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Home My WebLink About01-0439 PETITION FOR PROBATE and GRANT OF LETTERS Estate of GLADYS A. BURD also known as No. To: 21-01-439 Register of Wills for the , Deceased. County of Cumberland in the Social Security No. 178-07-6862 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut rix in the last will of the above decedent, dated May 16 and codicil(s) dated None named ,19~ (state relevant circllmstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumberland County, Pennsylvania, with h er last family or principal residence at 527 Messiah Village r Mec.hRni rsnllrf: (Upper Allen Township). (list street, number and muncipality) Decendent, then 81 years of age, died April 29 ,Jt~ 2001 , at Harrisburg Hospital. Harrisburg, Dauphin County, PpnnsylvRni::l 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: None Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: Unestimated $ $ $ $ None WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters testamentary (testamentary; administration c. La.; administration d. b.n.c. t.a.) theron. VJ 11) u C 11) ~~ VJ '-' <U .... 0::11) C '"00 c';: ro ',,= ~11) ~o... 11) '- ~ 0 ~ c CI) Ci3 ~II~ Susan A. Golob 11 East Winding Hill Road Mechanisburg. PA 17055 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA I sn COUNTY OF __ CUMBERLAND J :s 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. Sworn t,o or affir medand. SU...bscribed~. ~ II ~ ~ before me this 3rd day of Susan A. Golob ~. May :xt:!l~ S. ~//</ (/ 7HL""~,02/_,:/,f( -' '. ' . ~ i . Register ~ /b-.;2;2P~o ~o. 21-01-439 Estate of GLADYS A. BURD , Deceased DECREE OF PROBATE A~D GRA~T OF LETTERS AND NOW May 3 Ijjx 200}..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 MRY 16, 1996 described therein be admitted to probate and filed of record as the last will of Gladys A. Burd and Letters Testamentary are hereby granted to Susan A. Golob Probate, Letters, Etc. ......... Short Certificates( ).......... x-pa~es RenuncIation ................ JCP $ 235.00 $ 15.00 6.00 $ $ 5.00 TOTAL _ $ 261.00 . .. .. .... . . .~r.}'.. ?p'Q~..... . .... B FEES Filed (717) 697-8528 PHONE H] O'i.S()) RE\' 'J,Sh lIS 15 ro certify [hat the i nfcmndlion here given IS correctly copied from an original certificate of death duly filed with me as 'lcal R~gistrar. The origin~d certiflcate will be forwarded ro (he Stare Vital Records Office for permanent 'filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. /~/lffj;H;;;;';~ A~~\.~1iM pl'i~ //~'/ ~f~~ jl~~/.~\~\ I~~; ,,',' \"'? ~ I~ Q' ' ~,i~~ ~ ,-,f 0:.1' l.b ~ " ..'1 ~ j ;' ~ ~ * '( ..>~~'>- ~/ */ ~~\. -, /.c..~~ \'\, ~'''::---. " " / ~/' ~~;1I1JI----/<" ~~ /' -~~~,/"ENl \.\-.. /",,1 -""'~"I//lJJ/JIJI f~,~~~~ Fee for this ct'rrifJcarc. $2.00 P 7386309 fL1Jl<-f' -10 ~C'cJ / bate No. 21-01-439 ...., ,. Hl05.:43 Rev 2187 COMMONWEALTH OF PENNSYlVANIA. OEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH iYPE/PRINT IN PERMANENT BL ACK INK 81 . UNDER 1 YEAA Monlht D'I'" UNDER 1 DIIIi -lMinUI.. SEX afernale STATE filE NUMBER SOCIAL SECUR,TY NU!ol8ER 1. 178 - 07 NAME Of DECEDENT (f... ,"",dOle. lasl) Gladys A. Burd loGE (la.. a""""y) YIW Pl.4CE Of DEATH (Ctleck My one h ,;.ee '('lstlU(;I,OPi on ~j ",).oet HOSPiTAl, , Mt.Pleasant,PA Inpa,_.$" ERlOulpa\..n'O 7. Ia. FACilITY NAME {It nol.n!.JtfUllOrl. QIVe sheet and numbefl BIRTHPlACe :c.ty .rod Staid QI fc(eqn COOflll'i} 5. COUNTY Of' DEATH DECEDENT'S USUAL OCCUP.Q'ION (Gov. Iund oI_k done dutotl(J""", 0I_1Ung We; do noc ..... rellled I - '.a. hanemaker 1111. hane DECEDENT'S MAIliNG ADDRESS (S",." C.oyIlOwo. SlaM. Z", Coael DECEDENT'S ACTUAL RESIDENCE iSee IIl5I'(UCIIOOa on omer SK1e) la. 17a. S",.-------.PA. MARITAL SINUS. M_ Nevel" Married. W~. OMIo'ced (SpecCy) l.rnarried 17c.6a 'fW,__ntliYedin lJp[)Pr RACE -AmencMllndian. 8lack.. Whce. ttc: 1~1 10~hi te SuRVIVING SPOuSE (II """.. !JI~ ma.oen namel lb. Dauphin Harrisburg Ie. KJND Of' BUSINE SS/INOUSTRY 527 Dogwood Drive 1.. Mechanicsburg, PA 17055 F.Q'HER'S wiY'Il~ larougher 1.. INFORMANT'S NAIloIE (T Yf'O'Pr..) _.Lero Burd METHOD Of DISPOSITION O lIuoel Q C'_11Oft 0 R_al"om SI". [J ~ ou... \Spec"" . 21a. :-~UN~ CompIeta ~.m. ~ only ..hen ~ IS noc av~iUbIe at lime ceNIy ca.- 01 dealh t lb. Coun I);d -- live III. -...nip? Leroy Burd A. 11 pn IWp CtIV- a1dMonoghan Twp., PA 8 Matiket Plaza Way Home !: M. ;()CAA~"~ ~ b~+1 07t'? DUE~IOAASACONSEQUENCEOf): . .. 'Q~tL j (" C tv/! Y\.A c-- DUE 10 (OR AS A CONSEOUENCE Of): ~, I Appf"oJ:unal. ; interval betW..n l~anode"" I I PART II: OIhe, signt/lc.... c:ondilIOna """"obuling 10 dee"'. buI IIlll ,....."'4l in lhe ~__in PI\RT I OUE 10 (OR AS A CONSEOUENCE Of]' WERE A010PSY FINDINGS Al.llUl.A8LE PRIOR 10 COI.U'1.ETION Of' CAOSL OF DEATH? MANNER OF DENH N.aIUl AI ~ o o DATE OF INJURY (hAOOIh. Day. 'NaIl TIME Of INJURY INJURY AT IMlRK1 DESCRIBE IfON INJURY OCCURRED. HomlCd o [J o ~ce OF INJURY. A.t home. tarm~..'. lactory. otfic. hi. building. .Ie ISpeclly' 3Oe. Yes 0 NoD Peoong tnvesugallon Yes 0 Nofl ala. a.... CERTIFieR IC~eck ""'" one) .CERTIFYING PHYSICIAN (PnYSlCldflCeflllVIOCJ cause of ~alt) .....*"e,... "::,,,(\Q(l~et" phVs,lC.atl l1d!S ptonO\lnced d~dlh ..no COl'npleled lIern 23} To the beat ot "'1 IIr.nowtedoe. de.th occurred due 10..... c......(s) .and ""'.00., .. atalH_ Y.. D NoD Suoc>de Could not be determined ^"i) ;z,. '~r-~' lli~ 01,1>, LICENSE NUMSER DATE SIGNED ("""'rh. Day. Yeat' 31. Mt) 0 -; Q'2- '11 lId. NAME AND ADOAESS ~ PERSON WHO COMPLETED CAUSE Of... OEATH (lIem 271 Type or Pnnl j.V; S J I~c- 1\1 l) o U4<>, ~rf"'-l ,,-n flN--A.& ,"'-..,: si)vY" 3a. P.t)" IIZ-- DATE FilED IMonlh Day. y",,,, f2~ I J 3 ~ ;l 0 CJ J ~ 8 ~ a ~ ~ <( z . PRONOUNCING AND CERTIFYING PHYSICIAN (PhV5'CldO bolh O}IOflOU()ClOg oedlh dfld l.:et1JlylO<J 10 causa 01 aedlh) To the ~1 o' my knowl.dgb, de.th OCCU,," a'lhe U~. dat~,.and p'ace, and due \0 tt".It.\lI..i~)"O{I m,nnel" alated,. "MEDICAL EXAMINER/CORONER On the b..il 01 examjnaUon and/or investigation. in my opinion, death occu.-red al the lime, dale, and place, and due 10 Ihe ,ause(.) and manne, .1 tlil11'd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~Ia " '\ ~ \' "i') ". ""~ " "....--1 LAW OFFICES SNELBAKER a BRENNEMAN ... . . 21-01-439 LAST WILL AND TESTAMENT I, GLADYS A. BURD, of the Township of Upper Allen, County of Cumberland and Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last will and Testament, hereby revoking and making void all former wills and codicils by me at any time heretofore made. FIRST. I order and direct that all my just debts and funeral expenses be paid by my Executrix, Executors or Executor, as the case may be, hereinafter named, as soon as conveniently may be done after my decease. SECOND. I give, devise and bequeath all the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situated, unto my daughter, namely, SUSAN A. GOLOB, absolutely and in fee simple, if she survives me. THIRD. If my said daughter, SUSAN A. GOLOB, does not survive me, then and in that event, I give, devise and bequeath my said residuary estate in equal shares unto my two (2) grandchildren, namely, JENNIFER SUZANNE CONWAY and MICHAEL JOSEPH GOLOB, share and share alike. LASTLY. I nominate, constitute and appoint my daughter, namely, SUSAN A. GOLOB, to be the Executrix of this, my Last will and Testament, but if for any reason my said daughter shall fail to qualify as such Executrix or cease so to serve, then and in such event, I nominate, constitute and appoint my grandchildren, namely, JENNIFER SUZANNE CONWAY and MICHAEL JOSEPH GOLOB, (or either of them if one should fail to qualify or cease to serve) to be the Executors hereof, each and all to serve without bond or .. . .. other security as a condition of qualification hereunder. IN WITNESS WHEREOF, I, GLADYS A. BURD, have hereunto set my hand and seal to this, my Last Will and Testament which consists of two (2) typewritten pages to each of which I have affixed my signature this / C:> ;U day Ofrn~ One Thousand Nine Hundred Ninety-six (1996). A.D. , ) . ..' ~i ,/,-' ) " :;V:O,(~ (I ;17:.- v.:d~ , ladys A. Burd (SEAL) The preceding instrument, consisting of this and one (1) other typewritten page, each identified by the signature of the Testatrix, was on the date thereof signed, sealed, published and declared by GLADYS A. BURD, the Testatrix therein named, as and for her Last will and Testament, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as wi ". &2 j ') ,', J \ i~' /,.t" ." '---...qv;~~ . . ~~ y . ", LAW OFFICES SNEL8AKER 8c BRENNEMAN -2- 'I I J. . COMMONWEALTH OF PENNSYLVANIA SSe COUNTY OF CUMBERLAND We, GLADYS A. BURD, RICHARD C. SNELBAKER and JANET R. STEGNER, the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last will and Testament and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the will as a witness and that to the best of his or her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. //.............) .. ,/"-J/.,/-" , . -.'-/1 /~ '--:~.,...'/C::7r -r'C4'...-f .. -\::: . .... . j"'/ witness ' Subscribed, sworn to and acknowledged before me by GLADYS A. BURD, the Testatrix, and subscribed and sworn to before me by RICHARD C. SNELBAKER and JANET R. STEGNER, witnesses, this I~~ day of mt24-t 1996. G?~aJ~.~ Nota y Public U.W OFFICES SNELBAKER a BRENNEMAN b Notarial Seal ~ Patricia J. -,-h(,rnson, Notary Public fu;eGhaniG.. SbU.. rg Bora, cumberland.. CoUnty. My Commission Expires Dec, 31, 1900 ~. /"._-" n~}2',C Pe\'in~~:;v~v2n;a AssrvCj2.~k.~:1 of ,,~,~~')f, E CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Gladys A. Burd, Deceased Date of Death: April 29, 2001 No. 2001-00439 PA No. 2101-0439 To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on or about May 9,2001: Name Address Susan A. Golob 11 East Winding Hill Road Mechanicsburg, P A 17055 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: NONE. Date: May 9, 2001 Ri ard C. Snelbaker, Esquire Snelbaker, Brenneman & Spare, P.C. 44 West Main Street Mechanicsburg, P A 17055-0318 (71 7) 697-8528 LAW OFFICES SNELBAKER. BRENNEMAN & SPARE o t - ~~-3q RECEIPT AND RELEASE WHEREAS, Gladys A. Burd, late of Upper Allen Township, County of Cumberland and Commonwealth of Pennsylvania, died on April 29, 2001, having first made her Last Will and Testament in writing probated before the Register of Wills of said Cumberland County on May 3, 2001, and Letters Testamentary were issued on the same date to Susan A. Golob, the Executrix named in the Last Will and Testament of said Decedent; and WHEREAS, said Executrix has entered upon and completed her administration of said Decedent's Estate as set forth in her First and Final Account attached hereto, and intends to distribute the net balance of the assets of said Estate to the person named in the Statement of Proposed Distribution also attached hereto, both of said documents being incorporated herein by reference thereto; and NOW KNOW ALL MEN BY THESE PRESENTS, that I, Susan A. Golob, being the principal legatee and distributee named in the Will of said Decedent and the person entitled to share in the residuary distribution of the Estate of said Decedent, do hereby declare and say that I have examined the attached Account and Statement of Proposed Distribution, and find the same to be true and correct, and in strict accordance with the terms and provisions 1 of said Will, and I do hereby acknowledge that I, this day have, had and received of and from Susan A. Golob, Executrix of the Estate of Gladys A. Burd, the cash, personalty and/or real estate set opposite my name in the above Statement of Proposed Distribution, in full satisfaction, payment and discharge of all such sum or sums of money, legacies and bequests, share or shares, purports and dividends which were due, owing and payable and belonging to me, by any means whatsoever, for or on account of my full share, part or dividend of the Estate of Gladys A. Burd, Deceased. NOW, THEREFORE, I, the said Susan A. Golob, do by these presents, remise, release, quit-claim and forever discharge the said Susan A. Golob, her heirs, executors and administrators, of and from my said shares or dividends of the Estate aforesaid, and of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever, for or by reason thereof, or of any act, matter, cause or thing whatsoever, from the beginning of the world to the day and date of these presents. AND, desiring to avoid the delay and expense of the settlement of said Estate by filing the foregoing Account of said administration in the Office of the Register of Wills of said Cumberland County and by having the balance in the hands of the Executrix, as shown by said Account, distributed by the Court of Common Pleas of Cumberland County - Orphans' Court Division, I do hereby agree that the foregoing Account and Statement concerning LAW OFFICES SNELBAKER. BRENNEMAN Be SPARE 2 LAW OFFICES SNELBAKER, BRENNEMAN & SPARE the matter of settlement may be recorded with the same effect upon me as if the same had been reported upon by said Court, in a decree of distribution made on such proposed Statement of Distribution by the said Court of Common Pleas - Orphans' Court Division. AND in consideration of the aforesaid settlement being made without the aid of such Court of Common Pleas - Orphans' Court Division, that I do hereby agree that if any debts or demands other than those included in the above referenced First and Final Account, as hereinbefore set forth, shall be hereafter recovered against the Estate of said Decedent and be legally payable out of the same, that I will return to the said Executrix such amounts thereof as may be necessary to pay such debts or demands. IN WITNESS WHEREOF, I have hereunto set my hand and seal this Jlth day of-:su.nA-- 2002. WITNESSED BY: d~ ~ b\illL ~t2~ - Susan A. Golob (SEAL) 3 LAW OFFICES SNELBAKER. BRENNEMAN & SPARE COMMONWEALTH OF PENNSYLVANIA) SSe COUNTY OF CUMBERLAND) On t his the 2 1 t-~\ da y 0 f -S ,-^-I'\ ~ 2002, before me, a Notary Public in and for said State and County, the undersigned officer, personally appeared Susan A. Golob, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. ~G1llct~ K~ Notary Public /. ~L'~."m".<H'>_", .....'~H__.. Notarial Seal ,i Sandra K Showers, Notary Pubtic .. Mechar~ Boro, Curnb9l"land ~. !My CommiSSion ExpIres Nov. 22, 2003 j Member. ~nnS"'V"1n!" .r"~,,,~";A~;""'" ,~, ~Jr.'",; ..' 4 ESTATE NO. 21-01-0439 FIRST AND FINAL ACCOUNT AND STATEMENT OF PROPOSED DISTRIBUTION OF AND BY SUSAN A. GOLOB, EXECUTRIX OF THE ESTATE AND UNDER THE LAST WILL AND TESTAMENT OF GLADYS A. BURD, DECEASED, LATE OF UPPER ALLEN TOWNSHIP, CUMBERLAND COUNTY, PENNSYLVANIA Susan A. Golob, Executrix as aforesaid and Accountant herein, avers as follows: DATE OF DECEDENT'S DEATH: DATE LETTERS TESTAMENTARY ISSUED: April 29, 2001 May 3, 2001 DATES EXECUTRIX NOTICE ADVERTISED: Cumberland Law Journal Patriot-News May 18, 25, June 1,2001 May 15, 22, 29, 2001 FIRST AND FINAL ACCOUNT PERSONALTY - PRINCIPAL ACCOUNT DEBITS The Accountant charges herself with the receipt of the following items of Decedent's Personalty valued as of the date of Decedent's death: 1. Verizon, 192 shares of common stock valued at $55.77 per share 2. Lucent Technologies, 22 shares common stock valued at $10.80 per share 3. Avaya, 22 shares of common stock valued at $13.49 per share 4. Messiah Village, Cluster Housing Agreement related to property located 572 Dogwood Drive, Mechanicsburg, PA 5. AARP Investment Program, account #0620 200 100.5 6. American Express, Mutual Fund Investment Account, #010548537389 002 7. American Express, Mutual Fund Investment Account, #011248537380002 8. American Express, Mutual Fund Investment Account, #01254853738 5 002 9. American Express, Mutual Fund Investment Account, #01262718519 7 002 10. PNC Bank, N.A., checking account #5003156054 11. PNC Bank, N.A., savings account #5030125528 12. Household goods, appraised value 13. Ladies diamond ring set with Marquise shaped diamond, appraised value 14. Capital Blue Cross/Blue Shield, premium refund on plan # 178076862 15. Old Guard Mutual Insurance, proceeds from conversion litigation 16. IDS Life Insurance Company, refund of unused premium on policy #9100.3140830 17. Medicare, refund of overpayment of deductible for 1996 18. PNC Bank, accountlink by Web Bonus promotion paid on estate checking account 19. Prudential, proceeds from sale of 25 shares of stock received from demutualization of Prudential from a mutual company to a stock company. Demutualization effective 12/18/01 until that time decedent's only interest was held in a life insurance policy. 20. Estate of Leroy Burd, reimbursement for H&R Block tax services 21. Commonwealth of Pennsylvania, refund on Inheritance Tax Return 22. Susan A. Golob, payment from personal funds to cover estate expenses TOTAL, PERSONALTY, PRINCIPAL ACCOUNT, DEBITS: PERSONALTY - PRINCIPAL ACCOUNT CREDITS LAW OFFICES SNEL8AKER. BRENNEMAN Be SPARE The Accountant claims credit for the payment of the following items from Decedent's Personalty Account: 1. Malpezzi Funeral Home, funeral services 2. Susan A. Golob, reimbursement for following items: a. Thank you cards and postage Page 1 36.87 $ 10,708.80 237.60 296.78 19,750.00 14,012.40 29,272.28 17,012.76 16,824.12 1,216.21 6,898.43 7,628.04 2,135.00 900.00 62.05 8.68 820.60 1.32 5.00 7 11. 00 259.00 15.79 10,000.00 $ 138,775.86 $ 8,743.30 648.47 b. Rolling Green Cemetery, inscription on headstone 18.00 c. Blossom Shop, funeral flowers 593.60 3. American Express, financial advisor fee 4. Pinnacle Health Hospitals, medical services 5. Register of Wills, short certificates 6. Register of Wills, Agent, estimated tax payment 7. Bricker's Auction, appraisal fee on household goods 8. Mumma's Jewelry, appraisal fee 9. Transportation expenses to Florida to search for and remove decedent's assets from residence which is individually owned by Leroy M. Burd (husband of Decedent) 10. Register of Wills, filing fee for Inheritance Tax return 11. Register of Wills, Agent, Inheritance Tax 12. Messiah Village, resident care 13. Register of Wills, filing fee for Supplemental Return 14. Register of Wills, Agent, tax due on Supplemental Return 15. PPL, electronic payment made from decedent's PNC checking account 16. Snelbaker, Brenneman & Spare, P.C., attorney services 17. Snelbaker, Brenneman & Spare, P.C., costs advanced: a. Register of Wills, probate fee 261.00 b. Cumberland Law Journal, advertising Executrix notice 75.00 c. Patriot. News, advertising Executrix notice 110.10 18. Reserve for filing fees, accounting fees and other costs associated with the administration of Decedent's Estate TOTAL, PERSONAL TV, PRINCIPAL ACCOUNT, CREDITS: $ PERSONAL TV - INCOME ACCOUNT DEBITS The Accountant charges herself with the receipt of the following income from the investment of Personalty Principal: 1. PNC Bank, savings account # 5030125528, interest 2. PNC Bank, checking account #50003156054, interest 3. Amencan Express, payout from annuity 4. AARP, dividends 5. Verizon, dividends 6. Lucent Technologies, dividends 7. PNC Bank, estate checking account # 5002138276, interest TOTAL, PERSONAL TV, INCOME ACCOUNT, DEBITS: PERSONAL TV - INCOME ACCOUNT CREDITS The Accountant claims credit for the payment of the following items from the Personalty Principal Account: 1. H&R Block, preparation of 2001 Individual Tax Returns 2. PA Dept. Of Revenue, tax due on 2001 Individual return TOTAL, PERSONAL TV, INCOME ACCOUNT, CREDITS: REAL ESTATE - PRINCIPAL ACCOUNT DEBITS The Accountant charges herself with the receipt of Decedent's Real Estate as follows: TOTAL, REAL ESTATE, PRINCIPAL ACCOUNT, DEBITS: REAL ESTATE - PRINCIPAL ACCOUNT CREDITS LAW OFFICES SNELBAKER. BRENNEMAN & SPARE The Accountant claims credit for the payment of the following items from Real Estate Principal Account: TOTAL, REAL ESTATE, PRINCIPAL ACCOUNT, CREDITS: Page 2 400.00 792.00 12.00 6,000.00 75.00 45.00 747.84 15.00 374.71 386.30 15.00 36.99 39.85 3,500.00 446.10 500.00 22,777.56 $ 2.98 1.18 280.00 210.70 73.92 0.88 31.22 600.88 $ $ $ 259.00 52.00 311.00 $ NONE $ NONE $ NONE $ NONE LAW OFFICES SNELBAKER. BRENNEMAN 8: SPARE REAL ESTATE - INCOME ACCOUNT DEBITS The Accountant charges herself with the receipt of the income from the investment of Real Estate Principal Account: TOTAL, REAL ESTATE, INCOME ACCOUNT, DEBITS: $ NONE $ NONE REAL ESTATE - INCOME ACCOUNT CREDITS The Accountant claims credit for the payment of the following items from the Real Estate Income Account: TOTAL, REAL ESTATE, INCOME ACCOUNT, CREDITS: $ NON E $ NONE Page 3 LAW OFFICES SNEL8AKER, BRENNEMAN 8: SPARE PERSONAL TV: PRINCIPAL ACCOUNT: Debits Credits Balance INCOME ACCOUNT: Debits Credits Balance TOTAL PERSONALTY REAL ESTATE: PRINCIPAL ACCOUNT: Debits Credits Balance INCOME ACCOUNT: Debits Credits Balance TOTAL REAL ESTATE: TOTAL FOR DISTRIBUTION: RECAPITULATION Page 4 $ 138,775.86 $ 22,777.56 $ $ 600.88 311.00 $ 115,998.30 $ 289.88 $ 116,288.18 $ NONE $ NONE $ NONE $ NONE $ NONE $ NONE $ NONE $ 116,288.18 LAW OFFICES SNELBAKER. BRENNEMAN 8: SPARE STATEMENT OF' PROPOSED DISTRIBUTION Susan A. Golob, Executrix and Accountant herein, proposes to distribute the balance of the Estate of Gladys A. Burd, Deceased, to wit: $116,288.18 in accordance with the Last Will and Testament of said Decedent as follows: 1. Susan A. Golob 100% of residue as per Item Second of Will a. Verizon, 192 shares of common stock, received in kind b. Lucent Technologies, 22 shares of common stock, received in kind c. Avaya, 22 shares of common stock, received in kind d. AARP I nvestment Program, received in kind e. American Express Mutual Funds (all ), received in kind f. Household goods, received in kind g. Ladies diamond ring set, received in kind h. Cash $ 10,708.80 237.60 296.78 14,012.40 64,325.37 2,135.00 900.00 23,672.23 $ 116,288.18 TOTAL FOR DISTRIBUTION: Page 5 COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF CUMBERLAND Susan A. Golob, being duly sworn according to law deposes and says: that she is the Executrix of the Estate and under the Last Will and Testament of Gladys A. Burd, Deceased, and the Accountant herein; that there are no unpaid creditors or claimants of said Estate; that there are no persons interested in the distribution of said Estate other than as stated in the foregoing Statement of Proposed Distribution; and that the facts set forth in the foreqoing First and Final Account and Statement of Proposed Distribution are true and correct to the best of her knowledge, information and belief. ~tl.~ /' Susan A. Golob Executrix and Accountant Sworn to and subscribed before me this l.1Rday of Jl-V1 Jl.-- 2002 S:~-K~ Notary Public . _.'.....:.~~..'_.~~"'-- I NolariaJSeai Sandra K. Showers, Notary PubItc Mechat~ Born, CUrnbet18nd County j My CommissIOn Expfres Nov. 22. 2003 : ~r"\:1""?".~r D~.......I"t~. ""'."""n~"'t f\ t~~"""".'''''''~;''''1':'': ........ r.t.,-;J,"'tl"';,..r-' LAW OFFICES SNELBAKER. BRENNEMAN & SPARE Page 6 ~ JMJrMcJJ~~~' Inventory of the real and personal estate of GLADYS A. BURD, Deceased PERSONAL TY: 1 Verizon, 192 shares of common stock valued at $55.77 per share 2 Lucent Technologies, 22 shares common stock valued at $10.80 per share 3 Avaya, 22 shares of common stock valued at $13.49 per share 4 Messiah Village, Cluster Housing Agreement related to property located 572 Dogwood Drive, Mechanicsburg, PA 5 AARP Investment Program, account #0620 200 100-5 6 American Express, Mutual Fund Investment Account, #01054853738 9 002 7 American Express, Mutual Fund Investment Account, #01124853738 0 002 8 American Express, Mutual Fund Investment Account, #01254853738 5 002 9 American Express, Mutual Fund Investment Account, #01262718519 7 002 10 PNC Bank, N.A., checking account #5003156054 11 PNC Bank, N.A., savings account #5030125528 12 Household goods, appraised value 13 Ladies diamond ring set with Marquise shaped diamond, appraised value 14 Capital Blue Cross/Blue Shield, premium refund on plan #178076862 15 Old Guard Mutual Insurance, proceeds from conversion litigation 16 IDS Life Insurance Company, refund of unused premium on policy #9100-31408 17 Medicare, refund of overpayment of deductible for 1996 TOTAL PERSONALTY: REAL ESTATE: Decedent owned no real estate at the time of her death TOTAL PERSONALTY AND REAL ESTATE: ~ Page 1 $ 10,708.80 237.60 296.78 19,750.00 14,012.40 29,272.28 17,012.76 16,824.12 1,216.21 6,898.43 7,628.04 2,135.00 900.00 62.05 8.68 820.60 1.32 $_227,785.07 0.00 $ 127,785.07 ,d :OMMONWEALTH OF PENNSYLVANIA ::OUNTY OF CUMBERLAND l J 55: Susan A. Golob sworn according to law, deposes and says that she is the Executrix of the Estate of Gladys A. Burd late of _--1Jpper A 1 ~.T.Qwns.hiI1-_. , Cumberland County, Pa., deceased and that the within is an inventory made by Susan A. Golob _, the said Executrix of the entire estate of said decedent, consisting of all the personal property 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. being duly ~worn ~a~ and subscribed before me, ~'SUJI() Q.1 ~i WA.e -IZ ~CJo!lo ;:>002 Executor - Administrator Susan A. Golob 11 East Winding Hill Road Mechanicsburg, PA 17055 Notanal Seal l Sandra K. Showers, Notary Public I., Mechanicst?uf9 Boro, Cumberland County ! , My CommissIon Expires Nov. 22, 2003 : Address ~ ~ ...... ....,..._l."l. ,,, .~. ,:"1-..,~ "". ....l.';......:(....,'....;.'".... Date of Death __ 29th 2001 April Month Day Year INSTRUCTIONS I. An inventory m;Jst be filed within three months after appointment of personal representative. 2. A suppiement inventory must be filed within thirty days of discovery of additional assets. 3. Additional :;heets may be attached as to personalty or realty 4. See Article IV. Fiduciaries Act of 1949. >- -0 CD 0-. I- W lit (Y) >- 0:: ..... Itl .:::t" W < Q) 0 ~ a.. l- v I 0 0 "" Q) CD W W C 0 0\ rl :z: 0::: Q) r':.H 0 I- a.. I t- ..J U. rl Itl Q) rl Z ..J < 0 rl a.. E u. <::t: (\J W 0 < w i >. > z 0::: H - rl Z 0 Q) c 0 ::I Q) ci "" z 0 C 0::: U CI) Z w < :::> ... a.. -0 c U Itl I - -.: 0 Q) '0 ..c H CD E -0 ~cu - .! O.c: Itl ::I 00 ..J U u: CCI 'rl ~ ~CI) 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 SNELBAKER RICHARD C 44 W MAIN STREET MECHANICSBURG, PA 17055 -------- fold ESTATE INFORMATION: SSN: 178-07-6862 FILE NUMBER: 2101-0439 DECEDENT NAME: BURD GLADYS A DA TE OF PAYMENT: 05/02/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 04/29/2001 NO. CD 001139 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $36.99 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: SUSAN GOLOB C/O RICHARD C SNELBAKER ESQ CHECK# 017 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS $36.99 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 SNELBAKER RICHARD C 44 W MAIN STREET MECHANICSBURG, PA 17055 _nnn. fold ESTATE INFORMATION: SSN: 178-07-6862 FILE NUMBER: 21 - 2001 - 0439 DECEDENT NAME: BURD GLADYS A DA TE OF PAYMENT: 07/19/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 04/29/2001 NO. CD 000064 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $6,000.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: SUSAN A GOLOB CHECK# 6 SEAL INITIALS: PB RECEIVED BY: $6,000.00 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 SNELBAKER RICHARD C 44 W MAIN STREET MECHANICSBURG, PA 17055 _____u_ fold ESTATE INFORMATION: SSN: 178-07 -6862 FILE NUMBER: 21-2001- 0439 DECEDENT NAME: BURD GLADYS A DA TE OF PAYMENT: 12/18/2001 POSTMARK DATE: 00/0010000 COUNTY: CUMBERLAND DATE OF DEATH: 04/29/2001 NO. CD 000655 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $374.71 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: RICHARD S SNELBAKER CHECK#12 SEAL INITIALS: AC RECEIVED BY: $374.71 MARY C. LEWIS REGISTER OF WILLS REGISTER OF WILLS /t; ~:Ad.~ - 5 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX Rec Fi: . DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 02-04-2002 BURD 04-29-2001 21 01-0439 CUMBERLAND 101 '02 FEB 1 3 RICHARD C SNELBAKER ESQ SNELBAKER ETAL C:~'d. 44 W MAIN ST ClImb;_ MECHANICSBURG PA 17055 :48 *,v REY-1547 EX AFP (12-00) GLADYS A 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 ~ RE-Y-=iSc,-j-ix-AFP--fi"2":oOj--NOY-iCi--OF-.rtiHiifiTANCi-Y-AX-A-PPRjfisii.rENT~--ALLOWAN-ci-oR------------ ----- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BURD GLADYS A FILE NO. 21 01-0439 ACN 101 DATE 02-04-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: .00 X 00 = .00 148,326.86 X 045 = 6,674.71 .00 X 12 = .00 .00 X 15 = .00 (19)= 6,674.71 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. Hortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Hisc. 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 11,243.18 .00 .00 115.719.97 .00 37,328.27 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) 10. Debts/Hortgage 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 (9) (10) 15,132.71 831.85 NOTE: To insure proper credit to your account 1 subllit the upper portion of this forll with your tax paYllent. 164,291.42 (11) (12) (13) (14) 11;.964 li6 148,326.86 .00 148,326.86 PAYHENT RECEIPT DISCOUNT (+) AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) 07-19-2001 CDOOO064 315.79 6,000.00 12-18-2001 CDOO0655 .00 374.71 01-28-2002 REFUND .00 15.79- TOTAL TAX CREDIT 6,674.71 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 · IF PAID AFTER DATE INDICATED 1 SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) /6~f/5 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG~ PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT *' (;;t/ REV-1U7 EX AFP (12-00> '--1,' DATE ESTATE OF DATE OF DEATH FILE NUMBER F 2 :15cOUNTY ACN 02-11-2002 BURD 04-29-2001 21 01-0439 CUMBERLAND 101 GLADYS A RICHARD C SNELBAKER ESQ SNELBAKER ETAL 44 W MAIN ST MECHANICSBURG '02 r/IAF~ 1 B l; _ PAl 7 o6:titrnL~ " Allount Rellitted 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, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ iE-v =i6'ifj-i:x-AFP--fi'2-:oi.r------...--iNifERI'T-ANCE--yix--Sy]rfEMENy-o-F"-ic-cOUN-f--.-i.---------------- -- --- ESTATE OF BURD GLADYS A FILE NO.21 01-0439 ACN 101 DATE 02-11-2002 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-04-2002 P R I N C I PAL TAX DUE: ........................................................................................................................................................................................................................... 6,674.71 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-19-2001 CDOOO064 315.79 6,000.00 12-18-2001 CDOO0655 .00 374.71 01-28-2002 REFUND .00 15.79- TOTAL TAX CREDIT 6,674.71 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) /6-cJ~P~5 ~ 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 'OZ RICHARD C SNELBAKER ESQ SNELBAKER ETAL 44 W MAIN ST t,. MECHANICSBURG PA ~jOS5 J\ DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 05-27-2002 BURD 04-29-2001 21 01-0439 CUMBERLAND 101 * REY-1547 EX AFP CDI-02l GLADYS A 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 ~ RE-Y-=is4-j-ix--AFP--fo1-:o21--Ncffici--oF--rNHiifiTAifCE-TAX-A-PPRAIsiH€NT~--AL1-oWANCE-(fR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BURD GLADYS A FILE NO. 21 01-0439 ACN 101 DATE 05-27-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Stock/Partnership Interest (Schedule C) (3) 4. Mortgages/Notes Receivable (Schedule D) (4) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets NO. 01 .00 .00 .00 .00 821.92 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax .00 .00 Ul) (2) (3) (4) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 821.92 00 821.92 .00 149,148.78 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: (5) .00 X 00 = .00 (6) 149,148.78 X 045 = 6,711.70 U7J .00 X 12 = .00 (8) .00 X 15 = .00 (9)= 6,711.70 PAYMENT KI:l;I:.lt"I (+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-19-2001 CDOOO064 315.79 6,,000.00 12-18-2001 CDOO0655 .00 374.71 01-28-2002 REFUND .00 15.79- 05-02-2002 CDOO1139 .00 36.99 TOTAL TAX CREDIT 6,711.70 BALANCE OF TAX DUE .00 INTEREST AND PEN. .56 TOTAL DUE .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 MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) ~/ STATUS REPORT UNDER RULE 6.12 Name of Decedent: Gladys A. Surd Date of Death: Apri 1 29. 2001 Will No. 21-01-0439 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 whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, ~tate the following: a. Did the personal representative file a final account wi th the Court? Yes No X. 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 - X No d. Copies of receipts, releases, joinders and approvals of formal or informal accoun s ay be filed with the Cerk of the Orphans' Court and may b at ac 0 this report. Date: 6/27/02 ~ J :'""''-1 Richard C. Snelbaker Name (Please type or print) 44 West Main Street Mechanicsburg, PA 17055 Address (717) 697-8528 Te 1. No. Capacity: Personal Representative (MAH:rmf/AM3) ~ Counsel for personal representative REV-1500 EX + (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG. PA 17128-0601 DECE- DENT CHECK APPRO- PRIATE BLOCKS COR- RE- SPON DENT RECA- PITULA- TION TAX COMPU- TATION o PA15001 c- OFFICIAL USE ONLY REV-1500 /b-.;}~~-' INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 2001 0439 YEAR NUMBER COUNTY CODE DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Burd, Gla s A. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 04/29/01 01/16/1920 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Burd, Lero M. 178-07-6862 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER ~ 1. Original Return 4. Limited Estate 6. Decedent Died Testate (AtlachcopyofWill) g, Litigation Proceeds Received ~ 2. Supplemental Return 4a. Future Interest Compromise (date at deatt\ after 12-'2-82) 7. Decedent Maintained a living Trust (Attach acopyofTrust) 10. Spousal Poverty Credit(dateof death between 12-31-91 and 1-1-95) 3. 8 5 o 8. 011 Remainder Return (date of death prior to 12-13-82) Federal Estate Tax Return Required Tota.l Number of Safe Deposit Boxes Election to taxul"\der Sec. S113(A} (Attach Sch 0) 'ffi\$.~~MQ$jt!$;RQ~fi!li;i\~49Qiljj!l$=!Q~~~PQl:!liltiWj:t(..w:ti\li!l>IfPilMl!'tlilffl$.l!qVQ:!~ijj!'l~l:lfQi NAME COMPLETE MAILING ADDRESS Richard C. Snelbaker, Es ire 44 West Main Street FIRM NAME (If Applicable) Mechanicsburg, PA 17055 Snelbaker, Brenneman & are, P.C. TELEPHONE NUMBER 717-697-8528 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested (6) None 1l,243.~Q NoJ;ym _ No:w ~, 1l5,719.~7 OFFICIAL USE ONLY d - :0 (l) r"; 9 <::l CJ - 00 None ~ 00 :0;. w ;;:) -~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) (7) ''T,~ , )> .,-. 37,328.27 (8) 15,132.71 831.85 (11) (12) (13) 164,291.42 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H}(9) 10. Debts of Decedent, Mortgage Liabilities, & liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) 15,964.56 148,326.86 None (14) 148,326.86 SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amountof line 14 taxable at the spousal tax rate,ortransfersunderSec.9116(a)(1.2) 0.00 X.O 0 (15) 16. Amountof Line 14 taxable at Imeal rate 148,326.86 x.a 45 (16) 17. AmountofLine14taxableatslblingrate 0.00 X ,12 (17) 18. Amount 01 line 14taxableat collateral rate 0.00 x .15 (18) 19. Tax Due (19) 20. ~ I~QK@'IewYQj).A#I!;RI!;Qij!E;$'tl8$A..l'I~j.jPQfMjQ\lER~AYMl!;rfi..-.1 0.00 6,674.71 0.00 0.00 6,674.71 NTF 29755 Copyright "l000 GreatlandlNelco lP - Forms Software Only PA REV-1500 EX (6-00) Decedent's Com lete Address: STREET ADDRESS 527 Drive, Messiah Villa e Page 2 r Allen Townshi , Cumberland Ct CITY Mechanicsb Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount STATE PA ZIP 17055 (1) 6,674.71 6,000.00 300.00 Total Credits (A + B + C) (2) 6,300.00 3. Interest/Penalty jf applicable D. Interest E. Penalty Totallnterest/Penalty (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 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 + SA. This is the BALANCE OUE. Make Check (3) 0.00 (4) (5) 374.71 (5A) 0.00 (5B) 374.71 1. 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? Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 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. 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 belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on information of which preparer has anv knowledqe. SIGN URE OF PE 0 RES SIBLE FO FiLiNG RETURN DAT.E / bl /3/<1' 3. 4. Yes No ~ I B ~ o D ached OTHER THAN REPRESENTATIVE OAT .I !'If r;1 " [72 P.S. Ii 9116(a)(1.1)(i)]. For dates of death on or after January 1,1995, the tax rate is imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S.!i 9116 (a)(l.l)(ii)]. The statute rlnA~ nnt AXl!mnt 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 onfy beneficiary. For dates of death on orafterJuly 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, ora stepparent of the child isO% [72 P.S.!i9116(a)(1.2)]. The tax rate imposed on the net value of transfers to orfor the use of the decedent's lineal beneficiaries is 4.5%, except as noted In 72.P.S.!i 9118(1.2) [72 P.S.!i9118(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. !i9118(a)(1.3)]. Asibling is defined, under Section 9102, asan indiVidual who has at least one parent in common with the decedent, whether by blood oradoptlon. o PA15002 NTF 29756 Copyright 2000 GreatlandlNelco lP - Forms Software Only Estate of: Gladys A. Burd 21-2001-0439 The following person(s) are signing the retUlll as representative(s) of the estate: Susan A. Golob 11 East Winding Hill Road Mechanicsburg, PA 17055 REV-1503 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Gladys A. Burd SCHEDULE B STOCKS & BONDS FILE NUMBER 21-2001-0439 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NO. DESCRIPTION VALUE AT DATE OF DEATH 1 Verizon, 192 shares comron stock valued at $55.77 per share. 10,708.80 2 Lucent Technolcgies, 22 shares COfflTOn stock valued at $10.80 per share. 237.60 3 Avaya, 22 shares of comron stock valued at $13.49 per share. 296.78 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 11,243.18 7 CPA31 NTF 10905 Copyright Forms Software Ol1ly, 1997 Nelco, Inc. REV-150B EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Gladys A. Burd SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-2001-0439 Include proceeds of litigation & date proceeds were received by the estate. All prop. jointly-owned with right 01 survivorship must be disclosed on Sch. F. ITEM NO. DESCRIPTION VALUE AT DATE OF DEATH 1 Messiah Village, Cluster Housing Agreement related to property located at 572 I'cgwCCd Drive, Mechanicsburg, PA 19,750.00 2 AARP Investment Program, account #0620 200 100-5 14,012.40 3 American Express, Mutual Fund investment account numter 01054853738 9 002 29,272.28 4 American Express, Mutual Fund investment account numter 01124853738 0 002 17,012.76 5 American Express, Mutual Fund Investment Account numter 01254853738 5 002 16,824.12 6 American Express, Mutual Fund Investment Account numter 01262718519 7 002 1,216.21 7 PNC Bank, N .A., Checking account numter 5003156054 6,898.43 8 PNC Bank, N.A., Savings account numter 5030125528 7,628.04 9 Household Goods, appraised value (copy attached) 2,135.00 10 Ladies diarrond ring set with Marquise shaped diarrond, appraised value (copy attached) 900.00 11 Capital Blue Cross/Blue Shield, premium refund on Security 65 plan #178076862 62.05 12 old Guard Mutual Insurance, proceeds frcm conversion litigation. 8.68 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 115,719.97 7 CPA81 NTF 10908 Copyright Forms Software Only, 1997 Nelco, Inc. APPRAISAL 'Personal Property of {}-LAdY S A, BUf c/ EST~ S.2.-7 f}/J5tJft.Dc/ /filE, I1c0l8!l ;)4,1/asT Appraised by Chuck E. Bricker AU094-L Date - (J / ITEM VALUE ITEM VALUE ), ()i) c.r L !MfUMM~S c:.are&.9 jtO>f.& 34 WEST MAIN STREET MECHANICSBURG, PA. 17055 APPRAISAL Phone: 766.9422 '1/'V\- ~ool APPRAISAL Appraisal For:lc-c:_.___L(~_\"" ....,\- ,"\r"A u.=- -:R..~ ~ _-' \'",,--~ '-f'\ 'c3 '-"-I....(~J 'u:)\~ -g I.-<:-&:\~S JG.CJ.."'-OJJ.. <Q.V\.$\~~ 1(\ ,\IJ.& (\ CD'C"~ o-t CL W\rue:'t;>~ ~"'6W1E'QC'0(\ 't.C\ Y-- ~,bV- C):a ~ \'1\ ~ b-\=>~~ W~~ 1'I\L"0;fu~ ~~, \'\- 6~ ~-M( &a.W-DI\ ,'<\ ~ s,~ G\ ~ "''C0'fu~ \k. ~ axe.. 0\- I{\\G2-. (!D\or', Q.0\- G-" ~~ ~ ~ ~~~ u::J8\~ -4P.~, ~~ _ ~.co a) l~~ \CO-r~ ~&&.\'R 0~ Ih- X\~ ~~ i3<c. \'5 ~ ~ ~ \\{\ Cc \,~ W%~. ~\& b..~ (\~ . \~ ~(_JD~ axe ~'L'~"S ~~, ~. ~\e ~,eo 'This appraisel ,constitutes our carefully "ud,'ed " f o th \ opInion 0 ~ e f~\OI replacement cosllhrough our facilities ...... the distress sales nolUfe ...alue of the orlicle(s) described above insofar . observation. We qme no liobil . hO"" Ihe maunllf'lg{s)ho....e permitted laken on the bo 5 ,1..' ' 'IYI WI' respect 10 any achon thot may be nl'3 opprOlsa . Appraiser REV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Gladys A. Burd SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER This schedule must be completed and filed jf the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. 21-2001-0439 DESCRIPTION OF PROPERTY %OF EXCLUSION ITEM INCLUDE NAME OF THE TRANSFEREE, THEIR DATE OF DEATH DECD'S (IF TAXABLE VALUE RELATIONSHIP TO DECD & DATE OF TRANSFER. NO. ATTACH COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST APPLICABLE) 1 Arrerican Express, Flex Armuity, 37,328.27 100 0.00 37,328.27 account number 93002967744 8 004 TOTAL (Also enter on line 7, Recapitulation) $ 37,328.27 7 CPA01 NTF 10910 Copyright Forms Software Only, 1997 Nelco, Inc. (If more space is needed, insert additional sheets of the same sjze) REV-1511EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Gladys A. Burd SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-2001-0439 Debts of decedent must be reported on Schedule I. ITEM NO. A. FUNERAL EXPENSES: DESCRIPTION AMOUNT 1 Malpezzi Funeral Home, funeral services 8,743.30 B. ADMINISTRATIVE COSTS: ,. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EtN No. of Personal Representative(s) Street Address City State 0.00 Zip Year(s) Commission Paid: 2. 3. Attorney Fees Name: Snelbaker, Brermeman & Spare 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 3,500.00 0.00 4. Probate Fees 261. 00 5. Accou ntant's Fees 0.00 6. Tax Return Preparer's fees 0.00 See Schedule attached Total from continuation pagers) 2,628.41 TOTAL (Also enter online 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 15,132.71 7 CPA11 NTF10911 Copyright Forms Software Orlly, 1997 Nelco, Inc. Estate of: Gladys A. Burd Item No. SGJEDULE H, PART B -- Administrative Costs Description 7 Susan D. Golob, reirobursetrent for postage, funeral thank you notes, funeral flowers and inscription on headstone 8 American Express Financial Advisors, senior advisor retainer 9 Register of Wills, Cumberland County, short certificates 10 Chuck E. Bricker, Auctioneer, appraisal fee on household gccds 11 Mumma's Jewelry, appraisal fee 12 Patriot-News, advertising Executrix notice 13 Transportation expenses to Florida to search for and remove decedent's assets from residence which is individually owned by Leroy M. Burd (husband of Decedent) 14 Cumberland Law Journal, advertising Executrix notice 15 Register of Wills, Cumberland County, filing fee for Inheritance Tax Return 16 Reserve for filing fees, accounting and other costs associated with the administration of Decedent's estate TOI'AL. (Carry forward to main schedule) . . . . . . Page 2 21-2001-0439 Arrount 648.47 400.00 12.00 75.00 45.00 110.10 747.84 75.00 15.00 500.00 2,628.41 REV-1512 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Gladys A. Burel Include unrelmbursed medical expenses. ITEM NO. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-2001-0439 DESCRIPTION AMOUNT 1 Pinnacle Health Hospital, medical services, account payable 792.00 2 PPL, payment of Utility invoice which was Electronically deducted from Decedent's PNC checking account #5003156054. 39.85 7 CPA12 NTF 10912 TOTAL (Also enter 0\\ line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 831. 85 Copyrignt ferms SoHware Only, 1997 Nelco, lnc. REV-1513 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES GlaNs A. Burd No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 Susan A. Golob 11 East Winding Hill Road Mechanicsburg, PA 17055 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Daughter 21-2001-0439 AMOUNT OR SHARE OF ESTATE 148,326.86 ENTER DOLLAR AMTS. FOR DISTRIBS. 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 None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS None 7 CPA13 NTF 10913 TOTAL OF PART 11-- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 Copyright Forms Software Only, 1997 Nelca, Inc. (If more space is needed, insert additional sheets of the same size) ,~ 1''', \~ LAW OFFICES SNELBAKER & BRENNEMAN LAST WILL AND TESTAMENT I, GLADYS A. BURD, of the Township of Upper Allen, County of Cumberland and Commonwealth of pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last will and Testament, hereby revoking and making void all former wills and codicils by me at any time heretofore made. FIRST. I order and direct that all my just debts and funeral expenses be paid by my Executrix, Executors or Executor, as the case may be, hereinafter named, as soon as conveniently may be done after my decease. SECOND. I give, devise and bequeath all the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situated, unto my daughter, namely, SUSAN A. GOLOB, absolutely and in fee simple, if she survives me. THIRD. If my said daughter, SUSAN A. GOLOB, does not survive me, then and in that event, I give, devise and bequeath my said residuary estate in equal shares unto my two (2) grandchildren, namely, JENNIFER SUZANNE CONWAY and MICHAEL JOSEPH GOLOB, share and share alike. LASTLY. I nominate, constitute and appoint my daughter, namely, SUSAN A. GOLOB, to be the Executrix of this, my Last will and Testament, but if for any reason my said daughter shall fail to qualify as such Executrix or cease so to serve, then and in such event, I nominate, constitute and appoint my grandchildren, namely, JENNIFER SUZANNE CONWAY and MICHAEL JOSEPH GOLOB, (or either of them if one should fail to qualifY or cease to serve) to be the Executors hereof, each and all to serve without bond or other security as a condition of qualification hereunder. IN WITNESS WHEREOF, I, GLADYS A. BURD, have hereunto set my hand and seal to this, my Last will and Testament which consists of two (2) typewritten pages affixed my signature this /h'U day to each of which I have One Thousand Nine Hundred rn~ Ninety-six (1996). of A.D. , C29~~~ (I '..~i/-yrf , ladys A. Burd (SEAL) The preceding instrument, consisting of this and one (1) other typewritten page, each identified by the signature of the Testatrix, was on the date thereof signed, sealed, published and declared by GLADYS A. BURD, the Testatrix therein named, as and for her Last will and Testament, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subsoribed our names as Vi~~ . r-r:'c~~ l..AW OFFICES SNEL8AKER & BRENNEMAN -2- COMMONWEALTH OF PENNSYLVANIA ) . COUNTY OF CUMBERLAND) SS. We, GLADYS A. BURD, RICHARD C. SNELBAKER and JANET R. STEGNER, the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last will and Testament and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as a witness and that to the best of his or her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ___, ~ ,0 C-,i,/,'~<-<,rA'. ~~---- }/ wi tness - subscribed, sworn to and acknowledged before me by GLADYS A. BURD, the Testatrix, and subscribed and sworn to before me by RICHARD C. SNELBAKER and JANET R. STEGNER, witnesses, this /{?-tI.- day of IntUt , 1996. Q~daJ ~.~J Nota y Public J.W OFFICES ,NELBAKER . JRENNEMAN Notarial Seal Patrida J. Thomson, Notary Public Mechaljicsburg Boro. Cumberland County My Commission Expires Dec. 31.1998 f/;:. ~11b-2r, PenJ1:.-:,vNania A..,socimion of ~:i1R \; REV-1500 EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 /In -:J.::J. 9' ~.t; DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 21 2001 0439 CQUNTYCODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Burd, Gladvs 178-07-6862 DECE- DATE OF DEATH (MM-DD-YEAR) T DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 04/29/01 01/16/1920 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 3. Remainder Return CHECK ~ 1. Original Return ~ 2. Supplemental Return B (date of death prior to 12-13-82) APPRO- 4. limited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required (date of death after 12-12-:82) PRIATE 6. Decedent Died Testate 7. Decedent Malntamed a living Trust 0 8. Total Number of Safe Deposit Boxes (Attach copy of Will) (Attach acopyofTrust) BLOCKS 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death between 0 11. Election to tax under Sec. 9113(A) 12-31-91 and 1-1-95) (Attach Seh 0) 'fijj$~@fjMO$'taEPQM#QtljlQ;Aijijqqjjjj!l$PQNbi!!IPl!~@9N!lItll!ll'tilWttAJlINf9!lMAUQjij$j.jqijU1m\pl!l~!:tttip*Q: NAME COMPLETE MAILING ADDRESS COR- Richard C. Snelbaker 44 West Main Street RE- FIRM NAME (If Applicable) Mechanicsburg, PA 17055 SPON & Soare, DENT Snelbaker, Brermeffi3Il P.C. TELEPHONE NUMBER 717-697-8528 None OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) None 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) No~C' d 4. Mortgages & Notes Receivable (Schedule 0) (4) None r,' 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 821.92 6. Jointly Owned Property (Schedule F) I 0 Separate Billing Requested (6) None N RECA- PITULA- 7. Inter-Vivos Transfers & Miscellaneous C;.': TION Non-Probate Property (Schedule G or L) (7) None ) 8. Total Gross Assets (total Lines 1-7) (8) 821. 92 9. Funeral Expenses & Administrative Costs (Schedule H)(9) None 10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule I) (1 0) None 11. Total Deductions (total Lines 9 & 10) (11) 0.00 12. Net Value of Estate (Line 8 minus Line 11) (12) 821. 92 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax (13) None has not been made (Schedule J) 14. Net Value Sublect to Tax (Line 12 minus Line 13) (14) 821. 92 SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) X.O (15) - TAX 16. Amountof Line 14 taxable at lineal rate 821.92 X.O 45 (16) 36.99 - COMPU- 17. Amountof Line 14 taxable at sibling rate 0.00 X .12 (17) 0.00 TATION 18. Amountof Line 14taxable at collateral rate 0.00 X .15 (18) 0.00 19. Tax Due (19) 36.99 20. 0 l!,;jj~kjj"R.EIl!yQjjA8eijeQjjE$tjNQAllEfj)Ni:l!:WA"'Q~R.pAYMEitrl - G/ . >~ BE;5\,lRE TO'ANSWER:ALL QUESTONS.ON .PAGE'2' AND RECHEqKMATH<< o PA15001 NTF 29755 Copyright 2000 Greatland/Nelco LP - Forms Software Only PA REV-1500 EX (6-00) Decedent's Com lete Address: STREET ADDRESS 527 Drive, Messiah Villa e Page 2 r Allen Townshi , OJmberland Ct CITY Mechanicsb Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount STATE PA ZIP 17055 (1) 36.99 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty jf applicable D. Interest E. Penalty Total Interest/Penalty (0 + 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 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 (3) 0.00 (4) (5) 36.99 (5A) 0.00 (58) 36.99 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS ,. 2. 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? If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 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 ~ I B ~ 3. 4. D ~ ADDRESS ARER OTHER THAN REPRESENTATIVE on on use [72 P.S.1i 9116(a)(1.1)(i)]. For dates of death on or after January 1,1995, the tax rate is imposed on the net value of transfers to or forthe use of the surviving spouse is 0% [72 P.S. Ii 9118 (a)(1.1)(ii)]. The statute rlnA<; not "!l(p.mnta transfer to asurviving 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 orafterJuly1,2000: 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.1i9116(a)(1.2)]. Thetax rate imposed on the net value of transfers to or forthe use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72.P.S.1i 9116(1.2) [72 P.S.1i9118(a)(1}]. The tax rate imposed on the net value of transfers to orforthe use of the decedent's siblings is 12% [72 P.S. 1i9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who hasat least one parent in common with the decedent, whether by blood or adoption. o PA 15002 NTF 29756 Copyright 2000 Greatland/Nelco lP- Forms Software Only REV-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Gladys Burel. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-2001-0439 Include proceeds of litigation & date proceeds were received by the estate. All prop. JolntJy-owned with right of survivorship must be disclosed on Sch. F. ITEM NO. DESCRIPTION VALUE AT DATE OF DEATH 1 IDS Life Insurance Corrpany, refund of unused premium on long term care pclicy #9100-3140830 820.60 2 Medicare, refund on overpayment of deductible for 1996 1.32 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 821. 92 7 CPA81 NTF 10908 Copyright Forms Software Only, 1997 Nelco, Inc. REV-1513 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES Gladvs Burel No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 Susan A. Golob 11 East Winding Hill Road Mechanicsburg, PA 17055 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s} Daughter 21-2001-0439 AMOUNT OR SHARE OF ESTATE 821. 92 ENTER DOLLAR AMTS. FOR DISTRIBS. 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 None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS None 7 CPA13 NTF 10913 TOTAL OF PART II -- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 Copyright Forms Software Only, 1997 Nelco, Inc. (If more space is needed, insert additional sheets of the same size)