The URL can be used to link to this page

Home My WebLink About01-0731 Estate of .Jacquline C. Myers also kno, wn as PETITION FOR PROBATE and GRANT OF LETTERS ,j/.Ol -731 No. To: Register of Wills for the r Deceased. County of Cumberland in the Social Security No. 174-20-4290 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 ,-1 r ~-"0 in the last will of the above decedent, dated " f r ~ and cod:icil(s) dated named ,19~~ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumberland (~I County, Pennsylvania, with her last family or principal residence at 1067.B Allendale Road. Mechanlc.burg. PA 17055 '^ f r ~, A L..L ~., I Lv r ~ ~ ) (list street, number and muncipality) Decendent.. then 72 years of age, died .July 14 )Mf'2001 I at Holy SPirit HosDital Except as follows, detedent 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: }Fe- IV ~ (!j;.p Decendent at death owned property with estimated values as follows: /1:;' (If domiciled in Pa.) All personal property $ 5 J c>c. OCt ~~y~ (If not dQmiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: WHEREFORE, petitioner(s) respectfully presented herewith and the grant of letters theron. ...... ~ <J c; u '0 .-.. .r;;~ u... ~~ ~.g -'ij II)Q. 0'.... ~o (is c 1>1) en OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA } sa COUNTY OF CUMBERLAND 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 an ruly a~innr Jhc;Jstate according t~.law. and subscribed { ~ "l 6th da)' of O'Q" ~2001 a s::: ~ Register ~ .. No. 21-01-731 Estate of JACQULINE C. MYERS , Deceased DECREE OF PROBATE AND GRANT OF LETTERS 2001 AND NOW AUGUST 7 ?Q9_. in consideration of the petition on the reverse side hereoft satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated 11-18-1999 described therein be admitted to probate and filed of record as the last will of JACQ'OLIl\IE C. MYERS 'l'R~rrnMF.N"rnRV RANDY A. CleAK and Letters are hereby granted to '1na~ 0-. i".;.. Clh PB'\)'r,/J:\ Reaister 01 Wills FEES Probate. Letters, Etc. ......... $ 40.00 Short Certificates( )........... $ 6.00 Renunciation ................ S x-pages $ 3.00 JCP 5.00 TOTAL - $ 54 00 Filed ...... ..(\p~~ Q I ~.QQ:L. . . . . . . . . . ... . . . . Norman M. Yoffe,Esq. AITORNEY (Sup. Ct. 1.0. No.) 214 Senate Ave. suite 203 Camp HillADDRESS Pa. 717Q7r::..1R1R PHONE :105.805 REV 9/86 This is to certify that the information here given is correctly copied fro~ an original certificate of death dul~ filed with me as Local R~gistrar. The original certificate will be forwarded to the State Vital Records Office for permanent filmg. WARNING: It is illegal to duplicate this copy by photostat or photograph. 21-01-731 Fee for this certificate, $2.00 p 7555210 No, -t~ fdM ~t7 Local Registrar ~~/~ ~o(jl Date Hl05 l4JRev 2187 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH TYPEJPR1NT IN PERMANENT BLACK INK NAME OF DECEDENT If.5I. MoO<lIe. lasa\ SEX Female 2. PLACE 0# OEAtH 4CI'\ecIl. 0I\ty flf\e -- 'iH InsullCt.of~ on UINI ';la(M) HOSPITAL' I__mr E~I"" 0 SlRE filE l<\J...[fI SOCIA"f.lCURIT'f NU~ 3. 1 _ - AGE (la51 -rl UNDER 1 YEAR __ Caya UHOfR I DA't _ ! Minut.. 72 y,. $. COUNT'f OF OERH Cumberland Mo. .... DECEDENT'S USUAL OCCU~ION (G."" IuoCl aI.work <lOne duf::,'& .- oI-IUn9~~crerary"" I 1\ e. "II. DECEllE NT'S MAILING ADOflESS (51<.... CoIyIOoon. ~. Lop Code) 1067 -B Allendale Road Mechanicsburg, Pennsylvania 1705 KINO OF BUSINESS/lNDUSTRV Distribution llECEDENT'S ACTUAL RESIDENCE r.>ee..-ucoona on oetla SIde. SURVIVING SPOUSE ,N_.~"-_I Cumberland Did -- 1Ml.. e ..........7 17...0 ::...~:: 01 IoIOTHER'$1IIAME (hs.. _. _ Sut....,.) c""'_ I.. FAJHER'S NAME IF.5I. M>d<\Ie. l.st) II. INFORMANT'S NAME (TvpelPt"", 1711. Coun James Myers Randy Cicak ". 1NF000000T'S~~~T'~a1'iIM~~a. 17020 _. PlACE OFOlSPOSITION. _oI~..." c,_ OfOlller~ast Harrisburg Cemetery LOCAJION. c..,......... SIal., ZIp Code Harrisburg, Pa. 17109 4 -) ., 1 ") ") DAlE OF INJURY IMonltl. Oar. Veat' Hal",.. gJ o o COt.lkl nol be aelefmloed Iwp Clara Smith 21d. NAMEANO~~r:~~rHDme, Inc. 37 East Main Street Mechanicsburg, Pa 17055 nc. lICENSE NUUlIER DAlE SIGNED jMCWI\. OIly. "'..I 23... 23C. *S CASE REfERRED TO MEDICAL EXAMlltEAlCORONER7 Yea 0 No~ at. , ApprOJl.....e 'inl__ :_end_ I : PART II: OIher.~_COf1UoIIuIinOlOlleelh.lluI _ ~inlhe..-.,.ng..... grwen in A\RT I. ~~ TIME OF INJURY INJURVIiI WOf\K7 DESCRIBE HON INJURY OCCURRED Pending IOWSltgattoO o o o PlACE OF IfoUURY . AI"""'., .arm.O:;_, Iactorv.oflil:e M. bu1ldinQ. ..., IS_'V) 30e. lOCAJION (SIr_. ColV/TOwn. SWel HomllCide Y.. 0 Ace..... Sui<:Ode NoD i ~ ~ o ::. ~ .. z 2". 2.... CERTIFIEA tCt-eck on.., one) -CEATIf'YlNG PH"'S.~SAN (Phr~tan teflllY&09 cause 01 deillh when .anoiNt' phvSlClan has pronouncea de.Uh .!no completed lIem 23) To u.. be._ of "'Y' kno.......,. de.th occ:unecl dUe IG"'. cauae(..and manner .. ,'.'Iad at. .PAONOUHC&NG AND CEATIf'VING PHYSICIAN (Ptl~&an OOltl ~onouoctn9 uealh ,1l1d t.:ef1:lly.og 10 CJ.uStt oll1edlh\ To lb. be&t 01 my knowtedgtt, deil1h QCcurrect atlhe Om., da.e, .nd place, and due 10 the ca"se(I..nd manne,.. stilled.. "MEDICAL EXAMINER/CORONER On the b..i, olexamin.tion and/or inv.'lig.tion. tn my opinion~ death occurred at the time, date, and place, and due to Ihe c.u$e(a) and manner as $\.'".. . . . . . . . . . .. ............................................ ..., .. ............................... 1'. REGIS 'S SIGNATURE AND NUMBER ~~~/~~~ ~'-4I'~ Ilc~1 ..... 0 NoD M.D o 14Jvlu 11. .200 I I" .__ LAST WILL AND TESTAMENT OF JACQULINE C. MYERS I, Jacquline C. Myers, of Cumberland County, Pennsylvania, being of sound mind and memory, do make, publish and declare this my Last Will and Testament, hereby revoking any and all Wills by me heretofore made. FIRST: I direct the my funeral be conducted in a manner corresponding with my estate and situation in life, and that all my just debts and funeral expenses be paid and satisfied by my Executor hereinafter named, as soon as conveniently may be after my decease. SECOND: I give, devise and bequeath all of the rest, residue and remainder of my estate, both real, personal and mixed, of whatsoever kind and wheresoever situate, to my cousin, Randy A. Cicak of Perry County, PA; providing however, that he survives me for at least 60 days. THIRD: As to any part of my estate that cannot be distributed pursuant to any preceding paragraphs of this Will, I direct that the same be distributed among my issue per stirpes. FOURTH: I hereby nominate, constitute and appoint my cousin, Randy A. Cicak, to be the Executor of this my Last Will and Testament. If the said Randy A. Cicak, is unable or un~lilling to serve as such, ! then appoint Christine A. Kissel, of Harrisburg, PA to serve in such capacity. I direct that my personal representative be excused form entering and/or filing any bond, to insure the proper performance of his/her duties, in any jurisdiction where such bond would be required in the absence of this sentence. PAGE 1 OF 2 PAGES y,C'J7J; J.C.M. , IN WITNESS WHEREOF, I have hereunto set my hand and seal this /6-r~ day of /JOV-e111h-er , 1999. TESTATRIX ~-" C.~L~ /JACQ INE C. MYERS ' (SEAL) ~ED:. ( uJ1AyAU~ /~ \vi 11!~ ADDRESS ;;!~ Jj).Jlal.J,~ fz'! dt ~ /dtL,tJ f/;/!I:/(J ( ?rfl/ ADDRESS d,t1-o COMMONWEALTH OF PENNSYLVANIA: COUNTY OF C' U........1:d r L t'\ '" cA . ss Jacquline C. Myers, the Testatrix, and the above witnesses, whose names are signed to the foregoing instrument, being first duly sworn, each hereby declares to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament in the presence of the witnesses 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 their knowledge the Testatrix was at the time eighteen years of age or older, of sound mind and under no constraint or undue influence. Subscribed, sworn to and Clf7knowledged /) before me by the Testatrix, and the above witnesses, this ~ day of / IOVfJJ7~Y , 1999. ~#?~ 0-NOTAR PUBLIC My Commission Expires: ........------~_.... I ... r-',~1;..t'..qPd ~i.':AL'~' '. ..0.... ,. "".' '.. ,,'~"".l...r ,.""......~ .",J.t;$:-'~ . JEFFRE t N. YOFFE, Notary PublIc . . Camp Hill 2.cwo. Cumberland County i M'I Comrr:1~~,;~':J1~ El(~;TDS Od. 23. 2000 ~..--...:- .-.__..._........__~._'c__._.,._., .': .'._ PAGE 2 OF 2 PAGES ve.W. (/ J.C.M. myers, jacquline\will COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: YOFFE NORMAN M WEST SHORE OFFICE CENTER 214 SENATE AVENUE SUITE 203 CAMP HILL, PA 17011 -------- fold REV-1162 EX(11-96) PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT EST A TE INFORMATION: SSN: 174-20-4290 FILE NUMBER: 21-2001- 0731 DECEDENT NAME: MYERS JACQULlNE C DA TE OF PAYMENT: 12/11/2001 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/14/2001 REMARKS: OVID INC C/O NORMAN YOFFEE CHECK#1708 SEAL NO. CD 000625 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $188.10 I I I I I I I I TOTAL AMOUNT PAID: INITIALS: DO RECEIVED BY: REGISTER OF WILLS $188.10 MARY C. LEWIS REGISTER OF WILLS '\., /~- c>1y.9- // COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z8D6Dl HARRISBURG1 PA 171Z8-D6Dl NOTICE OF INHERITANCE TAX APPRAISE"ENTJ ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESS"ENT OF TAX ODATE ESTATE OF DATE OF DEATH FILE NUMBER P 1 :.'UNTY ACN ReecE r:;c. Re{j; ~,jC NORMAN M YOFFE STE 203 214 SENATE AVE CAMP HILL .02 FEB-1 CIerI':. PA 17011CWnbcj ...., Pi~ 01-29-2002 MYERS 07-14-2001 21 01-0731 CUMBERLAND 101 *' REV-1547 EX AFP (12-0DJ JACQULINE C A..ount Re..i tted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE1 PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REY=is47-ix-iFP--ci2":ol'-f-NOYici--OF-'rtiHERiTANCi-YAX-APPRA-isii.rENT~--itLOWAirci-oi----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MYERS JACQULINE C FILE NO. 21 01-0731 ACN 101 DATE 01-29-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED 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. "ortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/"isc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Ad... Costs/"isc. Expenses (Schedule H) 10. Debts/"ortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Govern..ental Bequests; Non-elected 9113 Trusts 14. Net Value of Estate Subject to Tax NOTE: ll) (2) (3) (4) (5) (6) (7) (9) llO) CHANGED .00 3.938.14 .00 .00 6.066.13 .00 .00 (8) 81157.00 589.95 (11) ll2) (3) ll4) (Schedule J) NOTE: To insure proper credit to your accountl sub..it the upper portion of this forD with your tax pay..ent. 101004.27 8.746 95 11257.32 .00 11257.32 ll5) .00 X 00 = ll6) .00 X 045 = (17) .00 X 12 = (8) 11257.32 X 15 = (9)= .00 .00 .00 188.60 188.60 If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ~ returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. AIIount of Line 14 at Sibling rate 18. AIIount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: PAY"ENT RECEIPT DISCOUNT (+) A"OUNT PAID DATE NU"BER INTEREST/PEN PAID (-) 12-11-2001 CDOO0625 .00 188.10 TOTAL TAX CREDIT 188.10 BALANCE OF TAX DUE .50 INTEREST AND PEN. .00 TOTAL DUE .50 . IF PAID AFTER DATE INDICATED 1 SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $11 NO PAY"ENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT-- (CR) 1 YOU "AY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOR" FOR INSTRUCTIONS.) JRD/June 30, 1992/17858 " DEe 0 4 2001 Estate No.: 21-01-731 ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA In Re: Estate of Jacquline C. Myers Late of Upper Allen Twp 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: Randy A. Cicak Counsel for Personal Representative: Norman M. Y offe Esq. Date of Grant of Original Letters: August 7, 2001 Date of Delinquency Notice: Novmeber 17,2001" 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 November 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: December 3, 2001 .. ills JGm[h~ Distribution: Personal Representative Counsel for Personal Representative Estate File A hearing is scheduled for ~ // <i' ~ II ...Jpo~t ~' .;l1J. In Courtroom No.3. If the Certification of Notice is fi d prior t the hearing date, the hearing will automatically be cancelled. Ge O~ ~ \~-\\- 0\ .. . CERTIFICATION OF NOTICE UNDER RULE 5.6(a} Name of Decedent: Jacquline C. Myers Date of Death: 7/14/01 will No. Admin. No. 2001-00731 To the Register: ~ ---- I certify that the Notice of Beneficial Interest required by Rule beneficiaries of the above-captioned estate on 8/7/01: 5.6 (a) of the Orphans 1 Court Rules was served on or mailed to the following Randy A. Cicak 110 Ann Street Duncannon, PA 17020 Dated: 9/17/01 YOFF~E, P.,C. B~/ ~., Itt~ NORMAN M. YaFFE, ESQUIRE Attorney for Estate of Jacquline C. Myers, Deceased 214 Senate Avenue, Suite 203 Camp Hill, PA 17011 (717) 975-1838 Attorney ID No. 07135 myers, jacquline\notice beneficial interest or: ,.. .....,., ::: c,p :j ~. rr ,.' (~~t 1 9 o CJ - - ;a C> o U1 :o~ (t)() r.~~,;~, ~ i::~~;' 2t .. .. NOTICE OF BENEFICIAL INTEREST IN ESTATE BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of Jacquline C. Myers, deceased, No. 00731 of 2001 TO: Randy A. Cicak 110 Ann Street Duncannon, PA 17020 Please take notice of the death of Decedent and the grant of letters to the personal representative (s) named below. You may have a beneficial interest in the Estate as follows: You are the sole legatee. Name of Decedent Jacquline C. Myers Last known address of Decedent: 1067-B Allendale Road, Mechanicsburg, PA 17055 Date of death: 7/14/01 Place of death: Holy Spirit Hospital, Camp Hill, PA 17011 County of grant of original letters: Cumberland Decedent died X testate -- intestate. A copy of the Will _X_ is is not attached. Name (s), address (es) and telephone number (s) of all personal representatives appointed Name Address Telephone Randy A. Cicak 110 Ann St., Duncannon, PA 17020 717-834-5538 Name(s), address (es) and telephone number(s) of all counsel Name Address Telephone Norman M. Yaffe, Esquire 214 Senate Ave., Suite 203 717-975-1838 Camp Hill, PA 17011 " '- ~ ~ Additional information may be obtained from the Und~gned. Date __8/7/01 Signature // Name: Norman M. Yoffe, Esquire Address: 214 Senate Avenue, Suite 203 Camp Hill, PA 17011 Telephone: 717-975-1838 Capacity: Personal Representative X Counsel for Personal --- Representative ESTATE OF JACQULINE C. MYERS, DECEASED IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 2001-731 ACCOUNTING OF RANDY A. CICAK, EXECUTOR TO HIMSELF AS SOLE LEGATEE The undersigned Executor has fully administered the above captioned Estate and has delivered to himself the sole legatee the difference between following assets and expenses and disbursements made by him as follows: RECEIPTS: 1. From proceeds of 55.365 shs of pioneer Fund Cl. A. (IRA a/c)...... ..... ..... ..1,190.35 2. From proceeds of 127.804 shs of Pioneer Fund Cl. A. (non-IRA a/c)... ...... .... .2,747.79 3. From proceeds of Allfirst Savings a/c #860000001798526.......................... .1,141.45 4. From proceeds of Allfirst Checking a/c (same a/c # as above) ............ ..... .... .2,424.68 5. Receipt in kind of 1995 Buick Skylark........ ..2,500.00 10,004.27 DISBURSEMENTS: Pa Inheri tance tax............................. 179 . 1 7 Myers Funeral Home... ............... ...... ...6,500.00 Yoffe & Yoffe, P.C. for attorney fees.... ... .1,500.00 Cumberland County Register of wills for probate expenses.......... .......... .... ....57.00 Randy A. Cicak for miscellaneous costs...... ...100.00 8,336.17 Net distribution to Randy A. Cicak......... ....... ........ ... .1,668.10 Dated: 9/25/01 JACQULINE C. MYERS, By RAN Y Sole L atee of the Estate of Jacquline C. Myers, Deceased tf.Otdi ~ )C It, h /" t c~~ PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION STATUS REPORT UNDER RULE 6.12 Name of Decedent: Jacqullne C. Myers Date of Death: 7/14/01 Will No.: Admin. No.: 2001-731 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 whether administration of the e<:;tate is complete'. Yes X No 2, If the answer is No, state when the personal representative rewwnably believes that the administration will be complete: 3. If the answer to No.1 is yes, state the following: A. Oid 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 Clerk of the Orphans' Court and may be attached to this report. Signa~ fl. ()~ Date: 9/24/01 a U""I c;::? o EX <! ~:L: Randy A. Clcak Name (Please type or print) ,J 110 Ann St., Duncannon, PA 17020 Address - .('i' G) :::~':": (MAH:rmtJ ~;3,~, 'W'<_.', (0) <lJa: ex: c..J c:::J '2:1 717-834-5538 55 .;J) ,,;~ ..0 'I.:: s:: 11>= Go Telephone No. Capacity: X Personal Representati ve Counsel for Personal Representative R.W - 27 w .., ::!l:$Ul O"'~ W"O ",00 O"'~ ..~ ~ z o ;: ~I! ",,:l Q. ~ o " ""'~"'~~MMOJtiSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG FA 17126-0601 DECEDENT'S NAME lLAST, FIRST, ANt: MIDDLE INlTIALI use.~ank tJIock\c seplRtl!wOl4s REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT /C, - FILE NUII8ER cJ- ;J<;?- 1/ "" 2001-00731 .,,"" COUNf'fCOOE' t- Z W C W () W C Myers, Jacquline C. SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH /14 / 01 8/1 /28 174 - 20 - 4290 7 (IF APPLICABLE) SURVMNG SPOUSE'S NAME [tASl FIRST, AND 'AIODtE INITlAl.) SOCIAL. SECURITY NUM8ER N/A THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS Xl 1,OrlginalRetum D2.SupplementalRelum 0 3.RemainderReh.Jm(dQQfde~PriOrto12-13-112) o 4. Limited Estate 0 4a. Future Interest Compromise (dare of ~ aftec 12.12.82j 0 5. Federal Estate Tax Retum Required o 6, Decedent Died Testate lAllachcopy ofWiI] 0 7. Decedent Maintained a Living Trust [.AlIach CClPY of Trust) _ 8. Total Number of Safe Deposit Boxes D g, Litigalion Proceeds Received 010. Spousal Poverty Credit [c'ilIeoldM!hIle\Weet112.31.9111lc'1.:.95) D 11, Election to tax under Sec. 9113(A) IAltach SchO) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NN.4E COMPLETE MAILING ADDRESS Norman M. Yoffe, Esquire !;; w o z ~ on w '" '" o o 214 Senate Avenue, Suite 203 Camp Hill, PA 17.QU ;.-.1 ~~:' FIRMNA.\lE (lf~pliCallle) Yoffe & Yoffe, P.C. TELEPHONE NUMBER 717 975-1838 . ('':' d 1. Real Estate (S<:heoule A) (1) (2) c::l c-:J 938 14 2. Stocks and Bonds (Schedule B) 3 ~ 3. Closely Held Corporation,Partnership or Sole-Propri&lorship (3) z o ~ :> t: lL c( () w 0: 4. Mortgages & Notes ReceivaDle (Schedule D) 5. Cash, Bank. Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Inler-Vivos Transfers & Miscellaneous Non-Probate Property (SChedule G or l) 8. Total Gross Assets (total Lines 1-7) (8) 157 .00 589 . 95 10 , (4) (5) (6) (7) 6, 066 13. \,:;:) '!l ..,. 9. Funeral Expenses & Administrative Costs (Sdledule H) (9) (10) 8 10. Deb~ of Decedent Mortgage Liebilities. & Liens (Schedule I) 11, Total Oeductions (total Lines Q & 10) (11) 8 1 12, Net Value of Estate (Line 8 minus line 11) 13, Charitable and Governmental Bequests/Sec9113 Trusts for which an eledion 10 tax has not been mane (Schedule J) 14. Net Value Subjactto Tax (line 12 minus line 13) 15, Arnount of line 14 taxable at the spousal tax rate , , See instructions on reverse side for applicable percentage 16, Amount of line 14 taxable at6%rale 17 Amount of line 14 taxable at 15% rale (12) (13) (14) x .0 (15) x .06 (16) (17) (18) x .15 18. Tax Due 7a5lO :offi' () - 004 . 27 746 .95 257 32 1, 257 .32 188 60 DATE 9/20/01 DATE 9/20/01 Decedent's Complete Address: .TREETADDRE.S 1067-B Allendale Road .)' Cln' Mec:hanicsburg I STATE PA I ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page Hine 18) 2. CreditslPayments A. Spousal Poverty Credil B. Prior payments C. Discount 9.43 (1) 188.60 Total Credits (A + 8 + C) (21 9.43 3, InteresVPenalty if applicable D, Interest E. Pena~y 5, TotallnteresVPenalty (D + E) (3) If line 2 is greater than line 1 + line 3, enterthe difference. This Is the OVERPAVMENT. Check box on Pagel Llne19lo requ"ta refund (4) If line 1 + line 31s greater than line 2, enter the difference. ThiSls tile TAX DUE. (5) A. Enler the interest on the tax due, (5A) S, Enterthe total of Line 5 + 5A. This is the BALANCe DUE. (58) 179.17 Make Check Payable to: REGISTER OF ~/LLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BV PLACING AN "X" IN THE APPROPRIATE BLOCKS 1, Did decedent make a transfer and: a, retain the use or income ofthe property transferred; '.h.""".hh hh.h'h'.h,.h"h.h' b, retain the right to designale who shall use the property transferred or its income; , c. retain a reversionary Interest; or...............".................................,,,............... d, receive the promise for life of either payments, benefits or care? ,.hh..h'h." h.h'.h'.h'.h' 2, If death occurred on or belore December 12, 1982, did decedent within two years preceding death transfer proparty without receiving adequate consideration? If death occurred after December 12, 1982, did decedent transl", property within one year of death without receiving adequate consideration? hh.hhh'"h"",hh''.hh'h''' ' .....h.""h.h'... ".. .. 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?" '''h",'''''''''''hhh''h..hh'''.hh,h.''''''.''h.h" ".h..hh"h".h .h ,0 4, Did dacedent own an individual retirement account, annuity, or other non-probate property? h,K] 4, Ves o 'hh'O hO ,,0 No IKI IXI I IXI ~ o '1"""'.J":!'ii~)it "~\jh,, .~t 72 P ,5, 99116 (a) (1,1) (i) provided for the reduction of the tax rate imposed on the net value of transfers to or for the use of the sUIVivin9 spouse from 6% to 3% for dates of death on or after July 1, 1994 and before January 1, 1995. 72 P.S. 99116 (a) (1,1) (ii) provided for the reduction of the rate imposed on the net value of transfers to or for the use of the SUIVivin9 spouse from 30/0 to 0% for dates of death on or after January 1, 1995. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of arets and filing a tax return are still applicable even if the sUlViving spouse is the only beneficiary. tF THE ANSWER TO ANV OF THE ABOVE QUESTIONS IS VES, VOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN FOR OATES OF DEATH ON OR AFTERJANUARV 1,1995 - Please answer the following Question by placing an "x" in the appropriate space. Old the decedent create a trust or similar arrangement which is solely for the surviving spouse's benefit for his or her entire lifetime? Vea 0 No IlG If you answered yes to the above question, the tax on the trust or similar arrangement is postponed until the death of the second spouse, at which time it will be fully taxable et the rate(s) applicable to the remainder beneficiary(ies), Enter the value of the trust on Schedule J, Part II, in order to remove it from the calculation of the tax due in this estate. You may wish to file Schedule 0 in order to make the election avaiiable under Section 9113. If the election is made, the trust or similar arrangement is taxed in the estate of the first decedent spouse, the portion of the trust or similar arrangement which benefils the sUlViving spouse is taxed at the zero tax rete, and the remainder is taxed at the rate(s) applicable to the remainder beneficiary(ies). If you choose to make the election, you must attach Scheduie 0 to a timely-filed tax retum, along with Schedule(s) K andlor M in order to show the apportionment of the trust or similar arrangement between the sUlViving spouse and the pmainder beneficiary(ies). lI.EV-1503 EX+ (4-80) _~..k~ ~g; COMMONWEALTH OF PENNSYLVANIA INHElI.ITANCE TAX RETURN RESlDFNT DECEDENT SCHEDULE B STOCKS AND BONDS ESTATE OF FILE NUMBER Jacquline C. Myers 2001-00731 (All property jointly.owned with Right of Survivorship must b. disclosed on Schedule F.) ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. 55.365 shares of Pioneer Value Fund Class A (IRA account) 1,190.35 2. 127.804 shares of Pioneer Value Fund Class A (non-IRA account) 2,747.79 TOTAL (Also enter on line 2, Reccpitulation) (If more space ;s needed, insert additional sheets of same size.) $ 3,938.14 UV.l.soIEX+(2.87l w SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY Please Print or Type filE NUMBER 2001-00731 COMMONWEALTH Of PENNSYlVANIA ....HUITANCE TAX RI!TURN RUIDENT DECEDENT ESTATE OF Jacqullne C. Myers (All pral"rfy lolntly.own.d with th. 1'g1.. of Survlvorthlp In,,,' ~. cflulo..d on Sch.cful. FJ ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. 1995 Buick Skylark 2,500.00 2. Allflrst Bank Savings ale #860000001798526 1,141.45 3. Allflrst Bank Checking ale (same #) 2,424.68 TOTAL (Also enter on line 5, Recapitulation) S 6,066.13 (Attgc:h additionol SY:" )( 11" ,het. if more tpOU it needed.) """"""""'''* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Jacquline C. Myers FILE NUMBER 2001-00731 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Funeral Home 6,500.00 37 E. Main Street, Mechanlcsburg, PA 17055 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 0.00 Name of Personal Representative (s) Randy A. Clcak Social Security Numbe~s) I EIN Number of Pe""nal Repreoentative(s) SlnletAddlllSS 110 Ann Street City Duncannon State PA Zip 17020 Year(s) Commission Paid: 2. Attomey Fees Yoffe & Yoffe, P.C. 1,500.00 3. Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation) Claimant None Street Address City State ZIp Relalionsl1ip of Claimant to Decedent 4. Probate Fe.. Cumberland County Register of Wills for Probate 57.00 and Short Certlflcates 5. Accountant! Fees 6. Tax Return Preparer's Fees 7. Randy A. Cicak, to reimburse for transportation 100.00 costs, telephone charges, etc. TOTAL (Also enter on line 9, Recapitulation) $ 8,157.00 (If more space Is needed,lnsen additional sheets of the same size) ......"",,."'''. COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RElURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER 2001-00731 Jacquline C. Myers Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. Allfirst Bank car loan on 1998 Buick 372.95 2. Meadowood (for July apt. rent) 217.00 TOTAL (Also enter on line 10, Recapitulation) $ 589.95 (If mare space IS needed, insert addItional sheets of the same size) IlEV.151) EX. 11.97) '* SCHEDULE J BENEFICIARIES oomI.O~W~kll\1~ fllC""S'1\..\Jl\NI"'- INHERITANCE TAX RETURN RE IDENT DE DENT ESTATE OF Jacquline C. Myers FILE NUMBER 2001-00731 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER Np.,ME p.,NO p.,OORESS Of PERSON(S) RECEIVING PROPERiY Do Not Li.t Tru.teo{.f OF ESTAlE I. TAXABLE DISTRIBUTIONS (include outright spousal distribution,) 1. Randy A. Cicak cousin 100% 110 Ann Street Duncannon, PA 17020 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 fOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size:1