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Home My WebLink About01-0785 .. ... . ,t . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT 280601 HARRISBURG, PA 17128-0601 -~.., ~ J (--;) - /0 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER dL -0 L COUNTY CODE YEAR __JE-S N~BER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- Z SMITH LAURETTA J 189-09-0408 W DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE C W 08/18/2001 03/07/1919 REGISTER OF WILLS 0 W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER C UJ [ZJ 1, Original Return D 2, Supplemental Return D 3, Remainder Retum (dale of death prior to 12-13-82) ~~en D 4, Limited Estate D 4a, Future Interest Compromise (date of death after 12-12-82) D 5. Federal Estate Tax Retum Required uc::~ UJa.u [ZJ D :coo 6. Decedent Died Testate (Attach copy of Will) 7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Depos~ Boxes uC::...J - a.al a. D 9. Litigation Proceeds Received D 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95) D 11. Election to tax under Sec, 9113(A) (Attach Sch a) <l: I- THIS. SECTION MUST BEC()MPLET~D;Al.lLCP~RESIi'PNDENCE AND<:;q~~.IDENTIAJ...TM.INf'()~MAtlPN$HPI.JJ...DaE.DI~~<:;tED.TO; z NAME COMPLETE MAILING ADDRESS UJ 0 FRANCINE J DOUGLASS 1820 LINGLESTOWN ROAD z 0 FIRM NAME (If Applicable) a. HARRISBURG, PA 17110 en HAMILTON & MUSSER CPA' S UJ c:: c:: TELEPHONE NUMBER 0 u 717-234-7000 1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 202 66 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5, Cash, Bank Deposits & Miscellaneous Personal Property (5) 27, 943 38 Z (Schedule E) 0 6. Jointly Owned Property (Schedule F) (6) 9, 803 .28 !c( D Separate Billing Requested ...J 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 341, 815 66 :::> . I- (Schedule G or L) ii: 8, Total Gross Assets (total Lines 1 - 7) (8) 379, 764 98 <( . 0 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 5, 253 . 74 W a::: 10. Debts of Decedent, Mortgage Liabil~ies, & Liens (Schedule I) (10) 11, Total Deductions (total Lines 9 & 10) (11) 5, 253 . 74 12. Net Value of Estate (Line 8 minus Line 11) (12) 374 , 511 .24 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 374 , 511 . 24 SEE INSTRUCTIONS FOR APPLICABLE RATES Z 0 15. Amount of Line 14 taxable at the spousal tax < rate, or transfers under Sec, 9116 (a)(1.2) X .0_ (15) I- 16, Amount of Line 14 taxable at lineal rate X .0_ (16) :::> a.. 17. Amount of Line 14 taxable at sibling rate X .12 (17) :!!: 0 18. Amount of Line 14 taxable at collateral rate 374 , 511 . 24 X .15 (18) 56, 176 . 69 0 >< 19. Tax Due (19) 56, 176 . 69 ~ 20. D I CHECK HEReIFXOUAR15R!iQQe$T'~<$A.R~~QNboF AJ\lPVERPAYMENtl STFPA42021F.1 > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSe sloe AND ReCHeCK MATH < < " Oecect'ent's Complete Address: STR,tHADDRE,SS 4833 E TRINDLE ROAD CITY MECHANICSBURG Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount STATE P A ZIP 17050 (1) 56,176.69 2,808.83 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) 2,808.83 Total Interest/Penalty (0 + E) (3) 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 53,367.86 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 53,367.86 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; ........................................ D b. retain the right to designate who shall use the property transferred or its income; . . . . . . . . . . . . . . . . . .. D c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? . . . .. D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. [Xl D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI U F P.ERSON~P~~RETURN No [Xl [Xl [Xl [Z] [Xl [Xl ADDRESS 333 MISTY OAKS CT SIGNATURE OF P. EPARER OTHER THAN ~ E /I~ )~- eJ ADDRESS 1820 LINGLESTOWN RD DAYTON, OH PRESENTATIVE ~ 45415 DATE 11/09/01 HARRISBURG, PA 17110 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. 99116 (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 exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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. 99116(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 Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. STF PA42021 F.2 " REV-150l)EX + (1-97) (I) J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER LAURETTA J SMITH All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH N/A STF PA42021F.3 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) I. REV-1503~X + (1-97) (I) 1- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF LAURETTA J SMITH FILE NUMBER All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. 32.167 SHARES EVERGREEN HIGH YIELD BOND FUND, CLASS A CUSPID # 646-1002970396 VALUE AT DATE OF DEATH 202.66 SIT PA42021 FA TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 202.66 :. REV-1504EX + (1-97) (I) I - COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE-PROPRIETORSHIP ESTATE OF LAURETTA J SMITH FILE NUMBER Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. N/A STF PA42021 F.5 TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) , REV-1507~X + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF LAURETTA J SMITH FILE NUMBER All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. N/A STF PA42021FB TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) , REV-150e.'EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF LAURETTA J SMITH 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. LEGG MASON MONEY MARKET 27,038.78 2. FULTON BANK - DEPOSIT FROM PA TREASURY DEPT ANNUITANT 010831 904.60 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 27,943.38 STFPA42021F9 REV-150s'Ex + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEOENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF LAURETTA J SMITH FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT{S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. CLAUDE W BLOSSER SR 3605 KOHLER PLACE APT 16 CAMP HILL, PA 17011 BROTHER-IN-LAW B. c. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOiNT Attach deed for joint~-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 02/00 FULTON BANK ACCT# 1068-51473 19,606.57 50 9,803.28 TOTAL (Also enter on line 6, Recapitulation) $ 9,803.28 (If more space is needed, insert additional sheets of the same size) STFPA42021F.10 1 REV-151O"EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF LAURETTA J SMITH FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM I/lK:LUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHP TO DECEDENT fWJ Tff: DATE DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER OF TRANSFER ATTACH A COPY OF Tff: DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1. AETNA ANNUITY #7518909048031NM 195,741.18 100 95,741.18 2. MFS/SUN LIFE OF CANADA (US) 53,375.58 100 53,375.58 #50-77-7700053381 3. OHIO NATIONAL #E1248337 54,105.27 100 54,105.27 4 . MFS/SUN LIFE OF CANADA (US) 38,593.63 100 38,593.63 #50-777-770088385 TOTAL (Also enter on line 7, Recapitulation) $ 341, 815.66 (If more space is needed, insert additional sheets of the same size) STF PA42021 F 11 J REV-151;.EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF LAURETTA J SMITH FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: MYERS FUNERAL HOME 3,640.00 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions B. Name of Personal Representative( s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address 2. 3. City Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) State Zip Claimant Street Address City Relationship of Claimant to Decedent State Zip 4. Probate Fees 334.00 5. Accountant's Fees 500.00 6. Tax Return Preparer's Fees 350.00 7. 8 . 9. 10. ll. 12. VERIZON TELEPHONE DANONE WATERS OF AMERICA FULTON BANK - BANK FEES FOR STATEMENT COPIES PA STATE EMPLOYEES RETIREMENT SYSTEM ANNUITY REPYMT AT&T - LONG DISTANCE TELEPHONE CHARGE BARBARA BLOSSER- TRUCK RENTAL 16.14 10.15 25.00 361.84 .71 15.90 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 5.253.74 STFPA42021F12 ~. REV-151a.EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF LAURETTA J SMITH FILE NUMBER Include unreimbursed medical expenses. ITEM NUMBER 1. N/A DESCRIPTION AMOUNT STF PA42021 F.13 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) .... REV.151:iOEX + (9-o0) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIOENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF LAURETTA J SMITH NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] HOBART BLOSSER 1. 3008 SOUTH COURT WILLIAMSBURG, VA 23185 2. CLAUDE W BLOSSER II 333 MISTY OAKS CT DAYTON, OH 45415 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) NEPHEW NEPHEW AMOUNT OR SHARE OF ESTATE 50 50 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, 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) STFPA42021F14 .. CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: lAUREITA J SMITH Date of Death: 08/18/2001 Will No. 1 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 08/22/01 : Name Address ClAUDE W BlDSSER II 3008 SOIl'T'H COIlRT WIlLIAMSBIJBG~ VA 23185 333 MISTY OAKS CT DAYTON, OH 45415 HORART RT OSSFR' Notice has now been given to all persons entitled thereto under Rule 5.6(a) except N/A Date: Signature Name Address Telephone ( Capacity: _ Personal Representative _Counsel for personal representative ., ", . ' Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters No. 2001-00785 PA No. 21-01-0785 ESTATE OF SMITH LAURETTA J (LA::i'l' , Yl1<.::i'l' , M1UULt;) Late of HAMPDEN TOWNSHIP CU1Vlbt;1<.LAl\JU CUUN'l Y , Deceased Social Security No. 189-09-0408 day of August WHEREAS, on the 22nd dated November 13th 1995 was admitted to probate as the last will of SMITH LAURETTA J (LA::i'l' , .b'11<.::i'l', JVllUULt;) 2001 an instrument late of HAMPDEN TOWNSHIP CUMBERLAND County, who died on the 18th day of August 2001 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, MARY C. LEWIS , Register of Wills in and for the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to BLOSSER CLAUDE W II and BLOSSER HOBART S who have duly qualified as Executor (rix) and have agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office the 22nd day of August 2001. 'Tn" ," f c.. ~'c~'~f'&~,;~ 1<.eglst 0 Wl S * *NOTE* * ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) .- . f" ~ SAIDIS. GUIDO. SHUFF & MASLAND 2109 Marlcet Street Camp Hill. PA LAST WILL AND TESTAMENT OF LAURETTA J. SMITH I, LAURETTA J. SMITH of Hampden Township, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any will previously made by me. I - I direct the payment of all my just debts and funeral expenses out of my estate as soon as may be practical after my death. II - I bequeath all of my estate of whatever nature and wherever situate unto my nephews, Claude W. Blosser II and Hobart S. Blosser, in equal shares, the share of a deceased nephew to be paid to his issue per stirpes. For the purposes of this distribution, adopted children shall be included in the same manner as natural born children. III - I appoint my nephews, Claude W. Blosser II and Hobart S. Blosser, Executors of this, my Last Will and Testament. Neither of my personal representatives shall be required to post bond in this or any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal on this, the / .J rL- day of :.--.;JI/~i- . , 1995. ....-.--.... / "".:' , -' . .....) .-".' / :->\~Z-.-~:a-l~K{~, s~~7f( (SEAL) I , . SAIDIS, GUIDO, SHUFF & MASLAND 2109 Market Street Camp Hill. PA Signed, sealed, published and declared by LAURETTA J. SMITH, Testatrix therein named, on this and one (1) other sheet of paper as and for her Last Will and Testament, in our presence, who, in her presence, at her request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. \X~A /;/"-, - (/ 5) .:LJ.~ Name' :J ( l~,,-/ !/...J.. /' ;; 1 Address ~( , , I I I I d/o9 /lJevvtd Sl ~MLI,;-1.;. Address I I :r::~o~ Page 2 '" I \ SAlOIS, GUIDO, SHUFF & MAS LAND 2109 Market Street Camp Hill. PA ----I COMMONWEALTH OF PENNSYLVANIA) SS. COUNTY OF CUMBERLAND) WE, the undersigned, the testatrix and the witnesses, respectively, whose names are signed to the foregoing instru- ment, being first duly sworn, do hereby declare to the under- signed authority that the testatrix signed and executed the instrument as her Last Will and Testament and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free will 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 witnesses and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind, and under no constraint or undue influence. II II ,: q !i II " II 'I II Ii J'" - ~ , .J J / -'<----<<-'0 y -.:,,-ZZ ,>-, (//---1 U ~ '\ Testatrix 'x~ r 1..J-U1~ >.; Witne'ss ' '~a~~. Subscribed, sworn to and acknowledged before me by the testatrix, .and ~~pscribed an~ ?worn ~o before me by both wit- nesses, thls \::)W day of ~(T\~("Y\ bs-i- , 1995. Notarial Seal Jo A. Luxenberger, Notary POOIC Camp Hi!! Bore. Cumberiand County My C..ommissro Exp!res May 6, 1996 , . . 1\ ,-. ",.- . ~r '. . .~,:IL~.~ J " . '. ,"''''' .\';; , '--lij 1~I11rtr~1 JI ~';. ~~W',; Jlfil~"a;: MYERS-HARNER FUNERAL HOME, INC. 1903 MARKET STREET P.O. BOX 291 CA~P HILL. PE~NSYLVA~IA 17011 ROBERT H. HAR."IER SUPERVISOR LOCALLY OWNED AND OPERATED TELEPHONE 717,; 37.9961 September 5, 2001 Mr. Claude Blosser 3605 Kohler Place, Apt 16 Camp Hill PA 17011 Services for LauRetta J. Smith August 22, 2001 Charges for Services selected Professional Services Use of Facilities Autorrotive Equiprent $ 3,445.00 $ 3,445.00 Charges for Merchandise Selected Merrory Folders $ 40.00 Cash Advanced Clergy Certified Copies Hair Dresser $ 75.00 40.00 40.00 $ 155.00 $ 3,640.00 Total due wi thin thirty. days, please: 91 /0 - ~ 19-'4L 60-14222 313. . ~ ~~!~~ OF ;11/ c: IZ.J - f) A tt..uP tJ... j- "".N' E A.. II c.. /-/0 M tE. 7iJ(2e~ 'f1./0J51t~O 01)(. J/V""rJQ.~O FO/Z.'"ry AM.o ~ - $ Jb'lo ;;. DOLLARS ~~R~ * ~~J1 FOR F<>i\J,';?'f2 A L c:;:.;< p~ tvSQ-S 11'000011 .11' 1:03.30.l. 2 21: 2 2. 11 3 b b 5 11 0 II' "'I " . ( \ RECEIPT FOR PAYMENT ------------------- ------------------- Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Receipt Date Receipt Time Receipt No. 8/22/2001 14:10:02 1026640 SMITH LAURETTA J File Number 2001-00785 Remarks BARBARA W. BLOSSER PB ------------------------ Distribution Of Receipt ------------------------ Transaction Description Payment Amount Payee Name PETITION FOR PROBA SHORT CERTIFICATE EXTRA PAGES JCP FEE 305.00 18.00 6.00 5.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D Check# 4967 Total Received.. ....... $334.00 $334.00 ~d~ ]v j; LfJ.~ J&&f ~ ~ ./' uJ~ VIJ.- J3!?~ ... . t ~ HAMILTON & MUSSER PC, CPA'S 1820 LINGLESTOWN ROAD HARRISBURG PA 17110 717 -234- 7000 NOVEMBER 9, 2001 CONFIDENTIAL Mr. Claude W. Blosser II 333 Misty Oaks Court Dayton, OR 45415-1370 For professional services rendered in connection with postage, phone calls, and preparation of inheritance tax return: $500.00 Preparation oftax returns: $350.00 $ 850.00 Amount due I ~ ~ Ver170~ Page 1 of 9 717 737-4351-894 29Y , . -~ PI ease make oavment to Ver i zon September 1 J 2001 and return this Rage with your Qayment Due Date October 1, 2001 $16.14 Fill in Amount Paid LAURETTA J SMITH 4833 E TRINDLE RD APT 570 MCHNCSBRG PA 17050-3668 111.111..1111111.1.11111111111111111111, 111,1111111,111111.1.1 $ wITJ.w0 PO Box 28000 Lehigh Yly PA 18002-8000 10971707374351894702802139000006000000000000000001614700000 R21 028 ~,. Veri70n SunvnarY~y'our account ..... ~i Page 3 of 9 717 737-4351-894 29Y September 1, 2001 , Charges from I ast month Amount of your last bill........ ...... $14.57 Amount you paid through Sep 6...... -14.57 Amount you s till owe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $.00 r Charges for this month Our charges.......................... $16.14 Call 1 800-660-7111 if you have a question Total for this month.... . Due Date Oct 1 .. ........ Total amount due A late payment charge of 1.25% may apply to any ba I ance carr i ed forward to next month 's bill. For Spanish speaking customers: Si usted no entiende 0 tiene alguna pregunta sobre esta factura Ilame al 1 800-479-0305. Preguntas sobre pagos 0 arreglos de pago Ilame al 1 800-834-0709. $16.14 $16. 14 1 95 /0 - 0;) 190/ ~22 313 PAY 6~~~~ OF_Ve tZ/ 2:-0,u ,") J ~ A/ ,:f tV KJ -%- $ /~.l#; ----- DOLLARS FOR fJl t)AJp. 7/7 -7J"} - '135"/ * ~R~ ~~~~ .. - - . - - . " .. I ~ J ~ DANONE . \I/llef' ,d . \o,'rl1 IlIIeriell I Account NOA 16 - 656 - 2051 Your next delivery days: 08/30/01 & 09/28/01 Your Sales Representative: RICK 07/20/01 10.15 Previous Balance 8.40 Credits 08/01 Check Payment [ReW: 1-122967J 8.40- Current 08/02 Char~es 12 1/2 Gal Spring Returnable 1 INCREASE 1/2 GAL CRATE 6 RETURN 1/2 GAL BOTI'LE Basic Service Charge @ O. 70 8.40 08/16 1. 75 10.15 I AIIIount Due Total Bottles on Hand 1/2 - Gallon Crates(s): 21/2 - Gallon Bottle(s): 6 93 /D - 0> 19QL 60-14222 313 PAY {) TO THE A;VOtUG WIt/8.t.S ORDER OF ~ r- ;1Jo IlL; J./ A M e-IVJC.. ~ $ 10 !2. "xv -rC?/J tA,v~ ~ - DOLLARS [i~!2~R~ *~~ FOR L,.v tJ T ll:,,<Z- 11100 0 0 q ~ III I: 0 ~ . ~ 0 .... 2 21: 2 2. q ~ b b 5 q 0 III ... Please check the reverse side for billing information and nutrition facts you should know. For Customer Service: 1-800-4-WATERS (800) 492-8377 Send this form with your payment. o Address change. Please check box and see reverse. Make Check Payable To: ~ Danone Waters of North America, Inc. P.O. Box 7126 Pasadena, CA 91109-7128 . ThiS address must show through window of reply envelope. Account No: 416-656-205 Current'CttargIs: 10. 15 ~ 3651-02-011 RIM Y LORETTA SMITH 4833 E TRINDLE RD STE 570 MECHANICSBURG, PA 17050-3668 1...111...111....1.1.11.....11..11...11..1..1..1..1.1.1..1.1.1 Plquult III_ 09/04/01 "'Du:~ 10.15 Amount Paid: $ I 0 . / .)- DANONE II/Hen ur Sorrh{merica 00010157> ,- . .. ~. .;., ..~;. 3 is to advise you that we have this day CHARGED YOUR ACCOUNT as follows: DESCRIPTION r ,. ,'- -+:;- "? r -, TO .r ~ '--' L~ ,- ,_c-o ~ ,._.... _~:n_l\~ ..~.. , - ""- ro. ", ~ i L-- -" - --"--- L --1 FultmBank 60-1421313 LANCASTER, PA., _.V~ ~ \ ). \ (.l \ , -- . $ .... ~~ - #" ~" ----- 5 r---.. ,... _ 1 U( '\ C::X. . '--' ..' '" ...- ,/, '\ -/ -t---:~e~ ~'::' aa I Gtti500 ''39 ~-_._- -"----- ------ , r.!.:" ." ; -.., - ... - :~ -;~~~_~~=._...lIt..::;..~ ~.........""') :;"_1&. ~_...~_~.~..~ ......_ 97 10 -10 oj _~__~____19__~ ~22 3\3 PAY rJ / '6~~~~ OF -n ~ S TA I E ~,0 {' L 0 Ie 5 r< Ii::TII2~Mg.vr , I~~ rj~/.-{)tJ{).'t.l~I.il';L o..t.//l- 1I,v~ ~~t2~R~ Lt]vo.l))T1\- ::')IMJ,H FOR IIfCf---(t)1 4'Yo~ 11100 0 0 q ? III I: 0 :l ~ :l 0 ~ ~ 2 21: $ 3~/. ~ svsr e A/1 / -- ------ DOLLARS * (j~{J(~ 2 2 ~ q:l b b 5 q 0 nl 1 j I' ~~ t:~ . -'. I J -.-----.--.- -~ , .~ -. COMMONWEALTH OF PENNSYLVANIA STATE EMPLOYEES' RETIREMENT SYSTEM HARRISBURG REGIONAL COUNSELING CENTER 30 NORTH THIRD STREET. ROOM 319 HARR!SBURG. PAl7101 717.783.9065 1.800.633.5461 FAX: 717.783.9599 October 2, 2001 Estate of Lauretta Smith C/O Claude Blosser 3605 Kohler Place Apt. 16 Camp Hill, PA 17011-2759 Invoice #8710 RE: SS#: Lauretta Smith 189-09-0408 Dear Mr. Blosser: We have recently been informed of the death of Lauretta Smith, a retired member of this System. We wish to extend our condolences to you at this time. Since Ms. Smith died 8/18/01 and the August check was not returned to our office, this account has been overpaid in the amount of $361.84 for the period from 8/19/01 - 8/30/01. It will therefore be necessary for our office to be reimbursed for $361.84 to liquidate this overpayment. The reimbursement should be made payable to The State Employes' Retirement System, and mailed with the enclosed copy of this letter to the address shown above. We also need a certified copy or an original death certificate for our file. Upon receipt of the reimbursement, this account will be closed. There are no further benefits to be paid from this System. Should you have any questions concerning this matter, please do not hesitate to contact me at the above address or by telephone at (717) 783-9065 or 1-800-633-5461. Thank you for your cooperation. Sincerely, Jp!&c L'o&uJ Linda Dolan, Administrative Assistant Harrisburg Regional Counseling Center Enclosure " )~our AT'&T' Statement July 27-August 26, 2001 .. r I '\ ... ". . #BWNCJFM #09131131S73010# 0 66615AV102S5B3SOA07700"SDGT 1'1.111".111"'1111.111111.1111111..11'11..1.,1..111.1..111,1 LAURETT A J SMITH 4833 E TRINDLE RD STE 570 MECHANICSBURG PA 17050-3668 Summary of dl"rgcs Previous balance ....................................................................17 .85 Payment received Aug 13 - Thank you ............................. -17.85 A T& T direct dialed calls........................................p 3 ............0.60 Other charges and credits ....................................p 3 ............0.03 Taxes and surcharges ..........................................p 3 ............0.08 Total amount due Date due $0.71 September 20, 2001 ~AT8.T Customer 10: 717 737-4351 Page 1 of 3 Customer Service: 1800222-0300 Text Phone (TTY): 1 800833-3232 Internet Address: www.att.com 4J~ Extra! Extra! Sign up for A T& T Global Military Saver Pluss,", Calling Card plan, and enjoy low domestic rates. We've even waived the monthly fee! Continued.. PAY I TOTHE ORDER OF J) I'f- T .* Ce:iI/i5 [j~~R~ FOR II' 0 0 0 0 q ... II' I: 0 ~ ~ ~ 0 ~... 2 21: 2 2. q ~ b b 5 11 0 II' 94 10- ~ 60-14222 313 19 0/ - I $ ..7/ DOLLAR S *f?~~ Total amount due Date due $0.71 September 20, 2001 Amount enclosed: $1 , 71 11111.11"1.111.1.,.1,.1,11,,1,1.1.1..,11.,1.11,,,11 AT&T PO BOX 8212 AURORA Il60572.8212 LAUAETT A J SMITH Ju127-Aug 26, 2001 Customer 10: 717 737-4351 0 D Moving? Check the box and print new address on back. 09131131573010040000000000071000000007100000000710 PETITION FOR PROBATE and GRANT OF LETTERS Estate ofl-..A.u.~-IIA J :3VY'I/~. No. dll-~ I - 7'l"S also known as To: Register of Wills for the , Deceased. County of in the Social Security No. /89- 07 - 0 Cfo S- Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older a)l the execut e>f23;. in the last will of the above decedent, dated N 00 'C:zfA ~~ 1:3,. and codicil(s) dated named ,19~_ (state relevant circumstances, e.g. renunciation, death of executor, etc.) 1<6" ,"fJ)..~..'~CI , 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: $ ~70 000,00 / . $ $ $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters -rG 5 TJ<TVv\ ~ r _ (testamentary; administration c.I.a.; administration d.b.n.c.t.a.) theron. ~ '" ~ <L> U .::: <L> :9~ "'~ <L> .... a:<L> .::: .,,0 C'O <<S";::: 3~ <L>..... ;:;0 0; .::: Ol) Vi ~ ( '\/1 ' L~:~>~--V1/{~ ~ --tfo t?ft-I2-,.s I3LoS~ 300 e, .sOl.A...TH Cb..-Lt'2.--'i 11-' II ( I '" VV\ 5 \3.l..\.~ ,Vpt- "2--'3/&-1 / C?L. AtJ~ (.,(/; }!J 1.0 :-),) L.3 ,'Z "33:3 /l-I1SJ Y C t4 ""..$ (:r- I.).q -/rcA./, CH l/ ')<1/ ':J---- , OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA } ss COUNTY OF Cillffi~ 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 y . i the estate according to law. en ()Q' ::s l::i ... s::: ~ ~ Sworn to or affirmed and subscribed before me this . 22nd. day of AUGpST ~2001 'Frxl'iC, ~J~ ~ ~~. R~~~ 17 -d-. -)0 No. 21-01-785 Estate of LAURETTA J. SMITH , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW AUGUST 22 ~001 . 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 NOV. 13,1995 described therein be admitted to probate and filed of record as the last will of LAURETTA J. SMITH TESTAMENTARY CLAUDE W. BLOSSER,II AND HOBART S.BLOSSER and Letters are hereby granted to ~ C ~;.. t:'--.{JA~ Register of WI FEES $ 305.00 $ 18.00 $ $ 6.00 5.00 TOTAL _ $ 334.00 Filed ...... AQGUS.T .22.,2001.. . . .. .. . . . . Probate, Letters, Etc. ......... Short Certificates(6 ) . . . . . . . . . . Renunciation ................ x-pages JCP A TIORNEY (Sup. Ct. 1.D. No.) ADDRESS PHONE ~ p.~ l.4>.~ r-.;l';?-ol H 1 O";}WC, RFy' 9/S(j This is to certify that the information here given is correctly copied from an original certificate of death dul~ filed with Loc~l Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filmg. me as WARNING: It is illegal to duplicate this copy by photostat or photograph. ,- "'~"'~ "'{-/ 7'-- ..' .'~' .; . ~- " ' /'// {'I."A':L~~t:. .,' f.A:/)'l/4/ '. <'. 1"-'< v 21-01-785 No. Fee for rhis certificare, $2.00 Local Regisrrar AUG 21 200\ P 7620654 Date 43 Rev. 2J87 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH UNDER' YliNI - Deyo STAtE FIlE NUMBER SOCIAL SECuRITY NUMBER NAME OF DECEDENT (fit.. MidcJIe, L_J .. LauRetta J. Snith 3. 189 09 - 0408 ClInberland ea. White SUAVIV1NG SPOUSE (........~maden....... OECEOEHT'SUSUAI.~ (Giwlund.._k .........._ ~~dO"'_''''od) 11 ary ~ OECEOEHT'SUAIl.IHG_S8lS1r...~._z..~ 4833 E. Trindle Rd. Mechanicsburg, PA 17050 ... _A'SHAMElf... _.laol) ~ .312dl:'21 Pennsylvania CoIogo (1.4orS.) .lIt. DId - Mia. Cl.lnberland _1 .1ill :;.,-=.::::.. MOTHEA.S........,lf..........._Sur.....) Martha E. Sebright .. 1NF~%1iY~~.trc:~t-lt~ Hill, PA ...... ..-,-.. 'e. 1Nl'000000'S NAME (T ypoIPrirol Henry Wolf Claude Blosser 17011 METHOD OF DISPOSITION O -~ c_o ___.0 _ llIho< ... ~OFf I'\ACEOFDlSPOSmOH. _ "~ory. C.......... .. 0IIl0I ..... lOCRlON .~. 51.... 2lp~ ... Rolling Green Mem. PAr 3'''. Camp Hill, PA 17011 ~~rs~~, 1903 Mkt St, CH, PA 17011 Dc. lICENSE NUM8EA ORE SIGHED -'Dov. -I nit. lie. WU CASE REfERRED 10 MEDICAl. EXAMlNEAK:OIlOHEA? ....0 NlA8I .. .. .- I inIerYIlf beIwMn :_ and.... I I I PART H: llIho<...-_CllIlll'iILOIngoo_..... nol'.......... in... Ul'ldIfIVIngcauae given in PART I. E ~Cbi) OItwtilzj. WERE AU10PSY FINllINGS -..e&.E PRIOlllO COUPlETlON OF CAUSE OF OERH? =A OF DE;;Y DATE OF W-'URY (~. o.v, 'lUr) flUE OF INJURY INJURY R_? OESCAIIIE HOW INJUlIY OCCURRED. Yooo NoD - o o "-- o o o PlACE CY INJURY. AI home. tarm...,.... fadofy. ollce U. __ ....'Spocolvl _. __ 0 NoD - -.. TAAR'SS~~A ~I/~I ;';/1 J'. Could noI be "em"n'" a.. 2" CERT_A IChOCk on., onol .CUTIf'YING PHYSICIAN (PhySl108n cen.fyRJ cawse d 0N&h W'hert anoIheI phySIC.., haspronounced deaItlll\O complehtd Item 23) TOlhe....ot...,knowtedtIe......occurNd.....lhecau..(.)and........................ .............. _.... ........,.......,.......,.... _.. 29. -PRONOUNCING AND ceATWYINQ PHYSICIAN (PhyscIan boIh ;,lfonounong 0HIh and C$1IfyIng 10 cau. 01 deattll ToU. beet 0' m'l knowledga...m occurred""""". dIIte. and pl... and....... ....uuMCaJ.....,.,..r .....t............................. 'IIEDICAL EXAIIINEAlCOAONEA ~anu:, a.::':t::=.~~~t.I~.~~ ~~~~~l.~: I.~ ~:'. ~.i~~ ?~~ ~~~~ ~~ ~~ ~'.~~'~: ~~.~~~~: ~.~~~ ~~ ~~~ ~~~~~~).~ 0 318. SAIDIS, GUIDO, SHUFF & MASLAND 2109 Market Street Camp Hill, PA II LAST WILL AND TESTAMENT OF LAURETTA J. SMITH I, LAURETTA J. SMITH of Hampden Township, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any will previously made by me. I - I direct the payment of all my just debts and funeral expenses out of my estate as soon as may be practical after my death. II - I bequeath all of my estate of whatever nature and wherever situate unto my nephews, Claude W. Blosser II and Hobart S. Blosser, in equal shares, the share of a deceased nephew to be paid to his issue per stirpes. For the purposes of this distribution, adopted children shall be included in the same manner as natural born children. III - I appoint my nephews, Claude W. Blosser II and Hobart S. Blosser, Executors of this, my Last Will and Testament. Neither of my personal representatives shall be required to post bond in this or any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal on this, the / .s..r;(- day of l. ;/l;~t.- 1995. ..,_......\ // \ ... . . ~/\c'i:ta~t(~' S;~~~~' (SEAL) SAIDIS, GUIDO, SHUFF & MASLAND 2109 Market Street Camp Hill, PA II 'I Signed, sealed, published and declared by LAURETTA J. SMITH, Testatrix therein named, on this and one (1) other sheet of paper as and for her Last Will and Testament, in our presence, who, in her presence, at her request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. ~..../~. , "'.. - s' ./l'........, (~.h /I~i.j~ / Addres s -( , ~ J..1~ Name I" c. ~~ dlo9lJJcvJ1I ~I ~~~ Address Page 2 SAIDIS, GUIDO, SHUFF & MASLAND 2109 Market Street Camp Hill, PA II COMMONWEALTH OF PENNSYLVANIA) SS. COUNTY OF CUMBERLAND) WE, the undersigned, the testatrix and the witnesses, respectively, whose names are signed to the foregoing instru- ment, being first duly sworn, do hereby declare to the under- signed authority that the testatrix signed and executed the instrument as her Last Will and Testament and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free will 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 witnesses and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind, and under no constraint or undue influence. .__.'~,/ . /~',:,,".., .} .( ~ , ,c . /'~d~'<T~~a~i~L;,I'~~ ~. r V'~lA... '~ ( f \ l. - _ W" une.. :~. Subscribed, sworn to and acknowledged before me by the testatrix, .and,~~pscribed an~ ~worn ~o ~efore me by both wit- nesses, thl.s ~ day of --N(Tlt€...M~ , 1995. Notarial Seal Jo A. Luxenbe~r, Notary Public Camp Hill Bora. cumberland County My Commi&'Siol1 Expires May 6, 1996 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 BLOSSER CLAUDE W II 333 MISTY OAKS CT. DAYTON,OH 45415 -------- fold ESTATE INFORMATION: SSN: 189-09-0408 FILE NUMBER: 21-2001- 0785 DECEDENT NAME: SMITH LAURETTA J DATE OF PAYMENT: 11/15/2001 POSTMARK DATE: 11/13/2001 COUNTY: CUMBERLAND DATE OF DEATH: 08/18/2001 NO. CD 000531 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $53,367.86 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CLAUDE W BLOSSER II CHECK# 99 SEAL INITIALS: PB RECEIVED BY: REGISTER OF WILLS $53,367.86 MARY C. LEWIS REGISTER OF WILLS .. Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 11/21/2001 BLOSSER CLAUDE W II 333 MISTY OAKS CT. DAYTON, OH 45415 RE: Estate of SMITH LAURETTA J File Number: 2001-00785 Dear Sir/Madam: It has come to my attention that you have not filed the Certification of Notice Under Rule 5.6 (a) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.6, shall file with the Register of Wills or Clerk of the Orphans. Court his/her Certification of Notice. This filing will become delinquent on 12/02/2001. Your prompt attention to this matter will be appreciated. Thank You. """ :-:r o E: j".':f- lil a ~.... o u /i. 0'\ N :>- o z .."J Sincerely, ~ Co !fLu, ~ /J1rJ &% CJ MARY C. LEWI S REGISTER OF WILLS p ,~ .Q .~: s= i:i)= 00 cc: File Counsel Judge Name of Decedent: Date of Death: .-0 'iJ? CERTIFICATION OF NOTICE UNDER RULE 5.6(a) '-..., Ii c} t2 r::::rrA (J'- . --S "''1 ! n."'- A (./ Ie> / G I ';;loc I Will No, 'J. 06,1 .- 007 'C)/" To the Register: Admin. No. 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 I.....A..Jr..eTJIJ.. T. ...s fV'I i"tH: Name C L A, tJ ()G"' H fJ ;3 4" (2, Address w ,~L.o.>s 2' ..=...It. '''Jl''''"" i"lt'\. _,I 0"':'__J " '" I~ I Y , tOil ,(5 ~ ~v)'-O,U ofl t/;;-/f/) I ....., 73 L t>5;0 e:/~ J 00'( 5~n-/ O,c,vc.l '"'-"('-'-11 tlA 5 -g,'h2. k:. 1.//+ ~~;;)- Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: ;1..;0 (..,J '0 >! ) :::;:,'l ;.~~I; ',~~:i,; . ~ty () ..J) u(l) 11)0: cc. fl0, dD6/ /'\ , { L0J-,--,-_JL';)j~ Signature Name (jf~~v~~~ ~ Address {LJ .3 rn I ~I V O"lA.;-; -=-.r ( ~ o ()YiOW , Df/ LJ.')!J / ') cd" -::t o g 4, CI~ q.:n Telephone ( ) c:2 f::,t; D L, I '-/ Capacity: -$- Personal Representative 1'_) ~ ~ :2: IJ) ,..0 ":c: E 0) ';j 00 'j ,""'" -:::9, _Counsel for personal representative - p ~ STATUS REPORT UNDER RULE 6.12 LA cJ neTlPr J .5M-/T,..} Name of Decedent: Date of Death: A Vip I Y I ;;} 00/ Will No.:lI-';;)b~, - bO 78" 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 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 X 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 Y No Date: 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. ~~j Signature II-.;?~-DJ ..... r" ....; o If) ";C a.. CLAJ,()e w. KJ lo 5:~5B R 17 Name (Please type or print) -3.3..3 m, -S1"Y OIf.cJ O-'t" 09v]Y>P '?4./ '1lfilN,- Address . J ~, ~ <..,:1 I....~ . ....... (':t~I: o (I) ~a: rr) I c...J c:::::l <") .\~: I::~ , ,'i) ~.g w= 00 { q:J? ~~q O(,IL/ Tel. No. Capacity: ~personal Representative Counsel for personal representative p (MAH:rmf/AM3) i (0 -d - Ie COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 171Z8-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX RecorCk;C' Re~!i:~;tsf. c of DATE :Ils ESTATE OF DATE OF DEATH E.ILE NUMBER P12 :OdOUNTY ACN FRANCINE J DOUGLASS HAMILTON 8 MUSSER 1820 LINGLESTOWN RD HBG PA .02 JAN-4 Clerk 1711~umbeflanc .. ,1"1' \._, ..;~.1j i. 12-31-2001 SMITH 08-18-2001 21 01-0785 CUMBERLAND 101 _~ 'J! ~~ REY-1547 EX iFP 112-00) LAURETTA J Allount Rellitted ) CHANGED (1) (2) (3) (4) (5) (6) (7) .00 202.66 .00 .00 27,943.38 9,803.28 341.815.66 (8) PA 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 ~ R'EV=is4-j-Ex--AFP--fi'2-:ooY-NoYiCE--oF-INHEifiTAifci-TAX-jrpPRA-isEi'-iNT~--ALlowAifCi-(rR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SMITH LAURETTA J FILE NO. 21 01-0785 ACN 101 DATE 12-31-2001 TAX RETURN WAS: (X) ACCEPTED AS FILED APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax 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. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (9) UO) 5,253.74 .00 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 379,764.98 1j.?53 74 374.511.24 .00 374,511.24 NOTE: I~ an assessment was issued previously, lines 14, lS and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ~ returns assessed to date. ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due (11) (12) (3) (14) .00 X 00 = .00 .00 X 045 = .00 .00 X 12 = .00 374,511.24 X 15 = 56.176.69 (9)= 56,176.69 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 11-13-2001 CDOO0531 2,808.83 53,367.86 TOTAL TAX CREDIT 56,176.69 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.) /b-/?6 ~ ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RECORD ADJUSTMENT DATE ESTATE OF DATE OF DEATH FILE NUMBER -COUNTY ACN HAROLD S IRWIN STES 201 202 35 E HIGH ST CARLISLE III PA 17013 01-29-2003 HALL 09-11-2000 21 00-0785 CUMBERLAND 101 '* REY-1595 EX AFP (01-OS) J R A.ount Rellitted ESTATE OF HALL J R FILE NO. 21 00-0785 ACN 101 (1) (2) (3) (4) (5) (6) (7) 39,500.00 156,309.38 .00 .00 88,375.02 .00 .00 (8) MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE __ RETAIH LOWER PORTION FOR YOUR RECORDS ....... REV=is93-E3f-AFP--COY:03Y-----..-iiftiERiYANC-i-TA-i-RE-coRi,--Afi:.uSTifiNT-..----------------------------- ADJUSTMENT BASED ON: VALUE OF ESTATE: BOARD OF APPEALS REFUND 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adllinistrative Costs/ Miscellaneous Expenses (Schedule H) Debts/Mortgage Liabilities/Liens (Schedule I) Total Deductions Net Value of Tax Return Charitable/Governllental Bequests; Non-elected 9113 Trusts Net Value of Estate Subject to Tax 10. 11. 12. 13. 14. TAX: 15. Allount of Line 14 at Spousal rate 16. Allount of Line 14 taxable at Lineal/Class A rate 17. Allount of Line 14 at Sibling rate 18. Allount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS. (9) (10) 34,092.21 1,691.45 (11) (12) (13) (14) DATE 01-29-2003 (Schedule J) (15) (16) (17) (18) .OOX 00 = 248.400.74X 045= .00 X 12 = .OOX 15 = (19) 284,184.40 35,783.66 248.400.74 .00 248.400.74 .00 11.178.03 .00 .00 11.178.03 . . ~. ""''''''.lor OTJ AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 11-30-2000 AA451517 558.90 17,094.08 12-07-2000 AA451555 .00 2.205.86 01-18-2001 REFUND .00 4,824.97- 06-26-2002 REFUND .00 165.08- TOTAL TAX CREDIT 14,868.79 BALANCE OF TAX DUE 3,690.76CR INTEREST AND PEN. .00 TOTAL DUE 3,690.76CR · IF PAID AFTER DATE INDICATED, SEE REVERSE (IF TOTAL DUE IS LESS THAN $1, 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.) BOARD OF APPEALS DEPT. 281021 HARRISBURG, PA 17128-1021 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE ~ HAROLD S IRWIN III ESQ 35 E HIGH ST STES 201 & 202 CARLISLE PA 17013 IN RE ESTATE OF: J R HALL DOCKET NO.: TAX TYPE: APPEAL TYPE FILE NUMBER: ACN: APPRAISEMENT: PETITION FILED: EXAMINER: MAILING DATE: . ,.1<. DECISION AND ORDER 0213859 INHERITANCE REFUND 21 00-0785 101 JANUARY 23,2001 JUNE 14,2002 WILLIAM J. ZDRADZINSKI Direct Dial: (717) 787-5761 Fax: (717787-7270 Email: wzdradzins@state.pa.us JAri 1 4 20m On January 23,2001, the Department issued an appraisement and assessment that valued the real estate reported on Schedule A of the estate's original inheritance tax return at $83,000.00. Petitioner has now established that the taxable value of that real estate should be reduced to $39,500.00, the value determined by an independent appraisal. Petitioner has also established that the January 23, 2001 assessment imposed tax twice on Mellon Bank Checking Account #432-216-8644: first, as item 1 on Schedule E and second, as item 20 on Schedule E. Page 1 of 2