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Home My WebLink About01-1111 .. l PETITION FOR GRANT OF LETTERS Estate of HELEN A. CARCHIDI No. ~ I - 0' - I W also known as n/a , Deceased Social Security No.207-07-6250 ROBERT P. CARCHIDI Petitioner(s), who is/are 18 years of age or older, apply)ies) for: (COMPLETE "A" OR "B" BELOW:) GJ A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut or Decedent, dated 11/22/99 and codicil{s) dated none named in the Last Will of the State relevant circumstances. e.g., renunciation, death of executor, etc Except as follows, Decedent did not marry, was not divorced and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incapacitated: o B. Grant of Letters of Administration (c.I.a., d.b.n.c.t.a.: pendente lite, durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence I (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence at 770 Poplar ChurchRoad, Camp Hill, East Pennsboro Township, Pennsylvania (list street, number and municipality) Decedent, then 90 years of age, died November 21 , 2001 , at West Shore Health and Rehab (location) Decedent at death owned property with estimated values as follows: {if domiciled in PA All personal property......................................... $ {if not domiciled in PA Personal property in Pennsylvania .................... $ (if not domiciled in PA Personal property in County.............................. $ Value of real estate in Pennsylvania ........................................................................................ $ Total....... ...... ........ ........ ........................ .... ..... ..... .... ......... ....... ............ .............. .... $ 7,000.00 7,000.00 Real Estate situated as follows: none Wherefore, Petitioner{s) respectfully request{s) the probate of the Last Will and Codicil{s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: Signature Typed or printed name and residence ROBERT P. CARCHIDI 380 N. 28TH STREET CAMP HILL PA 17011 RW-1 ) 7 -;)5' -I \J ~ " 21-01-1111 Oath of Personal Representative Commonwealth of Pennsylvania County of CUMBERLAND The Petitioner{s) above-named swear{s) and affirm{s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner{s) and that, as personal representative{s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to and affirmed and subscribed before me this 5t..h December ~c~ fL~B. day of 2001 ~Q~~y DECREE OF REGISTER Estate of HELEN A CARCHIDI also known as nla Social Security No: 207-07-6250 Date of Death: 11/21/01 AND NOW, DECEMBER 6,2001 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters ~ Testamentary 0 of Administration Deceased No. 21-01-1111 are hereby granted to Robert P. Carchidi ((c.t.a., d.b.n.c.t.; pendente lite; durante absentia; durante minoriate) in the above estate and that the instrument(s), if any, dated November 22,2001 described in the Petition be admitted to probate and filed of record as the Last Will of Decedent. FEES Letters .................................... $ 40.00 Short Certificates(s) ............... Renunciation .......................... Extra Pages ( ) ............... I. T.R....................................... JCP Fee ................................. Inventory ........................ ........ Other.. ........ ............................ $ 6.00 $ $ 6.00 $ $ $ 5.00 $ $ Attorney: Murrel R. Walters, III 1.0. No: 24849 Address: 54 East Main Street MechanicsburQ Telephone: 717-697-4650 Pa 17055 TOTAL .............................$ 57.00 DATE FILED: D~, 5,2001 l105.80'i REV 918(, This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local ~egistrar. The original certificate will be forwarded to the State Vital Records Office for permanent'4filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. 21-01-1111 Fee for this certificate, $2.00 p 7902301 No, ~M~ f~~ ;Q;Fi Local R gistrar /{ITl.l.P~..d.V J 4 .i dC! I Date Hl0, :43Ae. 2187 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH 5 TIJE FilE ~UU8ER SOCIAl. SECURITY "UMBER TYPE/PRINT IN PER"'ANENT BLACK INK NAME OF DeCEDENT (h.. ModdIe. Lag, SEX Helen A. UNDER I yfAft UNDER I D/Ii-' __ Days _! loIinut.. a.Female AGE (La.. &1r>aay) BIRTHPLACE ICoIy ....cl Saale '" FCI891 COUflUYJ 90 Highspire, PA Y.. S. COUNTY OF OEArH .... CUmber land DeceOENT'S USUAl OCCUPAI'ION (~"'=:.:i.. ":: '::~:di' 3. 207 - 07 21, 2001 =tlyjO RACE. Amencan I_n. __. _e. 8IC: ($peclt,) White l.lAAlfAI. STATUS. Uamed _......I8CI.W_. DMIn:ed~ 14. Widowed 17e.6!l....__.. F.a~t. PEmn~horo 1'I..lp SURIIIVING SPOUSE ,8""'.__namel West Shore Health & Rehab 770 Poplar Church Road 11b. Coonry Did -- ... ... Cumberland --"1 17,..0 ::"'--==~OI MOTHER'S HALlE ,f... r.toddl8. _ Surname) C<Iy"-o I.. FAI'HER'S NAME (FoSS. M_e. La"l Harvey Walmer Robert P. carchidi ". INFORMANT'S MAIUHG ADDRESS ISIr.... C....'-. SIMa. Zip Codel _. N. 28th Street earn Hill PA 17011 PlACE OF DlSPOSITION."- of ~8fY. Cromaloly LOCATION . C~. S..... Zip Code 01 au. PW<;e 1.- /NFOflI.lAHT'S HALlE (T ,.pel"''''') ..--.:-. 2tc. :138. TIME OF DeATH DATE PRONOUNCED DEAD (Mo,,",. Day. -.e"" 24. {I: .3 S- A M as II _'-I _ 0 , 27. NAT I: Ent., lhe diMases. KlfUnes 01 compIIcallOnS wNet. caused lhe dealh 00 not enl., lhe mode 01 aylOQ, suc.n a:i cardiac;: 01 resplfalory aflfll, shOca o. heart 'Pure l... ont'I ~ cause on eam hne C-t:J~ ~ 2JlSabE DUE 10(00 ~ ACONSEOUENCE Of): ." l :~~ -DUE mttJllASAC~oiJlNC( utI DUE 10(00 AS A CONSEOUENCE OIl: ...... \.-J WERE AUlOPSY FINOINGS _lABLE PRIOR 10 COMf'lETlOH OF CAUSE OF llEATH1 r.tANNER OF DEATH DATE OF INJURY IManon. Day. -I g-- o n - Anne Gross ....B- a. I Appro.mate I inIarvaI bMwMn :__<te... I I , PART N: au. S'llfllllc:.... condiloons conlrobubng 10 death. bUI "'" r.SUIlnlI in Ih8 underlying.,.... 9'Y8n in PART I 1"11PrrB-r,1lE t16t-L7 ~ TIME OF IN.JURY INJURY I(J WORK? DESCRIBE HOW INJURY OCCURRED Horn"'.... P.ndtng Inve_"", o o o PlAce OF INJURY. AI home. t.rm~;"'. IlIC1OIy,olllC. buiIclinQ. ... (Spec..) - _. - -...... ': .... [J"" ....0'" y.. 0 s...c.M ... "- .~ Coukt not be del.,muled ~. 2.... CEJIT"'IER tC~8Ck ono~ onel .CERTIFYING PHYSICIAN (PhySIC.IilI1 Ct!fW)oIll9 cause QI dealtl wtIef1 .JOOOlet' pOV5lCoan hdS plOflOUnceo oe.Uh drKJ CUTlplt...efJ llefn 2Jl To'" beat o' "''I know.... dea'" occ.......... to the cauHCa) and m......' .. ataled. . . . . . . . . z @ ~ o ~ ~ Z .PRONOUNCtHG AND CERTI''tlNG PHySICIAN (PhVOC.an ()()lf1 fJf3l1OU1k;;llty lledlh dlld ~etllf\,1O() fO l.;du~ of 'kdltl\ To the bH"' 01 my knowMdQ_, de._ occ",riHI"m. ...., ate, and piKe, .nd du. 10 ,he c.u"..J .nd m.nn., .. ....1Hf 'MEDICAL UAMIIlERlCORONER On the b..is 0' ...minaUon .ndlM InveSlig.illion, in my opinion, d.alh occ:uI'red althe Urn., dat., and place, and due to the cause(a) and manner a. staled.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . _ _ . . . . . . . . . . . . . . . . . . . . . . . J.. REGI l&.uLWdJ LOCIVION (SIr_. C....ITown. Sla/el - JOt. SIGNAI'URE AND titLE OF CERTifiER OJ,,,. lICENSE NUM8ER DATE SIGNED ,...,..... Day. _, lIe. ~ ooSCf7 4--L Jld. f ( - ll--o J _ ANOAOOflESSOF PERSON WHO COMPLETED CAUSE OF cieATH " (lIeml7lTypeorPnnl ~ /LE"'fr e,.., ~Jt1t..,.... ~/ JoJ'~' 8't 0 I'Q'L../t"t'- c:::::.......-. WLI:J. leI&.-(... , ,4- o 32. ~. EF~Lffo(VM:on::y ie' .n _ No "'" b "'" ~ 3, c7J cO LAST WILL AND TESTAMENT BE IT REMEMBERED THAT I, HELEN A. CARCHIDI, a resident of Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my LAST WILL and TESTAMENT, hereby revoking any and all wills and Codicils previously .made by me. I I declare that I am not married, my beloved husband, PAUL J. CARCHIDI, having predeceased me, and that I have two (2) sons, ROBERT P. CARCHIDI and RICHARD C. CARCHIDI. II I direct that all my just debts and funeral expenses shall be paid from my residuary estate as soon as practicable after my decease. III I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. IV I give and bequeath my large diamond ring to my daughter-in- law, JOANNE CARCHIDI, per capita. V I give and bequeath my smaller diamond ring to my great- granddaughter, JESSICA CARCHIDI, per capita. VI I give and bequeath the sum of THREE THOUSAND ($3,000.00) DOLLARS to each of my grandsons, THOMAS R. CARCHIDI, JEFFREY P. CARCHIDI, JOHN M. CARCHIDI, ROBERT C. CARCHIDI, STEPHEN R. CARCHIDI, MICHAEL P. CARCHIDI, and BRADFORD S. CARCHIDI, per capita. VII If I have maintained joint accounts with either my son, ROBERT, or my son, RICHARD, but ROBERT or RICHARD predeceases me with the result that the joint account would revert to my sole ownership, then the balance of that account I give and bequeath to the surviving children of my deceased son, in equal shares, per stirpes. VIII All the rest, residue and remainder of my property, whether real or personal, wherever situate, including any property over which I may have a power of appointment, I give, devise, and bequeath to my sons, ROBERT and RICHARD, in equal shares, per stirpes. IX I nominate, constitute and appoint my son, ROBERT P. CARCHIDI, as Executor of this LAST WILL, to serve without bond. If ROBERT is unable or unwilling to act in that capacity, then I nominate, constitute and appoint my son, RICHARD C. CARCHIDI, as Executor of this LAST WILL, to serve without bond. IN WITNESS WHEREOF, I, HELEN A. CARCHIDI, have set my hand to this LAST WILL this ;J.,2 day of'-J1M? , 1999. ~d..~ ELEN A. CARCHIDI Signed, sealed, published and declared by the above-named HELEN A. CARCHIDI, as and for her Last will and Testament, in the presence of us, who, at her request and in her presence and.in the presence of each other, have hereunto subscribed ou na s as witnesses. w~ 2 ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND I, HELEN A. CARCHIDI, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my LAST WILLi that I signed it as my free and voluntary act for the purposes therein expressed. i~d'~ ELEN A. CARCHIDI Sworn or affirmed to and ac~nowledged before CARCHIDI, Testatrix, this c2;;~ day of /Lhut2tn6t.r me by HELEN A. , 1999. r " v0utIU- M. ~~~ Notary Public r Nota,rial Seal Public Diane M. Smith, Notary \ nd County MElChaniCs9ur~,oBnOEr~,p~~~~~~~ 22,2000 My Com miss AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND : we,(n,n0 f!. bWtos, W and~ A? tC../a'/45 , the witnesses whose names are signed to the attached or foregoing instrument being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her LAST WILL; that HELEN A. CARCHIDI signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as witnesses; and t to the best of our knowledge, the Testatrix was at the t' 18 years of age or more, of sound mind an under constr r/ undue influence. ~ ~~ Sworn or affYmed to and acknowledged before me this :;2 -,...{ day of .~chU~-fr)A-e.A._ , 1999. n '. xfm' rJUtIJUL }vl .. dx Notary Public Notarial Seal Diane M. Smith, Notary Public Mechanicsburg Boro, Cumberland County My Commission Expires June 22. 2000 3 ... " CERTIFICATION OF NOTICE UNDER RULE S.6(a) Name of Decedent: HELEN A. CARa-IIDI Date of Death: November 21,2001 Will No. Admin. No. 21-01-1111 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 December 17, 2001. Name Address Robert P. Carchidi 380 N. 28th Street Camp Hill, PA 17011 or; - - :<<' ::f-'l cr?' (ti Thomas R. Carchidi 100 Ruby Street Summerville,SC 29483 Jeffrey P. Carchidi 28 W. Main Street Mecharilcsburg,PA 17055 John M. Carchidi 608 Shield Street Harrisburg, PA 17109 :BS Robert C. Carchidi 40 Meadow Court Sewell, NJ 08080 20 S. Lewisbeny Road Mecharilcsburg,PA 17055 Jessica Carchidi Richard C. Carchidi nc: ",- ~""'" - (I" 3 ~, O. '~' {, 179S 2700E St. c;eorge, lJf 84790 Joanne Carchidi 179S 2700E St.c;eorge, lJf 84790 Stephen R. Carchidi 2818 Harris Drive Antioch,CA 94509 Bradford S. Carchidi 191 Cleopatra Drive Pleasant Hill, CA 94523 Michael P. Carchidi 2221 Santa Marie Drive Pittsburg,CA 94565 d - o C":) N o :g l'J '" :oS' {D 0 1~ 9 :0:0 (1) ~ :E~ ~~ ~', ~~~; o C":) N o -0 N d N \ Date: 12/17/01 Capacity: _ Personal Representative ~ Counsel for personal representativ~ 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 WALTERS MURREL R III ESQUIRE 54 E MAIN STREET MECHANICSBURG, PA 17055 -------- fold ESTATE INFORMATION: SSN: 207-07-6250 FILE NUMBER: 2101-1111 DECEDENT NAME: CARCHIDI HELEN A DA TE OF PAYMENT: 11/05/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 11/21/2001 NO. CD 003200 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $185.69 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: ROBERT P CHARCHIDI C/O MURREL WALTERS III ESQUIRE CHECK#106 SEAL INITIALS: VZ RECEIVED BY: REGISTER OF WILLS $185.69 DONNA M. OTTO DEPUTY REGISTER OF WILLS /~-~-/o \v 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 12-29-2003 CARCHIDI 11-21-2001 21 01-1111 CUMBERLAND 101 MURREL R WALTERS 'III ESQ 54 E MAIN ST MECHANICSBURG PA\17055 * REV-1547 EX AFP (ol-05) HELEN A Allount Rellitted ) CHANGED (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 5,600.94 .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 ~ RE-Y:iStrj-ix--AFP-foi-:031--Ncffici--oF-'X-NHiifiTAifci-TAx-A-PPRAisiifENT~--Ar.i-oWANci-(fR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF CARCHIDI HELEN A FILE NO. 21 01-1111 ACN 101 DATE 12-29-2003 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/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) 10. Debts/Hortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax I~ an assessment was issued previously, lines 14, 1S and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ~ 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 ITS: NOTE: + INTEREST/PEN PAID (-) 11.17- DATE 11-05-2003 NUHBER CD003200 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. 713.00 1.009.75 (11) (12) (13) (14) (9) (10) .00 X 00 = 3,878.19 X 045= .00 X 12 = .00 X 15 = AHOUNT PAID 185.69 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 5,600.94 1.722 75 3,878.19 .00 3,878.19 (19)= .00 174.52 .00 .00 174.52 174.52 .00 .00 .00 ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) /"J IJ r VO~ PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION STATUS REPORT UNDER RULE 6.12 Name of Decedent: HELEN A. CARCHIDI Date of Death: November 21, 2001 Estate No.: 21- 2001-1111 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes___X___ No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete (date) 3. If the answer to No.1 is yes, state the following: A. Did the personal representative file a final account with the court? Yes No___X_ B. The separate Orphans' Court No. (if any) for the personal representative's account is: (Not Applicable in Dauphin County) C. Did the personal representative state an account informally to the parties in interest Yes ___X_ No / D. Copies of receipts, releases, joinders and approvals of tmal or informal accounts may be filed with the Clerk f the Orphans' .' ourt and may be attached to this report. f I Date: December 10, 2003 ~tlJ ;V~ ~ '\ to \~ O~ MURREL R. WALTERS, III, ESQUIRE 54 East Main Street Mechanicsburg, P A 17055 717-697-4650 Capacity: Personal Representative ___X___ Counsel for Personal Representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENT'S NAME (LAST, FIRST, AND MIDDLE IN!TIAL) I- Z W C W U W C CARCHIDI HELEN A. DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) 11/21/2001 07/31/1911 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INlTIAL) W I- :::.:::$(1) U ."" w~(,) :1:,,9 U"-lll "- < [Rl1. Original Return o 4. Limited Estate D 6. Decedent Died Testate (AlIachcopyoIWiII) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (date of dealh after 12-12.82) o 7. Decedent Maintained a Living Trust (Attach copyorTrust) o 10. Spousal Poverty Credit (dale o/death between 12.31.91 and 1-t-95) OFFICIAL USE ONLY ('7-lS-1O FILE NUMBER 21 -0 1 1 1 1 1 ""'CciUNTYCOOE ---YEAR- - - mmBER-- SOCIAL SECURITY NUMBER 207-07-6250 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER D 3. Remainder Retum (dateofdeathp1iofto12.13.-82) D 5. Federal Estate Tax Return Required _ 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113{A) (Attach Sch 0) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS MURREL R .WAL TERS III ESQ. FIRM NAME (If Applicable) I- Z w C Z C "- <II W '" '" o U 54 EAST MAIN STREET TELEPHONE NUMBER 717/697-4650 MECHANICS BURG 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) (1) (2) (3) (4) (5) z o ~ ...J ::> l- ii: <t: U w D:: 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D 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) (9) (10) (6) (7) 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 z o 1= <t: I- ::> Q. :5 o u S 15. Amount of Line 14 taxable at the spousal tax rate, orlranslers under Set. 9116 (a)(1.2) X _(15) 3,878.19 X .045 (16) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 141axable at sibling rate X .12 (17) X .15 (18) (19) 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTI S ON REVERSE SIDE AND RECHECK MATH < < PA 17055 OFFICIAL USE ONLY ... 5,600.94 5,600.94 1,722.75 3,878.19 3,878.19 174.52 174.52 Decedent's ComDlete Address: STREET ADDRESS 770 POPLAR CHURCH ROAD CITY I STATE I ZIP CAMP HILL PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 174.52 Total Credits (A + B + C) (2) 3. InteresUPenalty if applicable D. Interest E. Penalty TotallnteresUPenalty (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) 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 174.52 11.17 185.69 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 IRl b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 IRl C. retain a reversionary interest; or ................................................................................."................... 0 ~ d. receive the promise for life of either payments, benefits or care? ............................................................. 0 IRl 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration?..............,..,.,.......................................................................... D [RJ 3. Did decedent own an "in trustfo~ or payable upon death bank account or security at his or her death? ................. 0 IRl 4. Did decedent own an individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . ........................ ... .....,..................................................................... D lXl 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 penaWes of pe~LJry, I declare that I have examined this retLJm, incJLJdin~ accompanying schedLJles 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 mformation of which preparer has any know1edge. SIG TURE OF PERS RESPONSIBLE FOR FILING RETURN DATE .' ~ c.A.., . 11/4/03 PA 17011 DATE 11/4/03 ADDRESS MURR L R. WALTERS III ESQ 54 EAST MAIN STEET, MECHANICSBURG PA 17055 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. ~9116 (a) (1.1) (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. ~9116 (a) (1.1) (ii)]. The statute does not exemDt 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. ~9116(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. ~9116(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. ~9116(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. """"""""',. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF CARCHIDI. HELEN A FILE NUMBER 21 01 1111 Include the proceeds of litigation and the dale the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1- MEMBERS 1ST F.C.U. 277.15 SAVINGS 2 2,668.05 CHECKING 3 2,155.74 INVESTMENT SAVINGS 4 SOLITARE DIAMONO RING 200.00 APPRAISED BY MUMMA JEWELRY 5 DIAMOND ENGAGEMENT RING 300.00 APPRAISED BY MUMMA JEWELRY TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 5,600.94 "'.'''''''''.9".. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF CARCHIDI. HELEN A FILE NUMBER 21 01 1111 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A FUNERAL EXPENSES: 1. MALPEZZI PREPAID 2 GINGRICH MEMORIALS ENGRAVING 7S.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (5) ROBERT P. CARCHIDI RENOUNCED Social Security Number(s} I EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees MURREL R, WALTERS III ESQ 560.00 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 CUMBERLAND COUNTY 78.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 713.00 (If more space is needed, insert additional sheets of the same size) ''''''''''''''9''.. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF CARCHIDI HELEN A FILE NUMBER 21 01 1111 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. WEST SHORE EMS AMBULANCE 124.20 2 BEVERLY ENTERPRISES WEST SHORE HEALTH AND REHAB 420.00 3 PHARMERICA MEDICAL 465.55 TOTAL (Also enteron line 10. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1 009.75 REV.'513EX.I_ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TIV< RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER rAW~HIDI Hf'1 EN A. ?1 01 1111 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 lal 11.2)1 1. JOANNE CARCHIDI DAUGHTER IN LAW DIAMOND RING 179S 2700 E ST.GEORGE,UT 84790 2 JESSICA CARCHIDI GREAT GRAND DIAMOND RING 20 S. LEWISBERRY ROAD DAUGHTER MECHANICS BURG, PA 17055 3 THOMAS R. CARCHIDI GRANDSON 1/7 TH OF RESIDUUE 100 RUBY STREET SUMMERVILLE, SC 29483 4 JEFFREY P. CARCHIDI GRANDSON 1/7 TH OF RESIDUE 28 W. MAIN STREET MECHANICSBURG, PA 17055 5 JOHN M. CARCHIDI GRANDSON 1/7 TH OF RESIDUE 608 SHIELD STREET HARRISBURG, PA 17109 6 ROBERT C. CARCHIDI GRANDSON 1/7 TH OF RESIDUE 40 MEADOW COURT SEWELL, NJ 08080 7 STEPHEN R. CARCHIDI GRANDSON 1/7 TH OF RESIDUE 2818 HARRIS DRIVE ANTIOCH, CA 94523 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, Insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent CARCHiDI, HELEN A. 21 01 1111 Paqe 1 Schedule J - Beneficiaries - 1 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 8 MICHAEL P. CARCHIDI GRANDSON 1/7 TH OF RESIDUE 2221 SANTA MARIE DRIVE PITTSBURG, CA 94565 9 BRADFORD S. CARCHIDI GRANDSON 1/7 TH OF RESIDUE 191 CLEOPATRA DRIVE PLEASANT HILL, CA 94523