HomeMy WebLinkAbout01-0864
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of ;( Of r elf-; J. . If. cJ t ~ No. ~ /" 0 J - ~ ~ t../
also known as To:
Register of W. Is f?r ,t?~ ~_ j
" Dece9~ed. County of ~. in the
Social Security No. / f'lj; - .3 (A -? CJ 7 I Commonwealt of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who islare 18 years of a~~r an the executft"K
in the last will of the above decedent, dated _~ cf2 r I I 9t? j/
and codicil(s) dated ~/ /J- r7 .
named
,19~
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
ears of age, died
m ~ ~- ~
Except as follows, de oent did not marry, w s not divorced and did not have a child born or adopted
~fter execution of the wi~ffered for probate; was not the victim of a killing and was never adjudicated
mcompetent: /J /"1-
/ /'
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 pe'i~IVania
situated as follows: / /)-
.
, ~dOCJ /,
~~ tJCJ (/
$
$
$
$
WHEREFOR~, petitioner(s) respectfully reqqest(s) the probate of the last will and codicil(s)
presented hereWIth and the grant of letters t- e G t a ~""e ~{O (' '(
(testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
theron.
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OATH OF"PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA I ss
COUNTY OF CllmherlFmci J
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
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No. 21-2001-864
Estate of
KAREN L. OOTZ
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW September 20th J9f 200~ 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 July 24th, 1994
described therein be admitted to probate and filed of record as the last will of
KAREN L. ROTZ
TESTAMENTARY
LINDA R. WELIX)N
and Letters
are hereby granted to
Q,
\
dt~ /
lliWIS .'
FEES
Probate, Letters, Etc. .........
Short Certificates( 4) . . . . . . . . . .
Renunciation ................
x-PAGES (3)
JCP
$ 50.00
$ 1? 00
$
$
TOTAL _ $ 5.00
SEPI'EMBER 9th,2001 $76.00
ATTORNEY (Sup. Ct. 1.0. No.)
9.00
ADDRESS
Filed
PHONE
MAILED LE'ITERS AND ORDER 'IO EXECUTRIX.
5.805 REV 9/86
This is to certify that the information here given is correctly copied fron: an original certificate of death dul~ filed with
Local Registrar. 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.
me as
No.
li._ (:\. ~'t.) ~~~~
Local Registrar
Fee for this certificate, $2.00
p
7578620
SEP 1 2 2001
Date
21-2001-864
"'05.103 Aev. 2187
COMMONWEALTH OF PENNSVlVANIA . OEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
,.n
UNOER , DAl'
-... I MlnuI..
SEX
STAfE F'l.E NUMBER
SOCIAL SECUAITY NUMBER
,NT
-.1<
NAME OF DECEDENT If~... Middle. Las,
1. Karen L. Rotz
AGE Ita. _vi UNDER' YEMl
~... Days
2. Female 3. 186 36
BIRTHPLACE (C./y alld PLACE OF DEATH tC_k 0f"Y """ -- _ ,MlIucl.,.,. on _, _I
Sw. Of Fere.on Coun.y, HOSPITAl.:
Chambersburg , PA 1_'_ W ER/OulpaIoel1l 0
7. ...
FACilITY NAME pi "'" oMl'MlOn. Qlve SI'''' and num_,
()()/
17.. SI.,.
PA
MARITAL STATUS. loi_
N.....' Marr*,. W~~
0N00c1d (Speo:oIy)
,.. Never Married
He.ex _.__In
White
SUIMVING SPOuSE
Iff'_.~_"""")
,-~;( ~
Dauphin
DECEDENT'S USUAL OCCUP>QION
(~=:~ "=' ':::Zl.:'f
. ,C,ertified Nurse Asst. l1~ursing Home
DECEOIENT'S MAllING AOOAESS lSlr.... CoIyIbon. SlMe.I~COClel DECEDENl'S
7073 Carlisle pike ~1~~
Carlisle, Pa 17013 ~~
Ie.
1711, Coun
Old
--
We in .
r.llm~l'" 1 ~ nn townlhip? 17d.O ::::'=..'::'01
MOTHEA'S NAME IF... _. loAa""" s...nam.,
Doroth Kitner.
~; J U9t" C::rd n'J
-
1..
FRHEIl'S NAME IF.... 1.1_. L....)
1.. Cal vin B. ~otz, Jr.
_ClAMAHT'S NAME IT ypII",;"c\
cily/lloro.
(l\<- h; -:. h.A-. L LA.. -re r ~ /\ (. (u,,\(' ~ /-
DUE 10 lOA AS A CONSEOUENCE OFt.
231>. >>C.
MS CASE AEFEAAED TO MEDICAl EXAMINERlCORONEIl? ;...,
Ve. 0 No~
2t.
, """"'....... PIl.Rl N: OlI>Ir .igMIcll1l CllI1CIIlioN conlriIlolIinO 10 de.llI. "'"
: inI_be_n not -in9 in 11\1 ~ _ giwIn in PAAT'
: onMt and de_""
: ,) r-
[ :
DUE 10 lOA "s A CONSEOUENCE OF):
DUE 10 (OR AS A CONSEOUENCE OF):
WERE AUTOPSY FINOlNGS MANNER ~ DEATH
AIAlLAlllE ""lOA 10
COMPLETIOM OF CAUSE _ural 't1. Hom;,:ide 0
OF DER'M?
Accident D Pend10g ,rwesttgation 0
v.. 0 No 0 Suicide D Could not be dO'erm!f\lCl 0
DAlE OF INJURY
("''''''''.lley. ""a"
TIME OF INJURY
ItoIJURY Al WORK' DESCRIBE HOW IN.JURY OCCURRED.
Yee 0 NoD
3 . M. 3Ile.
PLACE 01' INJURY. "'.hom.. larm. Itr.... I.Clory.otfic.
~ ..c. (Speedv!
2IL 211l. 2t. 3Oe.
CDl'TIF~" \0-- cnoy 0f\Il
.CERTIFYING Pt4YSICSAH tPhy5lOat'l CMffytnc;J cause r:J dHth wf\ef" ,)~f'tet Qhvs.c:l<Bn has OIOOQlJnced deal" ana com~ed nern 2~)
To..bntof...y .now...,.. cseethoccUff'lod esu.\o.... e~....).nd m.nn.I'.. .1.ted. .......,.......
'ME/IlCAl. VlAMIHER'COAONER
On the tMIaia 0' exam'natlon IndJOI' invesliQ..tiotl. in mV opinion, death occurred '1 tn. Um.. dll., and place. and due to the c.uae(a) and
",enn., .. .tlted. . . . . . .. . . ~ . . . . . . . . . . . . . . . , , . , . . . . , . , , , .
3'..
REGISlRAR'S SIGNATURE AND N B
~. ~bJ...~
~ \ 'd.L \ ,()I
D
.~ AND aRlIFY'NO I'IiYSIClAN (Ph_ /loin :><""""f\C"'9 oe.'" and ''''''Y''''l \0 cause of oea""
To the be'd of my knoVlrM1Sgfl', death oceurred.t the time. date, and pIKe, and due to the caUH(S'and manner .. slated..
\6-. otle \
)
LAST WILL AND TESTAMENT
I, KAREN L. ROTZ, of 7073 Carlisle Pike, Lot 39, Carlisle, Cumberland County,
Pennsylvania, do hereby make, publish and declare this to be my last will and testament, hereby
revoking all wills heretofore made by me.
1. I direct my personal representative to pay all of my debts, funeral and administrative
expenses as soon as convenient after my decease.
2. I authorize and empower my personal representative to sell any realty and/or personalty
owned by me at my death and not specifically devised or bequeathed herein, at public or private
sale or sales and to give good and sufficient deeds and/or bills of sale therefor, in fee simple, as I
could do if living. My representative is authorized and empowered to engage in any business in
which I may be engaged at my death, for such period of time after my death as seems expedient to
said representative.
3. I give, devise and bequeath all of my estate of whatever nature and wherever situate as
follows:
A. The proceeds of my savings account and checking account to Calvin B. Rotz,
Jr., Dorothy K. Rotz and Linda R. Weldon, share and share alike, or the survivor thereof;
B. My piano and antique rouge container to Erica L. Weldon;
C. My antique pie shelfand baby rattle to Matthew K. Weldon;
D. My antique drop leaf table and green crochet hook to Nathan A. Weldon; and
E. All the rest, residue and remainder to Erica L. Weldon, Matthew K. Weldon
and Nathan A. Weldon, share and share alike, the child or children of any deceased beneficiary
taking the share their parent would have taken if living.
4. If any of my beneficiaries are under the age of twenty-one (21) years at my death, then
said beneficiary's share of my estate I give, devise and bequeath to be held in trust by the
hereinafter mentioned trustee according to the following terms and conditions:
The trustee, as well as my representative, is hereby authorized to retain, unconverted, any
property, real or personal, that I may own at my death and shall be under no duty to convert it
into legal investments. The trustee shall have the power and authority to sell, transfer, convey,
invest and reinvest and to pay over the net income of the trust property, to or for the use of said
beneficiary, or to accumulate it in the sole discretion of the trustee. The trustee is also authorized
and empowered to pay over to, or for the use and benefit of said beneficiary such portion of or all
of the principal of the trust estate as in the trustee's sole discretion seems proper for said
beneficiary's support, maintenance, education, or medical care. My primary object is to insure the
support, maintenance, education and medical care of said beneficiary until he reaches the age of
twenty-one (21) years. As each such beneficiary reaches the age of twenty-one (21) years, then
whatever remains of income or principal of his trust estate shall be distributed to said beneficiary.
5. I nominate and appoint Linda R. Weldon to be the personal representative of my
estate, to serve without bond. If she cannot or does not serve, then I appoint Matthew K.
Weldon to be the substitute personal representative with the same powers and without the filing
of any bond.
6. I appoint Farmers Trust Company, Carlisle, Pennsylvania to be the trustee of any trust
created herein.
7. I suggest that my personal representative retain the services of Harold S. Irwin, ill,
Carlisle, Pennsylvania in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal thi~t:A day of July,
1994.
~..-{ /..-./ ;:;(~ (SEAL)
N L. ROTZ
Signed, sealed, published and declared by the above-named person as and for a last will
and testament, in our presence, who at said person's request, in said person's presence and in the
presence of each other have hereunto set our names as subscribing witnesses.
.,\JjA~~Jdeiw~
etty/vr ddu/
ACKNOWLEDGMENT AND AFFIDAVIT
WE, KAREN L. ROTZ, SHARON L. SCHWALM and CHERYL L. CLELAND,
the testatrix and witnesses respectively, whose names are signed to the foregoing instrument,
being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and
executed the instrument as her last will and that she had signed willingly, and that she executed it
as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in
the presence and hearing of the testatrix, signed the will as a witness 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.
~ y~
...... .P /./'2.../ (
. N L. ROTZ 7 --
yM~ t>f!~~
SHARON L. SCHWALM
~/e!k/
CHE L. CLELAND
COMMONWEALTH OF PENNSYLVANIA
:SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by KAREN L. ROTZ, the testatrix
herein, and subscribed and swofl>>to before me by SHARON L. SCHWALM and CHERYL L.
CLELAND, witnesses, thi~aJ day of July, 1994.
Notarial Seal
Betzi A Mooison, Notary Public
Carlisle Bora, Cumbel1and County
My Commission Expires Dee. 15, 1996
MenDer. PennsylvaniaAssodation of Notaries
2
72002
10:45
717-834-9012
R SCOTT CRAMER
PAGE 01
....'
CIRTIFICATION OF NOTICE UNDER RULE 5.6(a)
.... of. Dececlent I I<a {" cv r0 ~ t ~ AN e Ro 1 "2-
Dat:. of o..~hl q'J /0 liJoo I
, I
Will 110. joo / -- 06 ['it tf Admin. No. () /-0 I -(]& '/
'to the Regis ter,
I a.~lly ~h.t no~lc. of b.neflclal 1nt.~..t ~.q~1~.d ~y
Rule 5.'(4) of the Orphans' Court ~ules W4S served on'or mailed to
th./~ollowin9 beneficiaries of the above-captioned estate on
~11~<1l1 .
I!IIB
Addre..
L~) ;)CJ/
(?a \\ H ~ (~ t: o1'z J r i rm .r C-oi I a k..)d A uc, ~ ~ H" beIsb Ll .- '71 <-
-or";} rat h'-( 1<. (~1 2 ,.} r- '('60 [}(!o f l C( ~ ALty chQ ~ VJ i9/'S bU'YJ /.) ~- 7 a-ol
En (! c::v L .SCd)'u.S 00 Lt 57..) k)c.JI rY\.A1fY\C.".....u Ro c. d, L4or'-A~:it-JrCJol<, pt-- /9 3'1 'f
fu~LU Lu?Ldd~ Q.O 30 -Do a -Le.' C( f'C Ie. J-I-CL ~r b '-l t/ p~ 1)/10
t\J a:-\:;- \rt 0- "-' l...L-' e lei oJ 0 0 0 -PCl y .CJ (c C{ l<C C- I rc. (eo , 1-1 C<.... r r" I <5 b l..f "" f? ~ I 7/1 ()
Notlee ha. now been 91ven to all persons entitled thereto under
R~l. 5.6(.) except
Oat.. /'"i/~ 101
/
S!g~~ C1.l-e-k(oJ
Name J- I JLJd ~ LtJ::::/ /d. 0 pJ
~ddl:." ~ f'y\C- ~~-b^-, ~(~,
D Ujl...J c..~ ~ ILb /-J 1< --- I -20 c:JD
Telephone OJ 71 r 3 y --,5-0L40 t,
Capacity: )( Personal Repre.entative
Counsel for per.onal
representat'1ve
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DelCrlptlon
1. Checking account - M&T Bank
815
Value'
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Register of Wills of Cumber land County, Pennsylvania
INVENTORY
'",,- ..+.''':.,
'/! "
No. rJ\ ~ 0\ - ~(o~.
Dat.ofD.ath 9/10/01
'.~' EIIaIe of Karen L. ~otz
. ... known ..
. o.c.lltd Socfal Security No. 1 86 - 3 6 -7 04 1
;.,.. ~.,,",
.,..:.... p........ R....atJv.(.) of the above Estate, decea.ed, verify Ihallhe h.m. appearing In the 'oRowlng Inventory
.. ... of the persoMl ..... wh.rev" .ftuete and .. of lhe real..tate In the Commonw.aJlh or Penn.ylv.-Ia of '
- MId Peoedent. that the ytluatlon placed opposite .ach Item of .ald Inventory represenl. It. fair valu. .. 0' the date .
of ... D..denr. dHth, and that Decedent owned no rea' e.tet. out.,d. of the Commonw.alth of P.nn.ytvanla
...,.. that which appeare In a memorandum at the end of thl. Inventory. I m. verify thai the .tatement. made In
thtIl,,""IDI, are true and correct. Wle under.tand that fals. .I.emenl. her~ln are made .ubjed to th. penaltl..
", of ,.,.. C.8. Section 4804 ,"atlng to unlwom falsification to authorltlel.
: .~ ~;,-,".' t . .
.. '. '.,.....'. AM.-. .....
:'-~"""-, .
j ~".~', - -.
. LD. Ha..: .
Dated
T~e:
2. Savings account - M&T Bank
2,337
. 3. 'Christmas Club Savings - M&T Bank
184
.;.. ~ - .
4~ Certificate of Deposit - M&T Bank
5. Refund ~Overpayment to Agway
\
3,993
1,300
6. Vehicle
5,400
.; 7. Interest received - M&T Bank
62
8. Refund ~ Auto Insurance
84
. (Attach additional .heet. I necn..ry)
Tola':
F_ ef1N1-1
........ lip .. ,.,~ 8. AIIOdeIIan lilt
'" :.:,- .,'..... : J/' I., '.
-,...',,' ,
J:
1
.1:
t
! .
, .'
NOTE: The Memorandum of real e.tate outside the Commonwellth 0' Penn.rlven'e mey. .t the election of the plflonaI .
.........M. Indude the Yllue of ellChlt8m. but such fig..... lhould not be exllndld IntD lie 10'" 0' the 'nventory.
" ~l. ;;i,')~J':';;f~{'~ H..~ti
:r"
~.
. :.:' :'~_I,'.'"./ :. . : ':'. ~:.
Regllt"r. of Wills of Cumber L3nd
INVENTORY
. .
County, pennsylvanla'::.:::~".:
"0_':' .
. . :~..-;;; ~"~' .., .-
. " .
.......:..:,.."'!...~. ....;f.\.i. :
..~..:.i,~:~~~o" Karen L.' Rotz
;" ~ .": ~~n .t.;.:.: ."
:. .".<.; ~~..
No.
Oat. of D.ath 9 / 1 0 / 0 1
. DlOIutd SocI.1 Securfty No.1 86 - 3 6 -'7~O:4'1
; . .~;.,
. .
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'f .
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"'," .,' ,'....,.
'. '.\ ':'!~:~~~;-"\~::~\" :<~~:~#
..' ..':.".
,:;'~::.P,nonJll ~nt.uv.(e) of the IIbove Elle'e. d_...... verily thet the .eme 'PP'erlng In the followlng 'n~ntory ",.(;)::!:?t:i't~.
.;; .'.: ~ all of the pereon.I....t. wh.r,v~1f sltuat. and .n of the r..I..'a,.ln the Commonwealth of P.nn.ylvanla of '..'.;':;.:{;:r,F~'+..:.;:..~'/;".
" . .::. ... f)tcecIent, that the ytluatlon placid oppa.lt. .ach It.m of .ald Inventory repr...nt. n. falrvalu. a. of the dat.' ....:..'.,:;:::..~.:,.r~::}.:..:,\.:, \
.;' of "" Deoedenrs d.ath. and that O.cedent owned no r.al ..tat. outllde of 'h. Oommonw.alth of P.nn.ylYanla : ::.'.':,:'~..'L> .-:: .....
. J . .. .... . .
I.: .XCtIPI that which spplar. In a m.morandum at the end o' thll Inv.ntory. I/W. vlrlfy thai the .'at.mlnt. made In' '.--~:,"::i.;.t':..~\; ":'".
. ....'hlllnventory ar. true and correct. Wle underltand that 'al~. Itat.ment. herein ar. mad. subJ.ct to the penahl.. ,..,:,..~,:..j:;>.::\:::.:/{.,'
.' .' I" . " ,: I . . ~. ,. .":- '
,.:', .: , of 18 p.,. C.S. Sldlon 4804 ,ilatlng to unlwom falsHleatlon to authorities. . . ....:..:!:.;..V;:;:. '::/J .
, .
.~i:::::.;:--~':' J.o~' tIo~: ..'
)~. -
.. . i . ~. ~ ."
Dated
"':
,.... .'. :,{\".~"" . .'
~ ",' 1~ ". .. .....
Description
...l "."
lv;:e~.. .:'!j;fi~I~~c!{,
';. ::,),:'i' {- ~?~ ,'..:"rJ\ '.
. :.:~.: '.~;;'::;~r;r.; :~':;.~:;.:;: . . i
'T.~e:.
~~}
9;' Refund - Trailer "Insurance
.,,;
'. '" 1 o. Furni ture
500
,11.. Dividend - American Home
26
".. .".
.;,'.1:-2.. 112 Shares - American' Home Products
$57,,73/share
'1-3.. 3 ShClr~ - AT&T $17.58/share
6,443
53
14. Series EE Savings Bonds
2,122
'. 1 5 . . IRA
387
;:'('Au-*'adcJ16l.oLi 119h92t Sk~\~ne )Trailer (50% ownership) 3,000
mona I .e ,I n sary $6,000 Tolal:
NOTE: The Memorandum 01 r.1I e.tat. outside the Commonwealth 01 Pennsylvania may. at the .Iectlon of Ihe perlan"
fWfHHn..~ve.lodude th~ valu. of each .Item. but such flgurel lhould not be exeanded InID.... total of the Inventory. .
Fenn IfNI.?
. Prtptnd.., b Pennt)'lYlnll Bw AlIOdallan 1"1
,.," ..:. .:"..' ", ~ I '~.f :.., :' ~ '.~. '-:" .
. .;~!.2t;I:;, <,~:\';:.~t.
. '.': :.?":'5'< .]t..~.':' i.:'::
. 'J.' ....... .
. .
. 1" .: .
." "...'
. '" :.: i \ . .. ......
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
WELDON LINDA R
2 MCNAUGHTON DRIVE
DUNCANNON, PA 17020
-------- fold
EST A TE INFORMATION: SSN: 186-36-7041
FILE NUMBER: 21-2001- 0864
DECEDENT NAME: ROTZ KAREN L
DA TE OF PAYMENT: 1 2/ 1 1 /2001
POSTMARK DATE: 12/10/2001
COUNTY: CUMBERLAND
DATE OF DEATH: 09/10/2001
NO. CD 000626
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,123.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: LINDA R WELDON
CHECK# 5993
SEAL
INITIALS: DO
RECEIVED BY:
$2,123.00
MARY C. LEWIS
REGISTER OF WILLS
REGISTER OF WILLS
t
//-j?- /-3
.4
~REAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
,;. of DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
P 1 :tUbUNTY
ACN
Recor(.,;('
RGGlstc "-"
.02 FES-1
LINDA R WELDON
2 MCNAUGHTON DR
DUNCANNON
PA 1702CiBrh
Clunber ;,~\;
NOTE:
01-29-2002
ROlZ
09-10-2001
21 01-0864
CUMBERLAND
101
*'
REY-l!i41 EX AF' (12-00)
KAREN
L
(8)
Allount Rellitted
.00 X 00 =
5,224.00 X 045 =
1,112.00 X 12 =
11,724.00 X 15 =
Cl9)=
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax pay.ent.
26,886.00
8.826 00
18,060.00
.00
18,060.00
If an assessment was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will
reflect figures that include the total of ~ 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 rat. (16)
17. Allount of Lin. 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
Cl)
(2)
(3)
(4)
(5)
(6)
(7)
.00
9.005.00
.00
.00
14.881.00
3.000.00
.00
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
RE-Y=iSirj-Ex--AFP--fi'z-:ool--NO,.-icE--oF-i:NHEifiTAifcE-TAx-APPRjfisEiiENT~--ALLOWANCE-oi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF ROTZ KAREN L FILE NO. 21 01-0864 ACN 101 DATE 01-29-2002
TAX RETURN WAS: ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE
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)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
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 Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Est.te Subject to Tax
(9)
ClO)
8,786.00
.00
235.08
133.44
1,758.60
2,127.12
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
12-10-2001 CDOO0626 106.36 2,123.00
TOTAL TAX CREDIT 2,229.36
BALANCE OF TAX DUE 102.24CR
INTEREST AND PEN. .00
TOTAL DUE 102.24CR
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
40.00
Ill)
(12)
(13)
(14)
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT-- (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
"
REV-1470 E.'(6-88)
. *'
INHERITANCE TAX
EXPLANA liON
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG PA 17128-0601
DECEDENTS NAME FILE NUMBER
Karen L. Roth 2101-0864
REVIEWED BY ACN
ANITA MCCULLY 101
ITEM
SCHEDULE NO. EXPLANA liON OF CHANGES
Tax computations were made incorrectly for beneficiaries.
ROW
Page 1
/7-R'- /~
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG~ PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
*
REY-li07 EX AFP [01-02>
'02 APR 12 P 1 :54
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
03-18-2002
ROTZ
09-10-2001
21 01-0864
CUMBERLAND
101
KAREN
L
LINDA R WELDON
2 MCNAUGHTON DR
DUNCANNON
Allount Rellitted
PASto~o
l;{,fn,.v
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 ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REY=i6oj-E3f-AFP--fol-:oz1-------...--iNHERii'-ANc'E-YA3r-STAfEME-NY-ifF-Aifcouiif--.-..---------------------
ESTATE OF ROTZ KAREN L FILE NO. 21 01-0864 ACN 101 DATE 03-18-2002
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUE} APPLICATION OF ALL PAYMENTS} THE CURRENT BALANCE} AND} IF APPLICABLE}
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 01-29-2002
P R I NC I PAL TAX DU E : ...........................................................................................................................................................................................................................
2}127.12
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
12-10-2001 CDOO0626 106.36 2}123.00
02-26-2002 REFUND .00 102.24-
TOTAL TAX CREDIT 2}127.12
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
. IF PAID AFTER THIS DATE} SEE REVERSE TOTAL DUE .00
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1}
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ}
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
.1/24/2002 10: 45
717-834-9012
R SCOTT CRAMER
PAGE 06
~J
STATUS REPORT UNDER RULE 6.12
HaIIIS of DeCedent: 1jc7/l d /l .y 'tf!.t~
Date of Death~ ~P/#nr7~/~.b//;q,,:J(}O/
1Iill NO. cleo;,. c7/)j/f#'y( Admin. No. c2/-UI-1-O/:cLV
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 whether administration of the estate is complete:
Yes ~ No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No ^.
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative sXte an
account informally to the parties in interest? Yes No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the OrphAns' Court and may be attached to this report.
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REV.1500 EX (6-00)
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REV-1500
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I-
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W
C
W
o
W
C
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Rotz Karen L.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
9/10/01 4/19/48
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
N/A
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~ 1. Original Return
D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy or Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
D 4a. Future Interest Compromise (date or death after 12.12-82)
D 7. Decedent Maintained a Living Trust (Attach copy or Trust)
o 10. Spousal Poverty Credit (date of death belween 12.31-91 and 1.1.95)
I-
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OFFICIAL USE ONLY
L
7- 7- /.....::J
FILE NUMBER
~~-O..L
COUNTY CODE YEAR
o 08 ~~
NUMBER
SOCIAL SECURITY NUMBER
186 - 36
-7041
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
N/A
D 3. Remainder Return (date or death prior to 12.13.82)
D 5. Federal Estate Tax Return Required
8. Total Number of Sate Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
Linda R. Weldon
. ~;j;.1;;.i~tl~~ :1!i,e~($ri~l()'NQ$Nc~t~"~~Qfl.r.Il)J;N!i~UAj'AX':IN~OR"'AtIQN,.SliQIJ~1)~~~]~laEPTEQ::t<):;;::
COMPLETE MAILING ADDRESS
NAME
FIRM NAME (If Applicable)
2 McNaughton Drive
Duncannon, PA 17020
TELEPHONE NUMBER
717-834 5266
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r:t:
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. T olal Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(9)
(10)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z
o
~
~
~
l1.
:E
o
o
~
15. Amount of Line 14 taxable allhe spousal lax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
4,886
2,443
10,731
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
o
9,005
o
o
14,881
3,000
(8)
8,786
40
(11)
(12)
(13)
, ;
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dOFFICilH,:DSE o"NLY -. ...
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26,886
8,826
18,060
o
(14)
18,060
x.O_ (15)
x .0 45 (16) 220
x .12 (17) 293
x .15 (18) 1,610
(19) 2,123
i. ."......~:'.i-\.j'\:i.
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
>:liSESORE TO ANSYvE.~,:"LLQUe$tloNS Qli,(REyERSE:SII)E'ANDRECHECK;MATH .c:;C'
,. ...,....1'..'.,
REV-1503 EX. (1-97j
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Karen L. Rotz
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTiON
VALUE AT DATE
OF DEATH
6,443
112. Shares - American Home Products - common stock
Market value = $57.73/share
2.
Series EE Savings Bonds
2,122
3.
Individual Retirement Account
387
4.
3 Shares - AT&T - common stock
Market value = $17.58/share
53
TOTAL (Also enter on line 2, Recapitulation) $
(If mnrp ~n::lr.p i~ npoooo. in~p.rt lldditional sheets of the same size)
9,005
REV.l508 EX + (1.97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Karen L. Rotz
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
VALUE AT DATE
OF DEATH
DESCRIPTION
Checking Account
815
Savings Account
2,337
Christmas Club Savings Account
184
Certificate of Deposit
3,993
Refund - Overpayment to Agway
1,300
Vehicle
5,400
Interest
62
Refund - Auto Insurance
84
Refund - Trailer Insurance
180
Furniture
500
Dividend - American Home
26
TOTAL (Also enter on line 5, Recapitulation) $ 1 4, 881
(If more soace is needed. insert additional sheets of the same size)
REV-l509 EX+ (1-97)
'*'
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
Karen L. Rotz
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. Calvin B. Rotz, Jr.
1850 Scotland Avenue
Chambersburg, PA 17201
Father
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. Attach DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 4/6/93 1992 Skyline Trailer 6,000 50 3,000
VIN 33110460E
TOTAL (Also enter on line 6, Recapitulation) $ 3,000
(If more space IS needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) t.
~k
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
Karen L. Rotz
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Hoffman-Roth Funeral Horne, Inc. - Funeral Expenses
7,345
Grace Church
- Food for reception
258
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representalive(s)
Street Address
City
State _ Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
4. Probate Fees
5.
Accountant's Fees
750
6. Tax Return Preparer's Fees
7.
utilities
230
8.
U-Haul - Clean out trailer
80
9.
Postmaster - Express mail
40
1 O.
Miscellaneous Administrative costs
83
TOTAL (Also enter on line 9, Recapitulation) $
8,786
III .....,....... .............^ ,.... "....,..,.1.......1 ..../"''''..+ ......l,.."H....",.,1 I"'h"....+... nF .h.... ,...,.,.....n ....i...."'\
REV-'S'2 EX+ (1-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Karen L. Rotz
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
40
1.
Dr. Gordon - medical expense
TOTAL (Also enter on line 10, Recapitulation) $ 40
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Karen L. Rotz
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
Calvin B. Rotz, Jr.
1850 Scotland Avenue
Chambersburg, PA 17201
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not LlstTrustee(s) OF ESTATE
NUMBER
I
Father 1/3 checking and
savings acc ounts
2. Dorothy K. Rotz
1850 Scotland Avenue
Chambers burg , PA 17201
Mother
1/3 checking and
savings accounts
3. Linda R. Weldon
2 McNaughton Drive
Duncannon, PA 17020
Sister
1/3 checking and
savings accounts
4. Matthew K. Weldon
2036 Daybreak Circle
Harrisburg, PA 17110
Nephew
Antique Pie Shelf,
baby rattle, 1/3
rest and residue
5. Erica L. (Weldon) Jamison
650 Dampman Road
honeybrook, PA 19344
Niece
Piano, antique rouge
container, 1/3
rest and residue
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)
REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
I
FILE NUMBER
Karen L. Rotz
RELATIONSHIP TO DECEDENT
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
(L
6 Nathan A. Weldon
2036 Daybreak Circle
Harrisburg, PA 17110
Nephew
AMOUNT OR SHARE
OF ESTATE
Antique table,
crochet hook, 1/3
rest and residue
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)