HomeMy WebLinkAbout06-13-05
RE\l.l500EX(6-00)
'*' COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128.()601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Smith, Thurma M.
FILE NUMBER
21 05
00230
DATE OF DEATH (MM.DD-YEAR)
10/12/2004
-
I DATE OF BIRTH (MM.DD.YEAR)
103/04/1920
CQUNTYCOOE YEAR
NUMBER
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITIAL)
N/A
I SOCIAL SECURITY NUMBER
__~ 168-16-6880
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
I REGISTER OF WILLS
----t-sow:L SECURITY NUMBER
[!] 1. Original Retum
D 4. limited Estate
[!] 6. Decedent Died Testate (Allach copyolWiIl)
D 9. Litigation Proceeds Received
D 2. Supplemental Retum
D 4a. Future Interest Compromise (date of death der 12-12-82)
D 7. Decedent Maintained a Living Trust (Allach copy orTrusl)
D 10. Spousal Poverty Credit (dale 01 dealh belween 12-31..fl1 and 1-1-95)
D 3. Remainder Retum (datil ofd&alh prior 10 12-13-62)
D 5. Federal Estate Tax Retum Required
JL. 8. Total Number of Safe Deposit Boxes
D 11. Electio~ 10 tax under Sec. 9113(A) (AIlach Sch 0)
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NAME
Jacqueline M. Verney, Esquire
FIRM NAME "(1I AppIicabl&) .
COMPLETE MAILING AOORESS
Jacqueline M. Verney, Esquire 44 South Hanover Street
Carlisle, PA 17013
(1) 0.00
(2) 0.00
(3) 0.00
(4) 0.00
(5) 17,576.33
(6) 1,975.47
(7)
TELEPHONE NUMBER
(717) 243-9190
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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
(&:hedu~ E)
6. Jo;nUy Owned Property (Schedu~ F)
o Separate Billing Requested
7. Inter-VIVOS Transfers & MiscellaJleous Non-Probate Property
(Schedule GorL)
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 Govemmental BequestsfSec 9113 Trusts for which an election to tax has not been
made (Schedu~ J)
(B)
19,797.51
71,958.24
(11)
(12)
(13)
19,551.80
(9)
(10)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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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 Line 14 taxable at collateral rate
19. Tax Due
91,755.75
-72,203.95
0.00
(14)
.72,203.95
x.O_ (15)
x .0 (16)
x .12 (17)
x.15 (IB)
(19) 0.00
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
20.0
Decedent's Complete Address:
STREET ADDRESS
f-' Claremont Nursing &.Rehab Center
1000 Claremont Raod
CITYC"J'I
arIse
I STATEpA -----1 ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
0.00
0.00
0.00
-~--
0.00
Total Credits (A+ 8 + C) (2)
0.00
3. InleresllPenalty ~ applicable
D.lnterest
E. Penally
0.00
0.00
TotallnteresVPenalty ( 0 + E ) (3)
4. If Line 2 is greater than Une 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. enterthe difference. This is Ihe TAX DUE. (5)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(5A)
(58)
0.00
0.00
0.00
0.00
A. Enter the Interesl on the tax due.
0.00
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Ves No
a. retain !he use or income of the property transferred;............................. ......................... .................................. 0 ~
b. retain Ihe right to designate who shall use !he property transferred or its income; ...................... .................... 0 ~
c. retain a reversionary interes~ or.......................................................................................................................... 0 [i]
d. receive the promise for life of either payments. benefrts or care? ...................................................................... 0 iii
2. If dealh occunred after December 12. 1982. did decadent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 ~
3. Did decedenl own an "in trust fo~ or payable upon death bank account or security at his or herdealh?............. 0 ~
4. Did decedent awn an Individual Retirement Account, annuity, or olher non-probale property which
contains a baneficiary designation? ........................................ ................... ........................................................... 0 iii
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 petjury, , declare that, IIave 6~ this return, including accompanying schedules and sfalelTl8Tlls, and ID JfJe 11$1 of my knowledge and belief, it is true, correct
and complete.
Declaration of preparet other than the personal representative is bQsed on all informaliofl of which preparer has any knowledge.
SIGNATUREOFPm~SPO;rIB~~~ETURN N~/~J~ ~ 4~ATj ~-/3 -O~
ADDRESS '7n. t/IJ"",~,.,. Et1.~/... ..n_"/'-'f,-:;.,;e;;;7
GNATUREOFPREfii~ROi~iif::EI!!lsENTAk?a4.'3 !)///s.e;,?Vj,/L'4 /Zt2/7 DATE \1...._
DDR . ~.- - UU_ _uuj='<..J.),.:totS-
4<;, ~, 4~ :i, f~ t"/Ut ~
For dates of death on or after Juiy I, t994 and before January 1, 1995, !he tax rate imposed on !he net value oltransfers 10 Of for the use ot!he surviving spouse is 3%
[72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January I, 1995, the tax rale imposed on the net value of transfers to or for fhe use of the surviving spouse is 0% [72 PS. ~91t6 (aJ (1.1) (iin
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 far 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 Ihe nel value of Iransfers to or for the use of the decedent's lineal beneficiaries ~ 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate impcsed on Ihe nef value of transfers to or for the use of the decedent's sibiings ~ 12% [72 P.S. ~gll6(a)(1.3)). A sibling is deFmed, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
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LAST WILL AND TESTAMENT
I, THURMA M. SMITH, of South Middleton Township, Cumberland County,
Pennsylvania, being of sound and disposing mind and memory, do hereby make, publish and declare
this to be my Last Will and Testament, hereby revoking any and all former Wills or Codicils by me
made.
1.
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and
all inheritance taxes (whether such taxes may be payable by my estate or by any recipient of any
property) shall be paid from my residuary estate as soon as practicable after my decease and as part
of the administration of my estate. My personal representatives shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other
property not passing under this Will.
2.
I give, devise and bequeath all of my estate, both real and personal property, in equal shares,
unto my children, CALVIN J. SMITH and LINDA L. SMITH, absolutely.
3.
I nominate, constitute and appoint my said children, CALVIN J. SMITH and LINDA L.
SMITH, as Executors of my estate.
4.
I direct that my personal representatives shall not be required to file a bond to secure the
faithful performance of their duties in any jurisdiction.
5.
I authorize and empower my personal representatives, in their sole and absolute discretion,
to ptHchase or otherwise acquire and retain any investments of which I die seized or any real or
i..,
persOnal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of or
grant'options in regard to any or all property of any kind forming a part of my estate for such terms
and such prices as they may deem advisable; to borrow money for any purposes connected with the
~
T.M.S.
Page 1 of 3 Pages
protection and preservation of my estate; to mortgage or pledge any real or personal property
forming a part of my estate or to join in or secure the partition of same; to compromise any claims
or demands of my estate against others or of others against my estate; to make distribution in kind
and to cause any share to be composed of cash, property or undivided fractional shares in property
different in kind from any other share; to employ agents, attorneys and proxies and to delegate to
them such power as my personal representatives consider desirable and to pay reasonable
compensation for such services as may be rendered by such agents, attorneys and proxies; and to
execute and deliver such instruments as may be necessary to carry out any of these powers. In
addition, I direct that my personal representatives shall have the power to conduct an inventory of
any safe deposit box necessary to the administration of my estate.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 1 ~ day of
;)Vt"j , 1991r.
,,""J f:.'--'U\..A\YJ.. }y\. -<;~YV~' (SEAL)
Thurma M. Smith
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testatrix, as and
for her Last Will and Testament, in the presence of us, who at her request, have hereunto subscribed
es as witnesses thereto, in the presence of the said Testatrix and of each other.
(rr~a Ckhw
Page 2 of 3 Pages
COMMONWEALTH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
I, Thunna M. Smith, 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 Will; that I signed it willingly; and that I signed it as my free and voluntary
act for the pUIposes therein expressed.
J Lv-..,..>...:, n1 ~.,~zt
Thunna M. Smith
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Sworn or a
day of
rmed to and acknowledged before me by Thurma M. Smith, the Testatrix, this
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. otary Public
Notarial Seal
Tricla D. E~kenroad. Nota Pub
Carlisle Boro. Cumberland County
My Commission Expires Oct. 23. 2000
COMMONWEALTH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
We, /l11(/~ :J. H-t/Vn- and \TlfU/tJ.GLttJ /; A. 7JE'C.K.6f(
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 Thunna M. Smith, the Testatrix,
sign and execute the instrument as her Last Will; that the Testatrix signed willingly and that the
Testatrix 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 that to the best of our
knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
~~ .
Ad&ess Ek7 r/-ICrrr S'rA.~
(1-u.l-tt l.& 1'1f-17013
*~/fJ~r2 fluk.;
Ad ss 1.1.36 ~pnryi Ra~
(a.r/1sk/ fA 110/3
Sw~ m _od to md """"'bOO bo""'!"" thi, ci iJ-. f MY of t"t
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Notarial Seal
Trle.a D. Eekenroad. Notary Public
Carlisle Boro. Cumbe~and County
I My Commission Expires Oct. 23. 2000
Page 3 of 3 Pages
REV.1508 EX+ (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Smith, Thurma M.
FILE NUMBER
21-05-230
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of $urvJvorship must be discloSBd on Schedule F.
ITEM
NUMBER DESCRIPTION
1. Cumberland Valley Coop Assn 908 Mt. Rock Rd Shippensburg, PA 17257
VALUE AT DATE
OF DEATH
2. Claremont Nursing & Rehab Center guest fund acet 4446
2,430.00
146.33
3. Prepaid funeral Forethought Life Insurance Co. Forethought Center, Batesville, IN 47006
15,000.00
TOTAL (Also enter on line 5. Recapitulation) $
(If more space is needed. insert additional sheets of (he same size)
17,576.33
"^i18ERLAND V ALLEY COOPERATIVE ASSr,]
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DESCRIPTION
STOCK PURCH!\SE
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I 000 Clare01on~ Road
Corlisle. PA 17013.8805
m.,," (717) 243-2031
In (717) 240.1952
1(elwbilitation Center
1-27-05
John E. Smith
One Langsdorf
Carlisle, PA
Way
17013
S:.1~jec~: G'Jest F'Jn: !...:::>un: of
ThllrmR Smith
,~esicen~ r<-",:"-;-,jer:
~.1/'f6
:)eer Si:- or rl,,"adam:
O~r recc;'"cs ir'loicat= := Jalance reri',ciiling ir. the GuSSt ;:L'~d .t,:::::)J;-i~ C7 ~hf- iildivijua:
cap:ioned 2~::Jve of S 146.33 rurt:-'eli7:ore. !: :$ :::~iC2~S:: t:-:a: Y:>l.J are :Jne :'~
one ;ndivic-"':2:S to whO:ii ~h!s ac:c:)un: shoui.: :':; dis~r:j-...::e: e::;:"':3:;Y.
\Ne wC:Ji: ask yo'..!! :.-.:-ne:iiate ..:~:entio~ i:-: th!s rli2ae..,
V',Jf: have enclosed c- 2p;:>lica~i:>n for the disti"ijution c': :~e Gues~ ;:un'2S Please si;~, i,
aild have it nO:2:-:ze: 2.""18 retu~n :t to :.J5 in the en:lose::' e::veJe.:i€. 0./8 v.,:i!:. in tuiri,
,2...o:ess the 2=,;dic2::::- 2nd pre~2n:: u"',e d!S7.:i~'..!tic:n C'.~-?Sv. 2rs ~:'-~..'e"'2 i: ~~ ;:~~.
\r/s apologize fo: c:;-'::::i.iilQ YO'J with this process a~ :~:s lii7le. U:-;70~u~'c:ely. r29:.;;ai:O:lS
iequire GJr ti;7le!y cC'7,]letion of these :)roced~:es.
Very truly yours.
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De:'~a D. Surd
Guest Func Cashie~
cnc:losUic. Ap;Jiicati::;--; for Gues: F~;lC
.II sen' ice (/gcl/(Y OJ" Cwu/)(r/(//I(/ COUI1Uj
5336574
GROUP INSURANCE ENROLLMENT FORM
FORETHOUGHT LIfE INSURANCE COMPANY . FORETHOUGHT CENTER
/ivCJCHT"
;1PilOJfJiEii~Jiffi" r.t:~;;~~;l$[~~~~r(~~:, :i ' ~~ ~'-~~~~~i:i~:<~(f~='~~,~,.: 1 ': ~_,,~;,,'-'1
o M I dd i . II La NOM I V C I SO/ciol Sijcurity N,,/mb'Y":
~ r. First Name Mi Ie nitla sf orne: a e 1.:51 rema e tf 6
8 E~:T~URmtl ,vJSm,tA D:30!Birlh: I ~
,.; CERTlFICA TEHOLDER ....:.. COMPLETE ONLY IF OTHER ~~A~ INSURED
First Name / Middle Initial/Last Name:
LiNda.' Jv. SmdJ,
MAIUNG ADDRESS FOR iNSURED OR CERTIFICATEHOWER-
~)
!nOUAJ TO.; N Dc d.
I pJ:l
Slre~t!/"'1? I CI i ;<
FUNERAL PRICE
__ FACE AMOUNT _ I S/l)JGLE PREMIUM
.::l O?s 00 f,dJ/1I 'v-IJIt'
5, ~'2o. ," fa!"'7/.. } ':::::>/ COO. 00
PAYMENT MODE
/5, DOO. 0"
PAYMENT PLAN
:J 3 yr. Pay
:J 5 yr. Pay
:J 10 yr. Pay
o Flex
o Other
o Monthly 0 Annual 0 Semi 0 Quart~r1y
o Coupon Book 0 APA*-Autumafic Payment Authorization
* Atlilell complete!! Uluhvrl:uriolljinlll 1I",1,"oid'!d
check if APA i~ selecte,f.
Make check payable to Forethought Life Insurance
Company and write certincate number on check.
INeT/At PRE'oJlIUM + Mum.PAY PREMIUM ;;; TOTAL PRE,I,1/Ui\i A\iOL','IT
-.,..
REPLACEMENT is the illSllrallce appliedfor inlended to replace
or change any existing life insurance or annuity policy?
DYes }J{ No -If yes. please provide name of the insurance
company(s). policy number(s), and replacement formes), if required
by your state.
DIRECTIONS FOR PA YMENT OF PROCEEDS
To secure the Funeral Firm guarantees stated in the Funeral Planning
Agreement, proceeds are to be paid to the Funeral Firm in an amount
not to exceed the retail price ofth~ funeral provided. Th~se directions
may be changed any time befor~ the funeral is provided by giving
written notice to Forethought Life Insurance Company.
'\nv remainin~ proceeds are to be paid to the Beneficiary which is the
-:state of the Insured. If another Beneficiary is desired, provide the
i'fonnation b::!9w. (Benetic\ary should be other than the fun. eral ~ome.)
/iL I}; r,) J. ~nlll A -/ L J/vdo L. Srl! dA
. BATESVILlE, INDIANA 47006
Please Print
Social Security Number:
0/07 -Y'$/ -6S"<'/.2
WHERE TO SEND INFORMA nON ABOUT THIS INSURANCE
Telephone Number:
l/i7~?9
(7/7)_952 _2-:f99
Area Code
OPTIONAL HEALTH QUESTIONS" FOR UNOERWRHTfN PU.NS ONLY
TO BE COMPLETED ONLYBYTHE PROPOSED INSURED.
INSURED'S SIGNATURE IS REQUIRED IN SECTION 6,
Please allswer each questioll to Ihe best of your knowledge alld belief
1. Are you currently confined to a hospital. hospice. nursing home
(includingcustodialcare)orothersuch facility; or. within the past
twelve months, have you been told by a medical practitioner that
you should be confined but have chosen not to follow that
instruction?
o Yes 0 No
2. During the last five years have you been diagnosed as having, or
have you received active treatment from a medical practitioner
for any of the following:
o Yes 0 No
AIDS/ARC
Blood Disorder
Brain Disorder
Cancer
Circulatory Disorder
Heart Disorder
Kidney Disorder
Liver Disorder
Lung Disorder
If the answer to both health questions is "No." a certificate which
provides full coverage will be issued. If either answer is "yes." or if
the Proposed Insured is physically or mentally un.:tble to answer the
questions. a certificate with limited death benetlts durin!:! the first one
or t\VO years (depending on age and plan) will be issued.
AUTHORIZA TlON By completing the Health Questions and signing
this Enrollment Fonn. any medical practitioner or facility. or other
person is authorized to give Forethought Life records or information
regarding the Proposed Insured's health. This authorization is limited
to matters related to the Health Questions. This authorization is
First Name / Middle Initial/Last Name effective for a period of two years and six months.
The above informalion is true and complete to the best of my knowledge alld belief. Any persall who knowillply and with intent to defraud allY insurance
compallY or olher personfiles an application for insurance or statement of claim contaming any materially ,alse illformawn or conceals for the purpose
ofmlsletu1ing, information concernmg any fact material thereto commits a fraudulent insurance act, whiclllS a crime and subjects slIch person to criminal
and civil penalhes. No insurance will take effect unlillhe premium has 'been paid and a certificate has been issued while the Insured is living.
Signature of Proposed Insllred: Sigltatllre ot erlificateho!der-ALWAYS needed Ifpther thalllnSJ/red:
J,~-d-
I)-O~.PA lfsign~ by legal rl:!presl:!nrative or gUlJrdian, please attach legal documentation.
AGENT'S ST A TEMfNT is the insurance appliedfor iatended to replace or c allge an erisling life insurance or annuiiy policy? 0 Yes>> No
iflhe Health Qllestions are compleled, i cerlify Ihat Ihe informalioa was provided direclly by Ihe Proposed Insured.
------ ----._-
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~ C 0/\ l./ /./ ~/ ..c. 2 WHITE COPIES -For~(hought YELLOWeOpy -Fun~r:JJ Home PINK COpy - F3.mily
(l 1999 Forethought
0390)
REV-1509 EX+ (6-98)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
Smith, Thurma M.
FILE NUMBER
21-05-230
If an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Calvin J. Smith
722 Petersburg Road Carlisle, PA 17013
son
B. Linda A. Smith Packer
50 Blair Mountain Road Dillsburg, PA 17019
daughter
C.
JOINTLY.OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %Of DATE OF DEATH
ITEM FOR JOINT "AD' INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A.
a1b 06/01199 Waypoint checking acct # 20085250 5,926.43 33 1,975.47
TOTAL (Also enter on line 6, Recapitulation) $ 1,975.47
(If more space is needed, insert additional sheets of the same size)
VIWay~qi!lJ
'-.
Ol3-77E
CHECK 21 ACT A NEW FEDERAL LAW EFFECTIVE 10/28/04.
INCREASES EFFICIENCY & SECURITY OF U.S. CHECK PAYMENT
SYSTEM. YOUR NOVEMBER STATEMENT CONTAINS MORE
INFORMATION. QUESTIONS? VISIT WAYPOINTBANK.COM
STATEMENT D(TE
10 - 31- 04
,
----------------------------------------------------------------------------
'VERAGE B'HI,::
3.129 ~:
D ~ TE
10/0 I
10 i 0 I
10/08
010 !12
10!I 9
10 t! 9
10! 21
10 '31
P.O. Box 1711. Harrisburg. Pennsylvania 1710S~1711
Member FDIC
THURMA M SMITH
OR CALVIN J SMITH
OR LINDA L SMITH
% C'LVIN J SMITH
722 PETERSBURG RD
CARLISLE PA 17013-9231
ACCOUNT TYPE OF ACCOUNT
20085250 FOCUS FIFTY
PREVIOUS BALANCE
DEPOSITS
W ITHORA,IAL S
CHARGES
I NTER,E ST
ENDING BA.LANCE
- - - - - - - - - - -INTEREST SUMMA.RY- -
INTEREST EARNED FROM 9/30/04 TO 10/31/04
D"YS IN PERIOD
INTER.EST EARNED
ANNUA.L RERCENTAGE YIELD EARNED
INTEREST RAID THIS YEA.R
INTEREST ~ITHHELD THIS YEA.R
- - - - - - TRANSACTION SUMMARY-
TR~NS~CTION DEPOSITS/
DESCRIRTION CREDITS .
ELECTRONIC TRANS'.cTION 720.00./
US TREASURY 303 SOC SEC
CHECK 149
DEROSIT
ELECTRONIC TR~NS'CTION
RFBMSC HEA.LTH RREMIUM
CHECK 151
CHECK. 150
CHECK 152
INTEREST PAYMENT
3233.39 ;/
NO.
.40 V
-CHECKS PAID-
AMOUNT NO.
384.11
2000,00
D,ATE
149 10 - 0 1
150 10- 19
THANK YOU FOR BANKING AT WAYPOINT B'NK
CHECKS/
DEBITS
384,11./'
28489 V
2000 00./
2000,00 V
298,75v'
DA,TE
151 10- 19
152 10 - 21
2,6420"
3,953 3e.
4.967 7S
00
40
1.62806
,
31
,40
.15 l
2.73
00
B,A,L.t,N C:
33620~
297792
6211.32L.-
5926.~2~
3926'"
1926.43
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1028 OE
,t.,MO"I,\I:
2000 C ':
298 -5
Customer Service Toll-Free 1-866-WAYPOINT (1-866-929-7646) . In York Area 717/815-4500'
REV.1511 EX+ (12.99).
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Smith, Thurma M.
FilE NUMBER
21-05-230
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
,.
FUNERAL EXPENSES:
Ewing Brothers Funeral Home, Inc. (pre-paid) 630 S. Hanover St., Carlisle, PA 17013
15,000.00
B. ADMINISTRATIVE COSTS:
,.
Personal Representative's Commissions
Name of Personal Represenlative(sj Calvin J. Smith/Linda Smith Packer
Soci~1 Security Number(s)JEIN Number of Personal Representative(s) 197-40-6283 207-44-6542
Street Address 722 Petersburg Rdl 50 Blair Mt. Rd,
City Carlisle/Dillsburg, 17019
Year(s) Commission Paid: 2005
2,000.00
Slate Pa
Zip 17013
2.
Attorney Fees
2,500.00
3. Family Exemption: (If decedent's address is nol tne same as claimant's, attach explanation)
Claimant
Street Address
City
State
.Zip
Relationship of Claimanl to Decedent
4.
Probate Fees
100.00
5. Accountant's Fees
6. Tax Retvm Preparer's Fees
7.
Advertise letters: Sentinel 122.51; Cumb Bar Journal 75.00
197.51
TOTAL (Also enter on line 9, Recapitulation) S
(If more space is needed, insert additional sheets of lhe same size)
19,797.51
~
/,dOCHT'
GROUP INSURANCE ENROllMENT FORM
FORETHOUGHT LIFf INSURANCE COMPANY . FORETHOUGHT CENTER
5336574
. BATESV1llE, INDIANA 47006 Please Prillt
.......-...._.....~............t.<JJ"."".......7::;..;:>_..'r.:~:'l:..rl-.~F;.t.1:-':<..:'>_...""'7!:.-:;':"'..':"','-::~;:~~,:;c ~,>':;,;",_,:,::.., -', .,........, . .~...s .' -<'~'~"
,. .'
'PROPOSED .INSURED ."""\:"~",~;~f~':;".~,)-,,.."t":;',,.,;, A'..,,,:.......'. '" . "i,\:" . ",'.'c ...' . :...
~~-;'~~:;;':;;;;i;~;e';~;;i~;~';;,;,~~me; , '0 M~I~'~ Fem~l~- ,-. ,... Sjial Srriry N"',//;'
8 m:s T ~ u {? m II (V/S m It A D::Jof Birrh I
. : CERTIFlCA TEHOLDER....:. COMPlETE ONLY IF OTHER THAN INSURED .
Me First Name / Middle Initial/Last Name:
0.
0. Mrs.
0. Ms.
':&i Miss
MAILING ADDRESS fOR INSURED OR CERTlfICATEHOLOER-
')
fnOVAJ0 iN h d.
I Sf''}e:j
i r/'
5 rill' j)1
L j Nd a.' 1-...
S"ee~c/'-Z 10. j I<
FUNERAL PRICE
s: FACE AMOUNT. . I S""GLE PREMIUM
~ 07S OOf/T?ftt-c:r",;Jll'
s: YZ{).'" &,~7/.. I~/ COO, 00
PAYMENT MODE
15. {)oO, 0"
PAYMENT PLAN
:J 3 yr. Pay
:J S yr. Pay
:J 10 yr. Pay
:JFkx
:J Other
o ~I{llllhly 0 Anllu;tl 0 S~'ll1i 0 QLl;m~rly
o Coupon BO~lk 0 APA "'-AlllUlllJli.: PJ~m.:nt Au(h.lnn.tiu{\
'" Attill"h cO/!/l'kred wah,Jri:atio/l j;'flll </1<<[ ,"(,i.l.!,!
ch<'ck ifAP,\ ix select...d.
Make check payable to Forethmlght Lire IlIsuruncc
COf\lil\lny and \'irit~ certificate number on check.
Is/TIAL PRE\IIUAl + MUW.PAr PRE.\JlL'.\! ~ TorAl PRE.\~{U\I A\:OL"r
.
REPLACEMENT /S lire insurance appliedfoT inlended 10 replace
or change allY existing hie insurance or annuity policy?
o Yes '!g( No ~ If yes. pleas~ provid~ name of [he insurance
company(s). policy number(s), and replacement form(s), if required
by your state.
DIRECTIONS FOR PA YMENT OF PROCEEDS
(
Social Security Numbt'f':
0107
- 6 s:- <,/.2
-.yy
WHERE TO SEND INfORMATION ABOUT THIS INSURANCE
Telephone Nllmber:
i lip Code: a
1/70/ f
(7/7) _95' 2 ~25'9'7
Area Code
OPT/ONAL HE.4.l.TH QUESTIONS - FaR U\DW\Jttrn... Puss O,\iL)i
TO BE COMPLETED ONL Y BYTHE PROPOSED I1\SURED.
INSURED'S SIG:-;,\ TURE IS REQUIRED 11\ SECTIO" 6.
Please answer each question to the best o/your kllOldedge aud belief.
1. Are you currently confined to a hospital. hospic~. nursing hOI11~
(induJing cU-:.tudi;'ll c-are) oro[h~r such facility: or, \vithin the past
twelve months. have you been told by a medical practitioner that
YOll should be confined but ha\'~ chosen not w follow that
instruction?
o Yes 0 No
2. During the bst five years have YOll b..:::o;::n diagnosed as having. or
have you received active treatment from n medical practitioner
for any of the fottowing::
o Yes 0 No
AIDS/ARC
Blood Disorder
Brain Disorder
Cancer
Circulatory Disorder
Heart Disorder
Kidney Disorder
Liver Disorder
Lung Disorda
If the answer to both health questions is "~o," a certificate which
provides full con::rage will be: issued. If eithc:r answer is "ve's." or if
the Proposed Insured is physically or mentally unable tu a"ns\\L'r th<;?
questions, acertificate with limited death benefit'. durlng the first one
or two years (depending on age and plan) wiU be issued.
r 0 secure the Funt:ral Firm guarantees stated in the Funeral Planning
\\!.rcement. proceeds an~ to be paid to the Funeral Firm in an amount
H')r to exceed th~ retail pl"ic\: of the funeral prm'idel1. These directions
Ill,IY be changed any tune before th~ funeral is pwvided by giving
'.\Tittc-n noticl: to Forethought Life [ns.uranc~ Company.
AUTHORIZA TlOI'" By compkting the Health Questions and signing
\nv remaining proceecls arc to be paid to the Bendicial)' \vhich is the this Enrollment Form. any m~dical practitioner or faciEt\;, or other
:'it::\tr.:: of the Insured. if another Beneflcia.!"y is d~sir~d, provide the J
.. . b I (B f' h ld b h h I f l~ ) person is authorized to give Forethought Life records or informati.on
Ir~t~Jlat.(~n,,\ eJ31,1,~ ene. ~,clary S OLu. edot ertLan tslC unera, orne. regarding the Proposed Insured's health. Thisauthorizution is limited
l/ l. V, ,v ,.,::)011 -. /'I --I J,v 0 . rJ7 I T to matters rebted (0 the Health Question.'. This authorization is
'-irs( Na/lle / Middll! I"ilial / LaJ{ lv'ame effective for a period of two years and six months.
Tlte above illformation is true and complete to the best of my knowledge and belief AllY persall who knowingly and witlt intent to defraud any insurance
L'umpallY or other personfiles au appliClJtio11for insurance or statement of claim con/aming any materially lalse information or concealsfor tlte purpose
afmlsleading, information cOllcermng any fact material tllere/a commits a fraudulent insurance act} which IS a crime and subjects such persOIl to criminal
ana chil penalties. iVO insurance win take effect until the premium has been paid and a certificate has been issued while the Insured is living.
Signature of PrupoIed lll.wrt'd: I. ~i~I/~~!lre ofCerrificalt'holder --::- AL n:.\ rs 1/.t't'Jed ~ other r!ltln Insured:
~_ {J(~ '-. \..."l,,-&77C-
)_()~.P..\ If signed by legal r~presentathe or guardi:m, pl~a.se attach leglll d\}~Unwntalion.
.: c. v/,--
,-\7.;;aNulllber:
')0 / ~ I3fi
o Yes~ 1'0
,
2 WHrTE COPIES - F0f~ltl<)u:;hr YELLO\\' COpy - Fun~c.l.l H,'l1'~ P\:-::K COPY - FJrnil:
iD 19'N fQ{~th,,\.\'~r.\
I! ~';'! -
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16,1929), P. 1.1784
COi\IIVlONWEALTH OF PENNSYLVANIA
ss.
COL:NTY OF CUMBERLAND
Lisa Made Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2,1952, been regularly
isslled weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
JOllrnal on the following dates,
VlZ:
MARCH 25, APRIL I, 8,2005
Affiant further deposes that he is authorized to verify this statement by the Cumberland
La" JOllmal, a legal periodical of general circulation, and that he is not interested in the subject
malleI' of the aforesaid notice or advertisement, and that all allegations in the foregoing
statelJ1ents as to time, place and character of publication are true.
Smith. Thurma M.. dec'd.
Late of Middlesex Township.
Executors: Calvtn J. Smith and
Unda Smith Packer. c/o Jacque.
line M. Verney. Esquire. 44 South
Hanover Street. Carlisle. PA
17013.
Attorney: JacqueHne M. Verney.
Esqulre. 44 South Hanover
Street Carlisle. PA 17013.
SWORN TO AND SUBSCRIBED before me this
8 day of APRIL 2005
NOT ARt SEAl..
LOIS E. SNYDER, Notary Public:
CaIIsle Boro, Cumberland County
My Commission Expires MardlS, 2009
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Tammy Shoemaker, Classified Sales Manager, of The Sentinel, of the County and State
aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of
general circulation in the Borough of Carlisle, County and State aforesaid, was
established December 13th, 1881, since which date THE SENTINEL has been regularly
issued in said County, and that the printed notice or publication attached hereto is
exactly the same as was printed and published in the regular editions and issues of
THE SENTINEL on the following day(s)
March 15, 22, 29, 2005
COPY OF NOTICE OF PUBLICATION
EXECUTOR NOTICE
Letters Testamentary on the Estate of THURM A M.
SMITH. late of the Township of Middlesex, Cumberland
County, Pennsylvania, deceased, have been granted to
the undersigned.
All persons knowing themselves to be Indebted to said
Estate will make payment immediately, and those
having claims will pres~t them for settlement.
Calvin J. Smith, Executor
Linda Smith Packer, Executrix
clo Jacqueline M. Verney, Attorney
44 South Hanover Street
Carlisle, PA 17013
.'-.
.
.
Affiant further deposes that hel she is not
interested in the subject matter of the
aforesaid notice or advertisement, and that
all allegations in the foregoing statement
as to time, place and ch<lIacter of
~j;;::~~~
Sworn to and subscribed before me this
30th. day of March, 2005
C~rv I? U~~
Notary P .c
My commission expires: q! lot
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Chnstina L. Wolfe. Notary Public
Carlisle Boro. Cumber1and County
My Colmlission Expires Sepl1. 2008
Member. Pennsyt'lania Association Of Notaries
:r---':--'-~:;''''=-' --,-. -.. -=.,,;=;..,...--:;=>".<.,-';:~ ..::.,;,.':,.:=,.=,-'.:. ~-_-:=,.:;;c.,'__.c~_.._;';;;,,--,,;~.,_-,-~_,...;:-;=..-.=...-"::.__::.__::'::;::'>'~--~-'==-:"''''~=~~~-'_"~"
,,,--,--..::..._:'.':;'='='--,-,,-~~,...--~-.:.::--....-----== .
I
JACQUELINE M. VERNEY ESQUIRE
BUSINESS ACCOUNT
44 S. HANOVER
CARLISLE, PA 17013
1398
,PAY ~
,.r TO THE
ORDER OF .
, fJAe ~iAJ ~1 -~
,
~~~ AMERICAN
. ... HOME BAi'JK"
FOR ~ 'i..o~t. ;JO/-N'
DATE
'I/t/6S-
.
60-1 869-313
$ 1M. 57
~
r-IJ
~ I" DOLLARS 6'1
~'-
,,",-~"",.
.
~
,.
i
~'I
"
'.~:~~.,-
11'00 U9811' 1:0:1 ~:I ~8b9 :II:
~_HA~_~___ ~
0000 W ~8 ~811'
~ -:c ~
_ ~~ ,~~_,,-_-,,",",,'~__,=~~~~_~~_""'c~~.._...
DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
THE SENTINEL - LEGAL Est. Th. Smith
POBOX 130 CARLISLE PA 17013
AO NUMBER ClASSO sTART DATE STOP OA TE
282475 PUBLIC NOTICES 03/15/05 03/29/05
AD DESCRIPTION BILLING DA TE TELEPHONE NUMBER
EXECUTOR NOTICE LETTERS TESTAMENTA 03/30/05 717-243-9190
;
GROSS AMOUNT OF
147.01
DUE AFTER 04'29/05
TOTAL AMOUNT DUE
122.51
ENTER AMOUNT ENCLOSED
JACQUELINE M. VERNEY
44 SOUTH HANOVER STREET
CARLISLE, PA
17013
'J701J~'
20200000002824750000000000000001470100000122511
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, P A 17013
April 8, 2005
Cumberland Law Journal is published every Friday by the Cumberland County Bar
Association and is designated by the Court of Co=on Pleas as the official legal publication for
Cumberland County and the legal newspaper for publication oflegal notices.
TO:
Jacqueline M. Verney, ESQUIRE
RE:
ThurmaM. Smith,ESTATE
Legal advertisements must be received by Friday Noon. All legal advertising must be
paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
March 25, April I, 8, 2005
Second Proof Request
$ 75.00
$ 0.00
$ 0.00
$ 75.00
-------------
$ 0.00
Advertising Cost
Proof of Publication
Payment Received
Total Amount Due
Payment received March 22. 2005
by Beckv H. MorgenthalJExecutive Director
REV-1512 EX+ (12-03)
'*
COMMON"NEALll-l OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE L1ABIUTlES, & LIENS
ESTATE OF
Smith Thurma M.
FILE NUMBER
21-05-230
Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
DPW Estate Recovery Program P.O. Box 8486 HalTisburg, PA 17105-8486
71,958.24
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
71,958.24
*'
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX El48a
HARRISBURG. PA 17105-8486
February 23, 2005
LAW OFFICE OF JACQUELINE M VERNEY, ESQUIRE
44 S HANOVER ST
CARLISLE PA 17013
Re: THURMA SMITH
CIS *: 250164785
SSN: 168-16-6880
Date of Death: 10/12/2004
Dear Attorney Verney:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $7~,9S8.24 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.B. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $37,446.55, was incurred
during the last six "months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $34,511.69, is
to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. if the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
/),1 A;.1L-
A2}ft~t if 7'1U?~
Rebecca L. Himes
Claims Investigation Agent
717-772-6614
717-705-8150 FAX
Enclosure
REV-1513EX'IMO) ..
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Smith, Thurma M.
FILE NUMBER
21-05-230
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Truslee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS pnclude outright spousal disbibutions, and transfers under
Sec. 9116 (a) (1.2)]
Calvin J. Smith 722 Petersburg Rd Carlisle, pA 17013 son 50%
Linda A. Smith Packer 50 Blair Mountain Rd, Dillsburg, PA 17019 daughter 50%
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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00
(If more space is needed, insert additiooal sheets of the same size)