HomeMy WebLinkAbout01-0960
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of JhFI2"2c~f\ 11" 8J4;::~,,-
also known as
~\- 0\- qtoO
No.
To:
Register of Wills for the
County ofCLih-\h'i'nI J4.l.l in the
Commonwealth of Pennsylvania
Dec~sed.
Social Security No. d () ;).. .... d. ~ - ;;J. ~ 'I
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appll E S
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in LJ
h E- rt... last family or principal residence at
D~~nden~, then :i J../. y~ar~ ag~, died ~Q.m ~
at ~LttS"'~ "fY\~ ,\C ,~ ~~~ .
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
3
19-~CC01
, ,
$ \.} C\)~ .. <2\('\
$
$
$
Petitioner_ after a proper search h~ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
L~a
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
~
b btt~~~~~
cd.';:::::
3~
Q) '-
30
cd
=
00
en
~1~~~1~
\'\-\5-3
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
} ss
The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law.
affirmed and subscribed ~~ ~ ~. ~
15TH day of_
~~2 ~
Reg;ter l ~.
--
<n
--
Q)
1-0
::s
.....
~
s:::
bO
i:i3
No. ?1 - 01 - 960
Estate of
THERESA A BAKER
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW OCTOBER 17 ~2001 , in consideration of the petition on
the reverse side hereof, satisfactory proof havi~g been presented before me,
IT IS DECREED that DUNALD L BAKER
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
DONALD L BAKER
THERESA A BAKER
are hereby granted to
in the estate of
FEES
Letters of Administration
Short Certificates( 2) . . . . . . . . . .
Renunciation ................
JCP
$ 18.00
$ h 00
$
$ 5 00
TOTAL_$ 29.00
Filed .. 9.C.1Q~~g .17.,. . . . .. A.D. ~ 2001
ATTORNEY (Sup. Ct. l.D. No.)
ADDRESS
PHONE
Called gdministrator on 10-17-01.
'"'c, <::'f'\':' ":'''"7'''" ,",'cor:.
This is to certify that the information here given is correctly copied fro~ 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.
ll:- t\. ~b.L~~~
Local Registrar
Fee for this certificate, $2.00
p
7714038
OCT
5 2001
Date
HI05. 144 R.... 1191
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
'PRINT
N
"NENT
:KINK
STm FilE NUhI\lElI
SOCIAL SECURITY NUMBER
2001
BIRTHPl4CE (C~ and
Stal. or Fore;gn Country)
g=iIy)D
MARITAl. S'OO'us . Married
N..... 1.1.,,1<<. _.0.
DiYClrced (Specify)
White
SURVIVING SPOUSE
(11 wile. gIVe ma",en name)
14
17C.0 'Iea.dec_ntliYedin
twp.
Carlisle
c~ylboro
D,t;TE PRONOUNCED DEAD (Month. Day. '/ear)
2:lb. 2 .
WAS CASE REFERRED TO MEDICAL EXAMINER/CORONER?
v.~
NOD
4. 12:36 a.m. M. 25. October 3 2001 H.
27. ""'AT I: Ent... the _. injurieS or compliCations whICh caused lhe death. 00 not ant.r Ih. mode at dylnO. lOCh a&c.rdiac Of ,aapif.'ory a"&aI. Itlock 0' hurt t.ilur.. "~ppro.lmala
till only one CII_ on .ach Hna. : Intarval_an
: onaat and death
i
PART II:
Othar significant conditions eontriboling 10 delth. but
not r..utting in tha underlying CIU" given in PART I.
b.
d
WERE AUTOPSY FINDINGS
-.I..A8l.E PRIOR 10
COMPLETION OF CAUSE
OF DEATH?
'leaD
NoD
Natural
Accldanl
D
~
D
Homlc:ida
TIME OF INJURY
INJURY ,t;T WORK?
MANNER OF DE,t;TH
... 21b.
CERTIFWI (Check only one)
'CEflTIFYINQ PHYSICIAN (Phyoician certifying cauoe Of _ when IllOlher phytician has pronouncecl <lelI'" and C(Il1\JlleIed hem 23)
Totlle_..."'Yknowtedge.__rNd_lotlleCIUM(o)onclmln__II1II'O.................................................... .
Suicldo
21.
Pandlng InveallgaUon
Could not be delorrnln.o
'PflONOUHClNO AND ClRTIFYING PHYSICIAN (l>hyoician _ pronouncing dea1h and certilying 10 cau... 01 dea1h)
To tile -"''''Y k............... _ at __. _.and place. _ _'0 tile UUM\oj ___.. _eel..........................
3 2001
'MEDICAL EXAMlNER/COlIIONER
On the ... of e._lnetlon ondIor In"..'lvatlon. In my opinion. death occurrod atllllllmo, date. and ploco. and dUI to the cauM(l) and
__Itat8d................................................................................................. .
"0.
"". REGISTRAA'SSIGN,t;TURE~NONU~ _. "'. C'.... t'I-'- \
_ ~ ~ ~\.-..~~ 8.1 \ 1~111()1
PA 17111
M.
s ~Ob\
\
~
~
CERTIFICATION OF NOTICE UNDER RULE 5.6{a)
Name of Decedent: Theresa A. Baker
Date of Death: October 3, 2001
Estate No. 21-01-960
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
November 1, 2001
Name
Address
1. Donald L. Baker
115 South Bedford Street
Carlisle, PA 17013
2. Shawn A. Baker
229 Middle Road
Newville, PA 17241
3. Kami J. Hoffman
7 Enck Drive
Boiling Springs, PA 17007
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except None
Date:
November 1, 2001
Dale F. Sh
35 East High
Carlisle, PA 1
Telephone (717)
203
Capacity:
Counsel for personal representative
i --
'.,
.. .
IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU WILL
RECEIVE ANY MONEY OR PROPERTY FROM
THIS ESTATE OR OTHERWISE
Whether you will receive any money or property will be
determined wholly or partly by the decedent's will. If the
decedent died without a will, whether you will receive any money
or property will be determined by the intestacy laws of
Pennsylvania.
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In re Estate of Theresa A. Baker, deceased,
Estate No. 21-01-960
TO: Kami J. Hoffman
7 Enck Drive
Boiling Springs, PA 17007
Please take notice of the death of decedent and the grant of
letters to the personal representative(s) named below.
The Decedent Theresa A. Baker, died on the 3rd day of
October, 2001, at Hershey, Pennsylvania.
The Decedent died intestate (without a Will) .
The personal representative of the Decedent is:
Donald L. Baker
115 South Bedford Street
Carlisle, PA 17103
(717) 243-4807
The Decedent died intestate, a Petition for the Grant of
Letters of Administration was filed with the Office of the
Register of Wills of Cumberland County. 1 Courthouse Square,
Carlisle, PA 17013. Phone No. 717-240-6345.
the
A copy of the Will or Petition may be obtained by contacting
Register of Wills and paying the charges for duplication.
0:&st:r:lk:
35 East High Street, Suite 203
Carlisle, PA 17013
Telephone (717) 241-4311
Date: November 1, 2001
Capacity:
Counsel for personal representative
~.
IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU WILL
RECEIVE ANY MONEY OR PROPERTY FROM
THIS ESTATE OR OTHERWISE
Whether you will receive any money or property will be
determined wholly or partly by the decedent's will. If the
decedent died without a will, whether you will receive any money
or property will be determined by the intestacy laws of
Pennsylvania.
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In re Estate of Theresa A. Baker, deceased,
Estate No. 21-01-960
TO: Shawn A. Baker
229 Middle Road
Newville, PA 17241
Please take notice of the death of decedent and the grant of
letters to the personal representative(s) named below.
The Decedent Theresa A. Baker, died on the 3rd day of
October, 2001, at Hershey, Pennsylvania.
The Decedent died intestate (without a Will) .
The personal representative of the Decedent is:
Donald L. Baker
115 South Bedford Street
Carlisle, PA 17103
(717) 243-4807
The Decedent died intestate, a Petition for the Grant of
Letters of Administration was filed with the Office of the
Register of Wills of Cumberland County. 1 Courthouse Square,
Carlisle, PA 17013. Phone No. 717-240-6345.
A copy of the Will or Petition may be obtained by contacting
:::e~e::::::e:fl~i~~:land paYi:~~~~~Plication.
35 East High Street, Suite 203
Carlisle, PA 17013
Telephone (717) 241-4311
Capacity:
Counsel for personal representative
~ .
IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU WILL
RECEIVE ANY MONEY OR PROPERTY FROM
THIS ESTATE OR OTHERWISE
Whether you will receive any money or property will be
determined wholly or partly by the decedent's will. If the
decedent died without a will, whether you will receive any money
or property will be determined by the intestacy laws of
Pennsylvania.
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In re Estate of Theresa A. Baker, deceased,
Estate No. 21-01-960
TO: Donald L. Baker
115 South Bedford Street
Carlisle, PA 17013
Please take notice of the death of decedent and the grant of
letters to the personal representative(s) named below.
The Decedent Theresa A. Baker, died on the 3rd day of
October, 2001, at Hershey, Pennsylvania.
The Decedent died intestate (without a Will) .
The personal representative of the Decedent is:
Donald L. Baker
115 South Bedford Street
Carlisle, PA 17103
(717) 243-4807
The Decedent died intestate, a Petition for the Grant of
Letters of Administration was filed with the Office of the
Register of Wills of Cumberland County. 1 Courthouse Square,
Carlisle, PA 17013. Phone No. 717-240-6345.
A copy of the Will or Petition may be obtained by contacting
the Register of Wills and paying the charges for duplication.
Date: November 1, 2001 J'J0.f2.z 'f)~~
Dale F. Shughart, Jr.
35 East High Street, Suite 203
Carlisle, PA 17013
Telephone (717) 241-4311
Capacity:
Counsel for personal representative
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUR~A~......~....O. F..._....I.N.D .~IVI.D..U. AL TAXES
PARTMENT 20000 1
1".... . '.
HARRISBURG, PA11-~ 28-0601
Telephone
2/11/2002
.02 FEB 15 Ql0 :36
717 -783-0972
Dale F Shughart, Jr., Esquire
35 E High Street
Suite 203
Carlise, PA 17013
CiE'I}.
CUmbi;,
Re: Estate of Theresa A Baker
File Number: 2101-0960
Court Number: Cumberland-Orphans-21-0 1-960
Dear Mr. Shugart:
The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on
behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to
this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions.
Pursuant to the Petition, the 84 year old decedent died as a result of a motor vehicle accident. Decedent is
survived by the decedent's adult son, Donald L Baker.
Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no
objection to the proposed allocation of the gross proceeds of this action, $ 6,965.00 to the wrongful death claim and
$ 108,035.00 to the survival claim. Proceeds ofa survival action are an asset included in the decedent's estate and
are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. ~8302; 72 P.S. ~~9106, 9107. Costs and
fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merrvrnan, 669 A.2d
1059 (Pa. Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this matter. As the
Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any
hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from
this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the
Department may take in any other proposed distribution of proceeds of a wrongful death / survival action.
rely,
/ '--:J--
j) [2./~~)
J Pa tDi~
Inheritance Tax Division
Bureau of Individual Taxes
/
cc: Comberland County Clerk of Orphans Courts a,.'
.)
FEB 1 9 ZOU? .~
IN RE: ESTATE OF
THERESA A. BAKER
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT
ESTATE NO. 21-01-960
ORDER OF COURT
rU"lI7
consideration of the foregoing Petition, it is ordered that
AND NOW, this 2~r day of
, 2002, upon
settlement of the claims in this action for a total sum of One
Hundred Fifteen ($115,000) Dollars, One Hundred Thousand
($100,000) Dollars representing the entire liability limits of
third party coverage available through OneBeacon Insurance, and
Fifteen Thousand ($15,000) Dollars, representing the entire
underinsured motorist liability limits through Erie Insurance
Group, is approved. The allocation of settlement in the amount
of Six Thousand Nine Hundred sixty-five ($6,965) Dollars to the
Wrongful Death Action and in the amount of One Hundred Eight
Thousand Thirty-five ($108,035) Dollars to the Survival Action,
as compensation for decedent's pain and suffering, and requested
counsel fees and expenses are also approved. Petitioner is
authorized and directed to execute Releases to OneBeacon and Erie
in the forms attached to the Petition. Distribution is directed
as follows:
a. Dale F. Shughart, Jr., Esquire, counsel fees in the
amount of Five Thousand Six Hundred Seventy-six ($5,676.00)
Dollars;
.
b. Dale F. Shughart, Jr., Esquire, costs and expenses
in the amount of Three Hundred Thirty-eight and 80/100 ($338.80)
Dollars;
c. William A. Addams, Esquire, counsel fees in the
amount of One Thousand Nine Hundred Eighty ($1,980.00) Dollars;
d. Donald L. Baker, Administrator of the Estate of
Theresa A. Baker, deceased, the sum of One Hundred Seven Thousand
Five and 20/100 ($107,005.20) Dollars.
By the Court,
~.~4.
/ J.
Distribution:
Dale F. Shughart, Jr., Esquire, attorney for Donald L. Baker
Ellen Buller, OneBeacon
Douglas C. Kocher, Erie Insurance Group
Kami J. Hoffman
Shawn A. Baker
;)0
~ :1:
S;~. ..,
d
N
..,..,
fI1
CD
N
G'\
i:::;
N
.
IN RE: ESTATE OF
THERESA A. BAKER, deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE NO. 21-01-960
PETITION FOR SETTLEMENT OF
SURVIVAL ACTION AND APPORTIONMENT OF
SETTLEMENT WITH WRONGFUL DEATH ACTION
AND NOW, comes the Petitioner, Donald L. Baker,
Administrator of the Estate of Theresa A. Baker, deceased, by and
through his attorney, Dale F. Shughart, Jr., Esquire, petitions
Your Honorable Court to enter an Order permitting settlement and
apportionment of the decedent's survival action and the
beneficiary's wrongful death action, and in support thereof,
states as follows:
1. On September 15, 2001, at approximately 7:45 p.m., the
decedent, Theresa A. Baker, was a passenger in a motor vehicle
being operated by Barbara J. Lebo traveling on Forge Road near
Karn's Market in South Middleton Township, Cumberland County,
Pennsylvania. The Lebo vehicle was traveling lawfully in its own
lane of travel.
2. A motor vehicle being operated by Craig Cleeland and
owned by his parents, Alan and Diane Cleeland, was traveling in
the opposite direction and crossed a double yellow line and
impacted violently into the Lebo vehicle.
3. As a result of the accident the decedent sustained
numerous injuries including a fracture of her femur and was taken
to Hershey Medical Center for treatment.
4. Theresa A. Baker died, intestate, on October 3, 2001 as
a result of injuries sustained in the accident.
5. The Petitioner, Donald L. Baker, the sole surviving son
of Theresa A. Baker, and only statutory beneficiary in her
Wrongful Death Action, was appointed Administrator of the Estate
of Theresa A. Baker on October 17, 2001 to the above captioned
Estate number.
6. The Cleeland vehicle was insured under an automobile
policy with OneBeacon Insurance Company. The limit of third
party liability coverage under said policy is One Hundred
Thousand ($100,000) Dollars per person.
7. The decedent, Theresa A. Baker, did not own an
automobile and was therefore insured under the automobile policy
of Ronald L. and Barbara J. Lebo with Erie Insurance Company.
Said policy included VIM benefits in the amount of Fifteen
Thousand ($1S,000) Dollars for individuals who did not qualify as
a "relative" of the Lebo family under the policy.
8. At her date of death Theresa A. Baker, then age 84,
resided in her own apartment at One West Penn Street, Carlisle,
PA 17013 and was not therefore a qualified "relative" under the
Lebo policy entitling her to stack the coverages of their four
automobiles.
9. OneBeacon, insurer of the Cleeland vehicle, has offered
its entire policy limits of One Hundred Thousand ($100,000)
Dollars in settlement of this claim.
-2-
10. Erie, Lebos' VIM carrier, has offered its entire policy
limits of Fifteen ($15,000) Dollars in settlement of this claim.
11. petitioner has also confirmed the operator of the
vehicle responsible for the accident, Craig Cleeland, has no
other applicable insurance coverage. Attached hereto, made a
part hereof, and marked Exhibit "All, is an Affidavit of no other
insurance executed by Craig Cleeland's parents, owners of the
insurance coverage through OneBeacon.
12. Attached hereto, made a part hereof, and marked Exhibit
"B", is a proposed Settlement Release from OneBeacon.
13. Attached hereto, made a part hereof, and marked
Exhibit "C", is a proposed Settlement Release from Erie.
14. The decedent, Theresa A. Baker, was a widow. She was
predeceased by one son, Barry L. Baker, and survived by a second
son, Donald L. Baker, your Petitioner. Barry L. Baker is
survived by two children, Shawn Baker and Kami (Baker) Hoffman,
who are intestate heirs of their Grandmother's Estate, sharing
equally as issue of the decedents. Donald L. Baker, Shawn Baker
and Kami Hoffman are the only intestate heirs of Theresa A.
Baker.
15. Shawn Baker and Kami Hoffman both consent to the
allocation and distribution proposed in this Petition. Their
consents are attached hereto, made a part hereof and marked
Exhibit "D".
-3-
16. Donald L. Baker claims no personal pecuniary loss as a
result of the death of his Mother.
17. The funeral expenses of Theresa A. Baker are, Six
Thousand Nine Hundred sixty-five ($6,965) Dollars. A true and
correct copy of the funeral bill is attached hereto, made a part
hereof, and marked Exhibit "E".
18. There is no Pennsylvania Department of Public Welfare
claim for medical assistance pending. A true and correct copy of
the Clearance from DPW is attached hereto, made a part hereof,
and marked Exhibit "F".
19. Your petitioner requests that the sum of Six Thousand
Nine Hundred sixty-five ($6,965) Dollars be allocated to the
wrongful death action in reimbursement of the funeral bill.
20. Donald L. Baker retained Dale F. Shughart, Jr., Esquire
and William A. Addams, Esquire to represent him in pursuit of the
claims arising from the death of Theresa A. Baker at an hourly
rate billing of $165 per hour for their time expended, together
with reimbursement of out of pocket expenses incurred in their
representation.
21. An invoice itemizing the out of pocket expenses and
time expended by Dale F. Shughart, Jr. and William A. Addams in
representation of your Petitioner are attached hereto, made a
part hereof, and marked Exhibit "G".
22. Attached hereto, made a part hereof and marked Exhibit
"H" is a copy of a letter from the Department of Revenue,
-4-
confirming its approval of the aforementioned distribution.
23. The undersigned Dale F. Shughart, Jr., Esquire, counsel
for the Petitioner, and the Petitioner himself believe the said
settlement is fair and equitable under the circumstances of this
case.
WHEREFORE, Petitioner requests Your Honorable Court to:
a. Approve the settlement above stated;
b. Approve the payment of counsel fees and expenses as
stated above from the funds received;
c. Authorize petitioner to execute the proposed
Releases; and
d. Direct distribution of the net funds recovered to
Donald L. Baker, as Administrator of the Estate of Theresa A.
Baker as stated above.
Respectfully
fiugha
Court . 19373
35 East High Street, Suite 203
Carlisle, PA 17013
(717) 241-4311
Attorney for Petitioner
Donald L. Baker
-5-
VERIFICATION
Donald L. Baker, Administrator of the Estate of Theresa A.
Baker, hereby verifies that the facts set forth in the foregoing
petition for Settlement of Survival Action and Appointment with
Wrongful Death Action are true and correct to the best of his
knowledge, information and belief, and understands that false
statements herein are made subject to the penalties of 18 Pa. C.S.
~4904 relating to unsworn falsifications.
~Q~ ~ ~ ~'t\\
Donald L. Baker, Administrator
Estate of Theresa A. Baker
DATE: \ \ ~ \ \ C) 2-
Jan.
I Inn?
\.0.. '- \~ '", ...
~ : : 43AM
PEjRLESS Ins.
Hog, Fa. : 7011
No.4J21
') ~ ..'~
.. . "" I \"l
~
AFFIDAVIt
1 J c """"-3. tJ . '... __ c/";" lo..",J
J hereby d~pose and affirm th~t 1 had
no bodily injury bonds or liability insurance polieies that protided
cove~age to me or for m@ relating to the subject aeeident, vbich
occurred on,
, other than O;iDZ,,,,7'J"1.t1..1...
effec.ti.ve from 07/0"'101 co D~/q~/qA.. vhich had bodily
injut'y limits .of ~/OO DOC} each person and~3oo 000
each accident. Attached hereto is a true and ~orreet copy of the
declaration sheet applieable to that policy_
I verify that the stat~.ent5 made &bove are true and correct
to the best of my k~owledge. information and belief. 1 understand
that false $tatements herein are made subject to the penalities of
18 Pa. C.S. S4904 relating to unsworn falsifieatiou to authorities.
Jt t7;/1n ft Z-
Da t'e /
XN~~
t7/1b7/ct;)-
, ,
~~Af' {Yu~nt'~
,.
~rc\c.\ &chap
Notarial Seal
Notarial Seal .
Brenda K. BiIitIOP. Notary Public
Cam.&e Bore Cuinbedand County
My commiSSiOn ExpIrea."uar. 14, 2005
Men1*, pennsytvaniaAssOCianonotNotalieS
Ex+uf3/-r -A
i.
t
f"
,.
I
I
fj
r;~'
~':
i-;
r
t
GENERAL RELEASE
For and in consideration of the above payment to The Estate of Theresa Baker of
the sum of one hundred thousand Dollars, $100,000, IMlE, The Estate of Theresa
Baker, do hereby release and forever discharge Alan Cleeland, Diane Cleeland,
Craig Cleeland AND OneBeacon Insurance Group, their insurers, reinsurers,
employees, related entities, agents, and any and all other persons and firms, of and from
any and all actions, causes of action, claims, demands, damages, costs, loss of services,
expenses, compensation; consequential damage, or any other thing whatsoever, including
any claim for bad faith, on account of or in any way growing out of, any and all known and
unknown personal injuries, debts, and property damage resulting or to result from an
incident that occurred on or about the 15th day of September, 2001 at or near Boiling
Springs, Pennsylvania.
IMlE hereby acknowledge and assume all risk, chance, or hazard that the said
injuries or damages may be or become permanent, progressive, greater, or more
extensive than is now known, anticipated, or expected. No promise or inducement which
is not herein expressed has been made to melus and in executing this Release, IMlE do
not rely upon any statement or representation made by any person, firm, or corporation,
hereby released or any agent, physician, doctor, or other person representing them or any
of them concerning the nature, extent, or duration of said damages or losses, or the legal
liability therefore.
-1-
EXNI8/1 8
I/WE understand that this settlement is the compromise of a disputed claim ar
the payment is not to be construed as an admission of liability on the part of the pe
firms, and/or corporations hereby released by whom liability is expressly denied.
I/WE further certify, state, acknowledge, warrant, and declare that each and
person, attorney, carrier, entity or association which claims to have a lien on the pre
of this settlement arising out of this incident, lawsuit, or litigation, is aware of this R
and its terms and I/WE understand that said released parties hereunder are
expressly upon this unconditional express warranty in making payment hereunder.
The Releasor(s) accept responsibility for satisfying any liens that havE
asserted against this recovery by any worker's compensation carrier, health care p
or insurer, or anyone else asserting a lien, and hereby discharge Releasee(s) fr<
such responsibility.
In further consideration of the above payment, I /WE , for my/our heirs, nex
executors, administrators, successors, or assigns, covenant and agree to indemr
hold harmless Alan Cleeland, Diane Cleeland, Craig Cleeland AND OneE
Insurance Group, their insurers, reinsurers, employees, related entities, ager
attorneys, from all claims, demands, and suits for damages, costs, loss of s
expenses, or compensation which I/WE or my/our heirs, insurers, next of kin, ex
administrators, successors or assigns have or may have in the future on accoun1
any way growing out of the injuries or damages I/WE sustained in this incident.
I/WE certify that I/WE am/are over eighteen (18) years of age and I/WI
state that 1f\NE have carefully read the foregoing Release and I/WE know the
i
I
i
!1
,I
, 'j
;1
,,;
i
, I
~
t
i
f
~
,
~ '
f,
, '
I I
! ,1
I,
~' -
l
~
l",
i I
f i
:1
I
i i
~ ')
a.'-.,',
r.
i ~
[ 1
l j
I' ~
! I
i 1
t j
t"
" J
~ 1
i ' .~
I. .oj
lj
~ ;
L ;
.'
thereof and INVE have signed the same as my my/our free act and intending to be legally
bound thereby.
This Release contains the entire agreement between the parties hereto and the
terms of this Release are contractual and not a mere recital. The undersigned
acknowledge that he/she/they have had this Release reviewed by counsel of their
choosing, or that he/she/they understand that he/shelthey had the right to do so.
IN WITNESS WHEREOF, INVE have hereunto set my/our hand(s) and seal(s)
this _ day of
,2002.
WITNESSETH:
-3-
'&X ~ tl3/"{ 8 f.; ~
~ .
\.
COMMONWEALTH OF
)
)
)
COUNTY OF
On this _ day of , 2002, before me personally
appeared , known to me to be the person(s)
whose name(s) is/are subscribed to the within Release, and acknowledged that
he/she/they executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
NOTARY PUBLIC
My Commission Expires:
-4-
EX N J(3rl e p)-J
).
CLAIM#: O/D/7CS7i.{7H2
RELEASE AND AGREEMENT
I '
.t,-
Under policy # a.IZ-~oo~cr4' issued by ERIE INSURANCE EXCHANGElERIE INSURANCE COMPANY,
YWe, claiming coverage for myself/ourselves or on. behalf of-r;;c Esr>9r:1 0;: 7N;~t!SA A. 13v9~
in consideration of ;::i;~T-O e-N /#o'-C.sA,vo
($ I S, 0 00 . 00 ) dollars, which YW e have received, RELEASE AND DISCHARGE ERIE INSURANCE
EXCHANGElERIE INSURANCE COMPANY from any and all claims, causes of action or other rights which I/W e have,
have had or could have under the JNe)~A.r""s~~iE/J ~o~ TS
coverage as set forth in said policy, which claims, causes of action or other rights arose or could have arisen as a result of
a loss or accident which happened on the /5 ~ day of 5~~rr~ ,~t:Jt::>1 at or near
. Fo~~ R~<11 .s..~ ~r/JL):::;-V TCU_Nswd in the county of (} ~aL.4N<!1
m the State of &~~.,..~
In consideration of such payment, I1We agree as follows: 1) to assign Erie Insurance ExchangelErie Insurance Company
to my/our rights of recovery against any person(s) or party(ies) legally liable to me/us, 10 the amount of and for the
purpose of the payment noted above; 2) that I1We hAve not and will not make any separate sett1ement with nor give any
separate release to any person(s) or party(ies) who caused or are alleged to have caused the above mentioned loss or
accident; 3) that suit may be instituted by Erie Insurance ExchangelErie Insurance Company in my/our name; 4) to
execute all papers required 10 commence such suit; and 5) 10 cooperate in prosecuting any or all actions which Erie
Insurance ExchangelErie Insurance Company may bring to recover .from any person(s) or party(ies) for the claims or
causes of action which IIW e have growing out of said loss or accident.
It is expressly understood and agreed that, out of any amount recovered, costs of collection, including by not limited to
counsel fees, shall be first paid to ERIE INSURANCE EXCHANGElERIE INSURANCE COMPANY. Except in states
which apply comparative negligence in determining legal liability, any recovery in excess of collection costs shall be paid
to me/us, up to the full extent of my/our loss. In states which apply comparative negligence, any recovery of my/our loss,
in excess of collection costs, shall be reduced by a metor equal to the percentage of my/our negligence which contributed
to cause the ahove mentioned accident, before it is paid to me/us.
(CAUflON: READ BEFORE SIGNING)
Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this
day of
Witnessed by:
(SEAL)
(SEAL)
STATE OF
COUNTY OF
: SS
On this
day of
.
t to me known to be the person
foregoing instrument, and acknowledged that executed the same as
free aet and deed.
. before me personally appeared
who executed the
My commission expires .
Notary Public
~XtJI6/1'C
~
, .
IN RE: ESTATE OF
THERESA A. BAKER, deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE NO. 21-01-960
BENEFICIARY'S CONSENT
I, Shawn A. Baker, Grandson of Theresa A. Baker and Intestate
Heir of the Estate, have read the foregoing Petition and do hereby
consent to the allocation of the total settlement of One Hundred
Fifteen Thousand ($115,000.00) Dollars as Six Thousand Nine Hundred
Sixty-five ($6,965.00) dollars to the Wrongful Death Action and One
Hundred Eight Thousand Thirty-five ($108,035.00) Dollars to the
Survival Action.
Date: 2 / ~ 101.
><r::1 !B~~
E)( Nt"'} P
I I
IN RE: ESTATE OF
THERESA A. BAKER, deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE NO. 21-01-960
BENEFICIARY'S CONSENT
I, Kami J. Hoffman, Granddaughter of Theresa A. Baker and
Intestate Heir of the Estate, have read the foregoing Petition and
do hereby consent to the allocation of the total settlement of One
Hundred Fifteen Thousand ($115,000.00) Dollars as Six Thousand Nine
Hundred Sixty-five ($6,965.00) dollars to the Wrongful Death Action
and One Hundred Eight Thousand Thirty-five ($108, 035.00) Dollars to
the Survival Action.
Date: q'If),:] 0; 0 e1
I
~1W (f .dY\
. Kami J. Ho n
b- X fi I e r1 D p-, Z--
ui
Gl
U
'~
Gl
III
OJ
~ 'g,
< I, t\~;~"",..",
~ ,~'
a. ....'"
15 "'-J-
. 1
) ~'
<~,.J
~\ "~"O~
~ ,Co to j-'
,~ "~~ LL~'~
'~r . \ ii '\v
."t -'t.~ <
(.~ (J Q) ~
,,~ 1'-", a '5 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
l~- ~
Z
\~--, ~
''''" a: ,~
D.. ~
Q) III
., co
It' ~ Gl
'-l ~ lil
c
"
\)
".~
\J
'...
ci
z
O~I!
ijjj
o
~fwp ~
~Q)i~ ~i!i ~~ "-
~l ~~I~! a
~~~~
i~:I:;
!tww,g
~ ~;~.
e"
~,- ..~
~~..
>- U
.&J !!!
o ~
~"":',~
-~~
~.S!~
i .!.~
-'5 g' ~
iii i= l!? ..;
~... ~ 00
(.)!!e~g
~ ca.;;~:6
~; s~~
(I):e::~5
.wi !~';
)~.~.!'O~
~~ i~ ~~
.w"'io"O
:(I)!!iielllij LL
)CIll>C~QI LL
~ ~ 1ii :: (i5 '~ ~
)(1) ~ 'j.~ ~ (J)
~COell~!!! ~
)oi ~~~ ~
.g~fll<::J ~
).,J.! i lii~ frl
~C[:::c;:: a:
d5::l~~.E is
:Z~Ill'Og> ...J
~ ~ 1ii I .,'5> <
)~;;~~ ffi
.o~-~as ~
I- ii ~!?~ .. LL
z::ocr5;W
~:i-g!~ ~
wOiias~> C/')
~;o.,oa: W
C[....~6w C,,)
~.S! Ocr l!? CJ) ;;
!e~ ~~ 8. a: ffi
sli5~ 5 (J)
l!! ~~ C,,)
III C\l-g _ U5
11ll~6,~ ~
m 8"(jj
D ~ ~~
lO C.I)_
'\I
Gl
n;
c
Gl
n;
.g
t::
Gl
C,,)
.r:.
1U
Gl
C
c: '0
~ III
en ~ ,~
~ '9 8
~ 'S
- 0 ~
~ ~ 'E
~Gl'~~ ~
~ ~ ~ ~ i~- m
CI:~f6-5 0-. I!?~
~-~~~~~ ~~
~8~~~c3 ~~
(\.. \
"0 r~
Gl "....
III
co
Gl
U
Gl
"0
'0
Gl
E
co
c:
'3
LL
.r:.
1U
Gl
C
'0
Gl
cu
C
-
~
~ ~.c:" ~ -';-
:g~:e~.s
III ~~:e~
~Q.::o.IlIE '
: e 0 ~= ~"..,...,
: iQ - e .c: ~ ,"
:.Q~.g~
, e 1lI.Q VI "'_.
: ".c: E .l! 2'-
, ,e ::0. GI c: 1!
:5Il1ls~c.a
, re...." ", ...'
: ::0.. ~ ~ ~~ \
:~~~l!!::(
, -"" 0
: '&i Oi~.:'~ 'ii 0
:~i~~.Q~~
: ~'!!o~~'i ~
c::'c:":e <
: .:!:;.g ~ G1'i ~
'"'i::lO~Q. W
: '2-~~'~ = a:
:~~~~~::: f2
C!) 'ii c: 'S ~ 0 ~ z
~ 1II.:!.s ~i ~ 0
~~IlI~~E .~
c( ).,11I e 0 t tIl W
m:!:::Q1"C:Q.5 a:
:::2:
w
3~OH lVI:l3Nn:l - 31V81ldll:ll
lN31l~ . 31V81ldna
v66~ '''1 :10 -0 ':1 ':I-l'VNI~II:lO
~~
~
~~ ~ ~
.=-:
>-~j j
Ca..ii CD
o 5 ~ i
~S& LL
::I: Cl(S co as
~LLal'i
LL LL g g
0<("2"2
5t;88
~fff~~Gl
a: ~ ~ '~ .~
<;:jGl:> Gl
fu <3<( ,~ (J)
a: '-' c: i6
a.. LLLL ~ .2 'C:
ffio~~ ~
~ ~ Lt :> ~
0::)
~./)
.~
(t-
"~
~
,-)
j~
I
~
e
~
~
"1
~.
rv,
~
~
aa
g
'ii
15
~
~
~
~
i6
(5
I-
~ ~
cii
~
W
!::
a:
W
:r:
~
o
~
~~~~~~~~
~
~
~ ~ ~
j ~ _.~
1 ~
~ ~ 1
i6 ~ ~
'i
-g
]
1
3
LL
.=-:
z
w
:::2:
a..
5
o
W
~~~Gl~
c( 0 .~ U
LL ~ ~ .~ .~
~ Qi (J) ~
~ C,,) c: i6 "0
(J) ~ .2 'g 'iij
LL ell 19 Gl
~ 5 'iij ~ ~
(J) LL :> :::2: C)
::)
i6
'i
-g
"2
8
CD
al
i
8
'i
~
8
ExtJt8tl E
w
:::2:
o
I
...J
<
a:
w
z
::)
LL.
~ .=-:
(J) Z
Z ~~W
< 1:: a.. co
:::2: 8.5Gl
W III o!.
a: c:w.r:.
LL ~wu
o ~ ~ ~
ffi Gl ~ CJ
LL ~ ~ ~
~ --0 III
~ ~~
f- c(
~---
aa
~
g
'ii
~(;;(;;(;;
a:
I-
o
C/')
~
o
Gl
U
c:
co
~
.2
<
.....
C
Gl
E
~ * $
'6' C '0
c( ..... ~
i C ~
Gl Gl
c: E ~
~ ~ ~
a.. a.. u
en
C/')
w
...J
~ ~ ~ ~
c
w
~
C/')
;:j
C/')
:::2:
w
!:::
- ~
w <
U LL
Z 0
:5 w
C[
CD
"0"0
~ ; '0 '~~
.8.K e c: ~
CII -,2 ~ u
"lJ: - c:
='0 B 5 ~
'0 "'.!I 0 c:
",.E 'tI E ,2
e . III I1l t5
'E,g'O ~~
";11I", ~8
11'~ ~ '0
.l!!.E ~ ~
.E!~j m 8
~.&J " t5 Qi
~:!= Gl .c:
Ill...l e :: (5
-.~ ~ ~ ~
__G. .. cGl ~
~I::; E iii
'tIS.~ ~ 8
~:s eft ~-g
j8
':iJ";
--5 j l3
~~Ill.l!~
:;t~gJ~-~
50;: '2 co E
cli.! 5 g
ii-g'!Qol1l
'i~.2IE~
.S! .!Ii 'tI ~ I1l
-...I e c: c:
.S!8 :~5l
:;f~ ~ ~ lB
ill i ~ ~
. CII "'_ .... 0
=u e111 0 -0 _
Illlll e III
>-c 0 2l, Gl
~ ~~J m ~
.!i5. t5 ~ ,
.l!!5:; < ~E
i;.~ ~Qi~
liIe11111ecollllll
.! ~.~ III "0 l!! --
~-~ i g e::
a~8 ~ ~ ~
1!1!- "0 ai 0
~lll.!!! - - '=
"'CII" GlCOt.'l
'-i:llllz"O~
e .&Je"Gl(5
-8 l&CII(1)~t.'l
ei'S- ~ '0 Gl
:I Ollla::.....c:
" 'tIlw~~
i= ! I -= I- I1l ,-
a:
w
I
~
>-
a:
~
c(
:::2:
w
a:
CJ
>
a:
w
~
w
:::2:
w
C,,)
..J'W
C(>
C)~
~c(
~~~~~
~~~~~~
~ ~ ~.!a
~=~~
:;g~~
~E5~
lil:o:2
w,~ <:-
c5i~~
!~~~
~~j~
~8~~
~S:ll'~
o.E 'E ~
'3 .gt l3,cr
-cuQ),.J
~=;i
~~-i~
S~-6,~
~ o'c.a
r:~~
~ !!!I- III
~~~~
a;U.~-
~~2~
QI-l::!.o
en U) ::::J'~
-g lij ~-g
lll~~~
~E ~ 'i
,S QI <:.c
~~~lil
<: o..S ell
as_ as.c
Q)'] fig
~l~~
~ ~~,g
o=~.,
~llllllell
~~S~
QI 1: .,
-g"~E /^,.-.
as"OQI~ ,"'0/-
c"'-.. ...
~~~; f . CD
8~:e 6-- .c
~:2. ~ ~
~Sa;'Sl Q.
.8111l(l!1 ~
as 'E.c Cl "-'" l!!
Qlo!:?as (../'",
= aa~ "".t ~
~.!Il~~ C/-:._
l!!:~ l!? ~. C.I)('(
.~\~ ~ ~ ~ r
~~ ~~~ ,
"asO:3~/,
eIl-eIlo.~J
~~6~g' :--
5 <: ~:: ~ 1I:Jl!1l
"'::JlllOal-SSS
i
ii5
~
\...,..
r '"
(),
~
,~;c::, .
(~
,.-....
~
,::::)
\:
r
-l<<,...
13'
Gl
<3
Gl
Qi
(J)
III
~
a: Q)
w ~
Z III
~ ~
Z ~
o oS
CJ Qi
<i! .r:. ~
a: ~ a.
::) Gl a.
m 13 c(
tu a: E.~
~ ~ ~.~
C3 5 ~ ~
III1II I I"
Q)
c:
'Cij
5 W
E (J)
:::i i5
Qi z
~ to ~
~ ~ ~ ~
coc:wco
a.. ~:::2:CJ
:g,e~~ ~ ~
@~@~~~
aa~zal~~
'-':S~~...
Qi ~ oj g .9 .;
~'E~C,,)~.Cij ~
U:::~~CJ)~:>:::2:
~
QI
"0
o
U
0.
N
QI
'8
u
0.
N
QI
'8
u
Q.
N
'*
.,
.,
ell
-t;
"0
4(
Q) ,--
iii
(i5,
"0'
<:
III
.~
U
QI
iii
(i5
>.
....
u
III
Q)
:g
4(
~
U5
$
a;
.,
III
.c
~
:J
Q.
'0
l!!
:J
iii
<:
Cl
en
ai
~
't>
Q)
e
'6
.s
~i ~
5l16~
~'@ qf
~ ~ ~
Q.oll :=
'O~-;
~-~ t
iii:E c::
.~~ ~
(1)Q).c::l
~~
Co
; ;
i~
~:!
~
~ ~
g
i6
(5
~
w w
:!; :!;
o 0
J: J:
~ ~
4( 4(
cr cr
w w
z Z
::l ::l
u. u.
cr cr
w W
J: J:
I- I-
o 0
z z
<: <:
o :!;
I- 0
CJ) cr
z u.
< ~
~ <
a: :!;
u. w
o cr
o u.
Z 0
o ~
~ :>
:!: Ui
cr u
o w
u. cr
~ -g
i ~
~ ~
~ !
z ~
o <:
j:: a:
4( ::l
~ ell
cr W
u ~
I- 0
U w
~ :!;
o ~
Z
~D
U
C[
a..
~
C/')
. .
*'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
November 14, 2001
DALE F SHUGHART JR
DALE F SHUGHART JR ESQUIRE
35 EAST HIGH ST
SUITE 203
CARLISLE PA 17013
Re: THERESA BAKER
SSN: 202-20-2687
Dear Attorney Shughart:
Pursuant to your letter dated October 31, 2001, the Department of Public
Welfare (DPW) , Estate Recovery Program, has reviewed the information you
provided regarding the above-referenced individual.
It has been determined that this individual did not receive any type of
assistance during the questioned period.
Therefore, according to the information you provided, the Department's
Estate Recovery Program will not seek any recovery from this estate.
If you have any questions, please feel free to contact me.
Sincerely,
~~
Ronald D. Hill, Manager
TPL - Casualty Unit
(717}772-6604
(717}772-6553 FAX
~x.t\Jf7rJ ~
. .
DALE F. SHUGHART, JR.
ATTORNEY AT LAW
35 EAST HIGH STREET
SUITE 203
CARLISLE, PENNSYLVANIA 17013
Telephone (717) 241-4311
Facsimile (717) 241-4021
OF COUNSEL
HAMILTON C. DAVIS
LEGAL ASSISTANT
BONNIE L. COYLE
January 9, 2002
Donald L. Baker, Administrator
Estate of Theresa A. Baker
TO: DALE F. SHUGHART, JR., ESQUIRE
EIN: 25-1802515
Professional services rendered as follows:
Cash advances:
11/20/01 -
12/28/01
01/ /02
Recordex Services, Inc.,
medical records from Hershey Hospital. 211.32
Dauphin County Coroner, coroner's report. 50.00
Masland Associates, Inc., medical report. 25.00
Mail Box, mail medical records to
OneBeacon.
Mail Box, mail medical records to Erie.
Register of Wills, filing Petition
for Court approval.
Total cash advances -
11.24
11.24
11/28/01
12/06/01
12/17/01
30.00
338.80
10/30/01 - Review information on accident;
letter to claims adjuster. 1.0
10/31/01 - Office conference with Attorney Addams. 1.0
11/01/01 - Prepare for and office conference
wi th client. .5
11/20/01 - Review information from Hershey Medical
Center; submit payment for medical
records; telephone conference with
Attorney Addams. 1.0
11/26/01 - Obtain information on family insurance;
letter to Dr. Taylor. .6
12/05/01 - Receive correspondence and Report;
forward to client and Attorney Addams. .8
12/06/01 - Receive Dr. Taylor's Report; forward
to client and Attorney Addams. .5
12/15/01 - Review medical records. 4.0
~XH( 61 r G-
.,
. .
DALE F. SHUGHART, JR.
January 9, 2002
Page 2
12/17/01 - Review file; fax to Attorney Addams;
letter to OneBeacon; telephone
conference with Attorney Addams;
various correspondence; shipping
Records.
12/28/01 - Receive letter from OneBeacon;
letter to OneBeacon, Erie and
client.
01/02/02 - Review fax from Ellen Buller;
message for Ms. Buller; telephone
conference with Ms. Buller.
01/08/02 - Review file and information;
telephone conference with Attorney
Addams; office conference with
client.
01/09/02 - Review information from Douglas
Kocher at Erie; telephone conference
with Mr. Kocher.
01/10/02 - Preparation of petition for
Allocation and Approval and related
correspondence..
01/ /02 - Final estimated time in obtaining
Order and distributing settlement.
Total hours -
Total fee at $165/hr.
Attorney Addams:
2.5
3.0
2.5
1.0
5.0
10.0
34.4
$5,676.00
Review of information; assisting
Attorney Shughart. 12.0
Total fee at $165/hr. $1,980.00
Total attorney fees and cash advances - $7,994.80
f.yM/8J I G- (J.I Z
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPARTMENT 280601
HARRISBURG, PA 17128-0601
Telephone
2/11/2002
717-783-0972
Dale F Shughart, Jr., Esquire
35 E High Street
Suite 203
Carlise, PA 17013
Dear Mr. Shugart:
Re: Estate of Theresa A Baker
File Number: 2101-0960
Court Number: Cumberland-Orphans-21-0 1-960
The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on
behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to
this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions.
Pursuant to the Petition, the 84 year old decedent died as a result of a motor vehicle accident. Decedent is
survived by the decedent's adult son, Donald L Baker.
Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no
objection to the proposed allocation of the gross proceeds of this action, $ 6,965.00 to the wrongful death claim and
$ 108,035.00 to the survival claim Proceeds ofa survival action are an asset included in the decedent's estate and
are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. g8302; 72 P.S. gg9106, 9107. Costs and
fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d
1059 (Pa. Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this matter. As the
Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any
hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from
this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the
Department may take in any other proposed distribution of proceeds of a wrongful death / survival action.
~. rely,
I (t) r) D--
- ,'. .1/e<--1?~/
J Paul ibe'"i1
, Inheritance Tax Division
Bureau of Individual Taxes
cc: Comberland County Clerk of Orphans Courts
E~('" l b II N
.. .
. ~
IN RE: ESTATE OF
THERESA A. BAKER, deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE NO. 21-01-960
CERTIFICATE OF SERVICE
AND NOW, this 18th day of February, 2002, I, Dale F. Shughart,
Jr., Esquire, attorney for the Estate of Theresa A. Baker,
deceased, hereby certify that I have served a copy of the Petition
for Settlement of Survival Action and Apportionment of Settlement
With Wrongful Death Action by mailing a copy of the same by United
States mail, postage prepaid, addressed as follows:
Ellen Buller, Claims Representative
OneBeacon
P. O. Box 8851
Camp Hill, PA 17011-8851
Douglas C. Kocher, Claims Representative
Erie Insurance Group
4901 Louise Drive
Rossmoyne Business Center
P. O. Box 2013
Mechanicsburg, PA 17055-0710
Kami J. Hoffman
7 Enck Drive
Boiling Springs, PA 17007
Shawn A. Baker
229 Middle Road
Newville, PA 17241
/
r
ale F. Shughart,
35 East High Stre t,
Carlisle, PA 17013
03
Exhibit "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
SHUGHART DALE F JR
35 EAST HIGH STREET
SUITE 203
CARLISLE, PA 17013
-------- fold
ESTATE INFORMATION: SSN: 202-20-2687
FILE NUMBER: 2101-0960
DECEDENT NAME: BAKER THERESA A
DA TE OF PAYMENT: 03/21/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 10/03/2001
NO. CD 000983
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $3,658.91
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: DONALD L BAKER
C/O DALE F SHUGHART JR
CHECK# 93
SEAL
INITIALS: SK
RECEIVED BY:
REGISTER OF WILLS
$3,658.91
MARY C. LEWIS
REGISTER OF WILLS
'\.. //]-/O~
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
05-06-2002
BAKER
10-03-2001
21 01-0960
CUMBERLAND
101
DALE F SHUGHART ~Q2ES~iY 10
STE 203
35 E HIGH ST
CARLISLE
:r~4
I. ~', _
Ctfl~i170 13
*'
REV-1547 EX AFP 101-02)
THERESA
A
Allount Rellitted
) CHANGED
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
109,775.87
.00
.00
(8)
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'E-Y-=is4-j-i3f-AFP-(('-f:02i--NOY-ici--OF-'rNHiifiTAi"-cE-Y-Ax-jrpPRjrisiirENT~--Ar.i-oWAiicE-oi-------------- ---
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BAKER THERESA A FILE NO. 21 01-0960 ACN 101 DATE 05-06-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. 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
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)
28,211.87
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
109,775.87
'8.466 83
81,309.04
.00
81,309.04
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
TAX CREDITS:
254.96
(11)
(12)
(13)
(14)
(15) .00 X 00 = .00
(16) 81,309.04 X 045 = 3,658.91
(17) .00 X 12 = .00
(18) .00 X 15 = .00
(19)= 3,658.91
. "'.. I..n I KC~C~r'1 II (+J AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
03-21-2002 CDOO0983 .00 3,658.91
TOTAL TAX CREDIT 3,658.91
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 "CREDIr' (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
~
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
, Deceased
No. 21 - 01 - 00960
Date of Death 10/3/2001
Social Security No. 202-20-2687
Estate of Baker, Theresa A.
also known as
Donald L. Baker
The 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 located 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 the Decedent owned no real estate outside of 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 are made subject to the penalties of 18 Pa. C. S.
Section 4904 relating to unsworn falsification to authorities.
1.0. No.: 19373
Personal Representative
Signature:~~_~~. \)~.
-D~~~er
Signature:
Attorney: Dale F Shughart, Jr. Esquire
Signature:
Address:
35 E. High Street, Suite 203
Address: 115 South Bedford Street
Carlisle, P A 17013
Carlisle, P A 17013
Telephone: (717) 241-4311
Telephone: 7/7- Z/-f ~ ~ 'f~O '7
Dated: '7 /'ZI/O 2-
Personal Property
Personal effects, household goods and furnishings.
100.00
Allfirst Bank, checking account #00133 - 5105 - 2
Principal.
1 ,313.19
Gross proceeds, Survival Action
108,035.00
One West Penn Apartment Center, refund security deposit.
233.60
Sprint, refund on phone bill.
10.69
Capital Blue Cross, refund of premium.
83.40
OneBeacon, net proceeds from Wrongful Death Settlement
(6,965 - 489.48)
6,480.52
Erie Insurance, funeral benefit
2,500.00
(Attach additional sheets if necessary)
Total PenoDal Property and Real Eltate
Sl18,756.40
REV . 1500 EX" (5&)
w
...
ll::!!iw
Ull:ll:
WA-U
:cog
UIEIII
A-
C
....
lI)Z
g!W
l!l~
U~
. .
~~<1~/5 - 3
*'
REV.1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Baker, Theresa A.
...
Z
w
Q
w
U
w
c
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
~
......
ip' :::1': ()~::
j
FILE NUMBER
21 01
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
202-20-2687
00960
NUMBER
THIS RETURN MUST BE FILED IN DUPUCATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of death prior to 12-13-82)
o 4. Limited Estate
o
181
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death
after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach
copy of Trust)
o 10. Spousal Poverty Credit (date of death between
12-31-91 and 1-1-95)
THIS SeCTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIOEN'nAL TAX tNFORMAlIONSHOULO BE DIRECTED TO:
COMPLETE MAILING ADDRESS
6. Decedent Died Testate (Attach copy
alWill)
9. Litigation Proceeds Received
NAME
Dale F Shughart, Jr. Esquire
FIRM NAME (II applicable)
TELEPHONE NUMBER
717/241-4311
1. Real Estate (Schedule A)
2_ Stocks and Bonds (Schedule B)
3, Closely Held Corporation, Partnership or Sole-Proprietorship
Z
o
~
:5
:;,
...
ii:
c
U
w
II:
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)
D' 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A} (Attach Sch 0)
p
!, ~--'
t',)
L~_.
(8)
109,775.87
10103/2001
01l09!l917
35 E. High Street, Suite 203
Carlisle, P A 17013
(1 ) None
.,..-'-' ".
(2) No~>
-<'
(3) None
(4) None
(5) 109,775.87
(6) None
(7) None
(9) 28,211.87
(10) 254.96
13, Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not
been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(11 )
28,466.83
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(12)
81,309.04
15. Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 16. Amount of Line 14 taxable at lineal rate 81,309.04 x .045 (16)
0
~
:;, 17.Amount of Line 14 taxable at sibling rate .12 (17)
A- x
::I
0
U
g 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
181
1. Original Return
20. OJ
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
(13)
(14)
81,309.04
10, Debts of Decedent. Mortgage Liabilities, & Liens (Schedule I)
11. Total DeductIons (total Lines 9 & 10)
12, Net Value of Estate (Line 8 minus Line 11)
3,658.91
3,658.91
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. ~O)
Decedent's Complete Address:
STREET ADDRESS One West Penn Street,
Apt. 522
CITY
Carlisle
STATE PA'
ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
3,658.91
Total Credits (A + 8 + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
(3) 0.00
(4)
(5) 3,658.91
(5A)
(58) 3,658.91
Total Interest/Penalty (D + E)
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
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable 10.' REGISTER OF WILL$, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................................................................. 0 181
b. retain the right to designate who shall use the property transferred or its income;................................ 0 181
c. retain a reversionary interest; or............................................................................................................ 0 181
d. receive the promise for life of either payments, benefits or care?.......................................................... 0 181
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?........................ ....................................................................................... 0 181
o 181
o 181
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?........ ................................................................................................. ......
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 aJl information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
~~'R~~
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
115 South Bedford Street
Carlisle, P A 17013
DATE
31~l\~
ADDRESS
DATE
"G':v;:'[{r'"" 'h=-
ADDRESS
35 E. High Street, Suite 203
Carlisle, P A 17013
DATE
3/G/ Pc
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. 99116 (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 return 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.
r
,~
~
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Baker, Theresa A.
FILE NUMBER
21 - 01 - 00960
Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jolntly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
1
DESCRIPTION
VALUE AT DATE
OF DEATH
100.00
Personal effects, household goods and furnishings.
2
Allfirst Bank, checking account #00133-5105-2
Principal.
1,313.18
3
Gross proceeds, Survival Action, Court Order and Settlement Statement attached.
108,035.00
4
One West Penn Apartment Center, refund security deposit.
233.60
5
Sprint, refund on phone bill.
10.69
6
Capital Blue Cross, refund of premium.
83.40
TOTAL (Also enter on Line 5. Recapitulation)
109,775.87
IJ allfirst
THERESA A BAKER
115 S BEDFORD ST
CARLISLE
PA 17013-3404
Page 1 of 3
Golden Age Checking
Theresa A Baker
Acct No 00133-5105-2
September 18, 2001 thro October 17, 2001
" allfirst.com fI 24-hour
Customer Service
, -800-533-4630
Activity Summary
Balance on 09/17
Deposits and additions
Checks
Other activity
Balance on 10/17
$685.98
651.00
-159.80
-26.40
$1,150.78
Deposits and additions
Date
Description
Amount
10/03
ACH CREDIT
US TREASURY 303 sac SEC
3031036030THERESA A BAKER
$651. 00
202202687 A SSA
20012746285182
$651. 00
Checks
· Denotes missing sequence number
Number
Date
Amount
1867
1870'
09/18
10/09
$23.80
136.00
$159.80
Other activity
Date Description
Amount
10/12 ACH DEBIT
MONUMENTAL LIFE INS PREM MM3026137
1520419790THERESA A BAKER 20012840557687
-26.40
-26.40
033210 2
0009-98317440786 050
iii allfirst
End of Day Ledger Balance
Account balances are updated in the section below on days when transactions posted
to this account.
Date
Balance
$1,150.78
09/17
09/18
$685.98
662.18
Date
Balance Date
Balance
10/03
10/09
$1,313.18 10/12
1,177.18
Balancing your checkbook. Look on the back of your first statement page for a fast and easy
way to balance your checkbook.
What your Icons mean
o Customer Service
G) Credit to your account
033210 2
0009-98317440786 050
o Important reminder
e Charge to your account
~ Other banks' ATM
transaction
Page 3 of 3
For questions about
your statement or
change of address
information. please see
page 2.
IN RE: ESTATE OF
THERESA A. BAKER
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT
ESTATE NO. 21-01-960
ORDER OF COURT
11t
AND NOW, this ~ day of
FE.13Kl;lfY!Z'1
, 2002, upon
consideration of the foregoing Petition, it is ordered that
settlement of the claims in this action for a total sum of One
Hundred Fifteen ($115,000) Dollars, One Hundred Thousand
($100,000) Dollars representing the entire liability limits of
third party coverage available through OneBeacon Insurance, and
Fifteen Thousand ($15,000) Dollars, representing the entire
under insured motorist liability limits through Erie Insurance
Group, is approved. The allocation of settlement in the amount
of six Thousand Nine Hundred sixty-five ($6,965) Dollars to the
Wrongful Death Action and in the amount of One Hundred Eight
Thousand Thirty-five ($108,035) Dollars to the Survival Action,
as compensation for Decedent's pain and suffering, and requested
counsel fees and expenses are also approved. petitioner is
authorized and directed to execute Releases to OneBeacon and Erie
in the forms attached to the Petition. Distribution is directed
as follows:
a. Dale F. Shughart, Jr., Esquire, counsel fees in the
amount of Five Thousand six Hundred Seventy-six ($5,676.00)
Dollars;
b. Dale F. Shughart, Jr., Esquire, costs and expenses
in the amount of Three Hundred Thirty-eight and 80/100 ($338.80)
Dollars;
c. William A. Addams, Esquire, counsel fees in the
amount of One Thousand Nine Hundred Eighty ($1,980.00) Dollars;
d. Donald L. Baker, Administrator of the Estate of
Theresa A. Baker, deceased, the sum of One Hundred Seven Thousand
Five and 20/100 ($107,005.20) Dollars.
By the Court,
~~~Q lLw.IJ j
"--- J .
Distribution:
Dale F. Shughart, Jr., Esquire, attorney for Donald L. Baker
Ellen Buller, OneBeacon
Douglas C. Kocher, Erie Insurance Group
Kami J. Hoffman
Shawn A. Baker
Q ~.
~.~ 8 :D
(IC ::v ,11
::l '" ~~
- "
C1 r, '.
('. ..,.
; m
CD
N
(J'.
~
-
"-!r- 0
... 0',
SETTLEMENT STATEMENT
ESTATE OF THERESA A. BAKER V. CRAIG CLEELAND
March 8, 2002
RECEIPTS: Deposited in Dale F. Shughart, Jr.
Escrow Account
OneBeacon
Erie Insurance
100,000.00
15,000.00
Total receipts -
115,000.00
DISBURSEMENTS:
Donald L. Baker, Administrator
Estate of Theresa A. Baker
107,005.20
william A. Addams, Esquire, attorney fees
1,980.00
Dale F. Shughart, Jr., cost account,
costs and expenses
338.80
Dale F. Shughart, Jr., attorney fees
5,676.00
Total disbursements -
115,000.00
Remaining balance in Escrow account.
-0-
/)00t
art, Jr.
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Baker, Theresa A.
SOEJU.EH
RJERALEXPENSES&
ADftWtSTRAlNEOO6r8
FILE NUMBER
21 - 01 - 00960
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
B.
FUNERAL EXPENSES:
Hoffman-Roth Funeral Home.
ADMINISTRATIVE COSTS:
DESCRIPTION
AMOUNT
1. Personal Representative's Commissions
Donald L. Baker
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address 115 South Bedford Street
City Carlisle State P A Zip 17013
Year(s) Commission paid
Attorney's Fees Dale F. Shughart, Jr., Esquire (estimated)
2.
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
4.
City
Relationship of Claimant to Decedent
Probate Fees Register of Wills
State
Zip
6,965.00
5,750.00
6,500.00
235.00
500.00
24.00
103.55
8,134.32
28,211.87
5. Accountant's Fees
6.
Tax Return Preparer's Fees Estimated.
7.
1
Other Administrative Costs
Register of Wills, Short Certificates.
2
The Sentinel, advertise Letters.
Total of Continuation Schedule(s)
TOTAL (Also enter on line 9, Recapitulation)
. .
.
SdBl.EH
FIIWII Expens BI &
AdI,...1tvCostsccr6ud
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Baker, Theresa A.
3
Cumberland Law Journal, advertise Letters
4
Fes and costs of survival action settlement.
Total fees and costs = 7,994.80 x .9394
(115,000 divided by 108,035)
5
Register of Wills, filing Inheritance Tax Return and Inventory
6
Bonnie Coyle, notary fees.
7
Postmaster, certified mail.
8
Reserve for costs and fees of Account.
FILE NUMBER
21 - 01 - 00960
Page 2 of Schedule H
75.00
7,510.32
25.00
20.00
4.00
500.00
. .
'.
SCHEDULE I
DEBTS OF DECEDENT. MORTGAGE
LIABiliTIES. & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Baker, Theresa A.
Includ. unrelmburs.d m.dlcal .xp.n....
ITEM
NUMBER
1 Sprint, telephone
DESCRIPTION
2
PP&L, electric
3
One West Penn Street, rent
4
Monumental Life, insurance premium
5
Carlisle Regional Medical Center, medical bill
FILE NUMBER
21 - 0 I - 00960
TOTAL {AI.o .nter on L1n. 10, R.capltulatlon}
AMOUNT
26.05
31.51
136.00
26.40
35.00
254.96
. .
,"
'.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Baker, Theresa A.
FILE NUMBER
21 - 01 - 00960
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Donald L. Baker
115 South Bedford Street
Carlisle, P A 17013
RELATIONSHIP TO
DECEDENT
Do Not List T",stee(.)
AMOUNT OR SHARE
OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
Son
One- half ( 1/2)
2 Shawn A. Baker
229 Middle Road
Newville, P A 17241
Grandson
One-fourth (1/4)
3 Kami J. Hoffman
7 Enck Road
Boiling Springs, P A 17007
Grandaughter
One-fourth (1/4)
Enter dollar amounts for distributions shown above on lines 15 through 17. as appropriate, on Rev 1500 cover she~t
ll. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0c/
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Theresa A. Baker
Date of Death: October 3, 2001
Admin. No. 21-01-960
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 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 No X
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 attache this report.
Date: ~ 2.--y) ZOO 'L
&
e F. Shugh , Jr.
35 East High Street, Suite 203
Carlisle, PA 17013
(717) 241-4311
Attorney for Estate
_!"\
J....-'.
;::"j
:-....... 1
~.::.:
---
. ... ..,- -I
~
1-1
~
~
';;:-
~
~
en
~
~
~
P-<
~
~
';2.
p
o
u
P
'P
~
~
~
~
~
~
p
u
~
o
en
~
~
~
P-i
';2.
';2.0
01-1
~enO
~I-1"o
0';;:-0'
ul-1\
p...-I
~ 0
O~\
~...-I
~pN
~O
P U .
o 0
u- ~
en
~~~
~~~
~~~
P-<~
~~en
r40~
~
~~
~en
~1-1
~~
~~
~
.U
~
~
4,0
en
~';:d
~0
~p
';:dO
E-\~
o
~~
o
~
~O
~
~~
~~
en~
~~
~
o
~ (l) .,...\
O~~
~ ~ ro
ro ~
~~~
~ ~ (1)
(I) .,...\ 'M
'M ~ ~
~ 'M
.,...\ (1) a
aOJrd
rd 'M ro
~~
~ ~
... ro (l)
~ p..~
OJ
.;l. rd 00
ro (l) ~
~ ~ 'M
(1) ~
(l) ~
~~rd
(l)
rd~rd
,.....4 C OJ
ro 'M ~
C ~
o ~ ~
p c U
'M U
ro 0
., ~
~ 0' (l)
~ U '?
~ ro cO
o ~
U 0
U ~ ~
~ ro
00~
(l) c ~
~ 'M
~ ~ (1)
c ~
I.\-l ~ 0
o 0 'M
U ~
(l) U U
(I) ro ro
o (1)
p..(I)~
~ 'M ro
~~~
P-<~~
(I)
~
(l)
I.\-l
\.H
o
o
~
...-1...-1
...-100...-1
0000
ONNO
N C'lC'l
o
...r-"o ...0
('<")...-1 ('<")N
~
~~(l)~ ...
(l)OJ,.o(l)('<")
,.o,.oa,.o...-l
o 0 OJ 0
~~'?~'?->
U U 0 U ro
oo~o~
~
o
~
~
~~
o~
en
~1-1
'?'?
pl-1
O~
uP
u~
~
~~
~~
~~
1-14.
~~
P .
~r.4
~
p
~r.4
en~
~';2.
1-10
~p
E-\
~ .,
~(::I
~o
~1-1
en~
1-1~
~P-i
~
~~
,;;:-';:d
., (::I ~
(::I~
., ~ ~
~E-\E-\O
E-\~~~
~~~
~~P-i0
(::I0~~
01-1
~enu~
O~ ~
~~p
~~enO
~~~u
~~I-1U
(::Ir.4~~
(l)
~
ro
~
(1)
~
(1)
~
(I)
OJ
~
0'
(l)
~
\\\\\\\\ \
~'r>}.....\.;~; \ i .i\ 1
1.\ \11rti ~
\l~\\i\\\\
~t\\ r!'\i~ ~._.("fl.
A-~-\\~ -G~-'".::
:... ~ b'" -tS ~.~~
:,'~. i \ ~. . fI.:.~ ~;...
~~~~@_ ~t~~
"';' .'j"; ':J of; -;.. ~.l-.1.-'
N
~ ~ {t) {t)
~~ ~ ~ 0
~ ~ ~l'-
~~\\q
\-12~i~~~
% \ ~ \\ s
OJ
,.0
rd ~
(l) ro
~ U
'M
a (1)
ro c
'A 0
(l) 'M
~
,;;>,>c.J
,.....4 (l)
,.....4.,.,
~,.o
I.\-l 0
(l)
~ ~
ro 0
c.J
(1)
OJ C
,.0 0
'M
~ ~
~ (1)
~ OJ
o ~
c.J 0'
c.J
~ ...
c
(l) . M
~,\J
~ ro
a
,\J ~
ro 0
~I.\-l
~ ~
.,...\
~ ..
~,.....4~
ro ro ,\J
~ ~ 'M
~ 0 ~
o .,...\
p..~rd
a 'M (l)
'M rd (1)
rd (I)
(1) ro ~
'M c.J
~ (1)
~ 0 'M
l-1\.Hrd
(I)
OJ
~
ro
c.J
'M
rd
~
'M
o
(1)
,.....4
ro
~
~
~
o
c)
c.J
~
(l)
~
E-'
OJ
~
,\J
I.\-l
o
(I)
~
o
'M
~
~
,.0
'M
~
~
(1)
'M
rd
rd
(l)
(I)
o
p..
o
~
p..
(l)
~
+J
~
e'" ~9 v .""....." UOllnQ\)\.\\I 10 .1"
_pO'1" peoOdO,d UII'" .~.U0P'.OOO' c U\
~.~." I ';.:'p; ,\;,11(\\0;:>Q0
.~. 0 ' G 1 .-'-&)
l\a\\\. '"
~:ll~i"
~%9~21i~ .
t:... .~~11 ~ i \
c. ~ \19
%~ a ~i
~ .F..... <0 ~
.p' .. D
~1~11\ \j
~'i\\g\~~~
\\\\\i"~
l
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE NO. 21-01-960
ESTATE OF THERESA A. BAKER
LATE OF BOROUGH OF CARLISLE
FIRST AND FINAL ACCOUNT OF
DONALD L. BAKER, ADMINISTRATOR
DATE OF DEATH:
LETTERS GRANTED:
FIRST COMPLETE ADVERTISEMENT
OF GRANT OF LETTERS
ACCOUNTING FOR THE PERIOD:
October 3, 2001
October 17, 2001
November 6, 2001
October 3, 2001 to
May 13, 2002
Purpose of the Account: Donald L. Baker, Administrator, offers
this accounting to acquaint interested parties with the
transactions that have occurred during her administration.
The Account also indicates the proposed distribution of the
Estate.
It is important that the Account be carefully examined. Requests
for additional information, questions or objections can be
discussed with:
Dale F. Shughart, Jr., Esquire
35 East High Street, Suite 203
Carlisle, PA 17013
(717) 241-4311
Attorney for Estate
SUMMARY OF ACCOUNT AND INDEX
Principal
Paqes
Receipts
Gains and Losses on sales
or other dispositions
Less Disbursements
Reserves
Balance Before Distributions
Distributions to Beneficiaries
2
3
3
3
4
4
Principal Balance for Distribution
4
Income
Receipts
Less Disbursements
Income Balance for Distribution
Combined Balance For Distribution
4
4
5
5
Proposed Distributions to Beneficiaries 5
RECEIPTS OF PRINCIPAL
Real and Personal Property
Cash:
Allfirst Bank, checking account #0013305105-2
Principal
1,313.18
Gross proceeds, Survival Action
108,035.00
One West Penn Apartment Center, refund security deposit. 233.60
Sprint, refund on phone bill. 10.69
Capital Blue Cross, refund of premium. 83.40
Net proceeds, Wrongful Death settlement. 6,480.52
Erie Insurance, funeral benefit. 2,500.00
-2-
Tanqible Personal Prooertv:
Personal effects, household goods and furnishings.
Debts owed Estate:
Stocks and Bonds:
Realtv:
Gains (Losses) on sale and other
Disbursements:
TOTAL RECEIPTS OF PRINCIPAL
1.
2 .
3 .
4 .
5.
6 .
7 .
8.
9.
10.
11.
12.
13.
14.
15.
16.
DISBURSEMENTS OF PRINCIPAL
Hoffman-Roth Funeral Home, funeral bill
Register of Wills, probate fees
Register of Wills, Short Certificates.
The Sentinel, advertise Letters.
Cumberland Law Journal, advertise Letters.
Fee and costs of survival action settlement.
Register of Wills, filing Inheritance Tax Return
and Inventory.
Bonnie Coyle, notary fees.
Postmaster, certified mail.
Dale F. Shughart, Jr., attorney fees
PA Department of Revenue, inheritance taxes.
Sprint, telephone.
PP&L, electric
One West Penn Street, rent.
Monumental Life, insurance premium
Carlisle Regional Medical Center, medical bill
Subtotal -
-3-
100.00
-0-
-0-
-0-
-0-
$118,756.40
$ 6,965.00
235.00
24.00
103.55
75.00
7,510.32
25.00
20.00
9.00
2,491.50
3,658.91
26.06
31.51
136.00
26.40
35.00
$ 21,372.25
Reserve for the following Expenses:
1. Costs and fees of Account.
2. Preparation of Fiduciary Income Tax Return and
taxes due.
3. Donald L. Baker, Administrator's commission.
4. Dale F. Shughart, Jr., attorney fees
Subtotal:
TOTAL DISBURSEMENTS OF PRINCIPAL
PRINCIPAL BALANCE BEFORE DISTRIBUTIONS
PRINCIPAL DISTRIBUTIONS TO BENEFICIARIES.
To: Donald L. Baker, personal effects
To: Shawn A. Baker, personal effects
To: Kami J. Hoffman, personal effects
TOTAL DISTRIBUTION OF PRINCIPAL
TO BENEFICIARIES
TOTAL DISBURSEMENTS AND DISTRIBUTIONS
REMAINING BALANCE OF PRINCIPAL FOR DISTRIBUTION
RECEIPTS OF INCOME
M & T Bank, money market account #15004198225300
(estimated)
DISBURSEMENTS OF INCOME:
NONE
-4-
500.00
500.00
5,750.00
2,500.00
$ 9,250.00
$ 30,622.25
$ 88,134.15
$ 50.00
$ 25.00
$ 25.00
$ 100.00
$ 30,722.25
$ 88,034.15
$
600.00
-0-
. .
DISTRIBUTIONS OF INCOME:
NONE
-0-
BALANCE OF INCOME FOR DISTRIBUTION
s
600.00
COMBINED BALANCE FOR DISTRIBUTION
$ 88,634.15
STATEMENT OF
PROPOSED DISTRIBUTIONS TO BENEFICIARIES
AFTER ACCOUNT CONFIRMATION
To: Donald L. Baker, 1/2 of Estate
Shawn A. Baker, 1/2 of Estate
Kami J. Hoffman, 1/2 of Estate
$ 44,317.07
$ 22,158.54
S 22,158.54
Total proceeds for distribution -
$ 88,634.15
Donald L. Baker, Administrator of the Estate of Theresa A.
Baker, deceased, hereby declares under oath that he has fully and
faithfully discharged the duties of his office; that the
foregoing First and Final Account and Schedule of Distribution is
true and correct and fully discloses all significant transactions
occurring during the accounting period, that all known claims
against the Estate have been paid in full, that to his knowledge,
there are no claims now outstanding against the Estate; and that
all taxes presently due from the Estate have been paid.
~~~ ~~~
Donald L. Baker, Administrator
~b<T-
NOTMIAL SEAL
BONNIE L COYLl, NOTARY PUBLIC
BORO 011 CARUSLE, CUMBERLAND COUNTY
MY COMMISSION ~RES OCTOBER 17 2002
Sworn and subscribed before me,
this /33 day of May, 2002.
-5-