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HomeMy WebLinkAbout01-0530PETTITION FOR Pr'ROBATE and GRANT OF LETTERS Estate of ~^~=(-~~5 ~7 ~ V~J No. 21-01-530 also known as To: Register of W' is f r th Deceased. County of ~ a in the Social Security No. _ 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 ~ i~ in the last will of the abov ecedent, dated named and codicil(s) dated , 19~ (state relevant circumstances, e.g. renunciation, deat of executor, etc.) Decendent was domiciled at death in ~ +~ County, Pennsylvania, with 1i 1_T~ ___ la t family or principal residence at r n n .~~ .., nn (list street, number andMmun~cirpality) at Decende t, t en ~~ y rs of age, died I 1 1~V ~~ ~~~ Exc t a o to e e i t ry, was not divorced and did not have a child born or adopted after execution of th ffered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death o ed property with estimated values as follows: n~ (If domiciled in Pa.) All personal property $ ~Q~,~ (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pen lvania $ situated as follows: WHEREFORE, petitioner(s) respectfully re ues s r o the last will and codicil(s) presented herewith and the grant of letters theron. (testamentary; administr ion c.t.a.; administration d.b.n.c.t.a.) a .~.. U ~ ~ ~ ~~ ~[ ~o ~~ ~~ a v vw ~ o 7 ~ ~°nv jl~ w , ,~ ~ i COMMONWEALTH OF PENNSYLVANIA 1 COUNTY OF CUMBERLAND ss The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly admi i ter t state according to law. Sworn to or affirmed and subscribed before me this 29th day of MAY }2001 ~ n Registe y OATH OF PERSONAL REPRESENTATIVE jvp. 21-01-530 Estate of LEWIS G DAVIS ,Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW JUNE 5 ~ 2001 m consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated-- APRIL 8, 1997 described therein be admitted to probate and filed of record as the last will of LEWIS G DAVIS and Letters TESTAMENTARY ; are hereby granted to THOMAS M KENDLE ster of Wills FEES Probate, Letters, Etc.......... ~ 18.00 Short Certificates( ) ... , , , . , . , $_ 3 , CC AT'T'ORNEY (Sup. Ct. LD. No.) x=pa es. 6.00 Renunciation ................ $~~ JCP ~ 5.00 TOTAL ADDRESS $ 37.00 Filed .. ?'?AY, 29, 2001 PHONE 105R05 RFV 9/86 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be Forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 7402048 No. ~ ~-. F~~~ Local Registrar 2001 Date 21-O1-530 Nlos., u Rev.7lST COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS yNT CERTIFICATE OF DEATH ENT NAME DF DECEDENT Ii ry. MiOM.Lacl "-'"'----~- -- ____ STgE FKE NVMeER ~ _ l Lewis G• Davis SE% 50CML SECVRITV NUMBER ' +/Q Male DAiE OF pEATN ~MdaR paY.'~IYI AOE L 231 : 0 I . a. - 14 - 891 aa SvOway) uNDER1rEAR UNDER IDAy DATE OF EIRTN euTrNPLACE . 5/22/2001 MOraM Data Ilo,as • MNIAea !MOnm, DaT.'hMl Salad Fdagn Dgyr"y) PLACE QF DEATMICnefA dey or~a-sw mmRrucldNan ol•yr opal /IOSPITAL: s. 76 Y~ 6/ 18/ 1924 Richmond, VA MPM.r% ^ ER~OUwwra ^ DOa ^ NIw q CO T UNTY OF DEATN CRY. EORO, TNT OF DEATN FACILT' NAME In nq arR~naion, a4 Nanr ~•"~• ~ ISP•cMl ^ gM dw aM raan0en .~~ wL5 DECEDENT OF HISPANIC ORION,T ' ,.. Cumberland « Carlisle Todd Nursing HotYe ~® 1..^Ey...e,.dryta,p•" sP.ny"~'"•°°"~"'""•- , DECEDENT'9USUAL000UPRION %NIDOFSUSINESSRNDUSTRY W. NNSDECEDENTEVERIN •' arr .PUer'O~" ~ „ Whlte (Giva Megd.da adr Oia rra>d U.S.ARMED fORCES7 DECEDENT'S EDUCATgN MARITAISWUg. ManyO a.on;in, w; Ad usn .a.) C.H. MaSLand & Sons SunYmN G CSrousE N..«M.rrl•a~. oL•«nma»,..a. - ,,. ecurity uar Na ® Ib o E1N•«a„ws.aalwanr caw,. DNprne la •+e 0"a raacn nrMl Ca t Facto „p mla . ,:. ,7. ed DECEDEN''S MA4ING ADDRESS15na+l GyyTOiwl, Stab. ZOCO0e1 DECEDENT'S 11. n.ds.l blarri Madeline A. Mellott - 1000 W. South Str. "D'L'"L ,T.. BIM. PA Oi0 ,Ta.^ Nu 0aoa0anl tNeON RESIDENCE ~~ Carlisle, PA 17013 'Sasn'^~•a^• „~ a ," °"°°'°"'Oe' Clnnberland FATHER'S NAME IFan, MCda. Lady 1°' ~~PT +Ta~® ~aaa•"0nd_ Carlisle ,E. Lewis H. Davis MOTHER'S NAMEIFir4 MgOb, Mapn5urrlamp dyA wFOwL+`AN.'s NAME}~T,,dP,aaKI ,,, Hannah L. Brooks Arlita L Laois INFORMANT•s M . AE1NO ADpRESS15)raeL Cily/fpyrL $yN. Fp 18 Marilyn Drive METNOOOFasvoslTaN Carl l~" ,,,• , is e, PA 17013 vI DATE OF DISPOSITIp1 PLACE OF DISPOSITION SuW till GamMion^ Renloaal aprll$bb^ P,Oran, D•Y,1Mr) dOObr Plan NamadCarwary, Cramabry LOCAT1pN-CNy/TOwl, Sbb Zp Gon D ~^ ~~ , • 7t ` ^ 5/25/2001 aIDNAruREoF RALSERVICELICENSEEORPERSONACTINOASSUCN '+'• :,e~l~erland Valley Mein. Gr Carlisle, PA 17013 LICENS tA . E NUM NAME ANO AODRE$$OF FACILITY U0~"~19-L ~„• ~13iaing Brothers Funeral Home, Carlisle, PA 17013 a Onh wM11 Nrny~9 b tlb paR d M . OeaN oa rW n IM IaM, Data aM pace NalaO PIIYac'iar14 aaaaaW n lira dwun b JE Sl . ( Orbnne Taal ~ ' c«MF a wnn. j~ ~ I LICENSE NUMBER DATE SM.NED Mdh Dax wrl ~' "~~ \\ . / p.ab a•x ml. M naTlnae _ O S _ (- pY TIME OF DEATH GATE ED DEAD (MOna+. Day ParaOr,+,lO PrOnpla4:aaawn. Marl ~. 7k. . Ya13 CASE REFERRED TO MEDICAL EXAMINERICOgpNERT ~ ./ I ~ 27. MRT I: Einar Ob OiaMaas,'"Prriaa d nmpaoMidd •.NCn nusso IM wMn. Oo nd eraat Ob mon of OAnO, such as nr0iao „' LW wY orr pw On saa in. w raapvaldy anaal. aMn d Man lailwe. r Appoaimale PART N: MIb[pATE CAUSE IFwI inaarw unr•eaa ~•9nllcam nuOlaorr wariUrfyb0aam.aN tlrbbaddAwilan IdI••I arq OeMn raetalirl,nma d'O•M•gcwap•enn PART I. ~vnnanl-. R S W 'D ' .. ; ~ .. DIIE IOIOR AS A CONSEQUENCE CF): D. a ar•A baOYgmmMbale DllE roIOR ASA CDNSEOUENCE O,1: - nw. Em« lN1DEMYNIO ~ ~ CM)OEIDuaardwMay I a,r elrreo avaraa " OUE T007R AS A CONSEQUENCE Ofl: re.rlE n Own) LAtT OF DEQN~OFCAUSE ~ IMO"m. Day. lYarl __..__... ^`^'^~T DESCRIBE NORr INJURY OCCURRED. NMUrY ~k~w ^ ActiOera ^ P•M"glrN•M9etiOn ^ Nia ^ No ^ Nta ^ Na 1a~ wa ^ No ^ Suiciw ^ CdAe rld n dn.manao ^ op. M• PLACE OF IWURY -N lavne. farm. Rrw. bddy, OOka LOCATION CIy/ron, Slurp ~RTIFIf.R 1(;I'eCa 7M M' ~ . Me. 15PacA'1 (Sbaal. 701. 'CFJITIFY,ND-NYSICIAN1Pnyfcan cerlAyeaj osnedlkwn r,~M arrolMr Pnvsc.an na7 ddaartKeo Oeam arNl coin SK•N AND TITL~OF TIFIER lb M anal of my QrbrbEga, wain ottunW at•eb u•e uuapp ana mariner as abte0......... ~•O ham 231 L, J ............................................ 710. /~ ~~'~•~. ^~ 'PRONOUNCING AND CERTIFY010 PNYSMIAM(PnysKn"poa;pdrourKyp opam anO CerWY~r~9lo causadoeaml ;-~ UCEN$E NUMBE,,R^^ (- /~ DATE SKiNEpIMOnn yyyl Ta Ilre peel a/ my YpM•O,", Oealn OoewlW it Ob 1aM, Oate, an0 place, aM tlW la Ore caoula) a•W manner n a,allO .......................... ^ 71e. h~ ~ V 1 v ~ •"~ t \1 pa1.~ NAME AND ADDRESS dF PERSON 714 ~~ ~~/~ ~~I 'MEDICAL E%AMINER/CORONER Plem i7T 7ypep Print ( w110 COMPLETEDCAUSE OF pEgH ,(~ On tl,e paais Of eaaminatlon andtor inveatlgalion, iR my opinion, duln oecurra0 al Ipe Ume, One, and place, an0 due tp IM uuae(a) and ^ 6C 0 ~` W- 4r P tvSL~y, J ~ ' ' ~U maaMl as ftata0...... . 1a. ............ ............. .............. .................................................... ~w REGISTRAR'S SIGNATURE AN R n, 1 ..~` ~ T ~ ~~\ ~ ~"` R• ~~ A DATE fILEDIMgNn paY l}ar~l/`~ , •`^L ,. _ ~wriLL` RAJ I~~ f _ LAST WILL AND TESTAMENT I, LEWIS G. DAMS, of North Middleton Township, Cumberland County, Pennsylvania, declare this instrument to be my Last Will and Testament, hereby expressly revoking all Wills and Codicils heretofore made by me. 1. I direct my executrix to pay all of my debts, funeral and administrative expenses as soon as maybe done conveniently after my decease. 2. I authorize and empower my executrix to sell any realty owned by me at my death, and not specifically devised herein, at either public or private sale, and to give good and sufficient deeds therefor, in fee simple, as I could do if living. 3. I devise and bequeath all of my estate of every nature and wherever situate to my wife, Madeline A. Davis, providing she shall survive me by sixty days. 4. Should the gift in Paragraph No. 3 not take effect, I devise and bequeath all of my estate of every nature and wherever situate as follows to Thomas M. Kendle, Debra L. Deyo, Anita L. Davis and Gordon E. Davis, share and share alike. 5. I nominate and appoint Madeline A. Davis to be the executrix of this my Last Will and Testament; she is to serve as such without bond. Should she die before my death, renounce or refuse to serve for any reason, or die leaving any of my estate unadministered, Inominate and appoint Thomas M. Kendle, Debra L. Deyo and Anita L. Davis, as substitute executors, also to serve as such without bond, with the same powers as are given herein to my executrix. 6. I hereby suggest that my personal representative retain the services of Irwin, McKnight & Hughes, as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 8TH day of April, 1997. ~. ~~-~-Q(SEAL) LEWIS G. DAMS Signed, sealed, published and declared by LEWIS G. DAMS, the above named testator, as and for his Last Will and Testament, in the presence of us, who at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto. ~° 2 A CKNO WLEDGMENT AND AFFIDA VIT WE, LEWIS G. DAMS, CHERYL L. CLELAND and MARTHA L. NOEL, the testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his Last Will and that he had signed willingly, and that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the Will as a witness and that to the best of their knowledge the testator was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. ;~ ~.~.. LEWIS G. DAMS RYL L. CLELAND MAR HA L. NOEL COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND . SS: Subscribed, sworn to and acknowledged before me by LEWIS G. DAMS, the testator herein, and subscribed and sworn to before me by CHERYL L. CLELAND and MARTHA L. NOEL, witnesses, this 8TH day of April, 1997. ~ ~ ~~ N tart' Public Notarial Seal Roger B. Irwin, Notary Public Carlisle Boro, Cumberland County My Commission Expires Oct. 3, 2000 Member, Pennsylvania AssoClatfon of Notaries 21-01-530 RENUNCIATION In Re Estate of _ _ _ deceased. To the Register of Wills of U County, Pennsylvania. The undersigned the above decedent, h E be issued to WITNESS ~V i/ ~~~ ~ renounce(s) the right to administer the estate and respectfully ask(s) that Letters hand this day of ,~~~~ y~ Gad ~~ "^ e' (Signature) (Addy ss) l~ eb r ~, (Signature) (Address) r t (Signature) (Address) ...~--- CERTIFCATION OF NOTICE UNDER RULE 5.6(Al Name of Decedent: Date of Death: 5 G ~~5 ~~ Will No.: ~~ ~ ~ ~ ~~ J"~ Admin No.: To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on Name Aclclres~ J Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: Signature Name ~~ ~~~ ~ Address ~~3J ~~~~ elephone Capacity: Personal; Representative ^ Counsel'for personal representative COMMONWEALTH OF PENNSYLVANIA '~ ~. COUNTY OF CUMBERLAND 1 Suzanne E. Crumlich sworn is the Executrix being duly according to law, deposes and says that she of the Estate of Mary G. Morrison late of Upper Allen Township __ ,Cumberland County, Pa., deceased and that the within is an inventory made by Suzanne E. Crumlich __ _ the said Executrix of the entire estate of said decedent, consisting of all the personal proparty 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 . Sworn and subscribed before me, 18th of March 1~X 2002 ..~. ~,~~r My Commisston Expires Nov. 22, 20(f3 Date of Death ~ 20th Day f' ,. ,, ~ ~ f,' y "t'" E~2'ezutor -Administrator Suzanne E. Crumlich, Executrix 364 North Locust Point Road Mechanicsburg, PA 17055 Address June 2000 Month Ysar INSTRUCTIONS I. An inventory must be filed within three months after appointment of personal representative. 2. A supplerc,ent inventory must be filed within thirt y days of discovery of additional assets. 3. Additional sheets may be attached as to persona lty or realty .-..~-~ ' ~, 4. $ee Article IV Fiduciaries Act of 1949 s;,. % - o ~'-5= r"'' , . t N N ~a a. ~ .~ -~ ~ >- ° ~ ~ m -d ~ ' 3 ~ ~ ~ H u O W ~ W ~ ~ Q Qf S-~ ~ ~+ ~ - ~ '0 ~ ~ 8 LL J Q O ~ ~ d C~ ~ O ~ ~ O ~ ~ ~ ~ ~, .~ a~ a~ Q ~ i Z O ~ a o ~~ Z Z ~ Q ~ U i a o -o ~ ci z. c +' ~ o •o ~ ~ ~ cti i +~ ~ m -a cd ,t] .~ ~ ~ ~ ~ ~ m u U4J W I ~o -~ ~ U LL O •r-I C m a Inventory of the real and personal estate of MARY G. MORRISON, Deceased PERSONALTY: 1 AT&T, 600 shares of common stock 2 Bell Atlantic, 400 shares of common stock ~ 20,325.00 3 Bell South Corporation, 800 shares of common stock 22,299.16 4 Boeing Company, 30 shares of common stock 37,400.00 5 M&T Bank Corporation (formerly Keystone Financial) 1,171.88 4,914 shares of common stock 104,729.63 6 Goodyear Tire & Rubber Company, 1,000 shares of common stock 7 Lucent Technologies, Inc., 256 shares of common stock 23,593.80 8 ArvinMeritor, Inc. (formerly Meritor Automotive, Inc) 120 shares of common sto k 15,472.00 c 9 PPL Corporation, 500 shares of common stock 1,447.50 10 Rockwell International Corporation, 360 shares of common stock 11,515.65 11 Conexant Systems, Inc., 360 shares of common stock 13,252.50 12 SBC Communications, Inc., 1,998 shares of common stock 19,327.50 13 Quest (formerly known as US West, Inc.) 304 shares of common stock 95,841.66 14 AT&T Wireless (formerly Media One Group, Inc.), 150 shares of 25,640.52 common stock 3,604.70 15 M&T Bank, checking account #429422 16 M&T Bank, CD #31003910332136 15,510.07 17 M&T Bank, CD #31003910357522 20,035.51 18 M&T Bank, CD #31003910378966 <i5,033.11 19 M&T Bank, CD #31003910466018 ~ 20,012.02 20 M&T Bank, CD #31003910553378 15,02<.67 21 Harris Savings Bank, CD #17-31.159767 10,004.92 22 Harris Savings Bank, CD #17-54-202308 ..:38,458.92 23 Harris Savings Bank, CD #17.56-178157 20,058.87 24 Harris Savings Bank, CD #17.56-275746 20,000.00 25 Mellon Bank, N.A., CD #00688872 29,910.91 26 PNC Bank, N.A., CD #21001010948 95,133.03 27 PNC Bank, N.A., CD #21001010975 32,414.62 28 PNC Bank, N.A., CD#21001011077 45,717.86 29 Orrstown Bank, CD #5060063523 36,992.59 30 Orrstown Bank, CD #5060064732 25,044.52 31 First Union, CD #247412051003540 70,000.00 32 First Union, CD #247412061463056 30,150.79 33 Capital Blue Cross, premium refund on policy #189094114 70,132.89 34 Bell Atlantic, refund 950.99 8.77 TOTAL PERSONALTY: $ 1,006,214.56 REAL ESTATE: 1 Decedent owned no Real Estate at the time of her death $ 0.00 TOTAL PERSONALTY AND REAL ESTATE: 1,006,214.56 Page 1 Iin- L~3N- lG v-,appexianm ^ R E V -15 0 0 ~~ry~v~.lA i_ ~:~r...~f~,.-Y COMMONWEALTH OF PENNSYLVANIA - _ __ ....__. '~- DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER DEPT. 280601 ~ L GAD 5~3 U ~I ,y HARRISBURG, PA 17128-0601 RESIDENT DECEDENT _ ~e9NTyeoDE YEAR edM6ea DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~ Z Davis, Lewis G. 231 - 14 - 8910 W DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE W OS-22-2001 06-18-1924 REGISTER OF WILLS U W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~ Davis, Madeline A. - - ^X 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return ido~e oraezm pnorm rz-ta-ezl ~ Q y w u ~ ^ 4, Limited Estate ~ 4a. Future Interest Compromise mare oroozm ofior rz-rz~ezl 5. Federal Estate Tax Return Required ~ a m ^ 6. Decedent Died Testate (Anocn Dopy or mnn ^ 7. Decedent Maintained a Living Trust (anacn copy or Trusp _ 8. Total Number of Safe Deposit Boxes a a ^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit lae~o of aaam natwooo rzar-s+ a~a i-i-asl ^ 11. Election to tax under Sac. 9113(A) (A~MCh son of ~ .. w NAME COMPLETE MAILING ADDRESS o Jaclyn M. Smith., Esquire 26 West Hi gh Street y FN~.~1FBIOnp~ff, Flower & Lindsay Carlisle P A 17013 w rc a TELEPHONE NUMBER v (717) 243.6222 Z O a J H a Q U W d' (11) 41,723.70 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (LineBminus Line ll) (12) (40,923.70) 0 13. Charitable and Governmental BequeslslSec 9113 Trusts for which an election to tax has not keen (13) made (Schedule J) 14, Net Value Subject to Tax (Line 12 minus Line 13) (14) (40 , 92 3.70) 1. Real Estate (Schedule A) 11) 2. Stocks and Bonds (Schedule B) 12) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages 8 Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 800.00 (Schedule E) 6. Jointly Owned Properly (Schedule F) (6) ^ Separate Billing Requested Z Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) (8) 352.00 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts at Decedent, Mortgage Liabllltles, & Liens (Schedule I) (10) 41, 371.70 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 _ (15) Q H i6. Amount of Line 14 taxable at lineal rate x .0 (16) 17. Amount of Line 14 taxable at sibling rate x .12 (17) V 18. Amount of Line 14 taxable at collateral rate x 15 (18) Q 19. Tax Due (19) 6FFICIAL LfSE CINLY - 800.00 0 Decedent's Complete Address: airc~~iHUUrcw' Sarah A. Todd Memorial Home 1000 West South Street CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1 . Tax Due (Page 1 Line 19) (1) 0 2 . CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount p Total Credits (A + g + C j (2) 3. InterestlPenalty if applicable D. Interest E. Penalty Total InterestlPenalty (D + E) (3) 0 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 0 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the lax due. (5A) 0 0 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT s 3 , fife t t i_ s ~vt s a ., ..;. ; z , .., s ,}d +x,4r?:, rt ~ I . np.+ 9rtm ~,ir,,'~v h v 5lhrvl, r tt r, . ,t,';tr', . ,~ . .,. ,.., 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 :.................................................................................... ...... ^ ^X b. retain the right to designate who shall use the property transferred or its income :...................................... ...... ^ ^X c. retain a reversionary interest; or .................................................................................................................... ...... ^ ^X d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ ^X 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideralion? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ....:... ...... ^ ^X 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a benefciary designation? .................................................................................................................. ...... ^ ^X 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 antl statements. and to the best of my knowledge and belief, it is true, correct antl complete. Ueclaralion of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF Fj1=RSON RESPONSIBLE FOjt FILIN TOURN DATE_~ 02 ADDRESS 38 u~ ~ 1.(._ ~ 5/~ ~~~ 1 ~~~3 SIGNATURE OF PREP / T~~R THAN R ~PtRESF,WTATIVE . /) l 11 D2E ~ ! ©~ ADDRESS 2 Street, Carlisle PA 17013 )€l~ln~~;~Ij}'~:It4i~.",~3. ,`.!h6.+i#~'#4:` ~, TF''~... x lT,... ,~".. .?I?°m,~~,is`]f?t!?dtEl'.t+~"'~;,,":'.`>P, ,.,. ,. ,'. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii) The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and fling a tax return are still applicable even 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-0ne years of age or younger al death to or for the use of a natural parent, an adoptive paren or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefciaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)). Asibling is defined, under Section 9102, as a~ individual who has at least one parent in common with the decedent, whether by blood or adoption. 4EV-0500 E%•Y9)) SCHEDULE E p COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, $t MASC. INHERITANCE rAx RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned whh the right of survivorship must be disclosed on Schedule F. NUMBER DESCRIPTION ~. Mellon Bank Account (If more space is needed, insert VALUE AT DATE OF DEATH $B00.00 TOTAL (Also enter on line 5, Recapitulation) I S g00.00 same IjER~SHEX.~l9]7 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE H FUNERAL EXPENSES 8 ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. 1 2. 3. 4. 5. 6. 7 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Social Secudty Number(s) I EIN Number of Personal Representative(s) SVeet Address City State - Year(s) Commission Paid: Attorney Fees Saidis, Shuff, Flower & Lindsay Family Exemption: (It decedents address is not the same as claimant's, attach explanalion) Claimant SVeet Address $300.00 City Sfate Zip Relationship of Claimant to Decedent Probate Fees Register of Wills $ 37.00 Accountant's Fees Tax Return Preparefs Fees Inheritance Tax Filing Fee $ 15.00 Zif TOTAL (Also enter on line 9, Recapitulation) I $ 352.00 (If more space is needed, insert additional sheets of the same size) PEVJS4 EX• 9~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE 7AX RETURN RESroENT oECEOEIUT ESTATE OF SCHEDULEi DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & t Include unreimbursed medicalezpenses. NUMBER DESCRIPTION 1, Mealical Expenses from Sarah A. Todd Memorial Home 2. ~ Department of Public Welfare Lien AMOUNT $ 710.60 $40,661.10 TOTAL (Also enter on line 10, Recapitulation) I S 41.371.70 (If more space is needed, insert additional sheets of the same size) MR THOMAS M KENDLE 38 CAVE HILL DR CARLISLE PA 17013 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS PO BOX 6466 HARRISBURG, PA 1]105-646fi August 08, 2001 Re: LEWIS DAMS CIS #: 640148064 Co/Rec: 21/0087680 Date of Birth: 06/18/1924 SSN: 231-14-8910 Dear Mr. Kendle: Please be advised that the Department of Public Welfare maintains a claim in the amount of S40,661.10 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely 517,755.55, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely 522,905.55, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. 1f the estate coatains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, i Margaret Smitherman Claims.-Investigation Agent "717-772-6607 \717 =7D 5-8150 FAX Enclosure COMMONWEALTH OF PENNSriVANIA DEPARTMENT OF PUBLIG WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BO%8486 HARRI58URG PA t7t05-8486 August 7, 2001 STATEMENT OF CLAIM SUMMARY NAME. Estate of DAVIS, LEWIS 1D 640 148 064 MEDICAL CLASS 3 CLASS 6 TOTAL INPATIENT .DO .00 .00 OUTPATIENT .00 .00 .00 LONG TERM DARE 17,214.53 21,657.48 36,872.01 DRUG 541.02 1,248.07 1,769.09 REIMBURSEMENT TO DPW. 17,755.55 22,905.55 40,661,10 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23-6003113 Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Thomas Kendle 38 Cave Hill Drive Carlisle, PA 17013 Statement Date: 06/11/2001 Due Date: 06/26/2001 Re: Lewis G Davis Account Nr: 100967 -------------------------------------------------------------------------------- Date Description Days Rate Charges Payments Balance Quant -------------------------------------------------------------------------------- BALANCE FORWARD 1,491.20 1,491. 20 O5f07f01 PAYMENT 829.00 662. 20 05/07/01 PAYMENT -83.40 745. 60 OSJO1J01 MA - Other Med Expe -1.00 35.00 -35.00 710. 60 ~~ ~1~~10~~~~5~a~~~ ~ r~ ~ ~- NOTE: Please remit by JUNE 26, 2001, the Last amount printed on the statement. Please include Account Nr. from statement on MEMO LINE of your check. Any payments received after O5/31j2001 are not reflected on statement; please deduct any additional payments you may have made and remit the balance remaining. Thank You. BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 JACLYN M SMITH SAIDIS ETAL 26 W HIGH ST CARLISLE ESQ PA 17013 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REY-1547 E% 4FP (O1-OS) DATE 04-14-2003 ESTATE OF DAVIS LEWIS G DATE OF DEATH 05-22-2001 FILE NUMBER 21 01-0530 COUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF DAVIS LEWIS G FILE N0. 21 01-0530 ACN 101 DATE 04-14-2003 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) (1) .00 2. Stocks and Bonds (Schedule B) (2) .0 0 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 4. Mortgages/Notes Receivable (Schedule D) (4) .00 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 8 00.00 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 8 Total Assets (8) NOTE: To insure proper credit to your account, submit the upper portion of this form with y4.ur tax payment. 800.00 APPROVED DEDUCTIONS AND EXEMPTIONS: 352.00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9l 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 41,371.70 11. Total Deductions (11) 41 .723 _ 70 12. Net Value of Tax Return (12) 40,923.70- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 14 Net Value of Estate Subject to Tax [14) 40,923.70- . NOTE: If an assessment was issued previously, lines 14, 15 andior 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 (15 ) . 0 0 X 0 0 = . 0 0 16. Amount of Line 14 taxable at Lineal/Class A rate (16) •0 0 X 045 = .00 17. Amount of Line 14 at Sibling rate (17) .00 X 12 = .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 15 = .00 19. Principal Tax Due (19)= .00 ^ ~ ~ ~"„ ~ NUMBER ~+vv~~~~ ~ ~ - ~ I AMOUNT PAID DATE INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ^ IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) ~/ ~r~ STATUS REPORT UNDER RULE 6.12 Name of Decedent: ~° ter! S Date of Death: 5 ~ ~~© Will No.: ~~~~~-JF' (~ 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: State wly~ther administration of the estate is complete: Yes I~ NTO ^ 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 th personal representative file a final account with the Court? Yes No ^ b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes ^ No ^ c. Copies of receipts, releases, joinders and approval of formal or informal accounts maybe filed with the Clerk of the. Orphans' Court and maybe attached to this report. ~j~ Date: / /1' l Signature ~~~~ /~ ~~ Name ~~~ g ~U~ ~~ R ~l Q Address -~ N _` lS~ y 1 Q yr ~~3 ~ - ~~ Telephone No. ~~ ~ ~J ° ,m, ,~; Capacity: Personal Representative ^ Counsel for personal representative Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone:(717) 240-6345 Date: 4/09/2003 KENDLE THOMAS M 38 CAVE HILL DRIVE CARLISLE, PA 17013 RE: Estate of DAVIS LEWIS G File Number: 2001-00530 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 5/22/2003 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ,~~~`r~.a. ill. ~-- !~` /~ DONNA M. OTTO DEPUTY REGISTER OF WILLS cc : File Counsel Judge