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Home My WebLink About01-1045 PETITION FOR PROBATE and GRANT OF LETTERS Estate of Richard Qitien-ti n Rl gi n 6~0. also known as Richarn Qll~lltin E19in){' . To: Register of Wills for the Deceased. County of Cumber land in the Social Security No. 485 - 1 4 -7 R R 8 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 executrix in the last will of the above decedent, dated August 21. and codicil(s) dated N A 21-01-1045 named 19 84 , - (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumber land County, Penn~ylvania, with h is last family or principal residence at 3 Round Hill Road, Camp Hill East Pennsboro Township (list street, number and muncipality) Decendent, then 75 years of age, died at Harrisburq. Pennsylvania 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: N . A. March 25, 19! 2001 , , 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: $ unknown $ $ $ WHEREFORE, petitioner(s) respectfully request(s) the p'robate of the last will and codicil(s) presented herewith and the grant of letters testamentary theron. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) '" ~ u = ~ ~3 ~ I-< a:~ -00 s::-= ro-'= 3~ ~'- ;; 0 ~ = 01) i:i3 ~~~,~ H1 a ADn .IS1g' 3 Round H1ii Hoad Camp H111, PA i/Uii OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA I ss COUNTY OF CUMBERLAND J The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. ~[~' R' 19~ 3 Round H1ii Road Camp Hill. PA 17011 affirmed and 13th Vl c)Q" ::ll t:l ..... s::: ~ ~ /?,;2/ -e;l../ ~o. 21-01-1045 Estate of Richard Quentin Elgin , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW NOVEMBER 15 ~ 20 q 1n consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated August 2, 1984 described therein be admitted to probate and filed of record as the last will of Richard Quentin Elgin SR. AKA Richard Ouentin Elgin and Letters Tes tamentary are hereby granted to Ri ta Ann Elqin FEES Probate, Letters, Etc. ......... $ 18. 00 Short Certificates( ).......... $ 9.00 Renunciation ................ $ JCP FEE $ 5.00 TOTAL _ $ 32.00 Filed .rfQYF:~~K J~L .~qQ~.............. ~{~{<<~"~f ~4<"4 glster of 1I1s I i~ ATTORNEY (Sup. Ct. I.D. No.) 47077 Keith O. Brenneman 44 W. Main Street ADDRESS Mechanicsburg, PA 17055 (717) 697-8528 PHONE ~~~/ ~ Thi~ is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Rc.::gistrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 p 7234385 No. 21-01-1045 1A'."A~ ~L,>- ~ Local Registrar ?J(IJAA4 J. ~ d.tJo ( Date Hl05.143A.. 2187 COMMONWEALTH OF PENNSYLVANIA · OEPARTMENT OF HEALTH. VITAL RECOROS CERTIFICATE OF DEATH TYPE/PRINT IN PERMAI<ENT BLACK INK -~~~~~~~- SEll 2. t'h4l ~ PlACE OF DEATH ICt>eclo or<y.",. -- '" """ue''''''''''''''''' _ HOSPITAL: lftpat_ ~ E~I_ 0 STAlE FILE NUMl!ER SOCIAl S(CURITY NUMBER J. Lls5 - t L.J 1-~J-ul RAL S(~.VICE t\.~E ~ PEASOH ACTING AS SUCH LICENSE NUIoI8ER L_~ 22lt. ~/1!)1I~ ,f- ...tIle _ almy knowMdge. ..... occurred.. Ihe....., del. _place Slalee! . arod Tille' 23e. !ME OF DEATH DATE PRONOUNCi DE~ (1M"': Day, Yearl 24. ,: -:J 1 r'M 25. 3 2 S"/ (J I 21. MIff I: En.... the diM..... inturies or eompIicatlOM which cauHd Ihe!Hath Do not enter lhe mode of dying, such as carcbc Of I.sp;ratory auest, shock or heaIt 'aNt. ldl onfIt OM cause on.~'" /YIu ihO';j'4/1f r:;...fute I ~~~& tfl::.TOlOR A~QUENCEOf)o I ~ Hu-/I./~ OLE lOR AS A CONSEQUENCE Of): L/v-t-r hi Iud DUE TO lOR AS A CONSEQUENCE Of): I : WERE AUlOPSY FINDlHGS AWIUU8l.E PNOR TO COW'\.~ OF CAUSE OF llEAI'H? MANNER OF DEATH DATE OF INJURY (Mor-.. Day. "".., ~ HomfCMM o o o Hal..... Ac~lldenl P.Adtng Inveattrgatton Nor- Va D 2... 2.... ClRTWlER IC~ecll or<y one! .CERTIfYING PHYSK:IAN (Phy$lC~ Cf!f~ cause of death .."ne,.. ~nothtN' OhVSIC,ao has pronounced dedolh ana cornlJlti'led Itern 23) To'" beet 01 my knowlecloe. de.... occurred _ to'" cau..lll and manne' aa alaled. . . . . . . . . . o NoD Swcide CoulO na4I be det.fmf08d ~ S ~ o ~ w ~ ~ Z 'PRONOUNCING AND CERTIfYING PHY51ClAN (PI1_"" llolIl "",,>(,.,OC,ng uo.th ond cOIblyong 10 co.,se 01 <Ie.,N To tI'MI beat at my knowledge, deatl\ occurted a'.......... dl'e, Ind place, and d.,. 10 lhecauM(l) end mann.r.. .,.ted.. 'MEDICAL EXAMINER/CORaHER On '''.IM.ia of ...minallon ancllOl in.esllgalion. in my opinion. deal" oc:cu".d al "'.llm., dal., and plac., and due 10 Ih. causeCs) and manner.. ...,ed.................................................................................................. 31.. REGIS Ij ;\ 1.2.J \ I~ - <f)rn~ RACE . ~ lndien.lIleck. WIlil.. ole. 1Spegt,1 10. LU .-tE- SURVMNG SI'OUS( I. _. 9"'"'__1 '..... c..,.....,.. I "'D 1/ B. 2310. _. VMS CASE REFERRED TO ::0 EXAMINERlCOAONER? ~ lAppn>ximala PART.: 0dler1igMlcanl__-.g1O_...... 1=-= _t-*lngin_~_o;....inPARTI. I l TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED ~ 0 NoD o 21-01-1045 WE, RICHARD QUENTIN EillIN AND RITA ANN ELGIN (MR & MRS RICHARD EillIN,SR), 1345 OID WILLOW MTIL ROAD, ~HANICSBURG, SILVER SPRING 1OWNSHIP, CUMBERLAND COUNTY, PENNSYLVANIA, BEING OF SOUND MIND AND MEK>RY, DO MAKE, PUBLISH AND DEX::LARE THE FOLLOWING TO BE OUR LAST WILL AND TESTAMENT. AFTER PAYMENT OF ALL EXPENSES AND DEBTS INCURRED BEFORE AND UPON EITHER SPOUSE'S DEATH, THE REMAINDER OF OUR ESTATE IS B~UEATHED TO THE SURVIVING SPOUSE. THE SURVIVING SPOUSE IS TO SERVE AS EXEX::U1OR OF THE DEDEASED SPOUSE'S WILL AND WILL SERVE WITHOUT OOND. IN THE EVENT OF OUR SIMULTANEOUS DEATHS, OR AFTER OOTH OF US ARE DECEASED, OUR ENTIRE ESTATE IS TO BE DIVIDED ~UALLY AS POSSIBLE AIDNG OUR SIX' CHIIDREN: SUZANNE MARIE, CATHERINE ANNE, RICHARD QUENTIN JR., MARGARET MARIE, W. ANDREW, AND NAN( ELAINE. IF ANY OF THE AOOVE NAMED ARE DEX::EASED AT THIS TIME, THEIR SHARE IS TO BE DIVIDED ~UALLY AMONG THEIR CHIIDREN. IN THE EVENT THAT ANY OF OUR DEX::EASED CHIIDREN ARE CHIIDLESS, OUR ESTATE IS 10 BE DIVIDED EQUALLY AMONG OUR SURVIVING CHILDREN . AFTER WE roTH ARE DEDEASED, WE APPOINT OUR SON, W. ANDREW, 10 BE EXEX::UTOR OF OUR LAST WILL AND TESTAMENT AND DlREX::T THAT HE SHALL SERVE WITHOUT roNDe IN WITNESS WHEREOF, WE SIGN OUR NAMES TO THIS OUR LAST WILL AND TESTAMENT ON AUGUST 21, 19B4 IN THE PRE3ENeE OF THE WITNESSES WHO ALSO SIGN THIS DOCUMENT. q~~,~~.;:: ~~'-::ATURES ~ ~ {~~ t""", _'I " ." r''').Z-~: . '0 oil .....c:cY.'...... c; ; ;1-'-'7'" .~,1(1,7 ~.4 cY d~' ~,1t cl1r;yt,~ WIlmR~wft1I~~~usllC WITNESS SIGNATURE .ECHANICSBUr:i~ ;.,>~~~. {::.;~~:mUAND COUNTY IY COM~IS.~h~:.jiJ,Xrj!~:,~: ~':f'i. 3. 19.7 Member. hni'l^'. ';iI(1;:: "~,.;.I~i<;iIlHo:1 \>1 Notaries REGISTER OF WILLS OF COUNTY OATH OF SUBSCRIBING WITNESS codicil (each) a subscribing witness to the will presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that present and saw the testat or , sign the same and that signed as a witness at the request of testat_ in h presence and (in the presence of each other) (in the presence of the other subscribing witness(es)). Sworn to or affirmed and subscribed before me this day of 19_ Register (Name) (Address) (Name) (Address) REGISTER OF WILLS OF CUMBERLAND COUNTY OATH OF NON-SUBSCRIBING WITNESS NA1Jl'l F' Rita Ann Elgin and ~~~ Elqin, (each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that they are familiar with the signature of Richard Quentin Elgi,n * c~k testat~ of (one of the subscribing witnesses to) the will presented herewith and ~x that they believe'J the signature on the will is in the handwriting of Richard Quentin Elgin* to the best of thei.!'_~ knowledge and belief. 1- '~~T S Ltr~ Rlt nn gln_ (Name) 3 Round Hill Road, Camp Hill, PA 17011 NAN' 'I If:. (Address) 1/;/, .. FF t7 "~~ Elqin x~~~ (Name) *a.k.a. Richard Quentin Elgin, Sr. SfD >€lI1fAd(t- sT.. At(1,lt/u... e.- l-tfor5 Sworn to or affirmed and subscribed before me this 13th day of NOVEMBER ~ 2001 '7?~r~W?n/~A~ Reglst (Address) 41 LAW OFFICES SNELBAKER. BRENNEMAN Be SPARE CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Richard Q. Elgin, Sr. Date of Death: March 25,2001 Will No. 21-1045 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 February 20, 2002. Name Address Suzanne M. Horgan 6 Georgetown Drive Amherst, NH 03031 Catherine A. Burris 818 Chestnut Lane Oakes, ND 58474 Richard Q. Elgin, Jr. 3660 Boathouse Drive Hilliard,OH 43026 MargaretM. Masek 225 Town & Country Drive Danville, CA 94526 W. Andrew Elgin C)C"'.. - ~..~ 53 Bourbon Red Drive 3 ~~ Mechanicsburg, P A 17055V' Nancy E. Elgin 510 Seminole Street Bethlehem, PA 18015-1452 Rita Ann Elgin 3 Round Hill Road Camp Hill, P A 17011 d N ..,.., m c::n f'.,) --' :g t"J N ~ :0 m :~:~~I LA W OFFICES SNEL8AKER. BRENNEMAN Be SPARE Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None. Date: February 20, 2002 ~r1~ Keith O. Brenneman, Esquire Snelbaker, Brenneman & Spare, P. C. 44 W. Main Street Mechanicsburg, P A 17055 (717) 697-8528 Counsel for Personal Representative -2- COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND. } 55: Rita Ann E1qin according to law, deposes and says thatS he is the Executrix of the Estate of Richard Ouentin Elgin. Sr. late of _ East_. Penn_~~oro Township , Cumberland County, Pa., deceased and that the within is an inventory made by Ri ta Ann E1qin , the said Executrix of the entire estate of said decedent, consisting of all the personal propl!rty and real estate, except real estate outside the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value as of the date of decedent's death. sworn being duly Sworn to and subscribed before me, ~ Ch- ~~ r Executrix Ex c:utor . Aclministr.tor Fa~~"'I ~ ~ . ~ 2002 . ~a.nJA C>J~ I Notarial Seal -/; . Sandra K. Showem, Notary PubItc , I Mechanicsbu"9 Bom, Cumbertand 9Qunty . i My CommiSSion Expires Nov. 22, 2003 I 3 Round Hill Road Camp Hill, PA 17011 Address e _ ........,t.-.~ ".0 f""l-- _ _". Date of Death _:..: 25 O.Y March Month 2001 Year INSTRUCTIONS I. An inventory must be filed within three months after appointment of personal raar.esentative. ~'7'" " 2. A supplement inventory must be filed within thirty days of discovery of additio~ ~sets. ~ 3. Additional sheets may be attached a~ to personalty or realty fl"..,.., rn 4. See Article IV, Fiduciaries Act of 1949. :;;,' co I CO v N (:; :.n (1) ,.... ::.:~ C) -. r;'M'~ ~ 'r-! ..c: en l::: . ~ ~ en E-t >- .,; .. 0 CD t- W III U1 ~ ~ t- l::: ~ Ia W < 'r-! 0 CD 'l::tI A. t- ~ .0 u 0 0 0 en ,....j tIJ CD ,....j W ~ W ~ ~ C I .... J: A. LL ~ C t- ..J ~ ,....j Z LL ..J < 0 . Q) A. 0 W 0 < w Ol ~ >. . ,....j > Z ~ 0 N - Z 0 ro .j.J c C ~ tIJ ::I 0 - en Z 0 ..c: ~ I'd I'd 0 .j.J Z w < ..c: ~ - a.. -0 'r-! C) c Q) 'r-! '" ~ ~ - "i: 0 CD I .,g -0 ~ CD E 0 , - ::I ~ 0 /IS ...J 0 u::: a:lI ~nventory of the real and personal estate of Richard Quentin Elqin. Sr. deceased I. PERSONALTY - - Proceeds from Annuity Contract No. 40504707, TransAmerica Occidental Life Insurance Company. OWner: Mary Elgin ~ 6,023.9 1 TOTAL VALUE OF ESTATE: ~6,023.9 1 --- ---------..- \- ///-02/-~ 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 REY-1547 EX AFP CDl-02) KEITH 0 BRENNEMAN SNELBAKER ETAL 44 N MAIN ST MECHANICS BURG '02 ~PR-1 01'"" '48 \ !L . DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-25-2002 ELGIN 03-21-2001 21 01-1045 CUMBERLAND 101 RICHARD Q Allount Re.itted CIS', R.l'I~:.0:5 5 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ RE-Y=is4-j-ix--AFP--coi-:02i--NOY-iCi--OF-':ftiHEifiTANCE-Y-AX-A-PPRjrisEifENT~--Ai:.i-owAirCE-(rR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF ELGIN RICHARD Q FILE NO. 21 01-1045 ACN 101 DATE 03-25-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Hortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 6.023.91 .00 .00 (8) NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 6,023.91 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) (9) 10. Debts/Hortgage Liabilities/Liens (Schedule I) (10) 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 .00 .00 (11) (12) (13) (14) 00 6,023.91 .00 6,023.91 NOTE: If an assessment was issued previously, lines reflect figures that include the total of ALL ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. A.ount of Line 14 taxable at Lineal/Class A rate (16) 17. A_ount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. 6,023.91 X 00 = .00 X 045= .00 X 12 = .00 X 15 = (19)= .00 .00 .00 .00 .00 TAX CREDITS: ............ n;c,",c,u", (+J AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 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 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.1500 EX (6-00) REV-1500 '* COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 W I- ~~Ul uD::~ wD.U xOo uD::-' D.1tl D. c( ~ Z W C W U W C INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) El in, Richard Q., Sr. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 03/25/2001 12/22/1925 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Elgin, Rita A. Q9 1. Original Return o 4. Limited Estate o 6. Decedent Died Testate (Alfach copy of Will) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (dale of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach copy of Trust) o 10. Spousal Poverty Credit (dale of death between 12-31-91 and H.95) {'/ FILE NUMBER ~L-JL.L COUN1Y CODE YEAR JLL~~~ NUMBER SOCIAL SECURITY NUMBER THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 483 - 26 - 218t.' o 3. Remainder Return (dale ofdealh priorto 12-13-82) o 5. Federal Estate Tax Retum Required .Q... 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Attach Sch 0) z o ~ ....I :J t:: a.. <( U w 0:: NAME Keith o. Brenneman FIRM NAME (If ~ficable) Sne1baker Brenneman TELEPHONE NUMBER 717-697-8528 44 W. Main Street Mechanicsburg, PA 17055 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) (1) (2) (3) (4) (5) 6,023.91 (11) (12) (13) (14) x.o~ (15) x.O_ (16) x .12 (17) x .15 (18) (19) 19. Tax Due CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~.r- ;:.I :. : -11' F"? c:i N 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Joinlly 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) 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) (6) (7) (9) (10) 14. Net Value SUbject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o ~ ~ :J a.. :E o u ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 6,023.91 -;'] rn CO I ::0 --'J N 6 ...... (8) 6,023.91 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at Sibling rate 18. Amount of Line 14 taxable at collateral rate 20.0 6,023.91 6.023.91 o o Decedent's Complete Address: STREET ADDRESS 3 Round Hill Road Carn Hill Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount CITY STATEpA ZIP17011 (1) 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A + B + C ) (2) o TotallnteresVPenalty ( D + 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) n 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. (5) (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT o 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;.......................................................................................... D XJ b. retain the right to designate who shall use the property transferred or its income; ............................................ D XJ c. retain a reversionary interest; or.......................................................................................................................... D XJ d. receive the promise for life of either payments, benefits or care? ...................................................................... D XJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D KJ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D KJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ D U IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury. I declare that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which pre parer has any knowledge. F PERSON RESPONSIBLE FOR FILING RETURN G_ . , Executrix DATE '2 #: Cl"Z... ADDRESS 3 Round Hill Road, Carn Hill, PA 17011 SIGNATURE OF ~TATIVE ADDRESS DATE f} ~ , ;). 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 exemot 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. REV.15ll8 EX' (1-97) (I) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYL VPJoIIA INHERITPJoICE TAX RETURN RESIDENT DECEDENT Richard Q. Elqin. Sr. FILE NUMBER 2101-1045 ESTATE OF Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH Decedent's share of proceeds as beneficiary of Annuity owned by Mary Elgin, TransAmerica Occidental Life Insurance Company, Contract No. 40504707: $6,023.91 TOTAL (Also enter on line 5, Recapitulation) $ 6, 023 . 91 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI-EDU.E J BENEFICIARIES ESTATE OF Richard o. R1n~n C:::r NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Rita A. Elgin 3 Round Hill Road Camp Hill, PA 17011 NUMBER I FILE NUMBER ~1 01 .1 fl4r; RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE Surviving Spouse 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART 11- 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)