HomeMy WebLinkAbout01-0821
MARY C. LEWIS, REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
PETITION FOR GRANT OF LETTERS
Estate of BERTHA M. BELTZ
No.21
01 -~;l..1
also known as
, Deceased
Social Security No. 201-18-0809
PAUL BERT
Petitioner(s), who is/are 18 years of age or older, apply)ies) for:
(COMPLETE "A" OR "B" BELOW:)
G]
A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut OR
Decedent, dated 7/13/99 .:Jj L.' z.. () D 0 and codicil(s) dated N/A
named in the Last Will of the
State relevant circumstances, e.g.. renunciation, death of executor, etc
Except as follows, Decedent did not marry, was not divorced and did not have a child born or adopted after execution of the documents offered
for probate; was not the victim of a killing and was never adjudicated incapacitated:
o
B. Grant of Letters of Administration
(c.la., d.b.n.c.t.a.: pendente lite, durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse
(if any) and heirs:
Name
Relationship
Residence
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his/her last family or principal
residence at MESSIAH VILLAGE, 100 MT. ALLEN DR., UPPER ALLEN TWP., MECHANICSBURG, PA 17055
(list street, number and municipality)
Decedent, then 87 years of age, died AUGUST 22 ,2001, at MESSIAH VILLAGE, MECHANICSBURG, PA
(Location)
Decedent 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 ........................................................................................ $
Total ........................................................................................................:............ $
32. oou
--
'b.2.0v-v
Real Estate situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the Last Will and Codicil(s) presented with this Petition and the grant of letters in
the appropriate form to the undersigned:
Signature
Typed or printed name and residence
PAUL BERT
R.D.#1 8543 MCCLAYS MILL RD. NEWBURG PA 17240
RW-1 17 -5 -~
Oath of Personal Representative
Commonwealth of Pennsylvania
County of CUMBERLAND
The Petitioner(s) above-named swear(s) and 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
Decedent, Petitioner(s) will well and truly administer the estate acco~g to law.
Sworn to and affirmed and subscribed ~ C<M-f ./L-J
PAUL BERT
before me this 4TH day of
SEPTEMBER. 2001.
'i-YJa; ~ p{~
DECREE OF REGISTER
Estate of BERTHA M. BELTZ
also known as
Deceased
No.21
821
01
Social Security No: 201-18-0809
Date of Death: 8/1/01
AND NOW, SEPl'EMBRR 5 ,2001 , in consideration of the Petition on the
reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters at Testamentary 0 of Administration
are hereby granted to
((c.t.a.. d.b.n.c.t.; pendente lite; durante absentia; durante minoriate)
PAUL BERT
in the above estate and that the instrument(s), if any, dated JULY 18.7.000
described in the Petition be admitted to probate and filed of record as the Last Will of Dec~ent.
FEES
Letters................ .......... ..........
Short Certificates( s) ... ..?.. .. .... .
Renunciation .... ...... ................
Extra Pages (2 ) ...............
LT. Roo. ............... .....................
JCP Fee .................................
Inventory ................................
Other ............................ ..........
TOTAL .............................$
$
70.00
W'B1~~ ~1_dYnI.
$
$
$
$
$
$
$
$
15.00
6.00
Signature
5.00
Attorney: GERALD J. BRINSER
1.0. No: 09655
Address: 6 E. MAIN STREET, P.O. BOX 323
PALMYRA PA 17078
Telephone: 838-6348
DATE FILED: SEPTEMBER 5,2001
96.00
'_""<::'.':':(\<::' ?T".V ni~.f,
This is to certify that the infJrmation here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
21-01-821
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
p
7645657
No.
~>m
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
~
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Date
NAM( Of DECEDENT I' "III. MtdcIe. l'"
...
'.Female
.. 20 I - 18
!T.flfI'llEN!.JfIIKI'
SOCIAL SECURlTV NUMBER
.. 8-22-01
87
M. Beltz
UNDER' YEAfII
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8lRTHPLACI1C,Iy Md
SWeOlfor.,nCounrrVl
t. Bertha
AGECl.. ~
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HOSPITAL ---.
,_.... 0 ."""-.... [J
Cumberland 'N.o =.::'..
MOTH€A'S HAM! IF.t111 MoGdIII. ....IdrInSut"MMtI
Minnie B. Carmack
WOAMAHT'S MAIlWO ADDRESS i$l:f..~.,.... Lip J
8543 McClay's Mill Rd., Newbur ,PA 17240
PlACI ION. Ne!MofCefMl-V.C,etnlllClfY lOCATION.C~.s...llpCodll
...,....-
"Air Hill Cemetery
OF
.FogeISllllger-Bricker F .R. Inc.
LICFN9E NUMBER
. COUNTY OF DERH
Cumberland
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TIME cw DEATH ORE PRONOUNCED DIAD (MonttI. Day. 'tlMr)
N. /I YJ2. M. 03 -:2').- 0 I
". MfIT I: Enlet the ........ infUrleI Of compIicatII)M which caused Iht d..l" CD nul ....'M mode 01 dylnQ. eue" e. c..-diae Of ~.'elorr arr"', lhock Of Nt." lailu"
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OATE OF INJURY
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WI.S AN AU'IOPSV WEAl AU'IOPSV FINDINGS MANNEAOF DEATH
P€AFOAMEO? --,"-10
CQMP\.E11DH 01 CAUSE ri?f
Of 0ERH1 ........
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....0 ...l!I' _0 ...0 ....... 0
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o P\.AC!: OF INJl)AV. AI home. fifm. MrHl. tectorv. omc. Y.
buIdInO._.ISp<<:1lvI
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Could nul be dMermlMd
...
- -
con....lChcIl only ON)
"C!RTWYWICI PH'ISICIAN (PhytlNft~ ceuM 01 dn1tt wher>.w:JltIel' ohVIlC.-n "-Pfonounced deeltl at'Cleornpteled n.m 231
,......... of,., ~.. eccunM due to 11M cauM(llend 1tl8nMf.......... . . . . .
o
oPRONOUMCltQ AND caRTtFYlNO ""SJCIAIlII~" boltl UJOt'lOUt'lClI"l ONIh.rld ~ toe... 01 dealtll
10......... 01 "" 11M....... .s.a"'OC:cWNd" the....... det.. and ptec., ... dIM to.... ellUHi.) IIfId me"""" It..ed
-MEDICAL IXA...IAICOROHI"
On ttMt 1M.. of ...mlnatlon and/or Imre......ton. In my opinion, d.... OCcurTM ..Ihe lam.. date, .nd pl.ee. and du. to 1M cau..(.).nd
...an........atlMI.......... ................................. ...........,......................................
31..
REGISTRAR'S StQNATURE AND NUMeER
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White
SURVIVING SPOUSE
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17257
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PART I:
Otwtlgftifle"'cordliON~lOdNth. buI:
_fMUlingln"'~ceuM~irlf'llYn'
tNJUAV III WORK1 DESCRIBE HOW" IflUUAY OCCUAAED
.... 0 NoD
11
...
...
DATE FILED (M()f'I\tI 0.\1. ....."
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~ /,2-, I Sf
WILL
OF
BERTHA M. BELTZ
I, BERTHA M. BELTZ, currently of Upper Allen Township, Cumberland County,
Pennsylvania, realizing the uncertainty of this life, but with confidence in God and trust in
His Son, my Lord and Savior, Jesus Christ, who died for my sins upon the cross and rose
again to redeem me and give me eternal life, do hereby make, publish and declare this to be
my Last Will and Testament, hereby revoking any and all prior Wills and Codicils made by
me.
I. I direct that all my just debts and funeral expenses be paid from the assets of my
estate as soon as practicable after my demise.
II. I direct that each beneficiary of my estate under the terms of this my Will or as
beneficiary byway of beneficiary designation on assets passing outside of this my Will shall
be solely responsible for the payment of any death taxes assessed on the portion passing unto
him or her.
III. I intend to keep with this my Will a separate memorandum concerning disposition
of certain items of tangible personal property. I bequeath the items on said list to the persons
designated.
IV. I bequeath the sum of Three Thousand Dollars ($3,000.00) each unto Henry Bertey,
Paul Bert, Robert Bert and Eva Mae Brubaker, in appreciation for their counsel and help
during recent years of transition. If any of these individuals predecease me, his or her share
shall lapse.
V. All the rest, residue and remainder of my estate, of whatever nature and wherever
situate, including property over which I hold a power of appointment, I devise and bequeath
as follows:
A. One-third (1/3) unto Messiah Village, Mechanicsburg,
Pennsylvania, to be used in its Endowment Fund.
~
-1-
Y3~vJ h). ~
B. Two-thirds (2/3) unto Brethren In Christ World Missions,
Grantham, Pennsylvania, to be used as it determines best.
VI. I appoint my nephew, Paul Bert, Executor of this my Will. In the event that he fails
to qualify or ceases to act as Executor, I appoint Douglas R. Bert Executor in his place.
VII. I direct that no bond be required of my fiduciaries for the faithful performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I, BERTHA M. BELTZ, herewith set my hand to this
my Last Will, typewritten on two (2) sheets of paper including the attestation clause and
signatures of witnesses, this I~day of %-,2000.
ti~~z;: (SEAL)
BERTHA M. BELTZ ---0
Signed by BERTHA M. BELTZ, by her declared to be her Will in our presence, who
have hereunto subscribed our names as witnesses in her presence and at her request, this
l~ayof ~ ,2000.
/~..u-/ -L ~- residingat ~ ..:..u~, I!
tJJ.fud.tj'd,. Q,p~rfuL residingat -!M,KUN 1..<I!buJ1l. , flfl
-2-
COMMONWEAL TH OF PENNSYL VANIA
COUNTY OF LEBANON
WE, BERTHA M. BELTZ, GERALD J. BRINSER and ()JVJDj i.... CMwF01<.D ,
the testator and the witnesses, respectively, whose names are signed to the attached or
foregoing instrument, being first duly affirmed, do hereby declare to the undersigned
authority that the testator signed and executed the instrument as his Last Will and that he
signed willingly (or willingly directed another to sign for him), and that he executed it as his
free and voluntary act for the purposes therein expressed, and that each of the witnesses, in
the presence and hearing of the testator, signed the Will as witnesses and that to the best of
our knowledge the testator was at that time eighteen years of age or older, of sound mind and
under no constraint or undue influence.
~ ?!1. ~
BERTHA M. BELTZ
~.~~
W(TNESS /'
IAJ~ r!ft. CM;1f'L
WITNESS
Subscribed, sworn or affirmed and acknowledged before me by BERTHA M. BELTZ,
the testator, GERALD J. BRINSER and\..lJ2NJ)~ L.,. Cf-I\ WFo ~ , witnesses, this J 8'~
day of ~ ,2000.
~u~
Nota PublIc
(SEAL)
-3-
MARY C. LEWIS, REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
JS
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: BERTHAM. J:lEI. TZ__
Date of Death: 6/22/01
Estate No.
SSN: 201-18-Q609
File No. ~1-QJ-Q821
Date Letters Granted: 9/4/01
Will or Administration No.__
To the Register:
I certify that Notice of Estate Administration required by Rule 5.6(a) of the Orphans' Court Rules was served
on or mailed to the following beneficiaries of the above-captioned estate on 9/24&1
Name
HARRY BERGEY
Address
2840 LOUISIANA AVENUE
~l\1.. TIMO~_. _____
753 MESSIAH VILLAGE
ME:CHANIC~BJJR~__
7514 COLUMBUS AVENUE
SQ!..IIH RICl:lflEL[L__
P.O. BOX 290
GRl\NTH8M____ _
100 MT. ALLEN DRIVE
MI;CHANICSI3UR~
MI:L2122.7
EVA MAE BRUBAKER
ROBERT L. BERT
PA_JZQ5p_
BRETHREN IN CHRIST FOUNDATION
MI'J5~42_3
MESSIAH VILLAGE
_PA1?Q2.7-0290
Pl\ 17Q{)_5
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
PAU~BERT,EXECUIQR
Personal Representative
X Counsel for Personal
Representative
~9'~.1~
Signature
~.ERALD J.I3BltfSER,EsaUIRE (#0!;lE35~)
Name (Please type or print)
Date: 9/24/01
Capacity:
Address
lLE. MAl1'JSTRE:ET. P.Q._130X:32.:3
PAl.MYRA
PA.17078
Telephone No. (717)6:36-6348
LAW OFFICES
BRINSER, WAGNER & ZIMMERMAN
6 EAST MAIN STREET - SECOND FLOOR
(EAST MAIN & SOUTH RAILROAD STREETS)
P. O. BOX 323
PALMYRA, PA 17078
PHONE: (717) 838-6348
FAX: (717) 838-6912
MECHANICS BURG OFFICE
MESSIAH VILLAGE
100 MT. ALLEN DRIVE
MECHANICS BURG, PA 17055
PHONE/FAX (717) 795-1737
GERALD J. BRINSER
KEITH D. WAGNER
JOHN M. ZIMMERMAN
November 14,2001
Mary C. Lewis, Register of Wills
Cumberland County Court House
S. Hanover Street
Carlisle, P A 17013
In Re:
Bertha M. Beltz Estate
No. 2101-0821
Dear Ms. Lewis:
Enclosed you will find a check in the amount of$I,71O.00 as payment towards the
inheritance tax for the above-captioned estate.
If you have any questions, please feel free to give me a call.
Thank you.
Very truly yours,
BRINSER, WAGNER & ZIMMERMAN
~&.~~/~~
Gerald J. Brinser
GJB/wlc
Enclosure
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B0601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BRINSER WAGNER & ZIMMERMAN
22 N RAILROAD STREET
PALMYRA, PA 17078
-------- fold
ESTATE INFORMATION: SSN: 201-1 8-0809
FILE NUMBER: 21-2001- 0821
DECEDENT NAME: BEL TZ BERTHA M
DATE OF PAYMENT: 11/15/2001
POSTMARK DATE: 11/14/2001
COUNTY: CUMBERLAND
DATE OF DEATH: 08/22/2001
ACN
ASSESSM ENT
CONTROL
NUMBER
101
TOTAL AMOUNT PAID:
REMARKS: BRINSER WAGNER & ZIMMERMAN
CHECK# 101
SEAL
INITIALS: PB
RECEIVED BY:
REV-1162 EX(11-96)
NO. CD 000534
MARY C. LEWIS
REGISTER OF WILLS
RBGIs1ER OF WILLS , ','
AMOUNT
$ 1 , 71 0.00
$ 1 ,71 0.00
MARY C. LEWIS, REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
INVENTORY
Estate of BERTHA M. BELTZ
No. 21
01
0821
also known as
, Deceased
Date of Death 08/22/2001
Social Security No. 201-18-0809
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no
real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We
verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the
penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Personal Representative:
~ BERT
t/J-p~ /J~~
Dated 311t..-/~ t...
PALMYRA
PA 17078
Telephone: (717)838-6348
Description
Cash, Bank Deposits, & Misc. Personal Property:
Value
PNC BANK - CHECKING ACCOUNT #5000001102
12,648.60
BRETHREN IN CHRIST FOUNDATION
(INCLUDES ACCRUED INTEREST OF $56.08)
24,425.37
BURIAL FUND - REFUND
1,221.08
BLUE CROSS/BLUE SHIELD - REFUND
316.90
VERIZON - REFUND
15.54
Total
(Attach Additional Sheets if necessary)
38,627.49
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative,
include the value of each item, but such figures should not be extended into the total of the Inventory.
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LAW OFFICES
BRINSER, WAGNER & ZIMMERMAN
6 EAST MAIN STREET - SECOND FLOOR
(EAST MAIN & SOUTH RAILROAD STREETS)
P. O. BOX 323
PALMYRA, PA 17078
PHONE: (717) 838-6348
FAX: (717) 838-6912
March 12, 2002
MECHANICSBURG OFFICE
MESSIAH VILLAGE
100 MT. ALLEN DRIVE
MECHANICS BURG, PA 17055
~ ~;PHONgFAX (7~ ~5-1737
~,. ,- N ",~< ;~:::
,
:5
Xj
GERALD J. BRINSER
KEITH D. WAGNER
JOHN M. ZIMMERMAN
Mary C. Lewis, Register of Wills
Cumberland County Court House
S. Hanover Street
Carlisle, P A 17013
,-.)..)
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In Re:
Bertha M. Beltz Estate
No. 21-01-0821
Dear Ms. Lewis:
Enclosed you will find two (2) copies of the Inheritance Tax Return and one (1) copy
of an Inventory for the above-captioned estate. Also enclosed is a check in the amount of
$25.00 in payment of the $10.00 filing fee for the Inventory and $25.00 filing fee for the
Tax Return. The inheritance tax has already been paid.
If you have any questions, please feel free to give me a call.
Thank you.
Very truly yours,
wlc
Enclosures
BRINSER, WAGNER & ZIMMERMAN
w~~~~~
Estate Secretary
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT. ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
'02
nflI' -3
:.\1~! :?O
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
04-29-2002
BEL TZ
08-22-2001
21 01-0821
CUMBERLAND
101
GERALD J BRINSER
BRINSER ETAL
PO BOX 323
PALMYRA
ESQ
*'
REV-15~7 EX AFP (01-021
BERTHA
M
Allount Relli Hed
C,_
P A 1f}oViaJ
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 ~
REV=i5"4-j-iY-AFP-(iff':02Y-NOYici--OF-YNHiifiTANCE-YA'X-jrPPRAisiifiNT~--ALLOWANCE-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BELTZ BERTHA M FILE NO. 21 01-0821 ACN 101 DATE 04-29-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Hortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
38,627.49
.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)
(10)
3.178.35
8.608.36
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account.
subllit the upper portion
of this forll with your
tax paYllent.
38.627.49
11 .786 71
26.840.78
14.840.78
12.000.00
NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF 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
T X C DITS:
(15) .00 X 00 = .00
(16) .00 X 045 = .00
(17) .00 X 12 = .00
(18) 12.000.00 X 15 = 1.800.00
(19)= 1.800.00
AHOUNT PAID
1.710.00
+
INTEREST/PEN PAID (-)
90.00
DATE
11-14-2001
NUHBER
CD000534
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
1.800.00
.00
.00
.00
. IF PAID AFTER DATE INDICATED. SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1. NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
STATUS REPORT UNDER RULE 6.12
'~)(
Name of Decedent: BERTHA M. BELTZ
Date of Death: 8/22/01
Will No. 2001-00821
Admin. No.
Pursuant to Rule 6. 12 of the Supreme Court Orphans I
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
I . State whether administration of the estate is complete:
Yes X No
2 . If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3 . If the answer to No. 1 is Yes, state the following:
a.
account with the Court?
Did the personal representative file a final
Yes No X
b. The separate Orphans I 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.
Date: 5/29/02
~~.~l~
Signature I
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GERALD J. BRINSER we.
Name (Please type or print 1lt
6 E. MAIN STREET, P.O. BOX 323
PALMYRA PA 17078
Address
( ( 711) 838- 63'H~
Tel.No.
fY)
Capacity :
Personal Representative
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Counsel for personal
representative
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICiAl USE ONLY
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FILE NUMBER
21-0 0 8 2 1
COuNTYCOiiE -YEA~ - - NuMBER- -
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DECEDENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL)
BELTZ BERTHA M.
DATE OF DEATH (MM-DD-Year)
SOCIAL SECURITY NUMBER
DATE OF BIRTH (MM-DD-Year)
2 0 1 - 1 8 - 0 809
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
08/22/2001 OS/27/1914
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
N/A
SOCIAL SECURITY NUMBER
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00 1. Original Return
D 4. Limited Estate
00 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 olTrust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
D 3. Remainder Return (date of death prior to 12-1J..82)
D 5. Federal Estate Tax Retum Required
Q.. 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Atlach Sch OJ
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THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE ANDCONFIDENTlAL TAX INFORMATION SHOUl..D BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
GERALD J. BRINSER ESQUIRE 6 E.MAIN STREET
FIRM NAME (If Applicable)
BRINSER WAGNER & ZIMMERMAN P.O. BOX 323
TELEPHONE NUMBER
717838-6348 PALMYRA PA 17078
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)
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)
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
..-. ,...
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OFFICIAL USE ONLY
(1)
(2)
(3)
(4)
(5)
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38,627.49
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(8)
38,627.49
3,178.35
8,608.36
(11)
(12)
(13)
11,786.71
26,840.78
14,840.78
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
12,000.00
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
0.00 X .OL(15)
0.00 X .04.5 (16)
0.00 X .12 (17)
12,000.00 X .15 (18) 1,800.00
(19) 1 ,800.00
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SI.DE AND RECHECK MATH < <
R~V-1508~X+(1:7) ~
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
BELTZ. BERTHA M.
FILE NUMBER
21 01
0821
Include the proceeds of lijigation 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. PNC BANK - CHECKING ACCOUNT #5000001102 12,648_60
2. BRETHREN IN CHRIST FOUNDATION 24,425.37
(INCLUDES ACCRUED INTEREST OF $56.08)
3. BURIAL FUND - REFUND 1,221.08
4. BLUE CROSS/BLUE SHIELD - REFUND 316_90
5. VERIZON - REFUND 15.54
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
38627.49
R~V.15115<+(1'9:J .~.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
BELTZ. BERTHA M.
FILE NUMBER
21
01
0821
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
1.
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s) PAUL BERT
Social Security Number(s)I EIN Number of Personal Representative(s)
Street Address 8543 MCCLAYS MILL ROAD
City NEWBURG State PA Zip 17240
Year(s) Commission Paid: 2002
965.00
2.
3.
Attorney Fees BRINSER, WAGNER & ZIMMERMAN
1,930.00
Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation)
Claimant
Street Address
City
State
Zip
Relationship of Claimant to Decedent
4.
Probate Fees REGISTER OF WILLS
96.00
5.
Accountanfs Fees
6.
Tax Retum Preparer's Fees
7.
8.
9.
10.
CUMBERLAND LAW JOURNAL - LEGAL ADVERTISING
THE SENTINEL - LEGAL ADVERTISING
TAX RETURN FILING FEE
INVENTORY FILING FEE
75.00
87.35
15.00
10.00
TOTAL (Also enter on line 9, Recapitulation) I $
(If more space is needed, insert additional sheets of the same size)
3178.35
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF
BELTZ. BERTHA M.
FILE NUMBER
21
01
0821
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
5,899.36
1,
MESSIAH VILLAGE - BALANCE DUE
2.
OUTSTANDING CHECK AT TIME OF DEATH (MESSIAH VILLAGE)
2,709.00
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TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
8 608.36
MESSIAH VILLAGE
STATEMENT
100 Mt. Allen Drive
P.O. Box 2015
Mechan:csburg, PA 170552015
(717) 697-4666
Resident: BERTHA M BELTZ
Resident Number Date
000019710 08/31/2001
Page Amount Due
1 5,889.36
Discharge Date 08i2212001
B
I BRETHREN IN CHRIST FOUNDATION
l P.O. BOX 290
l GRANTHAM, PA 17027
T
o
Date
Description
1
Charges
Credits
Total
08/0112001
08/01/2001
08/0212001
Beginning Balance
WAGNER - PRIVATE RM - PVT PAY
21 DAYS AT 178.00 PER DAY
PC - JUNIATA REGULAR
OXYGEN
3,738.00
2,709.00
6,447.00
1,851.36
300.00
8,298.36
8,598.36
08/09/2001 GUEST ROOM - APARTMENT 175.00 8,773.36
08/2212001 GUEST ROOM - APARTMENT 175.00 8,948.36
0812912001 PAYMENT RECEIVED - THANK YOUI -2,709.00 6,239.36
08/3112001 PAYMENT RECEIVED - THANK YOU! -175.00 6,064.36
08/3112001 PAYMENT RECEIVED - THANK YOU! -175.00 5,889.36
--
Current Past 31-60 Days 61-90 Days 91.120 Days Over 120 Total Due IBERTHA M BELT
4,038.001 Due
0.00 1.851.36 0.00 5,889.36
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COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
BF=I T2 BI=RTHA M.
FILE NUMBER
21 01
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
nA21
AMOUNT OR SHARE
OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S} RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1.
HARRY BERGEY (Referred to as Henry Bertey in Will)
2840 lOUISIANA AVENUE, BALTIMORE, MD 21227
NEPHEW
$3,000.00 CASH
2.
PAUL BERT
8543 MCCLAYS MILL ROAD, NEWBURG, PA 17240
NEPHEW
$3,000.00 CASH
3.
ROBERT BERT
7514 COLUMBUS AVENUE, S. RICHFIELD, MN 55423
NEPHEW
$3,000.00 CASH
4.
EVA MAE BRUBAKER
753 MESSIAH VilLAGE, MECHANICSBURG, PA 17055
NONE
$3,000.00 CASH
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.
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
MESSIAH VillAGE, ENDOWMENT FUND (1/3 OF RESIDUARY ESTATE)
100 MT. AllEN DRIVE, MECHANICSBURG, PA 17055
4,946.93
2.
BRETHREN IN CHRIST WORLD MISSIONS (2/3 OF RESIDUARY ESTATE)
P.O. BOX 290, GRANTHAM, PA 17027-0290
9,893.85
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)
14840.78
WILL
OF
f
L
:,_J
BERTHA M. BELTZ
I, BERTHA M. BELTZ, currently of Upper Allen Township, Cumberland County,
Pennsylvania, realizing the uncertainty of this life, but with confidence}n God and trust in
His Son, my Lord and Savior, Jesus Christ, who died for my sins upon the cross and rose
again to redeem me and give me eternal life, do hereby make, publish and declare this to be
my Last Will and Testament, hereby revoking any and all prior Wills and Cqdipils made by
~: - .
me. .
1. I direct that all my just debts and funeral expenses be paid from the assets of my
estate as soon as practicable after my demise.
II. I direct that each beneficiary of my estate under the terms of this my Will or as
beneficiary by way of beneficiary designation on assets passing outside of this my Will shall
be solely responsible for the payment of any death taxes assessed on the portion passing unto
him or her.
III. I intend to keep with this my Will a separate memorandum concerning disposition
of certain items of tangible personal property. I bequeath the items on said list to the persons
designated.
IV. I bequeath the sum of Three Thousand Dollars ($3,000.00) each unto Henry Bertey,
Paul Bert, Robert Bert and Eva Mae Brubaker, in appreciation for their counsel and help
during recent years of transition. If any of these individuals predecease me, his or her share
shall lapse.
V. All the rest, residue and remainder of my estate, of whatever nature and wherever
situate, including property over which I hold a power of appointment, I devise and bequeath
as follows:
A. One-third (1/3) unto Messiah Village, Mechanicsburg.
Pennsylvania, to be used in its Endowment Fund.
~
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B. Two-thirds (2/3) unto Brethren In Christ World Missions.
Grantham, Pennsylvania, to be used as it determines best.
VI. I appoint my nephew, Paul Bert, Executor of this my Will. In the event that he fails
to qualifY or ceases to act as Executor, I appoint Douglas R. Bert Executor in his place.
VII. I direct that no bond be required of my fiduciaries for the faithful performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I, BERTHA M. BELTZ, herewith set my hand to this
my Last Will, typewritten on two (2) sheets of paper including the attestatiO!! clause and
signatures of witnesses, this I <ifthday of ~, 2000. \- .
~~~z: (SEAL)
BERTHA M.'BEL ii'o
Signed by BERTHA M. BELTZ, by her declared to be her Will in our presence, who
have hereunto subscribed our names as witnesses in her presence and at her request, this
l~ay of ~ ,2000.
/~~..L ~- residing at ~ ~'" I!
WfAr1.tJ 'cA. Q, fI~~ residingat J/" KWlJ MltruM , &3
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF LEBANON
WE, BERTHA M. BELTZ, GERALD J. BRINSER andlA)VJDj i.... Cl<.AwpoRD ,
the testator and the witnesses, respectively, whose names are signed to the attached or
foregoing instrument, being first duly affirmed, do hereby declare to the undersigned
authority that the testator signed and executed the instrument as his Last Will and that he
signed willingly (or willingly directed another to sign for him), and that he execut~d it as his
free and voluntary act for the purposes therein expressed, and that each of the witnesses, in
the presence and hearing of the testator, signed the Will as witnesses and tl}ati'o the best of
our knowledge the testator was at that time eighteen years of age or older, of sound mind and
under no constraint or undue influence.
~ fl). ~
BERTHA M. BELTZ
~'~R-
WITNESS /
/)J~ Cf, 0a1~
WITNES
Subscribed, sworn or affirmed and acknowledged before me by BERTHA M. BELTZ,
the testator, GERALD J. BRINSER and \,V(J.JJ)~ L. Ct-A W Fe) fJ) , witnesses, this J 8'f-1'...
day of ~ ,2000.
~~.~=
Not PublIc
(SEAL)
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