HomeMy WebLinkAbout01-1158
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of George C. ,sheaffer,
also known as
No. 21-01-1158
To:
Deceased.
Register of Wills for the
County of Cumberland in the
Commonwealth of Pennsylvania
Social Security No. 187-16-5409
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appt!:es
d.b.n.
(d.b.n.; pendente lite; durant,~ absentia; duranle minorilale)
the above decedent.
for letters of administration
on the estate of
Decedent was domiciled at death in CUmberland County, Pennsylvania, with
h is last family or principal residence at 340 N. Front Street, Wonnleysburq BorolJgh
(list street, number, Twp. or Boro.)
Decedent, then 78 years of age, died 9 November
at 340 N. Front Street, ~'Vonnleysburq, PA
~ 2001
, ,
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
situated as follows:
$48,000.00
$ 0.00
$ 0.00
$ 0.00
Petitioner_ after a proper search ha:>_ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name Relationship Residence .
George C . Sheaffer, Jr. son 5 Autumn Drlve, Dlllsburg ,PA 17019
Brenda Pyper
daughter
lv1ichelle Tana1avage
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in thc~
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Cumberland
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The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) will w I and
truly administer the estate according to law.
Sworn to or affirmed and subscribed J
before me this 17 th day of
~EMBER t. ~ ~
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No. 21-01-1158
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AND NOW DECEMBER 20 Xf9 2001, in conside(jhpn of t~ petition (In
the reverse side hereof, satisfactory proof having been presented before me, -'
IT IS DECREED that Georqe C. Sheaffer, Jr.
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
George C. Sheaffer, Jr.
are hereby granted to
in the estate of
Georqe C. Sheaffer.
~(l1i!':!il("LAv~-'Y
ISler of WI S
FEES
Letters of Administration $
Short Certificates( ).......... $
Renunciation ................ $
JCP $
TOTAL _ $
Filed ..................... A.D.
80.00
15.00
10 00
') 00
110 00
19_
ATIORNEY (Sup. Ct. J.D. No.) 17225
525 N. 12th Street, Lemoyne PA 17043
ADDRESS
(717) 761-5361
PHONE
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In Re Estate of
RENUNCIATION
George C. Sheaffer
To the Register of Wills of __
Cu~berland
County, Pennllylvania.
The undersigned
Micl!elle Tomalavage
21-01-1158
deceased.
of
d.b n
the above decedent, hereby renoUIlce(s) the right to administer the estate and respectfully ask(s) that Letters
be issued to
WITNESS
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Sheaffer, Jr.
hand this
t 14. day of ~e...k-. x~.l
12}r/o/
(Signature)
l1ichelle Tomalavage
401 East Main Street
Shiremanstown, PA 17011
(Address)
(Signature)
(Address)
(Signature)
(Address)
RENUNCIATION
21-01-1158
In Re Estate of
George C. Sheaffer
deceased.
To the Register of Wills of
Cu~berland
County, Pennsylvania.
The undersigned
Brenda Pyper
of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
-d. b . n.... o~ J:) ~1~~~ ~
be issued to
Georqe C. Sheaffer, Jr.
WITNESS
M"l
hand this 1'l.i2 day of J1.u..e.:..~~ ,21~.1
'1-13 /1~-::?~ /2-'j{- 0 I
Brenda Pyper
2851 Evans Road
Winston-Salem, NC 27127
(Address)
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CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent:
George C. Sheaffer
Date of Death:
9 November 2001
Will No.
Admin. No. 2001-01158
To the Register:
I certify that notice of beneficial interest 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 27 December 2001 :
TO: George C. Sheaffer, Jr.
5 Autumn Drive
Dillsburg, PA 17019
Brenda Pyper Michelle Tomalavage
2851 Evans Road 401 East Main Street
Winston-Salem, NC 27127 Shiremanstown, PA 17011
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except:
None
Date: 27 December 2001
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Name: Samuel L. Andes
Address: 525 N. 12th Street
Lemoyne, PA 17043
Telephone #717 761-5361
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Capacity:
Personal Representative
~ Counsel for Personal
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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
SAMUEL L ANDES ESQUIRE
525 N 12TH STREET
LEMOYNE, PA 17043
-------- fold
ESTATE INFORMATION: SSN: 187-16-5409
FILE NUMBER: 2101-1158
DECEDENT NAME: SHEAFFER GEORGE C
DATE OF PAYMENT: 09/09/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 11/09/2001
NO. CD 001600
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,029.27
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TOTAL AMOUNT PAID:
$2,029.27
REMARKS: SAMUEL L ANDES ESQUIRE
CHECK# 4290
SEAL
INITIALS: DO
RECEIVED BY:
REGISTER OF WILLS
MARY C. LEWIS
REGISTER OF WILLS
'lE\;'_1S:DEX i6-UQ',
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
C1CL""L U'5;F <)~\1i y
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FILE NUMBER
21
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
01 1158
NUMBER
COUNTY CODE
YEAR
SOCIAL SECURITY NUMBER
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Sheaffer, George C.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
11-09-2001 07-26-1923
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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~ 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate {Attach copy of Will)
o 9, Litigation Proceeds Received
187
16
5409
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of deafh after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trusf)
o 10. Spousal Poverty Credit (dafe of death between 12.31.91 and 1-1-95)
o 3, Remainder Return (dale of death priorfo 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)
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)
NAME
FIRM NAME (If Applicable)
TELEPHONE NUMBER
761-5361
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Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
12. Net Value of Estate (Line 8 minus Line 11)
COMPLETE MAILING ADDRESS
525 North 12th Street
Lemoyne, PA 17043
(1)
(2)
(3)
(4)
(5) 47,014.57
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(7)
(B) 47 .014.57
(9) 1,722.11
(10) 197.51
(11) 1, 919.62
(12)45,094.95
(13)
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
(14) 45 , 094.95
15 Amount of Line 14 taxable at the spousal tax
rate, or transfers under See, 9116 (a)(1.2)
16. Amount of Line 141axable allineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19 Tax Due
45.094.93
, .0 (15)
,.O~ (16) 2,029.27
x .12 (17)
x .15 (18)
(19) 2,029.27
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
20.0
Decedent's Complete Address:
STREET ADDRESS
340 North Front Street
CITY ~'lonn1eysburg I STATE I ZIP
PA 17043
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1) 2,029.27
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + 6 + C ) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( 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 relund (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)
6. Enter the total of Line 5 + 5A. This is the 6ALANCE DUE. (56) 2,029.27
Make Check Payable to: REGISTER OF WILLS, AGENT
-., ~ - - Hun."'1 ".
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 01 the property translerred; ............................... ................................... ........ D g]
b. retain the right to designate who shall use the property transferred or its income; ........... D 121
C. retain a reversionary interest; or. .................................. ...................................... ..................... .. D ~
d. receive the promise for life of either payments, benefits or care? ...................... ........... .... ..... 0 l'81
2. If death occurred after December 12, 1982, did decedent transler property within one year 01 death
without receiving adequate consideration?. ....................... ....................................... D IXf
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.. D I2<:l
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? . ............................ ........................... ............................... ....... D lX'I
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
DATE
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ADDRESS P D ~
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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)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net vaiue 01 transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (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 jf
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.
REV-1500EX+(1-97)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Georqe C. Sheaffer
FILE NUMBER
21-01-1158
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 l;chedule F.
ITEM
NUMBER
1.
DESCRIPTION
Savings account No. 5140163269 with PNC Bank, N.A.
(see document attached)
VALUE AT DATE
OF DEATH
$46,714.57
2.
Miscellaneous items of clothing and personal effects
$300.00
TOTAL (Also enter on line 5, Recapitulation) $ 47 , 014 . 57
(If more space is needed, Insert additional sheets of the same size)
Page: 1 Document Name: untitled
STMT CO
ACTION
PROD CODE DDA
STFD
40 OP
PAGE 1
ACCOUNT
1 THF TRANSACTION STATEMENT FORMAT 02/02/05 12.06.
MS 50852 ACTION COMPLETE
SEARCH FROM 01/11/13 THRU 02/01/10
5140163269 SHORT 'NAME SHEAFFER GEORGE C
ACTN POST EFFECTIVE CHECK NUMBER TRAN AMOUNT D/C BALANCI
TRACE ID DESCRIPTION
-;j~~1/1i113 3496 5,800.00 D
024101400 CHECK 3496 REFERENCE NO. 024101400
* 12/03 401.02 C 47,115.5'
00020013330300804 975187165409C01 PENSIONS EBS G-3N 01112C
* 12/03 401.02 D 46,714.5~
00020013371772026 975187165409C01 REVERSAL EBS C-3N 01112C
* 12/05 2.00 D 46,712.5~
00020013383115907 010386800000 DEC DUES BENEFITS PACKAGI
* 12/10 10.32 C 46,722.8'
I-GEN101121000004391 INTEREST PAYMENT
* 01/07 2.00 D 46,720.8'
00020020041223448 010386800000 JAN DUES BENEFITS PACKAGI
* 01/10 9.84 C 46,730.7:
I-GEN102011000004287 INTEREST PAYMENT
PF: 4-TOP 5-BOTTOM 6-INQ 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO 12-XTFD -STSM
Belgin Stubbs
Branch Service Manager
Camp Hill Shopping Mall Branch
7177612099T 7177612149F
belgi n.stubbs@pnc.com
)
0PNCBAN<
A member of The PNC Financial Servil.:es Group
140 Camp Hill Shopping Mall
Camp Hill Pennsylvania 17011
Date: 2/5/2002 Time: 12:14:43 PM
REV.1511EX+I1.97)
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GEORGE C. SHEAFFER
FILE NUMBER
21-01-1158
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Musselman Funeral Home and Cremation Services, Inc.
(see statement attached - balance of expense prepaid
prior to dea th) $438.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City State Zip
Yea~s) Commission Paid:
2. Attorney Fees (Samuel L. Andes) $1,000.00
3. Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees $125.00
5. Accountanfs Fees
6. Tax Return Preparer's Fees
7. Advertising:
Cumberland Law Journal $75.00
The Sentinel $84.11
TOTAL (Aiso enter on line 9, Recapitulation) $ 1,722.11
(If more space is needed, insert additional sheets of the same size)
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MusselmaJt1l
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Funeral Home
& Cremation
Services, Inc.
Established 1895
Brian C. Musselman, F.O.
Supervisor
William G. Pegan, F.O.
P.O. Box 137
324 Hummel Avenue
Lemoyne, PA 17043-0137
(717) 763-7440
Fax: 717-730.9798
www.musselmanfuneral.com
To Funeral Expenses of GEORGE C. SHEAFFER
Dec.14,2001
George C. Sheaffer, Jr.
5 Autumn Dr.
Dillsburg, PA 17019
FUR ITEMS PURCHASED, NOr COVERED IN ORIGINAL PRE-NEED CON'ffiAcr
Vase of flowers
Copies of death certificate
Lined urn vault
Minister's gratuity
Tip for honor guard
$53.00
10.00
400.00
50.00
25.00
'IaI'AL
$538.00
100.00
(Cumb. Co. veteran benefit)
SUB-'IaI'AL
1~ $438.00
n) Sbrt' 1
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FOR APPOINTMENT PHONE 717-763-7440
REV-15\2EX-(1-9l)
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SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
GIDRGE c. SHEAFFER
FILE NUMBER
21-01-1158
ESTATE OF
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1.
West Shore Emergency :1edica1 Services (ambulance bill)
2.
Connor Rich Ass=iates (medical bill)
$69.75
$123.34
$4.42
3.
Quantum Imaging (medical bill)
TOTAL (Also enler on line 10, Recapitulation) $197.51
(If more space is needed, insert additional sheets of the same size)
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INVOICE
INVOICE #: (
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WEST SHORE
503 North 21st Street. Camp Hill, PA 17011-2204
(717) 761-1038' 1-800-367-0512 (PA Only)
FEDERAL 10 1# 23-2463002
DATE: (
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PATIENT: ""HC,':,j:FE:F: ;'
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Bill TO:
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ACCOUNT#:
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POLICY NAME:
INS. #:
INS. #:
DATE OF SERVICE:
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PATIENT PICKED UP:
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PATIENT TAKEN TO:
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DESCRIPTION OF IllNESS/INJURY:
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DESCRIPTION
UNIT COST
QTY.
AMOUNT DUE
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COMMENTS:
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SUBTOTAL
CREDIT
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THANK YOU
TOTAL
i'~ MasterCard and ~I Visa Accepled
CONNER - RICH ASSOCIATES
INTERNAL MEDICINE
207 HOUSE AVENUE, SUITE 101
CAMP Hill, PENNSYLVANIA 17011
Billing Office 761-8345
Medical Office 761-8331
Statement Date
11/12/01
GEORGE SHEAFFER
340 N FRONT ST
LEMOYNE PA 17043
Account Number
29500
( 1)
Date Description Charge Credit
GEORGE SHEAFFER (29500.0)
10/01/01 CONSULTATION INITIAL INPAT 135.00
11/07/01 Ins Pmt-HGS ADMINISTRATOFS 80.66
11/07/01 Adjustment 34.18
10/02/01 SUBSEQUENT HOSPITAL DAY - 216.00
11/07/01 Ins Pmt-HGS ADMINISTRATOF S 133.20
11/07/01 Adjustment 49.50
10/05/01 SUBSEQUENT HOSPITAL DAY - 72.00
11/07/01 Ins Pmt-HGS ADMINISTRATOFS 44.40
11/07/01 Adjustment 16.50
10/06/01 SUBSEQUENT HOSPITAL DAY - 162.00
11/07/01 Ins Pmt-HGS ADMINISTRATO S 83.33
11/07/01 Adjustment 57.84
10/09/01 SUBSEQUENT HOSPITAL DAY - 144.00
11/07/01 Ins Pmt-HGS ADMINISTRATOIS 88.80
11/07/01 Adjustment 33.00
10/11/01 SUBSEQUENT HOSPITAL DAY - 100.00
11/07/01 Ins Pmt-HGS ADMINISTRATOIS 63.01
11/07/01 Adjustment 21.24
TOT) L FOR GEORC E SHEAFFER
pJ" 61'2
57 ~/
:J~
L'
IJrJ j
Total Due Current 31 - 60 Days 61 - 90 Days 91 -120 Days Over 120 Days
123.34 123.34 0.00 0.00 0.00 0.00
" /
Send Payment To
CONNER. RICH ASSOCIATES
207 HOUSE AVENUE, SUITE 101
CAMP Hill, PENNSYLVANIA 17011
Statement Date
11/12/01
Account Number
29500
Detach this stub and return with payment.
Balance Date
29500.0)
20.16 10/01/01
33.30 10/02/01
11.10 10/05/01
20.83 10/06/01
22.20 10/09/01
15.75 10/11/01
123.34
~...
Please
123.34 /L--, pay/his
~ amount!
QUESTIONS? Please Call:
E ACCOUNT BALANCE
4.42
Account Number:
Patient Name:
ServiceSlart:
SlalementDate:
17387226
SHEAFFER ,GEORGE C
08/21/01 Service End,
o 1 / 0 3 / 0 2 Last Statement Dale;
Page No.
.
09/10/01
1-877-254-9239
Contact:
ESTIMATED INSURANCE DUE
TOTAL PATIENT CREDITS
.00
ITRANS DATE
BALANCE
.00
8.00
12.00
35.00
4.00
15.00
61. 00
91.00
23.56-
61. 55-
44.95-
70.16-
19.89-
1.47-
08/21/01
08/21/01
08/21/01
08/21/01
08/21/01
08/21/01
08/21/01
10/08/01
10/08/01
10/11/01
10/11/01
11/08/01
01/02/02
DESCRIPTION
I
AMOUNT
PREVIOUS
URINARY LG BG MED
CATH FOLEY 5C20FR
CATH SET FOL 18FR
IRRIGATION SET
URIN DRAINSET
LEVEL II FC
ED LEVEL II PC
PA BS PYMT
PBS C/A HOSP
MEDI PYMT-HOSP OP
MEDI C/A HOSP-OP
AETNA PYMT
AETNA PYMT
MI0 MEDICARE
MI0 MEDICARE
MI0 MEDICARE
MI0 MEDICARE
Q38 AETNA
Q38 AETNA
O/P
O/P
O/P
O/P
[1:1 0 R HO SG 1 000032652 ACCOUNTBAI.ANCE I 4.42 I
THIS BILL REPRESENTS THE BALANCE NOT PAID BY YOUR INSURANCE
THIS IS NOW YOUR RESPONSIBILITY. PLEASE PAY PROMPTLY.
MI0 MEDICARE O/P .00 Q38 AETNA .00
PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID.
Until your insurance has paid, the PLEASE PAY THIS AMOUNT represents the balance we estimate you owe.
Any. ~~~~_n~~_'::!!:!E_~id by your insurance will be due from you... Thank you.
REV_1513EX+11971
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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)
1. George C. Sheaffer, Jr. Son 1/3
5 Autumn Drive
Di11sburg, PA 17019
2. Brenda Pyper Daughter 1/3
2851 Evans Road
Winston-SalEm, NC 27127
3. Michelle Tomalavage Daughter 1/3
401 East Main Street
Shirernanstown, PA 17011
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
1
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
GEDRGE C. SHEAFFER
FILE NUMBER
21-01-1158
ESTATE OF
(If more space is needed, insert additional sheets of the same size)
/?-c:JP-//
~ BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
SAMUEL LANDES
525 N 12TH ST
LEMOYNE
DATE
ESTATE OF
DATE OF DEATH
_,FILE NUMBER
'COUNTY
ACN
10-14-2002
SHEAFFER
11-09-2001
21 01-1158
CUMBERLAND
101
'*
REV-1541 EX AFP [01-02)
GEORGE
C
PA 17043
Amount Remitted
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 =iS4-j-Ex--AFP--foY:02Y-No7ficE--OF-INHEififANcE-TAjrAPPRA-isEMENT~--Ai:.i-oWAN-CE-(fR------------ -- ---
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF SHEAFFER GEORGE C FILE NO. 21 01-1158 ACN 101 DATE 10-14-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
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. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
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. Mortgages/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
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
47,014.57
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
1 J 722 . 11
197.51
(11)
(12)
(13)
(14)
NOTE:
.00
45,094.95
.00
.00
X 00 =
X 045 =
X 12 =
X 15 =
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
47,014.57
1.919 62
45,094.95
.00
45,094.95
(19)=
.00
2,029.27
.00
.00
2,029.27
.. . (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
09-09-2002 CDOO1600 .00 2,029.27
BALANCE OF UNPAID INTEREST/PENALTY AS OF 09-10-2002 TOTAL TAX CREDIT 2,029.27
BALANCE OF TAX DUE .00
INTEREST AND PEN. 10.32
TOTAL DUE 10.32
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
RESERVATION: Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMIN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.S.
Section 9140).
Oetach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side.
--Make check or money order payable to: REGISTER OF MILLS. AGENT
A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-13l3). Applications are available at the Office
of the Register of Wills, any of the 23 Revenue District Offices, or by calling the special 24-hour
answering service for forms ordering: 1-800-362-2050, services for taxpayers with special hearing and I or
speaking needs: 1-800-447-3020 (TT only).
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-150l) for an explanation of administratively correctable errors.
If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%) discount of
the tax paid is allowed.
The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (6%) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after
January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
1982 20% .000548 1992 9% .000247
1983 16% .000438 1993-1994 7% .000192
1984 11% .000301 1995-1998 9% .000247
1985 13% .000356 1999 n .000192
1986 10% .000274 2000 8% .000219
1987 9% .000247 2001 9% .000247
1988-1991 11Z .000301 2002 6% .000164
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NU"BER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REY-1541 EX AFP [0I-D21
SAMUEl LANDES
525 N 12TH ST
LEMOYNE
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
10-14-2002
SHEAFFER
1l-09-2001
21 01-115a
CUMBERLAND
101
GEORGE
C
PA 17043
Anount Renitted
--Di;~i~Xi:: ~~--i~ii"7nY':ill-:-aiii";'-.ij:;~:..ti';:3:..u:;ioD-i'';:iir"i:;'-:l!:Y::;'::-ri'n"iLi'Hi.tj;''~:=& i"i-,;.:;;j;;;;';:~:n:ii::------ ___ _:::-==--- .__
CUT ALONG THIS LINE
10. ]2
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
RETAIN LOWER PORTION FOR YOUR RECORDS ~
~
-~,~-,^---'.''''''~"-'''''''''''''~~'-~--'--
RESERVATION: Estates of decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ANDES SAMUEL L ESQUIRE
525 N 12TH STREET
LEMOYNE, PA 17043
n______ fold
ESTATE INFORMATION: SSN: 187-16-5409
FILE NUMBER: 2101-1158
DECEDENT NAME: SHEAFFER GEORGE C
DATE OF PAYMENT: 11/07/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 11/09/2001
NO. CD 001816
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $10.32
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: SAMUEL L ANDES ESQUIRE
CHECK# 4365
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$10.32
MARY C. LEWIS
REGISTER OF WILLS
I?-d,?_//
'v BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
'*
REY-liD? EX AFP (01-02>
SAMUEL LANDES
S2S N 12TH ST
LEMOYNE
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
12-03-2002
SHEAFFER
U-09-2001
21 01-US8
CUMBERLAND
101
GEORGE
C
PA 17{l~3
Allount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent.
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV: i6'ifj-Ex--AFP--foY--02y------...--zNirE'RITANcE--TAX--STAYEMENT-'ifF"-A'ifcouN-f--...---------------- _____
ESTATE OF SHEAFFER GEORGE C FILE NO.21 01-US8 ACN 101 DATE 12-03-2002
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: 10-14-2002
P R I NC I PAL TAX DUE: ...................................................................................................
.....................................................................................................................
2,029.27
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
09-09-2002 CDOO1600 .00 2,029.27
U-07-2002 CDOO1816 10.32- 10.32
TOTAL TAX CREDIT 2,029.27
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
II
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 MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
PAYMENT:
Detach the top portion of this Notice and sub.it with your pay.ent .ade payable to the name and address
printed on the reverse side.
If RESIDENT DECEDENT .ake check or money order payable to: REGISTER OF WILLS, AGENT.
If NON-RESIDENT DECEDENT .ake check or money order payable to: COMMONWEALTH OF PENNSYLVANIA.
REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, .ay be requested by completing an
"Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at
the Office of the Register of Wills, any of the 23 Revenue District Offices or from the Department's 24-hour
answering service for for.s ordering: 1-800-362-2050; services for taxpayers with special hearing and I or
speaking needs: 1-800-447-3020 (TT only).
REPLY TO:
Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, 8ureau
of Individual Taxes, ATTN: Post Assess.ent Review Unit, Dept. 280601, Harrisburg, PA 17128-0601, phone
(717J 787-6505.
DISCOUNT:
If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (570) discount
of the tax paid is allowed.
PENALTY:
The 1570 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period.
INTEREST:
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (670) percent per annum calculated at a dailY rate of .000164. All taxes which became delinquent on and after
January 1, 1982 will bear interest at a rate which will vary fro. calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are:
DailY Interest Factor
Year
Interest Rate
DailY Interest Factor
Year
Interest Rate
1982 2070 .000548 1992 970 .000247
1983 1670 .000438 1993-1994 n .000192
1984 1170 .000301 1995-1998 970 .000247
1985 1370 .000356 1999 n .000192
1986 1070 .000274 2000 870 .000219
1987 970 .000247 2001 970 .000247
1988-1991 1170 .000301 2002 670 .000164
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUKBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
IJ, /
L/JK
,,1
STATUS REPORT UNDER RULE 6.12
Name of Decedent: G-e..or~t C. Ske.o..ffir
Date of Death: Cf /Jovet'VI&fi( ZOO J
Will No.: Admin. No.: 21-01-1/58
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the
following with respect to completion of the administration ofthe 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 reasc;mably believes
that the administration will be complete:
---.
3. If the answer to No.1 is Yes, state the following:
a. Did the personal ~resentative file a final account with the Court?
Yes _ No ~
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the parties
in interest? Y es ~ No 0
c. Copies of receipts, releases, joinders and approval of formal or
informal accounts may be filed with the Clerk of the Orphans' Court
and may be attached to this report.
Date: 2.0 Odobv~~ Q ~
Si~ n n_
5~MV\EL L... A-IoJDES
Name
5 t.S N. 1<... 'f1o- .s-lvt e c+
LefV\oYNc. Pit n 0'13
Address
In 1'-1 $1>G.1
Telephone No.
Capacity: 0 Personal Representative
J3. Counsel for personal representative