HomeMy WebLinkAbout01-0683
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of _p (A. tf1 J. It:., I /; F
also known as
21-01-683
No.
To:
Register of Wills for the
County of in the
Commonwealth of Pennsylvania
Deceased.
Social Security No. :1. I cO.. 'I () -:1 1 Z 8
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl;~..s
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in '-... '" b · County, Penns..ylvania, with
h '2 r last family or principal residence at J e UJ. At ~.' /1 5 -f Lt -e t..h. ~4 . .
(list street, number and municipality)
Decendent, then S 0
at
rz.h 3 / fJO
a I
, ~ cJ4~4,
years of age, died
tOI) ~
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$
$.
$
$
Petitioner_ after a proper search h3.S..- ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name
'}10... /} he L La. ('l
(\.{ l-t ;., c
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
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
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law.
Sworn to or affirmed and SUbSCri.bed f v~ tJ ~ ~L'!.tJ::~(4,---
before me this 19 th day of _ _
~ JULY ~~ 2001
. ~Y(}';fm.~'/fi-"/4N~
. R~~rer 'L
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No. 21-01-683
Est"ate of
PAMF.T.A .T KTRF.
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW JULY 20 ~200 1 , in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that Ruby A Manhollan
is/ are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to Ruby A Manhollan
in the estate of PAMELA J KIBE
>;0"7 (J 5f".~~~ fill' L4~~7"
gister of Wills
FEES
Letters of Administration $ 18. 00
Short Certificates( ).......... $ 3.00
Renunciation ................ $ I) . 00
JCP $ 1).00
TOTAL _ $ 31.00
Filed ..........?:-.~~...... A.D. ){J 2001
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
~~w~
,t~~
RENUNCIATION
21-01-683
In Re Estate of
'\=6 '{Y\ e \ 0,. -::\ ~ ("'~ Y-:\ ~ -
~u~'oe.y-\~
deceased.
To the Register of Wills of
County, Pennsylvania.
The undersigned
WILLlAw\. :ro~f~ \Z.\\oe. ~
of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
D~l +c ~ \q~" G~\'l>\e:i ~\o;\ \Jl~~ 36'~5'IW<g\(55b.2.c~~,
be issued to (Z~b-..1 ~V\"'-~ \""^-
\
WITNESS
'_/h ~~
hand this I to VA-- day of ~. f.fV '.
,~~
(Signature)
401 dv+".) ~+. ~y)lJltlf, 14 17.5']
(Address) .
8a OQl1fs,l.~. frlJ1t
10<6 ~~..
fli.Ll ~JJl\)) 'fa.. 1102..2-
~ (Address)
(Address)
HI 05.90~ REV.(09100)
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
C\~s.~/~.
Robert S.Werman, Jr., MPH
Secretary of Health
No.
~II~
Charles Hardester
State Registrar
1568394
JUN 2 9 2001
Date
21-01-683
}'1
/ V"\ H1OS.'43R"'.2I87
TV_T
IN
PERIIAHEHT
IIl.ACI( _ ,.
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
1llfIT~ iC"V or..,
Sta.. Of Fcroogn ~o
s. 50 VIS.
COUNTY OF DERH
Youngstown
).
....
Dauphin
DECEDENT'S USUAL OCCUPRlOH
(::""-=:.:70~~:&:'f
Bartender
SUR\IIIIING SPOUSE
(1_.0--_
130 West Main Street
'" Mechanicsburg, Pa 17055
FRHEJI'S NAME ("'llSl. Middle. L....)
I.. Ral h H. Manhollan
N'OMlAHT'S NAME (T ypIlIPrinII
~ Ru Manhollan
METHOO OF DlSPOSlT1OH
~c_o
0IIw (SpM:ily\
-
Mechanicsburq
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(\ ~ t"c1
OM.
:=~n
:_ancI_
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NoD
PARTII: OIIwsign__~IO_.bul
.... -..IIing in.... ~cao.. giwOII in FMT L
DUE 10 lOA AS A CONSEQUENCE OF):
I :
DUE "10 lOA ASA CONSEQUENCE OF);
DUE "10101I AS A CONSEOUENCE OF);
WEREAUlOPSY A~ MANNER OF DEATH DATE OF INJUAV
AN..A8lE PAlOfl"lO (Monlh. Day. _I
COMPlETlOH OF CAUSE -.. )IiO.. Homicide 0
OF DERH1
- 0 p-..g InwMIgalIon 0
_0 NoD SUicide 0 Could.... be del_ 0
TIME OF INJURY
INJUAY /lr WORK1 DESCRIBE HOW INJUAY OCCURIlED.
_ 0 NoD
.1'ftONOUNCING AND CERTIFYING PHYSICIAN (Physooan bOIh ;.>ronouoono deaIh and c"'llyv1q 10 c""'"' 01 doa""
To the bHt 01 my knowledge. death occurqcf at !he""'. ct.1e. and piece, and'" to the caUM(a) and man,...... ".1"'_. . . .. . . . . . . . . . . . . . . . . . . . .
/Jv<.
c"-
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:zeit. 2'1.
CERTFIEIl /CI1edt any one!
'CERTFtIIIG PHYSICIAN lPhysooan Cf!fbIyong cause 01 _ '"'*' '""""" ghysc,," has pronounced do"'" at>O compleled hem 23)
T...._of""-.......deoth__.....eauM/.'_manIMt'.._. .......,............................................
"MEDICAL EXAMlNERlCORONEIl
On lho balls 01 .._natlon andlo< Investigation. In m, opinion, dealh occurred at the lime. date. and place. and due to the cause(.) and
mant'lefu st..ed.... . ...... . . . .. .. .. . .. ..... . .. .. . . .... . ......... ....... ........... . . . ................ . . . _. _. .......... ....
31..
REG'
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Name of Decedent:
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
f;;~1l J: KiM
Date ofDeath: !JEt'IE IH f1~.e /4 ~ooo
Will No. ~/-ol-~i'3
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
Address
II;,/, I0Atu5U.Y ~d t:&11111iL4-&7t:1//
.f,JS Ab.eTIIWt1tJiJ/!!/MiJe, J0,Gt hWVell A,
u / 71.'/P
~~ 1ft ~R ST. .#a'.#AAI~.8(/~ ~.
"M~~~ $S6P# ~C'~..k, 6,w~!{1!'.
:-roA/1 LylllAl g///lC,t1l tLS'AI/lvl/ VilYi/AJ/A
Notice has now been given to all persons entitled thereto under Rule 5.~a) except
t&f11 II. JJ1AlllltJUAN
.
&~J/ ~/LE# ST/~tJ
W,e/lLl i. ~"(/lItJ!Qf4!.
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Signature~ ,/:l ??~~
Name ~vev /I, #.441h'tJUAN
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Address I/L,tf, /6htO(G'/ ;&/-11>
Gmp fi~ yJ'/7&L
Telephone ( ) ~1- EtJ-/J.?J?l
Capacity: ~~rsonal Representative
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_Counsel for personal representative
JRD/June 30, 1992/17858
NOV 0 6 2001
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In Re: Estate of Pamela J. Kibe
Late of Mechanicsburg PA
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
Estate No.: 21-01-683
NO.
NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT
ORPHANS' COURT RULE
Personal Representative: Ruby A. Manhollan
Counsel for Personal Representative:
Date of Grant of Original Letters: July 20, 2001
Date of Delinquency Notice: October 30,2001
The undersigned, Mary C. Lewis, Register of Wills, in accordance with Rule 5.6,
. Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of
Common Pleas of Cumberland 'County, that neither the above named personal representative nor
the above named counsel for the personal representative have filed with the Register of Wills or
Clerk of the Orphans' Court his, her or its certification required by Rule 5.6(e), Supreme Court
Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e), Supreme Court
Orphans' Court Rules, was given by the Register of Wills on October 15, 2001
, and that the ten (10) day notice to file the certification has expired. Accordingly, in accordance
with Rule 5 .6( e) the Court is hereby notified of such delinquency and the undersigned requests
that a Court conduct a hearing to determine whether sanctions should be imposed upon the
delinquent personal representative or counsel for the delinquent personal representative.
Date: November 6, 2001
1\
~.
Distribution: Personal Representative
Counsel for Personal Representative
Estate File
A hearing is scheduled for~kJ c;J I J cb>/ at 9:.. JJ In Courtroom No.3. If the
Certification of Notice is filed prior to the hearing date, the hearing will automatically be
cancelled.
Gror4JU4rl
One Sided, One Page 8 1/2" X 11" Plain White Paper Document
COMMONWEALTH OF PENNSYLVANIA
COURT OF COMMON PLEAS
o FCUMBERLAND COUNTY
ORPHANS' COURT DIVISION
In Re: The Estate of:
NOTICE OF CLAIM
Court File No: c,,{ J- D 1 .-C:, ~~
PAMELA 1. KIBE
Deceased
TO: THE CLERK OF THE ORPHANS' COURT DIVISION Notice of claim by
creditor, Pursuant to Section 3532(b)(2) of the Probate, Estates, and Fiduciaries
Code, 20 PA.C.S.A. 93532(b)(2).
1) Claimant's name: FIRST USA
2) Claimant's address: c/o NCO ATTORNEY NETWORK SERVICES
CHEVY CHASE P A VILLION
5335 WISCONSIN AVENUE, NW SUITE 360
WASHINGTON, DC 20015
3) Creditor listed below is the owner and holder of a claim in the amount of
$2412.87
5)
6)
7)
The facts upon which this claim is based is a credit agreement between
Creditor and Decedent, identified as account number which is evidenced by
the attached affidavit of account stated.
Decedent's address: 130 W. MAIN STREET, MECHANICS BURG, PA 17055-6286
Date of Death:
That the claim arose prior to the death of the decedent on or about
4)
8) That the claim is secured by
On behalf of the claimant, I do solemnly declare and affirm n er the penalties of
perjury that they Information and representati ns de h . are true and correct
to the best of my knowledge, information and eli . ~
Dated: AUGUST 24,2001 mXent
Claimant
Written notice of claim was given to Personal Representative and/or his/her counsel
as stated below:
RUBY MANHOLLAN
Name
1166 KINGSL Y ROAD
Address
KAMP HILL, PA 17011
City/State/Zip
AlfGUST 24,2001
Date notice mailed
,
I
CLAIM FORM
ESTATE
OF
ORPF..ANS' COURT DIVISION O~
COURT OF COMMON PLEAS OF
~ /Y1 J:3 i2 re..- L.A-N'D COUNTY P A
_ _NO. .::< / - ;2d:7t:::'J / - G::, ~.3
PA-MEtA .T. ;(/8E
/'H E. 8(J/V roN'
in the amount: 0 f S S g.:3 . r;;2. L
Noti.ce of clai.m by
f~ed pursuant to s&ct~cn 3384, Probata, Estates and
TO THE~lU< OF THE ORPHANS' COURT DIVISION:
Fiduciaries Code Laws of 1972, Act No. 104 effective July 1, 1972 as amended.
Date /tt7 - ;2. ~ ~Do J
9441 LBJ FREEWAY
Lock.Box 30
Dallas~' TX 75243
Enter the claim of -/H e BoA/' /~IJ'
(Cla~~ and Address)
in the amount of S
5'$:3, .;)..~
against: the above entitled Estate. The decedent
who resided at
/3CJ
W. /YI A It.! 5"'- /rl Ed/7'AA.lId,8ttR&~ pa
(Addres s )
died on jj;?- - / .3... tt:J 0 .
(Date)
Written notice of said claim was mailed to
. ~ee' ~t tacned
(Personal Represen~ative or Counsel)
at
(Address)
The basis of aforesaid claim is as tollows:
on
(Date)
(Itemize fully to enable personal representative
to make proper Lnvest~ation).
/ice:; r ~
CY.~
~75--0g8
(Name)
441lBJ FREEWAY
Lock Box 30
Pallas_ TX 75243
(Address)
972-644-6360
Claimant's Counsel
(Address)
,
PROBATE COURT
Cumberland County, State of Pennsylvania
Pamela J. Kibe, Deceased
Case #21-2001-683
Proof of Mailinq
I mailed the creditors claim to the fiduciary (and attorney, if applicable) as
follows:
I deposited a copy/copies of the claim with the United States Postal Service
in a sealed envelope with the postage fully pre-paid. I used first-class
mail. I am employed in the county where the mailing occurred. The
envelope (s) was/were addressed and mailed as follows:
Ms. Ruby A. Manhollan
1166 Kingsley Rd.
Camp Hill, PA 17011
Date of Mailing:
County of Mailing:
"h.;:/
Dallas, Texas
I declare under penalty of perjury that the foregoing is t:rue and correct.
Date: ?<J~441
for
The Bon Ton
P.O. Box 741026
Dallas, TX 75374
.-
P ACKE"1 JE :
BTS-C024051F-001
84
RUN ON: 3/ 6/2001 02:57:50
NAME PAMELA ~ KIBE
+ ADDRESS
ADDRESS 130 W MAIN ST
CITY STATE MECHANICSBURG
SPOUSE
HOME PHONE
DATE OPEN
OTHER ACCT
PA17055 REQ PAYMENT
A/R BAL
CURR PAY
MEMO PUR
MEMO CR
HaL-BON
TOTAL
EMPLOYER COLD SPRINGS INN
ADDRESS 4-97*******************
CITY STATE ******************
PHONE: 717/766-9893 EXT:
COMMENTS:
PREV-BAL
583.26
573.30
CUR
PRY
PURCHASE
.00
.00
PAY/RET
.00
.00
FIN-CHRG
9.96
9.96
THE BON-TON
NRA - LOP
ACCT#086-275-088 F COLLECTO~
717/691-1352 LIMIT
11/95 AD~ CODE
AO~ ANT
00000000 IN/COLL
STATUS
593 CYCLE
o MPI
o HIMPITY
o HIMPILY
HIMPIMO
593
NEW BAL
593.22
583.26
PAST/DUE
57.00
.00
03/97
%DTLH
79
2
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1 · lJ/June 30, 1992/17858
NOV 0 6 2001
Estate No.: 21-01-683
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
In Re: Estate of Pamela J. Kibe
Late of Mechanicsburg P A
NO.
NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT
ORPHANS' COURT RULE
Personal Representative: Ruby A. Manhollan
Counsel for Personal Representative:
Date of Grant of Original Letters: July 20, 2001
Date of Delinquency Notice: October 30, 2001
The undersigned, Mary C. Lewis, Register of Wills, in accordance with Rule 5.6,
Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of
Common Pleas of Cumberland County, that neither the above named personal representative nor
the above named counsel for the personal representative have filed with the Register of Wills or
Clerk of the Orphans' Court his, her or its certification required by Rule 5.6(e), Supreme Court
Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e), Supreme Court
Orphans' Court Rules, was given by the Register of Wills on October 15, 2001
, and that the ten (10) day notice to file the certification has expired. Accordingly, in accordance
with Rule 5.6(e) the Court is hereby notified of such delinquency and the undersigned requests
that a Court conduct a hearing to determine whether sanctions should be imposed upon the
delinquent personal representative or counsel for the delinquent personal representative.
Date: November 6, 2001
Distribution: Personal Representative
Counsel for Personal Representative
Estate File
A hearing is scheduled for~~_h ~/i c:h:J/at tJ-/3J In Courtroom No.3. If the
Certification of Notice is filed prior to the hearing date, the hearing will automatically be
cancelled.
Geor~
Q~ ~c 012 1\- dC\ -~~
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Postage $
Certified Fee
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Return Receipt Fee
(Endorsement Required)
Restricted Delivery Fee
(Endorsement Required)
Postmark
Here
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Total Postage & Fees $ ~ ~ e....
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG1 PA 171Z8-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
,...."
HeCO:" L::.
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
02-04-2002
KIBE
12-13-2000
21 01-0683
CUMBERLAND
101
.02 FEB 13 fUO :48
RUBY A MANHOLLAN
~~~: ~~~~SLEV RD PA 8~yc.", ,II
C/
*'
REY-1547 EX AFP (12-0n
PAMELA
J
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=is4-j-i3f-AFP--fi'2-:0(jr-Ntfffci--OF-'rtiliiifffAircE-TAjtjrpPRA-fsii'-ENT~--AL1-owANcE-ifR-------------- ---
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF KIBE PAMELA J FILE NO. 21 01-0683 ACN 101 DATE 02-04-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
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. AlIOunt of Line 14 at Spousal rate (15)
16. Amount 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
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
ll)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
200.00
.00
.00
(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)
1l0)
8,100.00
.00
lll)
(12)
(13)
(14)
NOTE:
.00 X 00 =
. 00 X 045 =
.00 X 12 =
.00 X 15 =
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
200.00
R.IOO 00
7,900.00-
.00
7,900.00-
(19)=
.00
.00
.00
.00
.00
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AHOUNT PAID
DATE NUHBER 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
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.)
C;K
C-
STATUS REPORT UNDER RULE 6.12
PAJl1EI/I -- KibE
Name of Decedent: JEAN
Date of Death: !J;;f.F m BE/E I ~ ~OO6
Will No. c2/-()/- d,J?3 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~ether administration of the estate is complete:
Yes No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the perso~l representative file a final
account with the Court? Yes v/ 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
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
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Name/(Please type or print)
IIkt /i/;,.;aQ;:;Y LY. 6J/JljJ/.i1i;
Address ~ /7dl/
(7/1) 13o-tJ3cf7
Tel. No.
Date:
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Capacity:
Personal Representative
Counsel for personal
representative
(MAH:rmf/AM3)
REV-1500 EX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
I~ -d-.'-/ 5" - 5
REV-1500
OFFICIAL USE ONLY
c!.-
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I-
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FILE NUMBER
~L-~L __12 8'l
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
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~1.0riginaIReturn
D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy of Trust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
THIS RETURN MUST BE FilED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NU~ER
'() - 10 - c3Z If
D 3. Remainder Return (dafeofdeath pliorto 12-13-82)
D 5. Federal Estate Tax Retum Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
COMPLETE MAiliNG ADDRESS
e.UBtj R.I#-4N/-IcJi.LAN
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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 properr.;( Cpe} (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7_ Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
~.. fR)
. $!.J;\ZJ.(JtJ
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OFFICIAL USE ONLY
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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)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
'.0_ (15)
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16. Amount of Line 14 taxable at lineal rate
'0_ (16)
, .12 (17)
, .15 (18)
()
-
~
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
200
CHECK HERE IF YOU ARE REQUESTING A REFUNO OF AN OVERPAYMENT
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(11)
(12)
(13)
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(14)
(19)
CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
-0-
- 0.-
6-
0-
Total Credits (A + B + C) (2)
-0-
3.
InteresUPenalty if applicable
D. Interest
E. Penalty
0-
0-
4.
TotallnteresUPenalty ( D + E ) (3)
If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5.
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
0-
0-
0-
D-
-0-
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;... ........................ .................................... ........ 0
b. retain the right to designate who shall use the property transferred or its income; .............................. . D
C. retain a reversionary interest; or. .............................................. ............................ ................ 0
d. receive the promise for life of either payments, benefits or care?... .. . ..................... ................................ D
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................ ....................................... ..............................
3. Did decedent own an "in 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? .............
No
~
~
~
~
~
......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,
.............0
....0
Under penalties of perjury, I declare that I have examined this return, including accornpanying schedules and statements, and to the best of my knowledge and belief, it is true, correct
and complete
Declaration of preparer other than the personal representative is based on all information of which prepar er has any knowledge.
SIGN~E OJ PERSON RESPONSIBLI; FOR FILING RETURN
t . . 11: J'.J ~//.r;/},.J(.~4?-v
ADtJ'RE S ~ ~ .tlt.
//(,(,'b/tltiSUV ~, Wf/ffiL4 ' /7tJ//
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
/-<'_/';>_ 0/
ADDRESS
DATE
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 filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dales 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% 172 P.S. ~9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries IS 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate Imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
'EV.'"""'.I,.,,.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FilE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
AIo T #11/1l,eE cJF .4/1/(
tJ.1/~
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L. ff, , '7 t/lffJ/f C,GUt5.elry
(~LIJ - ~tJ(J.a) To //I?.<-jJ ojJEAI
1/Jg ~p;-)
$ ~.'7/ J/1. N)
TOTAL (Also enter on line 5, Recapitulation) ,;?C.Uv, (.,'./
(if more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) _
~k
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE Oi7
t'illl2liLl/
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
.:;[ ;t;I3&
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES: AMOUNT
1.
FaAl,EeI}{.., !lomJf.s :;E.ev/t,ES if '7;,,;J(/{UJ
OIE;1/;AI~ or GjV;i/e - ' 'l0tJ. 00
(rillS eRUT)ftf?S CiUJ-V€~'I77f' ~;v!J 11,6 G.4V1i // 7V /IE.e; ,;
&/FCl,Qt/.5E s#tf Jf/IJA/J- ,IIl1vE <7,ug -4T T/md of j8J!lr/f)
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number 01 Personal Aepresenlalive(s)
Street Address
City State __Zip
YeaTts) Comm'rssion Paid:
2. Attorney Fees
3. family Exemption: (II decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State ~ Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7
TOTAL (Also enter on line 9, Recapitulalion) $ .?g/titZttl
-
Debts ot decedent must be reported on Schedule I
o
(If more space IS needed, Irlsert addItIOnal sheels 01 the same size)