HomeMy WebLinkAbout01-0506
&W~~ Helen M. Kitzmiller
also known as
PETITION FOR PROBATE and GRANT OF LETTERS
~/- 01- D50lo
No.
To:
Register of Wills for the
Deceased. County of c'n m b e r 1 and in the
Social Security No. 203 - 1 0 - 8 11 2 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 r; x
in the last will of the above decedent, dated A p r; 1 ? 7
and codicil(s) dated N / A
named
,19~
(state relevant circnmstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in Cum be rIa n d County, Pennsylvania, with
her lastfamilyorprincipalresidenceat 332 Greason Road~ Carlisle~ PA 17013
Wpqr Ppnnqhoro Township
(list street, number and muncipality)
Decendent, then 8 1 years of age, died May 20 , 2l~ 2001,
~ 332 Grp~~nn Rn~~) r~rliqlp, PA 17011
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ 1,000.00
$
$
$
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters T est am e n tar y
(testamentary; administration c.La.; administration d.b.n.c.t.a.)
theron.
.e
dJ
U
c::
dJ
:g~
en_
Q)'"
o::~
-00
~.~
~''::::
3~
Q) '-
:; 0
~
c::
01)
ti5
Q -,
61 Jl()/11 /). vY;, M () A-A~
" .
Dolores M. Martin
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA 1 ss
COUNTY OF CUMBERLAND J
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
~
Martin
V:l
aQ'
:::s
l:::l
-
~
~
~
JLP.- ~3,~ - '0-
No. ~- 01- 05DLP
Estate of
HELEN M. KITZMILLER
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW ~ - 'A 4- JI~ 2 00 1, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated A p r i 1 2 7, 1 9 94
described therein be admitted to probate and filed of record as the last will of He 1 en M.
Kitzmiller
and Letters Tes t amen t ary
are hereby granted to Dolor e sM. Mar tin
FEES ~
Probate, Letters, Etc. ......... $ J i DO
Short Certificates(... ) . . . . . .. . .. $ q D 0
R . t' )( "+'G ~ $ ~ DO
..CR\lftel& Ion .:-... ;,j"(ip' .. $ r:::- ,- Ou
TOTAL _ $3~.OO
Filed ...................................
(&~
Dale F. Shughart, Jr.
AITORNEY (Sup. Ct. 1.0. No.) 19373
35 East High Street, Suite 203
ADDRESS Car 1 i s 1 e, PAl 7 0 1 3
(717) 241-4111
PHONE
~ .~, I
: .-'
.,,~ ~,,~ ,:,r.1: ("<;;or:.,
This is to certify that the information here given is correctly copied fro~ an original certificate of death dul~ filed with me as
Local Registrar. The original certificate will be fOlwarded to the State VItal Records Office for permanent filmg.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
)"i--~. ~~~~
Local Registrar
Fee for this certificate, $2.00
p
7401948
MAY 2 1 2001
Date
H105.1~ R.... 2117
COMMONWEALTH OF PENNSYLVANIA · OEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
..T
,.
Helen
UNClEfl1 YEAR
IoIorOI\a Deya
M.
Kitzmiller
SlRE 'IlE __R
SEll SOCIAl. SECuAlT'f NUMBER
I.Female 3. 203 - 10 8112
OA'E OF DEATH ,1.1_. Da~. '_,
.. May 20,2001
NT
II(
NAME OF DECEDENT IF..... _. L...,
.;/,.\
UNOER , OM
- l MlnuI..
~ OF IlEATH /Cl'eck""'" I)N - ..... ....rUCloOnl on _ ..
HOSPITAl: OTIER:
~ 0 E~_ 0 :::::" 0
...
FACll.lTV NME I" noI_. grye OI.HI ."".......-,
81RTHP\.ACE (CIy1llCl
S\oIe '" F",.." CclunII>iI
7. Cap~AR1; ,
0Ihet ~',.J
lSoec:"Yl 00. r1V 1'o1G'
Cumberland
White
SURVMNG SPOuSE
("-._--.
DECEDENT'S USUAl. ClCCUMIOH
(G!we-"'--~""
al--..,..;inclC....' ".1
. ilL Tax vo lec or 11..
DECEOENf'S MM.ING-AOON:SS 19r-.~. s.. l'.,Cocle\
332 Greason Road
Carlisle, Penna. 17U13
,..
mHEfl'sNAME(F''''M-'~l vin I. Martin
II.
-~sNAME~~lores M. Martin
OFOlSPOSlTl9f1
O lIurteI~ ~O .......'"""51..0
~ 0lIler~
,
llIONRUflE
'711.
Cumberland
DId
.......
... in.
-.,
_.
~.
z,co \
I:
K.
'"",,",.-.
!=-=.
I
I
MIlT M: OIMr.q,illcant ClClndlIiIlN ~"'_. bul
flClI reMlIllr>9in'" ~_ ~ in PMT I.
l~p\.n.~""'~-:l." ...
'"'
DUE 1O(OA AS A CONSEOUENC( OF):
WERE AU10PSY FINOINGS
~ 1'AlClft1O
COMPUmON OF CAuSE
or- DERH?
MNtNEA OF ourH
ORE or- ~URY
<'l/lntII.OIy. 'lltarl
TIME OF IHJUAY
INJURY R WORK? DESCRIBE HOt\f INJUAY OCCURREO.
_0 NoD
-.. ~
_ 0
SuIdcIe 0
HomiCide
Penclin9 -,Ian
_ 0 ....0
CoulcI "'" be del.",,,,,"
_ 21.
CUlTM'IEIII~ only one!
.CIIlTII'YING 'HYIICIAN (11II_ eAlflIIton9 cauM d _ _....."., Ohvs.c:_ has po""""",*, Geall\ 8I'Cl cCOT\llltleCl ftern 231
To"'_o'"",~.___Io.......M('land.........,_.'etlld............................ ...... ............... _...
~.c.
"f'flOMOUNCINQ AHO C!ln1fY1NG PHYSICIAN ~ boIIl ,,"">Ounc"'ll_ and c--,.ng 10.,..,.. 01_1
To... _ almy _~. ..'" __..... _, da.., and pi..... and.... to... "UMtal_ ",.nne' _ ".'lId.. . . . . . . . . . . . . . . . . . . . . . . . .
b\
"IIUJtCAL EXAMlNIAICOfIONE"
on lite.... of e.."'/natlon attdJor Inv..tlgatioft,ln tny opinion, ..,,, occur,.d III 'ltell"", d.'., .nc1 place, and d"elo IIle c."..(.j.nd
_ ultated.. . . . . . . . . .. . _... . . . . . .. . . . . . . . . .. . . . .. . . . ., . . . , . . .. . . .. . . . . . . . . . . . . . ... . . . .. . .. ... . . .. . . . ... .. .. .
"..
REGlSTRAR'S SIGNATURE AND N
o
Ic;\ \ I~ t 101
:N.
s - '\..\ - 0 \
a.\ 0.00 l
....'
LAST WILL AND TESTAMENT OF
HELEN M. KITZMILLER
I, Helen M. Kitzmiller, of West Pennsboro Township,
Carlisle, Cumberland County, Pennsylvania, declare this to be my
last Will and Testament and revoke all Wills and Codicils
previously made by me.
ITEM I: I direct that my just debts, funeral expenses, and
the expenses of the administration of my estate, including any
state, federal or other death taxes payable because of my death,
shall be paid from my residuary estate as soon as practicable
after my decease, as a part of the expense of the administration
of my estate.
ITEM II: I devise and bequeath all of my estate of every
nature and wherever situate unto my daughter, Dolores M. Martin,
provided she shall survive me by thirty (30) days.
ITEM III: Should my said daughter, Dolores M. Martin,
predecease me or die on or before the thirtieth day following my
death, I devise and bequeath all of my estate of every nature and
wherever situate unto my granddaughter, Kathy Deitch, provided
she shall survive me by thirty (30) days. Should my said
granddaughter, Kathy Deitch, also predecease me or die on or
before the thirtieth day following my death, I devise and
bequeath all of my estate of every nature and wherever situate
/~ '>n /({f~1k,
/
..,.. .'
unto her issue, per stirpes, living on the thirty-first day
following my death.
ITEM IV: I appoint my daughter, Dolores M. Martin,
Executrix of this my last will and Testament. Should my said
daughter fail to qualify or cease to act as Executrix, I appoint
my granddaughter, Kathy Deitch, Executrix of this my last will
and Testament.
ITEM V: I direct that my personal representatives, as well
as their successors, shall not be required to give bond for the
faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal,
this ~? day of April, 1994
14 ~ ~''ti,. ,
Helen M. ltzmllIer
[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, published and
declared by Helen M. Kitzmiller, the Testatrix therein named, as
and for her last Will, in the presence of us, who, at her
request, in her presence and in the presence of each other, have
subscribed our names as witnesses hereto.
.........' ~ 1
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, Helen M. Kitzmiller, Dale F. Shughart, Jr. and Mary M.
Price, the Testatrix and the witnesses, respectively, whose names
are signed to the 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 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 witness and that to the best of his/her
knowledge the Testatrix was at that time eighteen years of age or
older, of sound mind and under no constraint or undue influence.
'/7 if:. C2~
WJ.tness
Subscribed, sworn to and acknowledged before me by
Helen M. Kitzmiller, the Testatrix, and subscribed and sworn to
before me by Dale F. Shughart, Jr., and Mary M. Price, witnesses,
this C:<7':i!1- day of April, 1994.
/~~a%&
NOT ARIAt SEAL
BONNIE l. COYLE. NOT/.RV PUBLIC
HOllY SPRINGS. PA CUMBEHLAND CO.
:J 'COMMISSION EXPIRES OCTOBER 17. 1994
~
..--'
t:
~
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Helen M. Kitzmiller
Date of Death: May 20, 2001
Estate No. 21-01-00506
To the Register:
I certify that notice of estate administration required by Rule
5.6(a) of the Orphans' Court Rules was served on or mailed to the
following beneficiaries of the above-captioned estate on
May 30, 2001.
Name
Address
1. Dolores M. Martin
100 Greason Road
Carlisle, PA 17013
2. Kathy Deitch
175 Limekiln Road
Carlisle, PA 17013
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except None
Date: May 30, 2001
~r
Dale F. Shughar J.
35 East High Street, Suite 203
Carlisle, PA 17013
Telephone (717) 241-4311
Capacity:
Counsel for Personal Representative
I c-
(I,
..
IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU WILL
RECEIVE ANY MONEY OR PROPERTY FROM
THIS ESTATE OR OTHERWISE
Whether you will receive any money or property will be
determined wholly or partly by the decedent's will. If the
decedent died without a will, whether you will receive any money
or property will be determined by the intestacy laws of
Pennsylvania.
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In re Estate of Helen M. Kitzmiller, deceased
Estate No. 21-01-00506
TO: Dolores M. Martin
100 Greason Road
Carlisle, PA 17013
Please take notice of the death of decedent and the grant of
letters to the personal representative(s) named below.
The Decedent Helen M. Kitzmiller, died on the 20th day of
May, 2001, at Cumberland County, Pennsylvania.
The Decedent died testate.
The personal representative of the Decedent is:
Dolores M. Martin
100 Greason Road
Carlisle, PA 17103
(717) 249-4502
The will has been filed with the Office of the Register of
Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA
17013. Phone No. 717-240-6345.
A copy of the Will or Petition may be obtained by contacting
the Register of Wills and paying the charges for duplication.
Date: May 30, 2001 ~/'~
Dale F. s~:ti/ JJ
Attorney Supreme Court I.D. #19373
35 East High Street, Suite 203
Carlisle, PA 17013
Telephone (717) 241-4311
Capacity: Counsel for Personal Representative
..
IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU WILL
RECEIVE ANY MONEY OR PROPERTY FROM
THIS ESTATE OR OTHERWISE
Whether you will receive any money or property will be
determined wholly or partly by the decedent's will. If the
decedent died without a will, whether you will receive any money
or property will be determined by the intestacy laws of
Pennsylvania.
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In re Estate of Helen M. Kitzmiller, deceased
Estate No. 21-01-00506
TO: Kathy Deitch
175 Limekiln Road
Carlisle, PA 17013
Please take notice of the death of decedent and the grant of
letters to the personal representative(s) named below.
The Decedent Helen M. Kitzmiller, died on the 20th day of
May, 2001, at Cumberland County, Pennsylvania.
The Decedent died testate.
The personal representative of the Decedent is:
Dolores M. Martin
100 Greason Road
Carlisle, PA 17103
(717) 249-4502
The will has been filed with the Office of the Register of
Wills of Cumberland County. 1 Courthouse Square, Carlisle, PA
17013. Phone No. 717-240-6345.
A copy of the Will or Petition may be obtained by contacting
:::e~eg:::e:o~f2:~:lS and p~~~ duplication.
Attorney Supreme Court I.D. #19373
35 East High Street, Suite 203
Carlisle, PA 17013
Telephone (717) 241-4311
Capacity: Counsel for Personal Representative
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
SHUGHART DALE F JR
35 EAST HIGH STREET
SUITE 203
CARLISLE, PA 17013
u______ fold
ESTATE INFORMATION: SSN: 203-10-811 2
FILE NUMBER: 21-2001- 0506
DECEDENT NAME: KITZMILLER HELEN M
DA TE OF PAYMENT: 08/17/2001
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: OS/20/2001
NO. CD 000171
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,902.32
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: DALE F SHUGHART JR ESQUIRE
CHECK# 705
SEAL
INITIALS: AC
RECEIVED BY:
$2,902.32
MARY C. LEWIS
REGISTER OF WILLS
REGISTER OF WILLS
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
Estate of Kitzmiller, Helen M.
, Deceased
No. 21 - 01 - 00506
Date of Death 5/20/2001
Social Security No. 203-10-8112
also known as
Dolores M. Martin
The Personal Representative(s) of the above Estate,'deceased, verify that the items appearing in the following Inventory
include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania
of said Decedent, that the valuation placed oppoSite each item of said Inventory represents its fair value as of the date of
the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except
that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory
are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S.
Section 4904 relating to unsworn falsification to authorities.
Personal Representative
Signature: ~Q~g YYJ l m CJ1~
Do ores . artm
Attorney: Dale F Shughart, Jr. Esquire
I.D. No.: 19373
Signature:
Signature:
Address:
35 E. High Street, Suite 203
Address: 100 Greason Road
Carlisle, P A 17013
Carlisle, P A 17013
Telephone: (717) 241-4311
Telephone: 71 7 :2 Cf ~ LIS!) bl
Dated: 'D//7/ ~ l
Personal PrODertv
Clothing and personal effects.
10.00
Cash on hand in safe deposit box, 91 $2.00 bills and 9 $1.00 bills.
191. 00
Coins and currency in safe deposit box, value based upon attached appraisal of Frank R.
Loney, Jr.
31. 00
1987 Chevrolet Caprice Sedan, value based upon Kelly Blue Book.
935.00
1971 Ford FI00 pick up truck, value based upon attached appraisal of Keith R. Miller,
auctioneer.
200.00
Pennsylvania Central FCU, Account #30364-017.
Principal- 3,583
Accrued interest - -0-
3,583.00
(Attach additional sheets if necessary)
Total Personal Property and Real Estate
$4,995.00
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
continued
, Deceased
No. 21 - 01 - 00506
Date of Death 5/20/2001
Social Security No. 203-10-8112
Estate of Kitzmiller, Helen M.
also known as
Various evidences of bank accounts with Meridian Bank and Cumberland Valley Savings &
Loan, predecessors to First Union Bank found in safe deposit box, per attached report of First
Union.
0.00
American Red Cross, refund.
9.00
Internal Revenue Service, tax relief.
26.00
HeR, Manorcare, refund.
10.00
Total Personal Property
$4,995.00
.........
2
llEY.,"'u....~
/
*'
COMMONWEALTH OF PENNSYLVANIA
oePARTMeNT OF ReveNue
OePT.2lKlOOl
HARRISBURG. PA 17128-0601
/6-..:48~-/O
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
.
DECEDENrs NAME (LAST. FIRST, AND MIDDLE INITIAL)
Kitzmiller, Helen M.
~
z
"'
Q
"'
irl
Q
c
,
OS/20/2001
04/06/1920
OFFICIAL USE ONLY
FILE NUMBER
21 01
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
203.10.8112
00506
NUMBER
<IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MfDOlE INITIAL)
THIS RETURN MUST BE FILED IN DUPUCATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
[J 3.
ea pnor 0
emsn er
m .e
. ,. Original Return [J 2. Supplemental Return
"'
~ [J 4. Limited Estate [J 4a. Future Interest Compromise (date of death
"'~!:l
1dfg after 12-12-82)
:Z:~..J . 6. Decedent Died Testate (Attach copy [J 7. Decedent Maintained a Living Trust (Attach
u~~ of Will) copy of Trust)
~
~ [J 9. Litigation Proceeds Received [J 10. Spousal Poverty Credit (date of death between
12-31-91 and 1-1-95)
[J 5. Federal Estate Tax Return Required
1 8. Total Number of Safe Deposit Boxes
[J 11.Election to tax under Sec. 9113(A) (Attach Sch 0)
~
z
"'
Q
Z
Q
~
AME
Dale F Shughart, Jr. Esquire
IRM NAME (If applicable)
35 E. High Street, Suite 203
Carlisle, PA 17013
(1) None OFFICIAL USE ONLY
(2) None
(3) None
(4) None
(5) 4,995.00
(6) 226.50
(7) 73,193.00
(8) 78,414.50
(9) 10,268.00
(10) 256.00
(11)
10,524.00
67,890.50
~I ELEPHONE NUMBER
717/241-4311
,. Real Estate (Schedule A)
2. Slocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
z
o
~
~
~
~
~
u
"'
'"
4. Mortgages & Noles Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Joinlly Owned Property (Schedule F)
o Separale Billing Requesled
7. fnter.Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total lines 1.7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule I)
(12)
13. Charitable and Governmental Bequests/Sec 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)
(13)
11. Tolal Deductions (lotai Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(14)
67,890.50
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
3,055.07
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
3,055.07
15.Arnount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 16. Amount of Line 14 taxable at lineal rate 67,890.50 x .045 (16)
Q
g 17. Amount of Line 14 taxable at sibling rate .12 (17)
~ x
2
Q
u
~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
,
STREET ADDRESS
332 Greason Road
CITY
Carlisle
ISTATE PA
[ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
3,055.07
2,902.32
152.75
Total Credits (A + B + C)
(2)
3,055.07
3. Interest/Penalty if applicable
O. Interest
E. Penalty
(3) 0.00
(4)
(5) 0.00
(SA)
(5B) 0.00
TotallnteresUPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Une 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 DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
3. Did decedent own an win trust for" 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?......... ......... '.. .... ........ ...... ... ... ..... ............ ................. ..... ........ ....... ... ........
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................................................................. 0 a
b. retain the right to designate who shall use the property transferred or its income;................................ 0 a
c. retain a reversionary interest; or............................................................................................................ 0 a
d. receive the promise for life of either payments, benefits or care?.......................................................... 0 a
2. If death occurred after December 12. 1982, did decedent transfer property within one year of death without
receiving adequate consideration?........ ................ ........ ...... ..... ... ............ .......... ................. ... ..... ..... ........ ..... 0 a
o 1m
1m 0
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 thai I have examined this return, including accompanying schedules and statements. and to the best of my knowledge and belief, it is INe. correct
and complete,
Declaration of preparer other than the personal representative is based on all infonnatiOn of whiCh preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
~ 100 Greason Road
::;1e,.;N U~~LI::.~t-;L1Nm~~UUHI::.::;ti Carlisle, PA 17013
DATE
g~/7-61
UA I I::.
35 E. High Street, Suite 203
Carlisle, PA 17013
-0 ~l/()J
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. ~9116 (a)(1.1) (i)J.
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. 99116 (a) (1.1) (ii)J. 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. 99116 (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. 99116
1.2) [72 P.S. ~9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116 (a) (1.3)]. A sibling is defined,
under Sectlon 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT oeCC:CENT
I FILE NUMBER
21 - 01 - 00506
ESTATE OF Ki '11 HIM
tz:nu er, e en .
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
1 Clothing and personal effects.
DESCRIPTION
VALUE AT DATE
OF DEATH
10.00
2
Cash on hand in safe deposit box, 91 $2.00 bills and 9 $1.00 bills.
191.00
3
Coins and currency in safe deposit box, value based upon attached appraisal of Frank R. Loney, Jr.
31.00
4
1987 Chevrolet Caprice Sedan, value based upon Kelly Blue Book.
935.00
5
1971 Ford FlOO pick up truck, value based upon attached appraisal of Keith R. Miller, auctioneer.
200.00
6
Pennsylvania Central FCU, Account #30364-017.
Principal- 3,583
Accrued interest - -0-
3,583.00
7
Various evidences of bank accounts with Meridian Bank and Cumberland Valley Savings & Loan,
predecessors to First Union Bank found in safe deposit box, per attached report of First Union.
0.00
8
American Red Cross, refund.
9.00
9
Internal Revenue Service, tax relief.
26.00
10
HCR, Manorcare, refund.
10.00
TOTAL (Also enter on Line 5, Recapitulation)
4,995.00
,
Frank R Loney, ill
1215 Hillside Drive
Carlisle, PA 17013
June 18,2001
Dale F. Shughart, Jr.
Attorney At Law
35 E. High Street
Carlisle, P A. 17013
RE: APPRAISAL REQUEST
Dear Dale:
This is in response to your request to appraise the below listed personal property:
(I) 1923 Silver Certificate (large note) with blue seal on left,
blue one dollar on right and blue numbers. Signatures:
Speelman-White. Condition: Used (folded)
Appraised value.................................................................. .$17.00
(2) 1964 Kennedy half dollars. 90 % silver content
Appraised value.............................................. ..................... .$3.1 0
(16) Kennedy half dollars. 40 % silver content. Dates:
1965 through 1969 respectively
Appraised value........................ ............... ................ ......$11.20
The aforementioned appraisal is based on the following qualifications:
- Collector & dealer of numismatic material for over 30 years.
- Antique Dealer since 1995
- Certified Appraiser of Personal Property
If you have any questions, do not hesitate to phone me at 258-9502.
Respectfully, '--- -L.
;;::.~ ;{t::7'i AI.
v
AItomey :
Execuhix :
Vehicles Of :
As Of:
Purpose:
By:
MILLER'S AUcnONEERING SERVICE
KEITH R MILLER
AUcnONEER & APPRAISER
q9q Brick Church Road
Newville. Pa. I 72q I
(7 I 7) 776-6692
Appraisal Report
of
Personal Properly
Dale F Shughart Jr.
35 East High Street
Carlisle. Pa. I 70 I 3
Prepared for Executrix
Dolores M Martin
I 00 Greason Road
Plainfield, Pa. I 70B I
Helen M Kitzmiller
332 Greason Road
Carlisle, Pa. I 70 I 3
May 29, 200 I
iii 6:00 PM
Inheritance Tax
Keith R Miller Auctioneering Service
q9q Brick Church Road
Newville, Pa. I 72q I
Auclioneer AU2B63L
,
v
MILLER'S AUCllONEERING SERVICE
KEITH R MILLER
AUCllONEER & APPRAISER
q9q Brick Church Road
Newville, Pa. l72q I
17 I 71 776-6692
I am an auctioneer. licensed by the Commonwealth of Pennsylvania, having thirteen
years experience in sales in appraising of personal property.
Purpose of Appraisal
The purpose of this appraisal is to estimate the market value of the subject personal
property.
The type of value placed on all items listed is fair market value. I have no present
or contemplated future interest in the personal property.
Definition of Fair Market Value
The most probable price, as of a specifted date, in cash, or in terms equivalent to
cash, or in other precisely revealed terms for which the specifted property rights
should sell after reasonable exposure in a buyer and seller each acting prudently,
knowledgeably and for self interest, and assuming that neither is under undue
duress.
IAppraisallnstitute - I 9921.
Reterence material for obtaining prices include Kelly Blue Book of vehicles. This
appraisal consists of 3 pages of listed vehicles with a grand total of g; I I 35.00
dolla(s
One cover sheet and one explanation letter.
To insure confidentially copies are only supplied to the executrix Isl and the
attorney.
Keith R. Miller
AU2B63L
Pennsylvania May 29. 200 I
I 97 I Ford F I 00 Pickup Truck
This vehicle is ID Did lor a Kelly Blue BDDk value
Engine: VB
Trans: Auto
Drive: Rear wheel
Mileage: 78959
Vin : FLO(iEK23~0 I
Equipment: Base Vehicle
Condition: Poor
Trade in value: 5200.00
-
-
-
-
Main - 959 East Park Drive
Harrisburg, PA 17111
-
.
.
Branch - 25 West Main SI.
Shiremanstown, PA 17011
FEDERAL CREDIT UNION
Serving Members since 1938
www.pacentralfcu.com
717-564-4661 or 800-356-3875
fax 717-564-1503
August 14, 2001
Dale F. Shugart Jr.
35 East High Street Suite 203
Carlisle, P A 17013
RE: Helen M. Kitzmiller
Account #30364-017
Dear Mr. Shugart:
Ms. Kitzmiller maintained a share/savings account with our credit union. Upon
receipt of instructions from Dolores Martin, the account was closed and the check sent to
the Ewing Brother Funeral Home.
The Life Savings insurance benefit on our accounts was discontinued on
August 1,2000.
If you have any further questions, you may contact our office at (717) 564-4661 or
toll free (800) 356-3875 extension 112.
Sincerely,
(j.Jjp" J)JJ:
Justine Dechert
Supervisor, Member Services
-
::=
FEDERAL CREDIT UNION
Serving Members since 1938
,'.' ,.. }Vww'I'~~.!'.'!\f)'J!,f~u.com
L.tJ J. V:; J. 1'::..It: 'l:JJ.
ACCUUiH
ACCi'~; 3G364-~17
1-iI~ii~IE ;;
J'DIl..T ;;
SSi~ 203-18-8112
Si~A;1E;; KI"7'Znri_LER
i:;DDh:;;
CIr......
i:::HGi'1r.::
\ I.D t:J \~; :;, ~, d (~-; -. ~j~) G ~j
~:J ;::: i:~ i "1 D PIT I::::; i. ':::. .... db"" ':~; :-j
HELEi-i M. KITZ~~ILLER
332 di,EI~i3G;'i j:,D
C P: r: i... :;: .::) I.., i::: P (i
:i. "(,8:i. 3~"'~)"1I'r.:)
BIR"fH i)"fE. 04-~1-13E0
i.. ;; F i-i / !:; I:;;:: r ']';; ~:i .{'.... :i. "7 '-~J :;.
h:i:::r:" ;;
"'d"".' ,..,....,.....
CI'II"'1... VI"lll::.;;
i,.ii.': i GU;" ~ i..j
i..~t:. {'ABL~ .ri~i)_[C~;i-OR;; i
Pi_
~3H~1h:E
B~IL~;i-iCE
PLEDt3E CHECK
AMOUi~T CD HOLDS ;~
CD
:i.~, Ci...lJSi::IJ
;.:
nc.Ll:.I'f n. r~ITZtj~LL.Er:
332 GREASOi-i nil
CARLISLE, PA i7013-~4;'6
l.J i:: T H D .D j:;:
SHi:',r\E ~:iCCUUH'r~)
Main - 959 East Park Drive
Harrisburg, PA 17111
Branch - 25 West Main SI.
Shiremanstown, PA 17011
717-564-4661 or 800-356-3875
,. ,,fllJ\.71705~15P3 ,_..
VH II:': t'JC)'-J.~t-..l~'J.
i... i..J \..: ~;
.....,.-....'.,....
,~, 1!J1.~) ~J
l;i~'l.i: L;; :~J
AVAILABLE Al~-l'ICrPAi'E SHWAA Y'i'D LAol Acr
BALANCE A DAILY nIVD TDDfU DIVIDEi~D DA1'E 'r"(~:;
r ':'1'iHl-iLoI:.
~EE3 G~ CHANG~S :U
.. ~}fJ
.. 0~,
At2.. ~}~J b/l'i'~j:i. b
3fiJ0-1'-~.i -/
REGUESTED DATE - ~~/'28;~1 TO a8;14/'~1
1
Pi...~1i..j
UHTc.
iJE3Cr\~j:;TiGr'1
CGDE
Ai='r;:
SHARE ACCOU;~T 10
G~/2a/Bl
06/38/61 DIVIDEND
07/16/01 WITHDRAWAL
a8/14/~1
0'7'3::181
CURREi~T YEAR-TD-DATE DIVIDENDS
CHARGe-.
Ci-iARGC:S
B~1LHi-iCc.
PREy rous BALAI~CE
20..19
3&a3..v:J-
j..jEw BALAI~CE
42..a:r
;:~1GE
;HLAHCE
-,.....r..... r-.....
.;)~oc..;)..J
3603..G::i
..aa
.em
,f~N'
RcferencelD: 174782
First Union National Bank
Attn: Account Verifications
POBox 40028
Roanoke VA 24022-7313
Iune 22, 2001
DALE F SHUGHART, JR
ATTORNEY AT LAW
35 EAST HIGH STREET, SUITE 203
CARLISLE, PA 17013
SUBJECT: Verification / Comrrmation of Account and Balance Information provided for:
HELEN M KITZMILLER (SSN# 203-10-8112)
Date of Death: May 20, 2001
Denoslt Account Information
Account
Type
CERTIFICATE OF DEPOSIT
Account
Number
Date of Death
Balance
Average
Balance.
Date
Opened
Maturity Interest Accrued YTO Date
Date Rate Interest Interest Paid Closed
570433443
5/28/1998
CERTIFICATE OF DEPOSIT
571699794
5/28/1998
CERTIFICATE OF DEPOSIT
571934209
5/28/1998
CERTIFICATE OF DEPOSIT
1969940
5/2811998
.. Due to system limitations. we can only provide a twelve month average balance on depository accounts.
Other Account Information
Account
Type
Account
Number
Date of Death
Balance
Date
Opened
Date
Closed
Title(s)
ANNUITY
HLDlR710001793
6/12/2001
HELEN M. KlTZMILLER
CONTACT HARTFORD LIFE AT 1-800-862-7155 FOR INFORMATION.
ANNUITY
HLDlR710002572
6/1212001
HELEN M. KlTZMILLER
CONTACT HARTFORD LIFE AT 1-800-862-7155 FOR INFORMATION.
ANNUITY
HLDlR7 1 0002575
6/12/2001
HELEN M. KlTZMILLER
CONTACT HARTFORD LIFE AT 1-800-862-7155 FOR INFORMATION.
UNKNOWN
UNABLE TO LOCATE
4002069435
UNKNOWN
UNABLE TO LOCATE
4001934209
UNKNOWN
UNABLE TO LOCATE
4001934191
001032
F00f6NO
RefenmcelD: 174782
o Date of death balance does not include accrued interest.
'" If date of death occurrs on a weekend or a holiday, date of death balance does not include any transactions that were
made during that time period.
June 22, 200 I
Date
Julia Sorrells
Depository Representative
Servicenter Associate
Title
(540)563-7323
Phone Number
abs; at
00 t 032
.
SCHEDULE F
JOINTLY -OWNED PROPERTY
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
I FILE NUMBER
21 - 01 - 00506
If an asset was made joint within one year of the decedent's date of death, It must be reported on schedule G.
Kitzmiller, Helen M.
SURVIVING JOINT TENANT(S) NAME
A Dolores M. Martin
ADDRESS
RELATIONSHIP TO DECEDENT
Daughter
P. O. Box 71
Plainfield, P A 17081
JOINTLY OWNED PROPERTY:
LETTER DATE I, ,ur" DATE OF DEATH '10 OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of financial institution and bank account number DECD'S VALUE OF
NUMBER TENANT JOINT or similar identifying number. Attach deed for joinUy-held real VALUE OF ASSET INTERES' DECEDENT'S INTEREST
estate.
I A 01/25/1996 M & T Bank, checking account #1272195 453.00 50% 226.50
I
I I I
i i i
I I
i
I
I
I
I
TOTAL (Also enter on line 6, Recapitulation) 226.50
.
m M&I'Bank
June 27, 2001
Dale F. Shughart Jr.
35 East Louther Street
Suite 203
Carlisle Pa 17013
Re: Helen M. Kitzmiller
Account # 1272195
Dear Mr. Shughart,
The above referenced account was opened on January 25 1996. It was opened as a joint
account titled Helen M. Kitzmiller and Dolores M. Martin. The balance in the account as
of May 20, 2001 was $ 453.17.
If! could be of further assistance please call me at 717-240-4512.
Sincerely,
~t~~
Asst. Branch Manager
Manufacturers and Traders Trust Company. One West High Street, Carlisle, PA 17013 . (717) 240-4536 . Fax: (717) 240-4518
:.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Kitzmiller, Helen M.
FILE NUMBER
21 - 01 - 00506
This schedule must be completed and filed If the answer to any of questions 1 through 4 on page 2 Is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF
Include the name of the transferee, their relaUOl'\Shlp to decedent and the date of transfer. DECD'S EXCLUSION TAXABLE VALUE
NUMBER ALUE OF ASSET (IF APPLICABLE)
Attach a copy of the deed for real estate. INTEREST
I Hartford Annuity Contract #710001793, passing by 14,846.00 100% 0.00 14,846.00
Beneficiary Designation to daughter, Dolores M. Martin. I
2 Hartford Annuity Contract #710002574 passing by 7,167.001 100% I 0.00 7,167.00
Beneficiary Designation to great-grandsons, Zachery I
Deitch and Jordan Deitch.
3 I Hartford Annuity Contract #710002575, passing by 11,831.00 100% 0.00 11,831.00
Beneficiary Designation to Granddaughter, Kathy M.
Deitch.
4 Hartford Annuity Contract #7100025712, passing by 39,349.00 100% 0.00 39,349.00
Beneficiary Designation to Daughter, Dolores M. Martin.
I
,
,
i
I
TOTAL (Also enter on line 7, Recapitulation) 73,193.00
June 14,2001
Hartford Life
Dale Shughart Jr
35 East High St
Suite 203
Carlisle, P A 17013
Re: Hartford Annuity Contract Number: 710002572
Decedent: Helen M Kitzmiller
Dear Mr. Shughart Jr:
Thank you for your correspondence regarding the above Annuity contract.
The death benefit payable under this contract is not considered "life insurance" reportable on IRS
Form 712, (Life Insurance Statement). Please find below information in response to your request:
Contract Number: 710002572
Owner: Helen M Kitzmiller
Deceased: Helen M Kitzmiller
Owner's SSN: 203-10-8112
Date of Death: May 20, 2001
Date of Death Value: $39,349.01
Tax Cost Basis, (if applicable):
Neither Hartford Life nor its agents or employees provide tax or legal advice. We strongly recommend
that you speak with your tax advisor.
Should you have any questions regarding this information, please contract Annuity Client Services at
1-800-862-6668, Monday through Thursday, from 8 a.m. to 7 p.m., Friday from 8 a.m. to 6 p.m., or
Saturday from 9 a.m. to 2 p.m., Eastern time.
Si~~
~;CCiO
Investment Product Services
Contract Management (Technical) Team
Hartford Life Insurance Co.
Hartford Life
200 Hopmeadow Street
Simsbury, cr 06089
Telephone 860 547 5000
Mailing Address: P.O. Box 5085
Hartford, cr 06102-5085
....
.... r-.
....
.... lo
<0
~
l!l C
r-.
M L
OJ .., ~
M u Ul
~ '" QI ,
~
.., 0.< I
" .., N Ltl r- N
0 .... <;jo CO Ltl Ltl
U '"
" N Ltl lD CO
Ql QI lD r- CO Ltl
N Ul '" ,., r- Ltl r-
r- '"
Ltl QI >< CO r- r-
N .... 1\1 ,., ,.,
0 "'..,
0 0 Ul
0 - " QI
Z .... Ul 0.< 0.< Ul
... r- " " "
..
.. 0 .., '" 0
..c .... .... "'0.<
U .., ,. E +J
,. '" o 1\1
.Q QI U ..
0.< .. QI
.. QI '"
.., >. u 0
'" 1\1 "
0.< E 1\1 >. Ltl
'tl ...., CO
0 QI ,. 0.< a
:z; QI .... Ul ,. Ltl
.. +J " " I
e-. ,. .., H " <;jo
:z; .., 0.< .0: 0
., 0: ,. .... QI ....
0 I>l .... .... .... lD
U ..:l 0 C> 0.< '" a
U ..:l " 0 ~ " .., ..:l ;:>
.0: H 0 .., co 0.< " 'tl oLtl
:0: 0 'tl ;:> 'tl 0.< co e-. co
:0: 0:1 C>C> .... .... 0 .. > 0 U lD
0 e-. " " ~ 0 E 0 0.< Ltl lD
0: H ..-i ..... Z '" .0: .... 'tl -lD
~ :.: 'tl'tl ... '" .., " >< 'tl I
........ .... < .., QI .. H 0 "N
on :0: o 0 a: a.. 0.< .... '" <II OlD
0 "'''' < 3 .Q :t: ....co
I>l :z; "'''' E~ , e-. III " .., I
I>l I>l ..,.., .... "" :z; >< >< QI .., 0 "0
U ..:l ..... o.-i E ...J .... ., III e-. III '" .., III 0
.... 0 I>l 303 xw a 0 e-. :z; e-. e-. .0: 0.. :t:lD
Z 0: :t: CIlO'" 0 :0: :::>
w 0.. .. WeDu.. N .0: .... 0 ....
:; 0: ;:> QI a: z .... III :0: III
>
< e-. 0 0.... 0 ..... N on .. .0: ..
I>. H ~ >. 0.< ...JO< .... on QI QI
... ~ ..:l 0 ...J .... 0 'tl e-. 'tl
0 I>l QI ""a.. a.. lD 0: QI I>l QI
.... :z; C>'tl 0 (!) ~ :z; ~
Z I>l " ..
w <II III 0
:; "'....
l!! u..,
0: ..
~ 0 o '"
III ~ e-.:>:
Hartford Life
June 14,2001
Dale Shughart Jr
35 East High St
Suite 203
Carlisle, P A 17013
Re: Hartford Annuity Contract Number: 710002575
Decedent: Helen M Kitzmiller
Dear Mr. Shughart Jr:
Thank you for your correspondence regarding the above Annuity contract.
The death benefit payable under this contract is not considered "life insurance" reportable on IRS
Form 712, (Life Insurance Statement). Please find below information in response to your request:
Contract Number: 710002575
Owner: Helen M Kitzmiller
Deceased: Helen M Kitzmiller
Owner's SSN: 203-10-8112
Date of Death: May 20, 2001
Date of Death Value: $11,830.53
Tax Cost Basis, (if applicable):
Neither Hartford Life nor its agents or employees provide tax or legal advice. We strongly recommend
that you speak with your tax advisor.
Should you have any questions regarding this information, please contract Annuity Client Services at
1-800-862-6668, Monday through Thursday, from 8 a.m. to 7 p.m., Friday from 8 a.m. to 6 p.m., or
Saturday from 9 a.m. to 2 p.m., Eastern time.
Jb
S.Riccio
Investment Product Services
Contract Management (Technical) Team
Hartford Life Insurance Co.
Hartford Life
200 Hopmeadow Street
Simsbury, cr 06089
Telephone 860 547 5000
Mailing Address: P.O. Box 5085
Hartford, cr 06102-5085
-:;;:---
t. '" 1-3 "l en
OJ 0 0 ..
~ '1 III ~
\ rt n
.... ::r ;r:
0 OJ '" m
'1 ::s t'l Z
"l :z: "l Q 0 o."l :z: ..
III t'llll III '" n~'" '" t'l 0
0. 1-30.0 "- >-..J> '" "l ..,
'" '" to .... ;oVl-i f"- '< "l .... "
'1 il"'1 '" '" r- :I: .... 0 0 1-3 >
OJ :0: III "- ....r--< '" " III -<
;r:
.... 0.... il" '" II> .... '1 'tl m
c::: :< 0 r-33 '" III Z
<Xl '" 'tl il" 1-3 1-3 :z: 1-3 0 0 rn rn "" 0: t'l 0 ..
0 OJ rt ::r OJ 1-3 OJ c::: .... , "'., f"- f"- '" ()
0 '1 0 rt '" >< >< ~c .... rn rt rt t'l t'l
I rt ::s III ., ." r-.... ::r ::r :z: t'l
<Xl .... '" tJ' "" > Z-i ::r ::r c
'" 0 '" OJ .... ... n 0 0 :0: rn
'" '1 0.... '1 '" rt :I: .... ....
I 0.>< ::s rt ::r ~ ;0 0. 0. :><: "l
"'. 0. .... il" ::s' -..J ., f"- f"- .... III
'" U1 ... 0 51 0 0 ::s ::s 1-3 0
'" n 0 < '1 0 .... ~ "l"l ", :0:
<Xl 1-3 <Xl ... 0. " 0. '" :0:
U1 0. ::s ... rt 0 .... il"
" I:"' rt ::s 0 ::s I:"' n
0 OJ ... "l 0 I:"' n
'" .... .... .... t'l 0
.... III .... " III c:::
0 il" f". rt :z:
.c- ::s .... rt " 1-3
I ::s ::s rt '1
U1 " rn .... '" :z:
0 ..." '" 0
<Xl rt'1 0.
U1 '< OJ 51 f".
::s OJ rn
0 n '< rt
'0 '" '1
'" '1 f".
'1 n '" 0-
OJ 0 rn "
rt 51 " rt n
f".'ll .... f". ~
0 OJ rt 0 CD
::s ::s ::s ...., n
7<"
rn ... ... rn .... Z
'" ::s . 0 !'
rn 0
rt'll 0
.... .... OJ .... '"
.... .... >< '" U1
OJ ....,
w '" '" '0 rn U1
0 W W '" '"
0 W w ::s
f OJ n
0 '" '" '"' .... 0
0 .c- ...., .... rt ::s
-" I f". rt
'" OJ -
.,) -
rn n W
:0>. rt CO
J1 W
Xl '-J
(J1
II ~
A.) CO
c::" ....
(J1 ....
....
U1
June 14,2001
Hartford Life
Dale Shughart Jr
35 East High St
Suite 203
Carlisle, PAl 70 13
Re: Hartford Annuity Contract Number: 710002574
Decedent: Helen M Kitzmiller
Dear Mr. Shughart Jr:
Thank you for your correspondence regarding the above Annuity contract.
The death benefit payable under this contract is not considered "life insurance" reportable on IRS
Form 712, (Life Insurance Statement). Please find below information in response to your request:
Contract Number: 710002574
Owner: Helen M Kitzmiller
Deceased: Helen M Kitzmiller
Owner's SSN: 203-10-8112
Date of Death: May 20, 2001
Date of Death Value: $7,167.00
Tax Cost Basis, (if applicable):
Neither Hartford Life nor its agents or employees provide tax or legal advice. We strongly recommend
that you speak with your tax advisor.
Should you have any questions regarding this information, please contract Annuity Client Services at
1-800-862-6668, Monday through Thursday, from 8 a.m. to 7 p.m., Friday from 8 a.m. to 6 p.m., or
Saturday from 9 a.m. to 2 p.m., Eastern time.
7~o
S.Riccio
Investment Product Services
Contract Management (Technical) Team
Hartford Life Insurance Co.
Hartford Life Insurance Companies
200 Hopmeadow Street
Simsbury, cr 06089
Toll Free I 800 862 6668
Investment Product Services
Mailing Address: P.O. Box 5085
Hartford, cr 06102-5085
online.hartfordlife.com
M
.... <0
....
.... C'
l"- e.
v L;
L!'l C
I"-
('t) L
00 +> ~.
('t) u '" C
~ 'll OJ
~
+> .... 1 ~
<= +> L!1 '" m '"
0 .... '" '" m L!1
U 'll
<= M 0 N '"
OJ OJ m ,... N 0
~ '" I>. ~ <l' ,...
.... 'll
L!1 OJ >< M M
N .... III
0 I>.+>
0 0 '"
0 . <= OJ
Z .... '" .... .... '"
... .... <= <= c
u 0 +> III 0
..
.c .... .... 1>.....
U +> ::s E+>
::s '" o III
.Q OJ tJ ...
.... ... OJ
... OJ I>.
+> :>. u 0
'" III C
.... E III '" L!1
'tl ... +> CD
0 OJ ::s .... 0
'" OJ .... '" ::s L!1
... +> c c I
E-o ::s +> H <= <l'
'" +> .... <C 0
::> a: ::s .... OJ ....
0 r<! ... ... .... '"
U '"' 0 t>> .... III 0
U '"' <= 0 <= +> '"' ::s
<C '"' 0 +> .... <= 'tl L!1
::0: '" 'tl ::s 'tl .... CD E-o CD
::0: '" t>>t>> ~ .... 0 ... > 0 U '"
0 E-o <= C 0 0 E 0 .... L!1 '"
a: H .r-! ..... :I: "- .c: <C ... 'tl .",
r.. :.: 'tl'tl UQ~ .c: +> C >< 'tl 1
........ I-a: +> OJ ... H 0... N
CIl ::0: 0 0 ... ... .... III l'l0'"
" .c:.c: wz < :.. .Q :xl ....CD
r<! '" .<::.c: Q...J C1. E-o III <= +> I
r<! r<! +>+> ... '" >< >< OJ +> 0 ...0
U '"' ...-1..... w~ , .... ::> III E-o III .<:: +> III 0
... 0 r<! :>::.. ww 0 0 E-o :z; E-o E-o <C a. :xl CD
Z a: :z: >lE:...J 0 ::0: ::>
w a. ... a: ... en N .:: .... 0 ....
::!i a: ::s OJ W...J... ..... III ::0: III
> E-o 0 0'" :I: ...J N CIl ... <C ...
<
"- H r.. "'.... U '" a: .... CIl OJ OJ
... r.. '"' <"-< ..... 0 'tl E-o 'tl
0 r<! OJ N~U '" a: OJ r<! OJ
'" t>>'tl 0 <!l r.. :z; r..
... r<! <= ...
Z l'l III 0
w
::!i .<::...
w u +>
... a: ...
~ 0 0 III
., r.. E-o :z:
."
0
3
... ~
'" ;':>i
~
.. 0 1110
" CJ\ '1 to;(
..... rtO 0 I:
I'-' Hl:T 10 m
U1 g ~ .. :!j
..... Ol'-'c, 0
... ~~O IlolQ to;( tJl
0 U1~ III 0 to.I "II
0 t< 10 ~ ."
I'-' Ht<~ ...,< )>0
<
DlH HlO ;.: to;( I:
~[:j~ IIII:l to.I H m
to;( l!:to;(Q . '1 t< >i z
III III III It . :-I' to.I ....
110 rt 110 C H ~:t: l!: '0
III 11111 'Ot<tl ...... ~
'1 f'1l1 ilo'l!:to.I rtrt :-I
III III ' H ~~ H 0
I'-' g :r lO>i >i to.I
co;.: '0 ilo'>i I'-'Of;} N to.I
OIll.rt:T >i ~~ 1-'1-' :;c tl
O'10rtlll ~ rt~s 110110 H Dl
I rt. 1:1 I'-' ........ t<
Q)HI ..= ~ ~rt '" =' =' t< to;(
CJ\OtJl III lQlQ to.I 10
"''10H'1 I-' .... 10 !i!
'llolC='rt III rt rtlll
0\'"' ~ HI ~ 01-'
CJ\ Ul....O f 0111 ilo'
CJ\OO<'1 0 0
co >i co .... 110 I-' I-'rt 0
Ulllo g 110 ........ 0
I:lt< .... rtO ~
0 Ill.... rt .E rt='
CJ\ I-'Hl I-'
I'-' III 1110
0 g~ =' ~
"" !
I Hl
Ul I:lm I:l
0 ....I:l rt ~
co rt'1 '1 I:l I'-'
Ul '< ~ III '1 0
m III 0
.gg I:l 0 n
1-'110 '" ".
CD
III rt .... U1 n
'10 m ~ ...
1110 ....rt "" z
c:.a =' '1 !'
... -.J
o III rtO' C)
=' =' ~ :;
m.... C)
III ... ~ /
m '00
III =' ~ ,
'" ... =' m I
. III . C) /
... "" "" I-' ~
'" ~"'\O rtoo -.J f
~ 0"'''' ".1-' l
. . . (D III ~
... \D .....:J 0'. m III OJ
co "'WUl m
I III
0
0
='
rt
III
0
rt
June 14,2001
Hartford Life
Dale Shughart Jr
35 East High St
Suite 203
Carlisle, PA 17013
Re: Hartford Annuity Contract Number: 710001793
Decedent: Helen M Kitzmiller
Dear Mr. Shughart Jr:
Thank you for your correspondence regarding the above Annuity contract.
The death benefit payable under this contract is not considered "life insurance" reportable on IRS
Form 712, (Life Insurance Statement). Please find below information in response to your request:
Contract Number: 710001793
Owner: Helen M Kitzmiller
Deceased: Helen M Kitzmiller
Owner's SSN: 203-10-8112
Date of Death: May 20, 2001
Date of Death Value: $14,846.33
Tax Cost Basis, (if applicable):
Neither Hartford Life nor its agents or employees provide tax or legal advice. We strongly recommend
that you speak with your tax advisor.
Should you have any questions regarding this information, please contract Annuity Client Services at
1-800-862-6668, Monday through Thursday, from 8 a.m. to 7 p.m., Friday from 8 a.m. to 6 p.m., or
Saturday from 9 a.m. to 2 p.m., Eastern time.
7&~
S.Riccio
Investment Product Services
Contract Management (Technical) Team
Hartford Life Insurance Co.
Hartford Life Insurance Companies
200 Hopmeadow Street
Simsbury, cr 06089
Toll Free I 8008626668
Investment Product Services
Mailing Address: P.O. Box 5085
Hartford, cr 06102-5085
online.hartfordlife.com
'"
0 ex)
....
.....
..-
It) c
..,. u
It) C:
r--
C") If
ex) +J "'C
C") U en ('
~ '" <II
~
+J .... I 0;-
" +J 0 ..... '" 0
0 ..... ..... ~ 10 .....
U '"
" ~ r- 10 ~
<II <II r-~ N r-
M en J>. ~~ 0 ~
'" III - - .
r- <II >< ~ ..... M ~
..... ..... '" ..... ..... .....
0 J>.+J
ci 0 en
0 . " <II
Z .... en .... .... en
... r- " " "
.. 0 +J '" 0
..
.c .... ..... J>.....
U +J ;:l e+J
;:l en 0 '"
.Q <II U ...
.... ... <II
... <II J>.
+J >. U 0
en '" "
.... e '" >. It)
'" ... +J '"
0 <II ;:l .... 0
:z: <II ..... en ;:l It)
... +J " " I
E-t ;:l +J H " ~
:z: +J .... .0: 0
::> C<: ;:l ..... <II .....
0 '" ..... ..... ..... 10
U ..J 0 '" .... III 0
U ..J " 0 ~ " +J "" ;:l
.0: H 0 +J CO .... " '" Itl
:IE: 0 '" ;:l '" .... '" E-t '"
:IE: N "'''' !'- ..... 0 ... > 0 U 10
0 E-t " " ~ 0 e 0 .... It) 10
C<: H -rot ..-1 Z '" .0: ..... '" -10
r.. ~ "'''' .... '" +J " >< '" I
.......... .... < +J <II ... H 0 "'N
tIl :IE: o 0 0:: C- .... ..... '" '" 010
Q "'''' < ~ .Q 0:: .....'"
'" :z: "'''' E~ , E-t '" " +J I
'" '" +J+J !'-o :z: >< >< <II +J 0 ...0
U ..J ..... ..-t E ...J ..... ::> '" E-t '" '" +J "'0
.... 0 '" 3~ XW 0 0 E-t :z: E-t E-t .0: '" 0::'"
'" C<: 0:: "'0.... 0 :s: ::>
w '" ... wOOu.. N .0: ..... 0 .....
::!: C<: ;:l <II 0:: Z .... '" :0: '"
>- E-t 0 0..... 0 .... N tIl ... .0: ...
<
... H r.. >. .... ...JO< ..... tIl <II <II
LA. r.. ..J 0 ...J .... 0 '" E-o '"
0 '" <II OC-C- 10 C<: <II '" <II
:z: "'''' 0 el'" :z: r..
.... '" " ...
Z '" '" 0
w
::!: "'.....
W U+J
S C<: ...
0 0 III
en r.. E-t '"
.
COMMONWeALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOENT OECEDENT
SCI-EDUl..E H
FlN3W..EXPENSES&
ADI\IIIISTRA11VE COSTS
ESTATE OF Ki '11 HIM
tzrrn er, e en .
I FILE NUMBER
21 - 01 - 00506
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
B.
FUNERAL EXPENSES:
Ewing Brother Funeral Home.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
DESCRIPTION
AMOUNT
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State Zip
Year(s) Commission paid
Attomey's Fees Dale F. Shughart, Jr., Esquire (estimated)
4.
City
Relationship of Claimant to Decedent
Probate Fees
2.
3. I Family Exemption: (If decedent's address is not the same as claimant's. attach explanation)
Claimant
Street Address
State
Zip
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Register of Wills, Short Certificates.
2
Register of Wills, filing inheritance tax return and inventory.
6,945.00
3,000.00
36.00
12.00
25.00
250.00
10,268.00
Total of ContInuatIon Schedule(s)
TOTAL (Also enter on line 9, RecapItulation)
.
SchelUe H
Ft.nlraI Expens B S &
Ad.1i ....v'9Costs..........Jlld
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECeDENT
ESTATE OF
Kitzmiller, Helen M.
I FILE NUMBER
21 - 01 - 00506
3
Reserve for accounting.
250.00
Page 2 of Schedule H
.
DALE F. SHUGHART, JR.
ATTORNEY AT LAW
35 EAST HIGH STREET
SUITE 203
CARLISLE. PENNSYLVANIA 17013
Telephone (717) 241-4311
Facsimile (717) 241-4021
OF COUNSEL
HAMILTON C. OAVIS
LEGAL ASSISTANT
BONNIE L. COYLE
August 16, 2001
Dolores M. Martin, Executrix
Estate of Helen M. Kitzmiller, deceased
TO: Dale F. Shughart, Jr., Esquire
EIN: 25-1802515
Professional services rendered as follows:
08/14/01 - Two telephone conferences with Tina at
PA Central FCU and fax from Tina. .5
08/16/01 - Preparation of Inheritance Tax Return
and Inventory and related correspondence. 5.0
Total hours - 5.5
Total fee - $907.50
Fees billed to date:
06/01/01
07/02/01
08/01/01
08/17/01
742.50
726.00
214.00
907.50
Total -
2,590.00
Total fees anticipated to be
approximately $3,000.
,
.
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DeCEDENT
ESTATE OF .
Kitzrmller, Helen M.
I FILE NUMBER
21 - 01 - 00506
Include unreimbursed medical expenses.
ITEM
NUMBER
1
DESCRIPTION
AMOUNT
256.00
Checks written before death, clearing after death.
Sprint 29.00
Erie 115.00
Kough's Oil 112.00
TOTAL (Also enter on Line 10, Recapitulation)
256.00
.
~
.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT OECEOENT
ESTATE OF
Kitzmiller, Helen M.
I FILE NUMBER
21 - 01 - 00506
I RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE
~._,
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
I Dolores M. Martin Daughter 100%
P. O. Box 71
Plainfield, PA 17081
Enter dollar amounts for distributions shown above on lines 15 through 17 I as appropriate, on Rev 1500 cover she t
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS I
I
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHE T
.
.
LAST WILL AND TESTAMENT OF
HELEN M. KITZMILLER
I, Helen M. Kitzmiller, of West Pennsboro Township,
Carlisle, Cumberland County, Pennsylvania, declare this to be my
last will and Testament and revoke all wills and Codicils
previously made by me.
ITEM I: I direct that my just debts, funeral expenses, and
the expenses of the administration of my estate, including any
state, federal or other death taxes payable because of my death,
shall be paid from my residuary estate as soon as practicable
after my decease, as a part of the expense of the administration
of my estate.
ITEM II: I devise and bequeath all of my estate of every
nature and wherever situate unto my daughter, Dolores M. Martin,
provided she shall survive me by thirty (30) days.
ITEM III: Should my said daughter, Dolores M. Martin,
predecease me or die on or before the thirtieth day following my
death, I devise and bequeath all of my estate of every nature and
wherever situate unto my granddaughter, Kathy De~tch, provided
she shall survive me by thirty (30) days. Should my said
granddaughter, Kathy Deitch, also predecease me or die on or
-
before the thirtieth day following my death, I devise and
bequeath all of my estate of every nature and wherever situate
~~~~
.
,~
unto her issue, per stirpes, living on the thirty-first day
following my death.
ITEM IV: I appoint my daughter, Dolores M. Martin,
Executrix of this my last will and Testament. Should my said
daughter fail to qualify or cease to act as Executrix, I appoint
my granddaughter, Kathy Deitch, Executrix of this my last will
and Testament.
ITEM V: I direct that my personal representatives, as well
as their successors, shall not be required to give bond for the
faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal,
this .1?
day of April, 1994
/~ ~ ~.'tl" ,
elen M. ~tzm~lIer
[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, published and
declared by Helen M. Kitzmiller, the Testatrix therein named, as
and for her last Will, in the presence of us, who, at her
request, in her presence and in the presence of each other, have
subscribed our names as witnesses hereto.
,
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, Helen M. Kitzmiller, Dale F. Shughart, Jr. and Mary M.
Price, the Testatrix and the witnesses, respectively, whose names
are signed to the 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 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 witness and that to the best of his/her
knowledge the Testatrix was at that time eighteen years of age or
older, of sound mind and under no constraint or undue influence.
t!kj) 'If. c)~
Witness
Subscribed, sworn to and acknowledged before me by
Helen M. Kitzmiller, the Testatrix, and subscribed and sworn to
before me by Dale F. Shughart, Jr., and Mary M. Price, witnesses,
this c:?7':b- day of April, 1994.
IIOT ~~1Al. SEAL
BONNIE L COYU. NOT,I.RY PllBUC
HOllY SPlIIHGS. PA CUMIlE~V.NO CO.
:V'COMMISSION EXPIRES OCTOBER 17. 1994
~:x ~~ _
/ Notar ublic
c
STATUS REPORT UNDER RULE 6.12
Name of Decedent:
Helen M. Kitzmiller
Date of Death:
May 20, 2001
Will No.
Admin. No.
21-01-0506
Pursuant to Rule 6. 12 of the Supreme Court Orphans' Court
Rules, I report the following with respect to completion of the
administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No 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 accounts may be filed with the
::::: o:o:::/:~hans' Court a~~ ~t~ t:-:hiS report.
S1.gnature V \
Dale F. Shughart, Jr., Esquire
35 East High Street, Suite 203
Carlisle, PA 17013
(717) 241-4311
Counsel for Personal Representative
/ iP-d3d -ItP
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
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
10-01-2001
KITZMILLER
05-20-2001
21 01-0506
CUMBERLAND
101
DALE F SHUGHART JR ES~
STE 203
35 E HIGH ST
CARLISLE PA '.1,7013
'if(
V
'*'
REV-1547 EX AFP ell-DD>
HELEN
M
Allount R..itted
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 ~
REY=is4j-ix-iFP-li'2=oo:f-NC)f'ici--oF-i-titiEifiTAiici-YAx-APPR'A-isEMENY-;-iLLOWANCi-oi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF KITZMILLER HELEN M FILE NO. 21 01-0506 ACN 101 DATE 10-01-2001
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. Hortgages/Notes Receivable (Schedule D)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
U)
(2)
(3)
(4)
(S)
(6)
(7)
.00
.00
.00
.00
4.995.00
226.50
73.193.00
(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/Govern..ntal Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
10,268.00
256.00
(11)
(12)
(3)
(4)
(9)
UO)
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forti with your
tax paYlll8nt.
78,414.50
10.524 00
67,890.50
.00
67,890.50
NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
r~lect ~igures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
IS. AMount of Line 14 at Spousal rate
16. ADOunt of Line 14 taxable at Lineal/Class A rate
17. ADOunt of Line 14 at Sibling rate
18. AMount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due,
TAX CREDITS:
US) .00 X 00 = .00
(6) 67,890.50 X 045 = 3,055.07
(17) .00 X 12 = .00
(8) .00 X 15 = .00
(9)= 3,055.07
PAYttENT RECEIPT DISCOUNT (+) AMOUNT PAID I
DATE NUHBER INTEREST/PEN PAID (-)
08-17-2001 CDOOO171 152.75 2,902.32
TOTAL TAX CREDIT 3,055.07
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. 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.)