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Home My WebLink About01-1043 PETITION FOR PROBATE and GRANT OF LETTERS ESf~J.dle.MCJtLVIL No. ~/-OI -101./. a .4f:!:;;kn;;~ AtitJJe G\CUfK To: Register of Wills for the , Decea~G.4.,,- County of. G.A YY\ ~lCV'oJ in the Social Security No. I '1 , - ~"5 - ~tIIJ I KlW Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an,'the executv;:x in the last will of the above decedent, dated 'S"e p+err. be-r I ~ . 2bOC> and codicil(s) dated named ;-1$=- (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in hpr last family or principal residence at County, Pennsylvania, with me- (list street, number and muncipality) Decendent, then C14 years of age, died ()r %r.J\oe-v <e ,X7~4>, at Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in 'Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: $ $ $ $ lSbO ~ tV/A (VIA t-J/A WHEREFORE, petitioner(s) respectfully presented herewith and the grant of letters theron. ~ Q) u c: Q) '1::l_ .- V> V>_ Q) ... o::~ -g.g ~.;:: 30:: Q) ""- BO tIS c: OIl Ci5 _I isO-. ShWo1+e.. ~~ e~~~ han I" . u.. l '"lost:> ~w~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ss COUNTY OF C~~~ J The petitioner(s) above-named sV/ear(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. Sworn to or affi.rmed and subscribed { f ~ Lu ~ ~ before me this 14th day of ~ NOV. S2 ~2001 . a 7>f'.,u C. ;t,.",. Ot. -BB _ .'cu~ ~ I ' I Re 'ster ~ I? - ~D -I if .n I / c' JiQ., 21-01-1043 ~dcf I e J... R 1) f) I K I It Estate of PrdJ i e. fY). C In v K , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW t\\o" tM.kr_~___ _____ _ )(_2P~, in cOIl:;ideration ( . l'~ c'e:iti..-,i~. 'Jrl the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated 09-18-2000 described therein be admitted to probate and filed of record as the last will of ADDIE CLARK a/k/ a ADDIE M. CLARK and Letters TESTAMENTARY are hereby granted to LISA WOLFE 'fYhl (1., 'i!u".H n...p~ ~.~. - Register of Wi~ I FEES $ 25.00 $ 3.00 $ $ 15.00 :;.00 TOTAL _ $ '1 d 48.00 Fl e . . . NOV. .15,.2001. . . . . . . . . . . . . . . . . . RICHARD P. MISLITSKY A ITORNEY (Sup. Ct. LD. No.) 1 West High st, P.O.Box 1290 ADDRESS Probate, Letters, Etc. ......... Short Certificates( ).......... Renunciation ................ x-pages JCP Carlisle/Pa. 17013 PHONE 241-6363 ~j, c~ ' JI -J5-01 105.805 REV 9/86 This is to certify that the information here given is correctly copied from an original certificate of death dul~ filed with Th .. al'f] 11 b 1: d d to the State Vital Records Office for permanent filmg Local Registrar. e ongm certllCate wi e.lOrwar e . WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 p 7714058 No. me as )1._~. ~~&..~ Local Registrar OCT 9 2001 Date Hl0S.143 A." 2187 COMMONWEALTH OF PENNSYlVANIA. OEPARTMENT OF HEALTH 0 VITAL RECOROS CERTIFICATE OF DEATH $T41E FILE NUMHR SOCIAl. SECURITY NUM8liR 'NT ,NT it( NAME Of' DECEDENT IF.... MiddIe.l'" I. AOE(l.. ~ 8IRTHPLACE (CoIy_ wifrnlfi'gfc5nl'f PUlCf Of' DEATH 'c_.. ""'Y"'" -- _ "".n":I"",, on Olnet _, HOSPllAL; '-'_ 0 E~_ 0 7. DE ... FA~h~~~~rcf'Hoore"''''1tWl rvneet. ::...,10 14. Old 17e.O _. _ _ in - ... in. ~l1mhPrla.nd -...,? 17,..1ia ::"'0:-.:::'01 Carlisle MOTHER'S NAME (Firll. ModaIe. ~Sur_l Anna Day 1 . 1HF~~"W~csm-~~~~sburg, PA 17050 2Ilb. PlACE Of' DISPOSITION. Nama 01 c-..,. Crtonataty n~son Presbyterian 2tc. Church cemetery NAME AN!) ADORESS Of' FI\ClUTY 0 zz.:. 219 N, Hanover lICENSE NUMllER 23t0.1f N III" S75' - L SEll ~emale ,~t S. COUNTY OF 0EArH CUrrDerland DATE OF BIRTH ""'on"'. Oay. ._. Aug 17,1907 I. an. BOAO. TWP OF DEATH Carlisle 94 v",. .... .... ..,. DECEDENT'S USUAl OCCVPATION ICJHO Of' 8USlNESS/lNOUSTAY l~-=:~ "::'':::'.I::r , . UL OWner operator n~tique buslness . Iif~nr~~~~~z,,~, ~t~s Carlisle, PA 17013 0110:::::- ,.. FRHEIrS NAME (1".... Middle. lasl) 17.. Sl... 1110. Francis F. Callahan Ie. -ClAMAHT'S NAME (T ypaIf'nnl) Nancy C. Berzinec ~ ~ HTI DUE 10 lOR ASA CONSEOUENCE 01'): I :. 4. WlERE AU10PSY FINDINGS AIIUl.A8l.E ~ 10 CONPlET1OH DI' CAUSE OF DEATH? DUE 10 lOR AS A CONSEOUENCE 01'); DUE 10 (OA AS A CONSEOUENCE 01'): MANNER Of' DEATH DATE OF INJURY (Mon"'. Day. "'.., Hal.... ~ _ 0 -- 0 _ide 0 PoncfinO -'9a'1on 0 Could _ be cIa.orm'ned 0 No~ _ 0 No 0 -- :talo. 29. CUIT_RICI\eck oriy one! 'c:eJtT1fY1IG '"YSICIAN (PIl_ ~ "- d _ "'*' anol~er on"",,oan has P<onc..nced <Ie"'" ana C""",,,"Od nam 231 T.__.."'Y...............___.....ca..M(.I.ncI.........'U".,......................... .............................. .I'fIONOUNClNG AN!) CERTIFYING PtlYSlCIAH IPho;$oc.." boOn ;''''''''''0(;'''11 "".I~ ana c"""\""91O C_ 01 ae.'N To......... of my knowteclgft. de.... occwred .,the...... d.... and pface,.nct "".10 the cau"(I) 1M mann.,.. a'.ted., .... ......... . .. . . ...... -IIEDlCAL OAMINElllCOROHEA on tlIe lie.. of eu..,;natlOn .nd/or inv..lIgalioft. in my opinion. dealh oec..".d al Ihe tlm..If.le. and pl.ce, and due 10 Ihe c.....l.).nd "'_ .. st.ted.. . . . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . .. . . .. .. . . . . . . .. . .. .. . .. .. . . . . . . .. . . . . .. . .. .. . . . .. .. . .. . . . .. 31.. REGISTRAR'S SIGNATURE AND NUMBE l~ I idJ \ to I 3. 171 - 28 2001 RACE. "- _no 8laek. While. ole. (SIl<<IyI White tt. 1otAAIlAt. STATUS -........ ....-. -.... Wi~~ SUfMVING SPOUSE (1_. il"'e-'_ 1Wp. ~. 21. f ApcwostmaJ. '--" :--- I l "''"' ~ PART N: 0tI1er Iigni_ candIIionI ~ 10 _. ..... "'" -*'llin"'~__in Pt\RT I. TIME OF INJUAY INJURY I(f WORK? DESCRIBE HOW INJURY OCCURAEO. o NoD 34. ~ ~ lr ~ 'l '} L.t 1 ~ ~ ~ ~ c:;gasiJ CWdtand ~~ ~ &Il~~ I, Addie Clark, of 6113 Westover Drive, Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. c;JiJt&fJ I ask the Trustee of my Irrevocable Trust dated November 14, 1994, in its discretion, to transfer to my Executrix funds sufficient to pay all expenses arising from my last illness, care and burial including costs of inscribing my grave marker. I further ask my Trustee in its discretion to pay my Executrix sufficient funds from my Trust to pay all my debts, income taxes and any inheritance tax due on any and all property included in my Estate; and to further pay to my Executrix sufficient funds to pay the cost of administering and settling my Estate. I ask my Trustee to exercise its discretion in favGr of my last wishes. In the event that my Trustee refuses to honor my request, I authorize my Executrix to expend funds from my Estate in such amounts as my Executrix deems necessary and desirable to pay the expenses arising from my last illness, care and burial, including an inscription on my grave marker. I further direct my Executrix to pay from my Estate any income tax that may be due and payable. Inheritance taxes shall be paid by each beneficiary. , ~ ~ ~ $~ I hereby nominate and appoint my caring Granddaughter, LISA WOLFE, to act as Executrix of my Estate. In the event that Lisa cannot or is unable to act as my Executrix, I, in the alternative, nominate and appoint my loving daughter, NANCY C. BERZINEC, to act as Executrix of my Estate. My Executrix is specifically relieved from the duty or obligation of filing any bond or security. cr; Ituut t ~ " , ~ '" ~. ~ I ask my Executrix to arrange my final service and funeral at the Dickinson Presbyterian Church. I further ask my Executrix to arrange my interment alongside my beloved Husband and Children. cg~ I direct my Executrix to accumulate the personal property hereinafter set forth from wherever said personal property may be located and to further provide for the appraisal of said personal property. Hepplewhite Chest of Drawers Windsor Chair (Steeley) Bannisterback Chair Queen Anne Sewing Table Dresser Boxes (Cloisonne') 2 Small Paintings (Grandfather Callahan) Miniature Coffee Grinder Collection of Irons & Trivets Madonna Picture in Goldleaf Frame 4 Oriental Rugs (Bedroom) 2 Lg 1 Sm Small Reproduction Pedestal Table Stretcher Table Wooden Skates Mirror (Family) Astral Lamp Brass Skater Lantern Stamp Collection Door Stop-Bull Dog Door Stop-Bull Dog Door Stop-Shepherd Dog 10 Oriental Rugs Brass Cricket Cage ~ .. ~ ~ ~ ~ -t~ \r- ~ ~' "" ~ ~ Tilt Top Table with Bowl Cast Iron Toy, Horses and Wagon Portrait of Great Grandmother Green Small Brass Rayo Lamp with Painted Parchment Shade Star Sapphire Ring - 50th Wedding Anniversary Gift (From Estate of Ruth Hemminger) Diamond Engagement Ring Diamond Wedding Band 24 Carat Gold Necklace Diamond Earrings c;i/Jk After my Executrix has accumulated and provided for the appraisal of my personal property, I give, devise and bequeath the appraised value of said personal property to my children, DONALD CLARK and NANCY BERZINEC, and the children of my deceased daughter, CATHY HEFFLEFINGER, MATTHEW HEFFLEFINGER and SUSAN H. MILLER, in the following shares: A. One- Third Share to Donald Clark; B. One-Third Share to Nancy Berzinec; C. One- Third Share to be divided between Matthew Hefflefinger and Susan H. Miller In the event that any of the above-named individuals desires any of my personal property, to the greatest extent possible I direct my Executrix to give said personal property and to credit the value of said personal property against the individual's share of the value of my personal property. $~ In addition to the powers conferred by law, I hereby authorize my Executrix acting under this Instrument in her absolute discretion: A. To retain in the form received, or to sell either at public or private sale any of my personal property; B. To make distribution hereunder in either cash or kind, as may be agreed upon or as my Executrix in her discretion may deem wise; c. To sell, transfer, conveyor exchange any personal property which at any time may form part of my Estate including the personal property herein before set forth, for the payment of any debts or taxes, or for any purpose pertaining to the administration of my Estate. IN WITNESS WHEREOF, I, ADDIE CLARK, have hereunto set my hand and seal to this my Last Will and Testament, consisting of four (4) typewritten pages, the first three (3) of which bear my signature in the margin for identification, this {g day of ~~p~~ , 2000. Cl~_,~ ADDIE CLARK Signed, sealed, published and declared by the above-named, ADDIE CLARK, Testatrix, as and for her Last Will and Testament in the presence of us, who have hereunto subscribed our names at her request as witnesses, thereto, in the presence of said Testatrix and of each other. ~'.. · o. p. ~--r ADDRESS~~, ~ :~Rd~d ~ . ~ '.,. ~J/~~~.l. lib 20 _ - 7/7- ? 7b - () '7/1 ~-4- r~~ ADDRESS ~) faIVV/(W Sf C{}VY{l~~ ?A /10/3 COMMONWEAL TH OF PENNSYLVANIA : SSe COUNTY OF CUMBERLAND We, ADDIE CLARK, r; nl(Cflb;r0W Co.{he~ll1c t. ko.A1eAj and 'Va. CV L- , the Testatrix and witnesses, respectively, whose names are signed to the foregoing or attached 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 Testament and that she signed willingly and was executed as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix signed the Will as witnesses and that to the best of their knowledge the Testatrix was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. d~ lh.~ ADDIE CLARK ~~'. __D j! ~~6~~ r;;;1f~:JU Witness Subscribed, sworn to and acknowledged before me by ADDIE CLARK, the NOTARIAL SEAl SUE A. a.AlR, Notary PubIc Lower Allen Twp., Cumbertand Co., PA My Commission Dee. 28, 2002 . CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Addie Clark, alk/a Addie M. Clark Date of Death: October 6, 2001 Will No. Adm. No. 21-01-1043 To the Register: I certify that Notice of (Beneficial Interest) Estate Administration required by Rule 5.6(a) of the Orphans' court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on February 26, 2002. Name Address Susan H. Miller 18931 Jodywood Drive Jumble, TX 77346 Donald Clark 221 East Walnut Street Pasadena, CA 91101 Nancy Berzinec 6113 Westover Drive Mechanicsburg, P A 17055 Matthew Hefflefinger 79 Diamond Point Morton, IL 61550 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Date: I~D~ ~C~~!.&~ One West High Street, P.O. Box 1290 Carlisle, PAl 7013 717-241-6363 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, CUMBERLAND COUNTY, PENNSYLVANIA In re Estate of ADDIE CLARK, A!KIA ADDIE M. CLARK, Deceased, No: 21-01-1043 of Cumberland County TO: Susan H. Miller 18931 Jodywood Drive Humble, TX 77346 Please take notice of the death of Decedent and the grant of letters to the personal representative(s) named below. The Decedent, Addie Clark, aJk/a Addie M. Clark, died on the 6th day of October, 2001, Cumberland County, Pennsylvania. The Decedent died testate (with a Will); The personal representative of the Decedent is Lisa Wolfe. If the Decedent died testate, the Will has been filed with the Office of the Register of Wills of Cumberland County, Cumberland County Courthouse, Carlisle, Pennsylvania 17013, Telephone: 717-240-6345. A copy of the Will may be obtained by contacting the Register of Wills and paying the ::ges for~b:/::' J2tW ~ I I Richard P. Mislitsky, ES~ One West High Street, P.O. Box 1290 Carlisle, P A 17013 717-241-6363 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, CUMBERLAND COUNTY, PENNSYL VANIA In re Estate of ADDIE CLARK, AfK/ A ADDIE M. CLARK, Deceased, No: 21-01-1043 of Cumberland County TO: Donald Clark 221 East Walnut Street Pasadena, CA 91101 Please take notice of the death of Decedent and the grant of letters to the personal representative( s) named below. The Decedent, Addie Clark, a/kIa Addie M. Clark, died on the 6th day of October, 2001, Cumberland County, Pennsylvania. The Decedent died testate (with a Will); The personal representative of the Decedent is Lisa Wolfe. If the Decedent died testate, the Will has been filed with the Office of the Register of Wills of Cumberland County, Cumberland County Courthouse, Carlisle, Pennsylvania 17013, Telephone: 717-240-6345. A copy of the Will may be obtained by contacting the Register of Wills and paying the charges for duplication. Date: 2!7-~/OY !cfdlit~ One West High Street, P.O. Box 1290 Carlisle, P A 17013 717-241-6363 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, CUMBERLAND COUNTY, PENNSYLVANIA In re Estate of ADDIE CLARK, AfKI A ADDIE M. CLARK, Deceased, No: 21-01-1043 of Cumberland County TO: Nancy Berzinec 6113 Westover Drive Mechanicsburg, P A 17055 Please take notice of the death of Decedent and the grant of letters to the personal representative(s) named below. The Decedent, Addie Clark, a/k/a Addie M. Clark, died on the 6th day of October, 2001, Cumberland County, Pennsylvania. The Decedent died testate (with a Will); The personal representative of the Decedent is Lisa Wolfe. If the Decedent died testate, the Will has been filed with the Office of the Register of Wills of Cumberland County, Cumberland County Courthouse, Carlisle, Pennsylvania 17013, Telephone: 717-240-6345. A copy of the Will may be obtained by contacting the Register of Wills and paying the charges for duplication. Date: Z. J'Vff/O 11' ~tse,~ One West High Street, P.O. Box 1290 Carlisle, P A 17013 717-241-6363 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, CUMBERLAND COUNTY, PENNSYL VANIA In re Estate of ADDIE CLARK, AlK/A ADDIE M. CLARK, Deceased, No: 21-01-1043 of Cumberland County TO: Matthew Hefflefinger 79 Diamond Point Morton, IL 61550 Please take notice of the death of Decedent and the grant of letters to the personal representative(s) named below. The Decedent, Addie Clark, a/k/a Addie M. Clark, died on the 6th day of October, 2001, Cumberland County, Pennsylvania. The Decedent died testate (with a Will); The personal representative of the Decedent is Lisa Wolfe. If the Decedent died testate, the Will has been filed with the Office of the Register of Wills of Cumberland County, Cumberland County Courthouse, Carlisle, Pennsylvania 17013, Telephone: 717-240-6345. A copy of the Will may be obtained by contacting the Register of Wills and paying the charges for duplication. Date: ---2:/ 'l-tj f 6 'l.- ~P.~~ Richard P. Mislitsky, Esquire One West High Street, P.O. Box 1290 Carlisle, P A 17013 717-241-6363 Counsel for Personal Representative 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 LISA WOLFE 6353 STEPHENS CROSSING MECHANICSBURG, PA 17050 u______ fold ESTATE INFORMATION: SSN: 171-28-3296 FILE NUMBER: 2101-1043 DECEDENT NAME: CLARK ADDIE DA TE OF PAYMENT: 07/02/2002 POSTMARK DATE: 07/01/2002 COUNTY: CUMBERLAND DATE OF DEATH: 10/06/2001 NO. CD 001362 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $2,021.35 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: LISA WOLFE CHECK# 0097 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS $2,021.35 MARY C. LEWIS REGISTER OF WILLS 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 LISA WOLFE 6353 STEPHENS CROSSING MECHANICSBURG, PA 17050 -------- fold ESTATE INFORMATION: SSN: 171-28-3296 FILE NUMBER: 2101-1043 DECEDENT NAME: CLARK ADDIE DATE OF PAYMENT: 06/20/2002 POSTMARK DATE: 06/17/2002 COUNTY: CUMBERLAND DATE OF DEATH: 10/06/2001 NO. CD 001315 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $5,908.79 I I I I I I I I TOTAL AMOUNT PAID: $5,908.79 REMARKS: LISA WOLFE CHECK# 0096 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS MARY C. LEWIS REGISTER OF WILLS 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 MISLlTSKY RICHARD P 1 W. HIGH ST P.O. BOX 1290 CARLISLE, PA 17013 n_n___ fold ESTATE INFORMATION: SSN: 171-28-3296 FILE NUMBER: 2101-1043 DECEDENT NAME: CLARK ADDIE DA TE OF PAYMENT: 06/17/2002 POSTMARK DATE: 06/13/2002 COUNTY: CUMBERLAND DATE OF DEATH: 10/06/2001 NO. CD 001298 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $3,939.19 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: DIRECTORS DIVERSIFIED INS AG C/O RICHARD MISLlTSKY ESQUIRE CHECK# 1002 SEAL INITIALS: AC RECEIVED BY: REGISTER OF WILLS $3,939.19 MARY C. LEWIS REGISTER OF WILLS I/)_~- /"Y BUREAU OF INDIVIDUAL TAXES INHERITANC~ TAX DIVISION DEPT. 2806ft \~A~ISBURG, 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 n :r}~OUNTY ACN 06-24-2002 CLARK 10-06-2001 21 01-1043 CUMBERLAND 101 RICHARD P MISLITSKV ESQ 1 W HIGH ST PO BOX 1290 CARLISLE '02 'U" 1 I lj _ V ~_ PA 1701~t:"; *' REV-1547 EX AFP UI-D2l ADDIE Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE~ PA 17013 CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=is4j-EX--AFP--foY=02i--NOY-iCE--OF-:fNHEifiTAifcE-Y-Ax-jrpPRjrisEi'-iNT~--AL1-owAifCE-('-R----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF CLARK ADDIE FILE NO. 21 01-1043 ACN 101 DATE 06-24-2002 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. Hortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 2J024.75 .00 283.707.99 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) 10. Debts/Hortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) 14~078.62 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 285~732.74 '1 .969 96 263,762.68 .00 263,762.68 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 (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: .00 X 00 = .00 263~762.68 X 045 = 11~869.33 .00 X 12 = .00 .00 X 15 = .00 (19)= 11~869.33 7.891.34 (1ll (12) (13) (14) . "" ......... n____. . l+J AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) INTEREST IS CHARGED THROUGH 07-09-2002 TOTAL TAX CREDIT .00 AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 11~869.33 REVERSE SIDE OF THIS FORM INTEREST AND PEN. 5.84 TOTAL DUE 11~875.17 . IF PAID AFTER DATE INDICATED~ SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $l~ NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR) ~ YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) REV-1470 EX (6-88) ~ .'. INHERITANCE TAX EXPLANATION COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG PA 17128-0601 DECEDENrS NAME FILE NUMBER Addie Clark 2101-1043 REVIEWED BY ACN Sheila Megonnell 101 ITEM SCHEDULE NO. EXPLANATION OF CHANGES H B-1 Reduced to $2,024.75. Personal representative.fees can only be claimed against probate assets. ROW Page 1 /7-0l0-/V ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG I PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT '* REV-U07 EX AFP [01-02) RICHARD P MISLITSKY ESQ 1 W HIGH ST PO BOX 1290 CARLISLE PA 17Q13 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 10-28-2002 CLARK 10-06-2001 21 01-1043 CUMBERLAND 101 ADDIE Allount Rellitted 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 ~ RE-V=i(;ifj-E3f-AFP--foi-:02)-------...--iNirEii~.._ANCE--YA3f-STATEME-NY-ifF'-AC-couiiT--.-..---------------- - - --- ESTATE OF CLARK ADDIE FILE NO.21 01-1043 ACN 101 DATE 10-28-2002 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: 06-24-2002 P R I NC I PAL TAX DUE: ....................................................................................................................................................................mmmnm..n................nmm.....nn.... 11~869.33 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 06-13-2002 CDOO1298 .00 3~939.19 06-17-2002 CDOO1315 .00 5~908.79 07-01-2002 CDOO1362 .00 2~021.35 TOTAL TAX CREDIT 11~869.33 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 $l~ NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)~ YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) 11-~t)-/Y \. BUREAU OF INDIVIDUAL TAXES ~INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG I PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT '* IlEV-1U7 EX AFP (01-02) JUL 26 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 07-22-2002 CLARK 10-06-2001 21 01-1043 CUMBERLAND 101 A.ount Rellitted ADDIE l)2 RICHARD P MISLITSKY ESQ 1 W HIGH ST PO BOX 1290 CARLISLE PA 17),13 u 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 for. with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV:i6(fj-Ex-AFP-(Oi-:02-f------...-iNirERi~..-ANCE-;:AX-STAfEMEti;:-OF'-Accouiif--...--------------------- ESTATE OF CLARK ADDIE FILE NO. 21 01-1043 ACN 101 DATE 07-22-2002 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: 06-24-2002 P R I N C I PAL TAX DUE: ....m....mm......mm............m..mm...__._m..........mm........m....m..mm.........m.....................................................................................m............... 11,869.33 PAYMENTS (TAX CREDITS): INT AT REV PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 06-13-2002 CDOO1298 .00 3,939.19 06-17-2002 CDOO1315 .00 5,908.79 EREST IS CHARGED THROUGH 08-06-2002 TOTAL TAX CREDIT 9,847.98 THE RATES APPLICABLE' AS OUTLINED ON THE ERSE SIDE OF THIS FORM.~ BALANCE OF TAX DUE 2,021.35 INTEREST AND PEN. 10.28 . IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE 2,031.63 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-- (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) .. ~~ {J/ STATUS REPORT UNDER RULE 6.12 Name of Decedent: Addie Clark Date of Death: 10-06-2001 Will No.: 01-1043 Admin. No.: 21-01-1043 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 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: N / A 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: None c. Did the personal representative state an account informally to the parties in interest? Yes J!l No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be file ith the Clerk of the Orphans' Co and may be attached to this r 0 . Date: ~/ 03 Richard P. Mislitsky, Esquire Name 1 W. High st.,ste 208, Carlisle, Address PA 17013 ~717) 241-6363 Telephone No. Capacity: 0 Personal Representative I!J Counsel for personal representative ~EV.1500 EX 16-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 INHERITANCE TAX RETURN RESIDENT DECEDENT ~Oij:.l_ NUMBER -:=-1 z w c w u w c LU r., ll::!CIl UO::ll: LUQ.U :%:00 UO::..J Q.1IJ Q. 0:( DECEDENT'S NAME (LAST FIRST. AND MIDDLE INITIAL) CLARK, ADDIE DATE OF DEATH (MM-DD-YEAR) 10-6-2001 REV-1500 OFFICIAL USE ONLY C- 11-cJo~ /1.. FILE NUMBER J.-L-ci.. COUNTY CODE YEAR SOCIAL SECURITY NUMBER 171 - 28 - 3296 DATE OF BIRTH (MM-DD-YEAR) 08-17-t907 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER (IF APPLICABLE) SURVIVING SPOUSE'S NAty1E (LAST, FIRST, AND MIDDLE INITIAL) n/a [ij1. Original Return o 4. Limited Estate ~ 6. Decedent Died Testate (Anacl1 copy of Will) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise Idate of death afier 12-1H2) o 7. Decedent Maintained a living Trust (Attach copy of Trust) o 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95) o 3. Remainder Return (date of death poor to 12-13-82) o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes o 11. Election to tax under See, 9113(A) (Attach Sch 0) to- Z LU Q Z o Q. CIl LU 0:: 0:: o U ~lchard P. Mislitsky, Esquire FIRM NAME (If Applicable) TELEPHONE NUMBER COMPLETE MAILING ADDRESS One West HIgh street P. O. Box 1290 Carlisle, PA 17013 -0- ..._'" __:OFFICIAL USE ONLY (1) -O- J'" (2) (3) -0- _.- (4) -0- (5) 2024.75 (6) -0- 283707.99 (7) (8) 285732.74 (9) ,15228.87 (10) 7891 .34 (11) 23120.21 (12) 262612.53 (13) (14) 262612.'53 13. Charitable and Governmental Bequests/See 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) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 262612.53 x .0_ (15) x .O~ (16) x .12 (17) x .15 (18) (19) 11817.56 z o ~ ..J :J t- o: oct U W 0:: 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. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 11817.56 19. Tax Due CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT z o !;;: ~ :J C. ::E o u ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Lme 14 taxable at collateral rate 20.0 Decedent's Complete Address: 'STREET ADDRESS Thornwald Home 442 Walnut Bottom Road CITY Carlisle r STATE PA I ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A Spousal Poverty Credit B. Prior Payments C. Discount (1) o o o Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty o o Total Interest/Penalty ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 11817.56 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 11R17 '56 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. ~.idr~~~~~~:t u::k; ~n:~~~:f ~~::property transferred; .......................................................................................... ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 c. retain a reversionary interest; or.......................................................................................................................... 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........... ....... .......................................... ...................................... ............ 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. [Xl 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 No o o o o o o o IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. DaUL. Under penalties of pe~ury. 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 representat'lve is based on all information of which preparer has any knowledge. Mechanicsburg, PA 17050 Street, P. O. Box 1290, Carlisle, PA 17013 DATE r - ~ -02- DATE "'3-02- 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 PS. 39116 (a) (11) (i)J. 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. 39116 (a) (1.1) (iil]. 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. 39116(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. ~9116(1.2) [72 P.S. 39116(a)(1 )J. 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. 39116(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. REV., 508 ex. (1.97) ~ ,.~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF CLARK, ADDIE 2101-1043 FILE NUMBER Indude 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. VALUE AT DATE OF DEATH DESCRIPTION Cash in checking account 1,508.75 2. IRS Tax Refund 516.00 TOTAL (Also enter on line 5, Recapitulation) $ 2 , 024 . 75 (If more space is needed, insert additional sheets of the same size) ~'''ou.,,~ '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBA TE PROPERTY ESTATE OF FILE NUMBER CLARK, ADDIE 2101-1043 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH A COPY OF THE DEED FOR REAl ESTATE. VALUE OF ASSET INTEREST IF APPUCABlE) NUMBER 1. M & T Bank Corporation Irrevocable TRust 11-14-94 283,707.99 100% 283,707.99 (see attached statement) TOTAL (Also enter on line 7, Recapitulation) $283 707 gCl (If more space is needed. insert additional sheets of the same size) 431412600 TUA Addie M. Clark 5128.205 shs. Vision Group of Funds, Inc. Inst. Ltd. Dur US Govt Fund #120 1171 shs. M&T Bank Corp. 810 shs. Wachovia Corp. 1002.83 shs. Scudder Technology Fund Ben Int. Cl A Principal Cash Income Cash Total Market Value 10/6/01 DOD 10/6/01 51,230.77 80,544.31 23,439.38 10,268.98 109,880.44 8.344.11 $ 283,707.99 ,)M-!.)-:jL (Y~j 1 i : I)': /\.'11 .'.1 r~\~' lJ~ V \lrtl.',v r 31':. :tt'\:? !:)bL!. i j;)b rAve ~;t ~ ~ , ... ~ I ~ 1'-'" rt " e ~ ~ .. , 0 ., II " ! ... , i .. " ... ID '0 :n '01 g 0308 'lI "' .. ~ :,. 1\)1 of II 0 ... 0 '" ~I t. o 0 ... (f I\,) 00 <1\ W ... " ... l' " W Q .... CI ~ t'I .... n .. "I W .., "l CII ... II ... .. .... '" 5 ~ "': ~ 0 Q Q 1/1 " "" "" ... w J ,,"(I .. . "2- =~ ~i c:; ic. II . , ~ ::1~1 . o i :" f l__ ~ Q (, .. .... II i ., ... ... II,) I to ~ art !" 0 ... ~:R' rtl$' ., 1Io ID l\,)1 ~a w o. ... 0 loo. i~ , 0 o. " tIlCII ~~ ~~ I;" ~ < . e ~~ 0: , ,.. ..tj I i e" '" , '\I lit ~ e III I of :' ~ - ;' , I ... ...... ~ ... I i ~ Y ! ~ I ~o a I I . . , l'II I ~ to ". ~~ rr= ~~ l::l G 2;~" ...,~ .... ....... ........ ... ~e I r ..14 Q 00 oc::> 0 01 o~~ ell.... ..... ......... .......... .... " -g <;> 00 oe ., 'Q g ;~f \II "'III .111 \II ell It ~I = ~ ,.... ~~ " .. < ",I.ll "'.., :t:~ .. ClIO '0.- Q 0 .. rr ft'O ~... ~5 Q ~g ~1II ",cr. "'0 t 00 00 00 00 r ! .. :: ., !1 ... ~i '" ~ ... II,) .~ IICl1 ; 'tl ? "lit ..,'" 00' N It I 0 8. N .... 0.10 lD , (;J~ 0 I> (J!1Q <>ON ~' ... <l 0 gg 00 0 I> 0 00 .. ~ .... Nf\JN "'CJ>'" ~ ~i ... ~ CD..", ..'C ... . . . OJ '0..... ",1.1/1\,) '0 Q (f .. "'IIlN \D0C\ '0 'iT ~ ~rllO Nt1IO 0 it ~ : UlOO \1100 0 ... 0 0':>0 000 .. 41 I I , I I " 1 I I (I> 2 , I ~ I-' ...., ..... f:l fi~i ... .... ID .. :> ~ !' .... ~ . I ~~ N .. .... '" . at I CD I '" '" .. '-" ~ i wi"" , '!' '" ... 01 J . ., ;.. j., ...., ... ..., \0 .. ... ~J 00 Ol .. ..., ~ . ... ~ , '~~ 'M :0 I~ ~ I..... I :~~ I '-to Q' I a , . '>J 01 1 ~ ;0' CI 8 $ ~ ~ ni n .. ~ a 1'1 ~ I ~ i ~ . , I '-I ... , lit , I REV-1511 EX+ (12'99) . . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF CLARK, ADDIE FILE NUMBER 2101-1043 Debts of decedent must be reported on Schedule 1. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION AMOUNT 1. Forever Memorials Rev. Douglas Cronce, Services Reception costs Carlisle Memorial Service, Marker Georges Flowers Hoffman-Roth Funeral Home (see attached statementi of transactions) 1,948.50 250.00 248.87 145.00 132.50 5,136.00 I,BbU.BI B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Lisa Wolfe 3,200.00 Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 6353 Stephens Crossing Mechanicsburg City State ~ Zip 17050 Year(s) Commission Paid: 2. Attorney Fees Richard P. Misli tsky, Esquire 2,500.00 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 Register of Wills 48.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 8. 9. 10. Recorder of Deeds, filing fees Register of Wills, Additional probate fee Register of Wills, filing fees Reserve for settling estate 22.00 0.00 25.00 1,598.00 TOTAL (Also enter on line 9, Recapitulation) $ 1 5 , 228 . 87 (If more space is needed, insert additional sheets of the same size) REV.'5'2 EX. ('.97! , ~ Sri -, . ~f . .'" . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF CLARK, ADDIE FILE NUMBER 2101-1043 Include unreimbursed medical expenses. ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. DESCRIPTION AMOUNT 176.15 6,206.01 36.65 289.15 381 .04 331.35 44.62 96.44 129.93 200.00 Pharmerica, prescription drugs Thornwald Home, nursing care Pharmerica, prescription drugs M & T Bank fees 10-16-01 11-26-01 12-17-01 1-15-02 Thornwald Home - oxygen Mailboxes, Inc. 2-11-02 Accountant - Hartman & Associates 1-2-02 S 7,891.34 TOTAL (Also er.ter or. lir.e 10. Recapitulalior.) (If more space is r.eeded, ir.sert addilior.al sheets of the same size) February 4, 2002 Joel Toluba Mislitsky and Diehl One West High Street Carlisle, PA 17013 RE: TUA Addie M. Clark Dear Mr. Toluba: Private Client Services P.O. BOX 220 1415 RITNER HIGHWAY CARLISLE, PA 17013 717-240-4504 Toll Free 1-800-822-2155 As per your request, enclosed are transactions from October I, 200 I to date for the Addie M. Clark trust. If you have any questions, please feel free to contact us. Very truly yours, Jane F. 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C l'TI 0 .." 'It: 'It: 'It: 'It: 'It: ~ 0 OC 0 l'TI 0 'It: C') 'It: ... 0 0 .... ....0 "'0 .... ... -4 ~-I l'TICD -I .... > ... ....... r- .;:- .;:-% .;:-% .+: .+: ~ 00* ... ,." .+: -i .+: 0 I\) I\) I\) I\) I\) 0 *OW "'" 0 N - I\) 0 -"Q*::OW 0 %::tl .. "'" II :z -I O- W 0 OZ M .." 3:(") (I) 0 (I) l'TI- VI (I) (I) r- I\) .;:- ~ 0 W .+: ....... .;:- > 0 VI .;:- Z 0 r " .+: 0'1 (1)(1) 0(1) .;:- 0'1 ", I\) .;:-.;:- Ow 0'1 I\) .." ::00 .;:-.;:- *VI * ,." -I\) *. * l'TI % 0'10'1 *.;:- * CIl 1\)1\) *0'1 * 0 0> >r- 0 I\) l\) CIlr- 0 \0 \0 % . ~ <= .;:- 0 VI VI ::0 I -I ..., -0 %r> C')-O 003: 3: ~O% 0'1 I\) \0 I\) ... .... I\) I\) 0' \0 VI VI l\) N >0 CIl<= 0 .... -.j w .... .... 0 0 %, 0'1 0 VI VI -,J -,J 0 0 0 I I I I\)~ " ... <= <= \0\0 "':""..,,'" '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF NUMBER I. CLARK, ADDIE NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Susan H. Miller 18931 Jodywood Drive Jumble, TX 77346 FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Grandaughter Son Daughter Grandson 2101-1043 AMOUNT OR SHARE OF ESTATE 1/6 1/3 1/3 1/6 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 2. Donald Clark 221 East Walnut Street Pasadena, CA 91101 3. Nancy C. Berzinec 6113 Westover Drive Mechanicsburg, PA 17055 4. Matthew Hefflefinger 79 Diamond Point Morton, IL 61550 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) .., ~ ~ ~ ~ ~ "" ~ ." ~ 1 ~ j ~ ~ast C]A/iU and cr;~ ~ &It~~ 1. Addie Clark, of 6113 Westover Drive, Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. ~Vt5t I ask the Trustee of my Irrevocable Trust dated November 14, 1994, in its discretion, to transfer to my Executrix funds sufficient to pay all expenses arising from my last illness, care and burial including costs of inscribing my grave marker. I further ask my Trustee in its discretion to pay my Executrix sufficient funds from my Trust to pay all my debts, income taxes and any inheritance tax due on any and all property included in my Estate; and to further pay to my Executrix sufficient funds to pay the cost of administering and settling my Estate. I ask my Trustee to exercise its discretion in favor of my last wishes. In the event that my Trustee refuses to honor my request. I authorize my Executrix to expend funds from my Estate in such amounts as my Executrix deems necessary and desirable to pay the expenses arising from my last illness. care and burial. including an inscription on my grave marker. I further direct my Executrix to pay from my Estate any income tax that may be due and payable. Inherit.1I1ce taxes shall be paid by each beneticiary. o .. " ~ ~ ... ~ " ~ ~ ~ Seco.nd I hereby nominate and appoint my caring Granddaughter. LISA WOLFE, to act as Executrix of my Estate. In the event that Lisa cannot or is unable to act as my Executrix. L in the alternative, nominate and appoint my loving daughter. NANCY C. BERZINEC, to act as Executrix of my Estate. My Executrix is specifically relieved from the duty or obligation of filing any bond or security. cg Iwut I ask my Executrix to arrange my fmal service and funeral at the Dickinson Presbyterian Church. I further ask my Executrix to arrange my interment alongside my beloved Husband and Children. 9~ I direct my Executrix to accumulate the personal property hereinafter set forth from wherever said personal property may be located and to further provide for the appraisal of said personal property. Hepplewhite Chest of Drawers Windsor Chair (Steeley) Bannisterback Chair Queen Anne Sewing Table Dresser Boxes (Cloisonne') 2 Small Paintings (Grandfather Callahan) Miniature Coffee Grinder Collection of Irons & Trivets Madonna Picture in Goldleaf Frame 4 Oriental Rugs (Bedroom) :2 Lg 1 Sm Small Reproduction Pedestal Table Stretcher Table Wooden Skates Mirror (Family) Astral Lamp Brass Skater Lantern Stamp Collection Door Stop-Bull Dog Door Stop-Bull Dog Door Stop-Shepherd Dog 10 Oriental Rugs Brass Cricket Cage ~ ~- ~ J ~ i ~ Tilt Top Table with Bowl Cast Iron Toy. Horses and Wagon Portrait of Great Grandmother Green Small Brass Rayo Lamp with Painted Parchment Shade Star Sapphire Ring - 50th Wedding Anniversary Gift (From Estate of Ruth Hemminger) Diamond Engagement Ring Diamond Wedding Band 24 Carat Gold Necklace Diamond Earrings CJ4tk After my Executrix has accumulated and provided for the appraisal of my personal property, I give, devise and bequeath the appraised value of said personal property to my children, DONALD CLARK and NANCY BERZINEC, and the children of my deceased daughter, CATHY HEFFLEFINGER, MATTHEW HEFFLEFINGER and SUSAN H. MILLER, in the following shares: A. One- Third Share to Donald Clark; B. One- Third Share to Nancy Berzinec; C. One- Third Share to be divided between Matthew Hefflefinger and Susan H. Miller In the event that any of the above-named individuals desires any of my personal property. to the greatest extent possible I direct my Executrix to give said personal property and to credit the value of said personal property against the individual's share of the value of my personal property. S0tt€nlk In addition to the powers conferred by la\v. hereby authorize my Executrix acting under this Instrument in her absolute discretion: A. To retain in the form received. or to sell either at public or private sale any of my personal property: B. To make distribution hereunder in either cash or kind. as may be agreed upon or as my Executrix in her discretion may deem wise; c. To sell, transfer, conveyor exchange any personal property which at any time may form part of my Estate including the personal property herein before set forth, for the payment of any debts or taxes, or for any purpose pertaining to the administration of my Estate. IN WITNESS WHEREOF, I, ADDIE CLARK, have hereunto set my hand and seal to this my Last Will and Testament, consisting of four (4) typewritten pages, the first three (3) of which bear my signature in the margin for identification, this IV day of >~~ /,eL ,2000. ;;Z,td,t.. hI.~ ADDIE CLARK Signed. sealed, published and declared by the above-named. ADDIE CLARK. Testatrix. as and for her Last Will and Testament in the presence of us. who have hereunto subscribed our names at her request as witnesses. thereto. in the presence of said Testatrix and of each other. Chh/o\.: ..L, J!. ~4v~ ~l !:.th ~~ ADDRESS~~ .~.~C~''''''7 ~.5td ~-3 , ......-...l Q..,...<-......<...\....-..::.....'-Cc I <;;;b. DC 7~ '711- 7?c.- c 7// ADDRESS & )- !alrV/eL1) Sf-' ~r'tlStJ fA /76' 3 , .. COMMONWEAL TH OF PENNSYLVANIA : S5. COUNTY OF CUMBERLAND We, ADDIE CLARK, I. AkfLbJ(1{)f/ CaMe t'iJU - i C, J<lf1! ('vI I and ~' . t1Jcy L- , the Testatrix and witnesses, respectively, whose names are signed to the foregoing or attached 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 Testament and that she signed willingly and was executed as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix signed the Will as witnesses and that to the best of their knowledge the Testatrix was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. {Z~ rn..~ ADDIE CLARK r;;:j L Witness Subscribed. sworn to and acknowledged before me by ADDIE CLARK. the (.+Air/ilL f~ and~(L1 L this /7 'day 0 ~ L ,2000. and subscribed to and sworn or affirmed to before me by h Ilkt t1~)' j 1[( ()~.itnesses. Testatrix. ." {'.:: '\. . '.....f;.I; . '~..'_...: '"' ._':- . . , . .J '... - . -' .r. -,,' /."11 '.,. , V'/' f" 1- . -' ' "r'.. , ..-:- ~ NOTARIAL SEAl SUE A. ClAJA. NaRy PublIc Lower Alen Twp., ~ Co.. PA My Comml8ela1 ExpIres Dee. 28. 2002 --