(s)
Street Address
City State Zip
-
Year{s) Commission Paid:
2. Attorney's Fees IRWIN McKNIGHT & HUGHES 1,850.00
3. Family Exemption: (If decedent's address is oat the same as daimant's, attach explanation)
Claimant
Street Address
City State Zip
-
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 104.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Carlisle Coin Shop, appraisal fee 50.00
2 Chuck E. Bricker Auctioneer 237.50
3 Cumberland Law Journal - estate notice publication 75.00
4 Harvey M. Shuler, remove mobile home 500.00
5 Moyers Lock Service, repairs 379.00
6 Register of Wills - filing fees 25.00
Total of Continuation Schedule(s) 96.59
TOTAL (Also enter on line 9, Recapitulation) S 7,690.99
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc,
Form REV-1511 EX (Rev. 1-97)
Esta~e of: Harry E. Bailey
Sac Sec #: 284-16-7632
Date of Death: 02/26/2001
Continuation of Schedule H-B7
(Other Administrative Costs)
Item
if
Description
Amount
7
Register of Wills - short certificates
6.00
8
The Sentinel - Legal - estate notice publication
90.59
96.59
REV -1512 EX + (1-97)
, COMMONWEALTH OF PENNSYl\j/l..NIA
fNHERlTANCETAX RETURN
RESIDENT DECEDENT
ESTATE OF
Harry E. Bailey
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
SSjf 284-16-7632
02/26/2001
FILE NUMBER
21-01-0408
Include unreimbursed medical expenses.
ITEM
NUMBER
1
DESCRIPTION
Fulton Bank - outstanding car loan
AMOUNT
13,370.07
2
Pinnacle Health
594.00
3
PP&L
72.45
4
Pulmonary & Critical Care
100.00
5
RVG Management - lot rent
1,382.17
6
Thornwald Home
9.50
7
Verizon
91.12
TOTAL (Also enter on line 10, Recapitulation) $ 15,619.31
(If more space is needed, insert additional sheets of the same size)
Copyright(c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97)
REV-1513 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Harrv E. Bailev SSfI 284-16-7632
NUMBER
I.
02/26/2001
FILE NUMBER
21-01-0408
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF EST A TE
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [Include outright spousal distributions, and
transfers under Sec. 9116(a)(1.2)]
Edward L. Bailey
22 Woodwind Drive
Spartanburg, SC 29302
Son 1/4 remainder
2
Norma Hayhurst
P.O. Box 177
Waverly, PA 18471
Daughter
1/4 remainder
3
Reba Kingston
1812 East Ramble Court
Decatur, GA 30033
Daughter
1/4 remainder
4
Karen L. Walker
7461 Summerfield
Lambertville, MI
Daughter
1/4 remainder
Road
48144
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS,
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- 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)
Copyright (c) 2000 form software only The Lackner Group, Inc.
0.00
Form REV-1513 EX (Rev. 9~OO)
This is a true and exact copy of an original
presented before me on ,March 28, 2001.
~u..(Ll.t'P1/JU a.Cf'~ LAST WILL AND TESTAMENT
JPiAL YNN A. HAlQUS
Public, ~ of Ohio - OF-
My ~Sslon ')I'P;r~5 7-13-2002
HARRY EDWARD BAILEY
I, HARRY EDWARD BAILEY, of the City of Toledo, Lucas County,
Ohio, being of full age and of sound and disposing mind and memory, do
make, publish and declare this to be my Last Will and Testament hereby
revoking all Last Wills and Testaments by me heretofore madeo
ITEM I
I direct that all my just debts and funeral expenses
be paid out of my estate as soon as practicable after
the time of my deceaseo
jJ<....;
/T':':':(,).+
}..~- ))
I give, devise and bequeath to my wife, !:;gTHA ALLENE
BAILEY, an amount equal to her intestate share pur-
suant to her right of election under the laws of the
State of Ohio or any state I may be domiciled at the
time of my decease. If at any time before my decease
my wife,LBTHA ALLENE BAILEY, and I become diverced,
the above provision in Item II becomes null and void.
ITEM II
ITEM III
All the rest, residue and remainder of my estate, real,
personal and mixed, of every kind and description and
wheresoever situate, which I may own or have the right
to dispose of at the time of my decease, I give, de-
vise and bequeath to my children, NORMA JEAN HAYHURST,
KAREN LEE WALKER, EDWARD LEE BAILEY and RE BA LOU BAI LEY,
and any other child or children born or adopted from
my present marriage, share and share alike, subject
only to this provision that, if anyone or more of
my said mentioned children shall die previous to my
decease, leaving issue surviving, the issue of such
deceased child or children shall take the estate
herein devised and bequeathed to its parent or parents,
as the case may be, per stirpes.
ITEM IV
I make, nominate and appoint my Attorney, MELVIN L"
RESNICK, to be the Executor of this, my Last \\I'ill and
Testament" I hereby request that he be permitted to
serve as such without giving bond.
I hereby authorize and empower my said Executor to
settle, compromise and adjust all clai.ms due to or
owing by my estate at such times and upon such terms
and conditions as he may deem best.
I further authorize and empower my said Executor to
sell, trade, deliver, assign and convey any part or
all of my estate, real, personal or mixed, at such
--"_"'">w"_ ___
"-"_"'_""""---'-~.,_.. 1 ....
... -'.-...--"-. '."'. -".,-'.',,-,
\.,~
"
: i This is a true and exact copy of an original
Ii presented before me on March 28, 2001,
~I i , w>>-pt1i/ it (pluu;u()J
d' / .
"CN..'( i\. h%"t.".:;. t1mes a~d upon such terms and conditions and for
J I'IIbllc, State of OhIo such pr1ces as he may deem bes t, and to such ends
~ ~1.1sg.'1'In ll<ftIfi!ti 7-13-2otI2authorize him. to execute, acknowledge and deliver
~ I all necessary b1lls of sale, instruments of trans-
fer, deeds or other papers of conveyance as he may
find necessary or convenient in the premises. I
hereby exempt him from the necessity of obtaining
any court order for such purposes.
IN WITNESS WHEREOF, I have hereunto subscribed my name to
,., j
this, my Last Will and Testament this I ^ day of February,
1976.
~'
~~/ ,- ~.,,<"jt-L.-Y::'2~k,-;! .
Har " 'Edward Bailey
/,Y
/"'~ /
, c.i~ LV;Y
f ,_
The foregoing instrument was signed, published and declared
by HARRY EDWARD BAILEY, as and for his Last Will and Testament, in our
presence, who at his request and in his presence and in the presence
of each other, have hereunto subscribed our names as attesting witnesses
o~,the day and year ab~e written.
(/) '//
:J:j (,l. <.4-4 tI;< ,.4<-
I
'/
c/."
,"" I..,)
residing at '-.1.2 "
11.; , F,/ "
l/ l-z:{:..t1,A'L4 /,)/, / tL&J4
, .
,0
I
I
,
I
~
I,
~v,,-,
( )
\:~~J
residing at
):1(, (',
\ 'I'
",j,(r:.,-I...";;"
T,:r. oJ",
"
!l allflrst
March 28, 2001
A1Jfirst Finandal Cenh:r N..'\.
P.O, Box. 900
Mills~:;n~J"'ltlJ5, r
[L." '"~I
,,,1 ,'".: ",,;...'" ._.~,' "'"
~\~. ~;;.;.,
9~m
h,
'~'\ J
\';'''''1J
:, 3 ) 2.00!
Irwin McKnight & Hughes
Att: James D. Hughes
West Pomfret Professional Bldg.
60 West Pomfret Street
Carlisle, PA 17013-3222
IRV:J;i;'~,:"J, ~:~, [.r', 'f'
I '., , , i, :.. \ \.! ... ~
8, HUGHES
RE:
Estate of Harry E. Balley
Date of Death: February 26, 2001
Social Security Number: 284-16-7632
Dear Mr, Hughes:
In response to your request, please be advised that at the time of death, the above-
named decedent had on deposit with this bank the following accounts.
1. Account Type.... ................... .... Relationship w / Int. Checking Account
Account Number............. ..........0013124951
Ownership (Names oj)............... Hany E. Bailey
Opening Date....... .......... ..........06/28/78
Balance on Date ofDeath.........$ 9,810.15
Accrued Interest
$
2.62
Total. .... ............................. .....$ 9,812.77
2. Account Type........................... Safe Deposit Box Account
Account Number..... ...... ......... ... 00001000538100001925
Ownership (Names oj)............... Hany E. Bailey
This letter does not include any acccunts in whilh the decc&st'u may have been listed as power of attorney, custodian
of uniform transfers, representative puyee, or tnutee under <:1 written trust agreement.
. Page 2
March 28, 2001
For any additional information on these accounts, please contact our branches at:
344 South 10th Street, Lemoyne, PA 17043, telephone 717-737-3322 or 5528
Carlisle Pike, Mechanicsburg, PA 17055, telephone 717-255-2293.
Sincerely,
;:t. c?, ~acc'l'~,,?,'
Mary Anne Macieiag
Assistant Ill/CIS
(302) 934-2240
;)G;:::8i:2l3C1 15:::1 71-751;<12<1.7']
1'D&t4t'. ~ ax Nole 7672
,. ,
To
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c,",," . '.. \2}/.
,~~\~..t)/'~'
..~~/
. .. \ I .'
T'_Pt_1EP BUICl<
P,..,GE 13:
,.:;'~~"',;,','~~_~~" @ 'N~. ;;tp~~ ; r(l(r;,y~ ~
. F~
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eo""" . .. . . yJ
;-;r-, .\"~ Q..~'...t..,-1;.. .....'...{.....Jf'....'.
\ . '. . y",
~'J1""',~, li''''ILoiOwll
"=-, '~y~'/ J l5 \
I
BUICK
COMPA~--Y
"l*,o take (:"Or~"lf)'f'-'U'"
We at Turner BUick purcho.::!ed a 2000 Buick Park Ave
Sed IG4CW54K744239713 from the Estate of Ha.rry E Baily.
A check to Fulton bank in the: amount: of $13, 784~la to
payoff the Lein and d cheek ,to thQ E$t~t~ ter $Bt2lSMB2
for a total of $22,000.00 purchaae' price of vehicle.
~ ~ ~A.~L:
SR.C"'-:o~-
4lO1 CHA;\1BERS HILL ROAD, HARRISBURG, PA 17111
(717) 564-2140 FAX (l17} 564-2473
06/28/01 15:16
TX/RX NO. 7972
P.002
.
~~{.
G
C
H
E
C
K
OFFICIAL USEONI.Y
AEV-150Q EX + (6-00) REV-1500 I (p < Z 15 I?r-
-
INHERITANCE TAX RETURN FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA 21-01.0408
DEPARTMENT OF REVENUE RESIDENT DECEDENT
DEPT. 280601 COUNTY CODE
HARR1SBURG. PA 17128-0601 YEAR NUMBER
0 DECEOENT'S NAME (LAST, FIRST, AND MIOOL.E INITIAL) SOCIAL SECURITY NUMBER
E Bailev Harrv E. 284-16.7632
C DATE OF DEATH (MM-DD~YEAR) DATE OF BIRTH (MM-DD~YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
E
0 07/26/2001 07/24/1924 REGISTER OF WILLS
E (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE IN1TIALr- SOCIAL SECURITY NUMBER.
N
T
1. Original Return 1. 2. Supplemental Return [j 3' (dale of death
- . Remainder Return prior to 12-13-82)
APB X 4. Limited Estate _ 40. Future Interest Compromise (date of death after 12-12-82) 5. Federal Estate Tax Return Required
pRL
plO 6. Oecedent Died Testate _ 7. Decedent Maintained a LIving Trust 8. Total Number of Safe Deposit Boxes
....:.:; -
RAC (Attach copy of Will) (Attach copy ot Trust)
OTK o 9. litigation Proceeds Received DID. 0 11. Election to tax under Sec. 9113(A)
ES SpOiJsal Poverty Credit
(date of death between 1Z~31-91 and 1-1-95) {Attach Sch 0)
. TJoII$$ECTI()N'~U$T'BE'.eOMPLETEP:'.A.L""COI!RESl!ONDI'NCE&..C()NF'PENTIj(L .TAl!i.'U"F(lIlMATION'SI'IOULPBE'PIIlECTI'P'TO'
P NAME COMPLETE MAILING ADDRESS
C
0 0 James D. Hughes ESQ. 60 West Pomfret Street
R N
R 0 FIRM NAME lIt Applicable) West Pomfret Professional Bldg.
E E IRWIN McKNIGHT & HUGHES Carlisle, PA 17013
S N
T TELEPHONE NUMBER
717/249-2353
1. Real Estate (Schedule A) (1) None OFFICIAL USE ONLY
2. Stocks and Bonds (Schedule 6) (2) 4,297.50
3. Closely Held Corporation, Partnership or (3) None
Sole-Proprietorship .~~. ,...'~
',. .. ;. ~ d :0
4. Mortgages & Notes Receivable (Schedule D) (4) N~e' <1J
N C'l
R 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) None ,"',
,
E (Schedule E) ""T1
C '"
0.."1
A 6. Jointly Owned Property (Schedule F) (6) None
P 0 r,,'
I Separate Billing Requested U'I
T 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) None
U .
L (Schedule G or U -"-
A Total Gross Assets (total Lines 1-7) (8) ':' .<-4,297.50
T 8.
I 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 265.00 ,-.....'
0
N 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) None
11. Total Deductions (total Lines 9 & 10) (11) 265.00
12. Net Value of Estate (Line a minus Une 11) (12) 4,032.50
13. Charitable and Governmental Bequests/See 9113 Trusts tor which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 4,032.50
C SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
0
M
P 15. Amount of Line 14 taxable at the spousal tax
T U
A T rate, or transfers under Sec. 9116(a}(1.2) X "0 0 (15) 0.00
X A 4,032.50 45 (16) 181.46
T 16. Amount of Line 14 taxable at lineal rate X 0
I 17. Amount of LiM 14 taxable at sibling rate X " '2 (17) 0.00
0
N 18. Amount of Line 14 taxable at collateral rate X "15 (IB) 0.00
19. Tax Due (19) 181. 46
20. 'n-" 1....(:I11'c;I(I-l!;RI$.~f.Y<!!!.j(I!~fl~lii!!l!iS"I"l~Ci.j("Rl!fVNP.()f;:.AJII.(lV"RI1j(yMI;NT.I
> > BE SURE TO ANSWER All. QUESTIONS ON REVERSE SIDE AND TO" RECHECK MATH < <
Copydght(c) 'l.OOOtormsoftwale only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
503 Quail Court
CITY I STATE r ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due (Page I Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
181.46
Total Credits ( A . B . C) (2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
3.26
Total Interest/Penalty ( D . E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page lUne 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. (SA)
8. Enter the total of Line S . SA. This is the 8ALANCE DUE. (58)
Make Cheek Payable 10: REGISTER OF WILLS, AGENT
3.26
0.00
184.72
0.00
184.72
'l, ":::'!;'i'i",-i""
ii'"
o
o
o
o
o
o
Under penalties of perjury, I declare that I have examined this return, Including accompanying schedules and statements, and to the best of my knowledge and bf:iiel. it js lrwe,
correct and complete. Declaration of pteparer other than the personal representative is based on all information of which pteparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
DATE
/) -1M 'OL
bATE
'J. ...z.z.,-o 2-
or dates 0 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
urviving spa e is 3% [72 P.S. 9116 (a) (11) (i)].
F date 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 > .9116 (a) (1.1) (ii)). The statute does not exempt 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, 2QOO:
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. 91 16(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12"10 [72 P.S. 9116(a)(1.3)j. 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.
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
REV-1503 EX + (1~97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESlDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
FILE NUMBER
Harry E. Bailey
SS1f 284-16-7632
07/26/2001
21-01-0408
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE
NUMBER OF DEATH
1 125 shares John Hancock Financial Services - account 34.38 4,297.50
11639-3168
TOTAL (Also enter on line 2, Recapitulation) 4,297.50
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
Form RE.V-1503 EX (Re\l. 1-97)
REV-1511EX.(1~97)
ESTATE OF
Harry E. Bailey
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
SSIf 284-16-7632
07/26/2001
FilE NUMBER
21-01-0408
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES,
B.
ADMINISTRATIVE COSTS,
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) I E\N Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2.
3.
Attorney's Fees IRWIN McKNIGHT IX HUGHES
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
250.00
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Register of Wills - filing fee
15.00
TOTAL (Also enter on line 9, Recapitulation) $ 265.00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97)
REV-1513 EX. (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Harrv E Bailey SSII 284-16-7632
NUMBER
I.
07/26/2001
FILE NUMBER
21-01-0408
RELATIONSHIP TO OECEOENT AMOUNT OR SHARE
Do Not List Trusteels) OF ESTATE
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions. and
transfers under Sec. 91 16(a)(t.2)]
Edward L. Bailey
22 Woodwind Drive
Spartanburg, SC 29302
Son 1/4 remainder
2
Norma J. Hayhurst
P.O. Box 177
Waverly, PA 18471
Daughter
1/4 remainder
3
Reba Kingston
1812 East Ramble Court
Decatur, GA 30033
Daughter
1/4 remainder
4
Karen L. Walker
7461 Summerfield
Lambertville, MI
Daughter
1/4 remainder
Road
48144
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON- TAXABLE DISTRIBUTIONS,
A. SPOUSAL DISTRIBUTIONS UNDER SEC, 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- 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)
Copyright (c) 2000 form software only The Lackner Group, Inc.
0.00
Form REV-1513 EX (Rev. 9-00)
~ EQUISERVE@
January 29, 2002
JAMES D HUGHES
ATTORNEY AT LAW
IRWIN MCKNGIHT & HUGHES
60 WEST POMFRET ST
CARLISLE PA 17013 3222
JOHN HANCOCK FINANCIAL SERVICES
INC
HARRY E BAILEY
ACCOUNT NUMBER: 639-3168
----
Dear Mr. Hughes:
Thank you for your inquiry regarding the share balance ofthe above referenced account. We appreciate
the opportunity to be of service to you.
On January 28, 2002, account number 639-3168 held 125 shares. On that date, the closing price was
$39.17 per share.
On February 26, 2001, the above referenced account number held 125 shares. On that date, the closing
price was $34.38 per share.
If the executor of the estate is interested in liquidating the account, the shares must be re-registered into
the name of the estate. Please find below the transfer requirements forre-registration of the account
holdings. We would suggest that you send a brief letter of instruction; which states the request to have
the shares liquidated subsequent to the transfer transaction.
To change the registration when a shareholder is deceased, a physical transfer of the shares is necessary.
Accordingly, please provide the following documentation:
. The physical certificate(s), if applicable.
. The enclosed stock power endorsed by the Executor{ s) or Administrator( s) of the deceased
shareholder. The stock power must bear an original signature(s) guarantee from a financial
institution, such as a commercial bank, trust company, national bank, credit union, brokerage firm,
etc., that is participating in a Medallion Program, such as STAMP, SEMP, MSP or other STA
approved Medallion Program.
. A letter of instruction providing the full name, address and taxpayer identification number (Social
Security Number) of each transferee, as wen as the share amount each is to be issued. Specify the
combined total of the shares you wish to transfer. Be sure to include both certificate shares and
dividend reinvestment shares.
. A court certified copy of the appointment of the decedent's legal representative (Letters
Testamentary, Appointment of Representative, etc.). This certified copy must be dated within 60
days of the date of the transfer. This document can be a photocopy but must have an original -
Medallion Stamp Guarantee.
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,
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. The enclosed substitute W -9 certification form, completed and returned for each transferee (each new
account). Ifthe taxpayer LD. of the transferee is not certified, the account will be subject to
withholding by the Internal Revenue Service at the rate of 30% of all dividend disbursements.
Additional forms should be available from your local bank or brokerage firm.
. A notarized Affidavit of Residence, if required by the state of residence.
Note: In accordance with the rules of the Stock Transfer Association, we cannot register shares with the
word "or" as it does not denote definite ownership. The word "and" is used for joint registrations.
Enclosed is a Glossary of Terms to assist you with the completion of this transfer.
Should you have any questions, please call us toll free at 1-800-333-9231 or write to us at EquiServe,
P.O. Box 43015, Providence, RI, 02940-3015. Our telephone representatives are available Monday
through Friday between the hours of 8 a.m. to 6 p.m. Eastern Time. For certain routine information, you
may call us 24 hours a day, 7 days a week and access our teleservicing system.
Sincerely,
~u~trh
Sharlene A Edwards
Shareholder Service Representative
Reference Number: 00838756
Enclosure(s): Glossary of Terms
Stock Power Form
W-9 Certification Form
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