HomeMy WebLinkAbout08-23-05
Rr~.1500 EX (6--00) .,.
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
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FILE NUMBER
21 05
INHERITANCE TAX RETURN
RESIDENT DECEDENT
NUMBER
0457
COUNTY CODE YEAR
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Jumper, Erma, F.
DATE OF DEATH (MM-DD-YEAR)
11/26/2004
SOCIAL SECURITY NUMBER
182-36-8864
DATE OF BIRTH (MM-DD-YEAR)
03/06/1912
THIS RETURN MUST BE FilED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
N/A
~ 1. Original Return
D 4. Limited Estate
~ 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy of Trust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
D 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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COMPLETE MAILING ADDRESS
Jacqueline M. Verney, Esquire
44 South Hanover Street
Carlisle, PA 17013
NAME
Jacqueline M. Verney, Esquire
FIRM NAME (If Applicable)
Law Office of Jacqueline M. Verney
TELEPHONE NUMBER
(717) 243-9190
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
14,243.16
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4, Mortgages & Notes Receivable (Schedule 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)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
10,269.25
3,973.91
0.00
(6)
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(7)
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14,243.16
(9)
(10)
(8)
9,393.25
876.00
(11)
(12)
(13)
14. Net Value Subject to Tax (line 12 minus line 13)
(14)
3,973.91
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)
x .0 (15)
3,973.91 X.o 45 (16)
178.82
16. Amount of Line 14 taxable at lineal rate
17. Amount of line 14 taxable at sibling rate
x .12 (17)
18. Amount of line 14 taxable at collateral rate
x .15 (18)
19. Tax Due
(19)
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS
8 Bloserville Road
CITY C I' I I STATEpA I ZIP 17013
arls e,
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
178.82
0.00
0.00
0.00
Total Credits (A + B + C ) (2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( 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)
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
178.82
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
178.82
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 ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~
c. retain a reversionary interest; or.......................................................................................................................... 0 ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [iJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 ~
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 pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
DATE 1/f;23joS-
DATE
J-23-oS-
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
The statute does not exemDt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of as
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 a stepparent of the child is 0% [72 P.S. 99116(a){1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as n
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116{a)
individual who has at least one parent in common with the decedent, whether by blood or adoption.
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REV-1502 EX+ (6-9*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
Jumper, Erma F.
FILE NUMBER
21-05-0457
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
1/3 Tenant in common 8 Bloserville Road, Newville, PA 17241
VALUE AT DATE
OF DEATH
14,243.16
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
14,243.16
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HUD - I UNIFORM SETILEMENT STATEMENT
OMB Approval No. 2502-0265
A. U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT SElTLEMENT STATEMENT
B. TYPE OF LOAN 6. File Number: 7. Loan Number:
1. X FHA 2. FmHA
3. Conv. Unins. 4. VA 5. Conv. Ins. 8. Mortgage Insurance Case Number
C. NOTE: This fonn is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "(p.o.c.)"
were paid outside the closing; they are shown here for informational purposes and are not included in the totals.
NOTE: TIN - Taxnaver's Identification Number
D. NAME AND ADDRESS OF BORROWER: E. NAME, ADDRESS AND TIN OF SELLER: F. NAME AND ADDRESS OF LENDER:
Scot Hench Donald F. Jumper nla
Estate of Erma F. Jumper
251 Sheaffer Road 12 Springfield Avenue
Carlisle, , PA 17013 Newville, Fa 17241
G. PROPERTY LOCATION: H. SETILEMENT AGENT NAME, ADDRESS AND TIN
8 Bloserville Road Jacqueline M. Verney, Esq
Carlisle, Pa 17013 44 South Hanover St. Carlisle PA 17013
PLACE OF SETTLEMENT 1. SETILEMENT DATE
44 South Hanover Street 05/20/2005
Carlisle. PA. 17013
J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION
100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER:
101. Contract sales orice 43.000.00 40 I. Contract sales nrice 43 000.00
102. Personal Drooertv 402. Personal nronertV
103. Settlement chan!es to borrower lLine 14(0) 868.50 403.
104. 404.
105. 405.
Adiustments for items oaid hv seller in advance Adiustments for items oaid bv seller in advance
106. City/town taxes 406. CitV/town taxes
107. County taxes OS/20/2005-12/31/2005 128.40 407. Countv taxes OS/2072005-1iT3fT2005 128.40
108. Assessments 408. Assessments
109. 409.
110. School Tax OS/20/05-06/30105 137.08 410. School Tax OS/20/05-06/30/05 137.08
Ill. - 411.
112. 412.
120. GROSS AMOUNT DUE FROM BORROWER 44.133.98 420. GROSS AMOUNT DUE TO SELLER 43.265.48
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER:
20 I. Deoosit or earnest moneY 501. Excess denMit
202. Princinal amount of new loan/s) 502. Settlement charoes to seller (Line 1400) 536.00
203. ExistiOl! 108Ols) taken subiect to 503. Existim! loanl s) taken subiect to
204. 504. Payoff of first mortOllJle loan
205. 505. Pavoff of second mortl!lli!e loan
206. 506.
207. 507.
208. 508.
209. 509.
Adiustments for items unDaid bv seller Adiustments for items unnaid bv seller
210. City/town taxes 510. City/town taxes
211. County taxes 511. Coun~ taxes
212. Assessments 512. Assessments
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. TOT AI. PAID BY /FOR BORROWER 520. TOT AI. REDUCTION AMOUNT DUE SELLER 536.00
300. CASH AT SETTLEMENT FROMffO BORROWER 600. CASH AT SETTLEMENT FROMfTO SELLER
30 I. Gross amount due from borrower lLine 120) I 44 133.98 60 I. Gross amount due to sellei7Line 420\ I 43 265.48
302. Less amount naid bv/for borrower I Line 220) I 602. Less reduction in amount due seller (Line 520\ I 536.00
303. CASH FROM BORROWER I 44.133.98 603. CASH TO SELLER I 42 729.48
SELLER'S STATEMENT
The infonnation contained in Blocks E, G. H, and I and on line 401 (or. ifline 401 is asterisked.line 403 and 404) is important ta.... information and is being furnished to the
Internal Revenue Service (see Seller Certification). If you are required to file a return. a negligence peoaIty or- other saoctioo will be imposed 011)'011 ifdUs iIcm is mquin:d
to be reported and the IRS detennines that it has oot been reported. You are required to provide the Sdllement Agent with your correct ~ idbitdJeaboo 1IIIIDber. If you
do DOt provide die ~ AgaIl wiIb)1lUr correct taxpayer idcatificalioa 1IIIIDber, you may be subject to ciVIl or criminal penalties imposed by law. Unda penalties of
peJjwy, I certify that the number shown 00 this statement is my correct ta.xpayer identifICation number.
(Seller's Signature)
Donald F. Jumper
(Sella's SigpaIure)
Estate of Erma F. Jumper
'!-) EASY SOFT, Inc. 2001 Previous editions are obsolete
Page I
fonn HUD-I (3/86) ref Handbook 4305.2
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L. SETTLEMENT CHARGES
700. TOTAL SALESlBROKER's COMMISSION based on nriu S 43 . 000 . 00 @ PAID FROM PAID FROM
Division of Comrnission(line 700) as follows: BORROWER'S SELLER'S
701. ~ FUNDS AT FUNDS AT
702.~ SETTLEMENT SETTLEMENT
703. Commission nAid at Settlement
704.
800. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Oriaination Fee S
802. Loan Discount S
803. Annraisal Fee to
804. Credit rennrt to
805. Lender's Insnection Fee
806.
807.
808.
809.
810.
81!.
812.
813.
900. ITEMS REOUIRED BY LENDER TO BE PAID IN ADVANCE
90 I. Interest from
902. Mort<!alle Insurance Premium for
903. Hazard insurance Premium for
904.
905.
1000. RESERVES DEPOSITED WITH LENDER
100 1. Hazard insurance
1002. Mortl!a"e insurance
1003. City Pro"..rtv Taxes
1004. County Pronertv Taxes
1005. Annual assessments
1006.
1007.
1008. Allllrellate Accountino Adiustrnent
1l00. TITLE CHARGES
1101. Settlement or c10sina fee to Jacmlel ine M. Verney Esauire 250.00
1102. Abstract or title search to Karen Coon 150.00
1103. Title Examination to
1104. Title insurance binder to
1105. Document nre"""'tion to
1106. Notarv fees to Cash 6.00
1107. Attomev's fees to Jacnuel ine M. Verney Esnuire 100.00
(includes line numbers: Deed nreoaration
1108. Title Insurance to I
(includes line numbers:
1109. Lender'scoveral!e $
1110.~er'scoveral!e $ 0.00
I Ill.
1112.
II 13.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recordinl! fees: Deed $ 38.50 Mortllal!e $ Release $ 38.50
1202. Citv/cntv tax/stamns: Deed $ 430.00 Mortlla"e $ 430.00
1203. State tax/stamos: Deed t 430.00 Mortl!al!e $ 430.00
1204.
1205.
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Survey to
1302. Pest insoection to
1303.
1304.
\305.
1306.
1400. TOTAL SETTLEMENT CHARGES (enter on lines 103. Section J and 502 Section K) 868.50 536.00
CEKnHCA TIOHo I h~ ~oful~ =.."' fu, HUD-I S""""",, S"",""" "'" 10 "" ... of.., know"''' oo~ ;,. ""'~' of.' -"" "'"
disburs~ ade o~ 7C~Y me' iliis transaction. I further certify iliat I received a copy of the HUD-I S menl Statement.
Pl/:/l.P. I~~" 'III/I~).// ~...LLP-- /~ .--
Seller V r, I Donald F. Jt:1frrper'l Borrow/ Scot HEtRth -.,
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Seller Estate 0 Erma F. Jumper Borrower
The HUD-I Settlement Statement which I have prepared is a true and accurate account of the funds disbursed or to be disbursed by the undersigned as part of the settlement of
this nsaction. I J. J /
M. V,( OS/20/2005
S leme J\gent Jacqueline M. Ve ey I Esq Dale
WARN : It is a crime to knowingly make false statements to the United Stales on this or any other similar form. Penalties upon conviction can include a fine and
imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010.
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'enn.ylvAllia, bounded and de.cnbed purauant to a .Urfty ~ Th... A.
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IEGINtlING at a point in Stat. Hilhva, Route No. 6..1l at eon\er
of land now Or fOl"lll8rly of Diller 10 Latlllan; thaftOe ia .. 4 Il.Md, South
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or fo",er1y of f4aynar'd ".ary, North S2 d..grees liS l\\{nvtee w...t 279.95
tut to a atelte; thence by brll' bl!i~ retairad by the CJ-lInters, North
S9 ch!1.n:e. 119 .ll\ute. E..t 2At6.62 f..t to . point 11\ the canter of L. R.
21035; thence by the center of .aid Road, South S3 dagree. 20 minute.
1:...t 168.60 feet to a point; thence by lend n_ D1" fon.r1y of DiUer
I, LeMen, Saut" 5 dagr... 00 .ain~.. ENt 57.60 re.t to .. point; theftCII
by the .IIlIIe, South 33 cleSfte. 00 l\\iftute. E..t 62.00 f_t to the Place
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t1~fta therein ..t: forth except .. lIIOCIitied ..,. i:"'~Ilt: 'ata' JamaJ!7'
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REV-1511 EX+ (12-99)W
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Jumper, Erma F.
FILE NUMBER
21-05-0457
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Ewing Brothers Funeral Home, Inc 630 S. Hanover St. Carlisle, PA
7,869.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) Donald F. Jumper
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address 12 Springfield Ave
1,000.00
City Newville
,State Pa
Zip 17241
Year(s) Commission Paid:
2.
Attomey Fees
250.00
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
150.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Advertise letters a. Cumb Law Journal-$75.00; b. Valley Times-Star-$49.25
124.25
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
9,393.25
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can.
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff. . . . . . . . . .
FUNERAL HOME SERVICE CHARGES ()' m m
SELECTED MERCHANDISE: ~ ~ ~.
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20G Jupiter Gold Gasketed Casket. . . . . . .~ ~ CQ . . . . . . .
. roOro
#5 Regular Sealed Vault. . . . . . . . . .- . S. -r . . . . . . .
THE COST OF OUR SERVICES, EQU1PiEp;;rt,SlND MERCHANDISE
THAT YOU HAVE SELECTED . . ".;!; ~. . . . . . .
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Cash Advances ...... :::T CIl
Opening Grave. . . . . . . . . .~ SQ 61
ClergyiMass Offering, . . . . . . . w. m. ~
Certified Copies of the Death Certificate. . "'"': m
Flowers. . . :I:
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Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
(717)243-2421
December I, 2004
Donald F. Jumper
12 Springfield Ave.
Newville, P A 17241
The Funeral Service for Erma F. Jumper
Satin Pillow
Rock Charge
TOTAL CASH ADVANCES AND SPECIAL CHARGES .
Total
Total Cost.
. . . . . . . . . . . . . . . . . . . .
SUB-TOTAL
IT../ITIAL PAYMENT I DISCOUNT I CREDITS
TOTAL AMOUNT DUE
The unpaid balance over 45 days is subjected to a 1.00 % service charge per month - 12.0000 % per annum.
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$26.50
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$1429.00
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CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, P A 17013
June 10, 2005
Cumberland Law Journal is published every Friday by the Cumberland County Bar
Association and is designated by the Court of Common Pleas as the official legal publication for
Cumberland County and the legal newspaper for publication of legal notices.
TO:
Jacqueline M. Verney, ESQUIRE
RE:
Erma F. Jumper, 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:
May 27, June 3, 10,2005
Advertising Cost
$ 75.00
Proof of Publication
$ 0.00
Second Proof Request
$ 0.00
Payment Received
$ 75.00
Total Amount Due
$
0.00
---------
---------
Payment received May 24. 2005
by Becky H. Morgenthal/Executive Director
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16,1929), P. L.1784
COMMONWEAL TH OF PENNSYL VANIA
ss.
COUNTY OF CUMBERLAND
Lisa Marie 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
issued 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
Journal on the following dates,
VIZ:
May 27, June 3, 10,2005
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
Jumper. Erma F., dec'd.
Late of West Pennsboro Town-
ship.
Executor: Donald F. Jumper, c/o
Jacqueline M. Vemey, Esquire, 44
South Hanover Street, Carlisle,
PA 17013.
Attomey: Jacqueline M. Verney,
Esquire, 44 South Hanover Street,
Carlisle, PA 17013.
SWO TO AND SUBSCRIBED before me this
10 day of June
NOTARI SEAL
LOIS E. SNYDER, Notary Public
Carlisle 8oro, Cumbertand County
My Commission Expires March 5, 2009
REV-1512 EX+ (12-03)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Jumper, Erma F.
FILE NUMBER
21-05-0457
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.
Carlisle Regional Hospital P.O. Box 4100 Carlisle, PA 17013 hospital charges
876.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
876.00
J~L-ll-l~~)li~E) ~~:11 ~HOEMAKER~ 1~~,A~E~n
(fA~)1 111 lib 4)l~
~,f .2 '! 3- 91 <1 ~
fr' tt r;
(~!~J~/6
PATIENT ACCOUNT STATEMENT
/.- ",,~.. n I Irt r
~ j~
~I; ,I REGIONAL P.O.8oIl41oo
~ t DIe ^ L C f ~ T &l II. Cllfllele. PA 1101304100
ADDRESS SEKYICE REaUESTED
~, ~~l/~~l
.17152 UIIICA liMn.
'" 'AVIIO .,. CfWlIf CARO.1'lt.L our .a.ow ANO .1 IIEYER1l! lilDE
01 CAAO U81NO FO" ~'l'MENT
~c .0 ~l 0 ilO?~O
..... ~ IIlSCIWl'l 1__ VISA ~~ MIPltAN IlQ'IUI
ACCOUNT NO. srA1DII!JI'r MTI BAUMel DUE
-
~
04/11/2005 I
t876.0
92'6051 04/04/200
MAKE CHECKS PAYABLE TO:
JUMPER. ERUA F
12 SPRlNGFtELD AVE
: NEWVILLE PA 17241
CIoI
CAAUSLE REGIONAL MeDICAL CENTER
24& PARKER ST.
P.O. BOX 4100
CARUSLE PA 1m3-4100
IH.III...UI.n...II..II.n...I.I..II......lnlnJI...I..I.1
11I.1II11.1..I.IJIII...II,..IIIIJI..,.II.,',,".II,J.'...'"
'IQ INSURE l'AopeR CREDIT. DaI,Ct rAM) ReT\JIVI ffllS PORTiON IN 114E ENClOSED l:NVE1.OPE.
- q r:!~!.:!,!C!'_i~~U_~~!!..'!_~_".!~.!.~2?lk"~"_~~"V" ~n.~~ $icle.
-JUMPER, ErmA F
DATE
OF
92'60S1 11/D4/201 INPATIENT
DESCRIPTION
11/30/04
12/D2/04
12102/04
12/02/04
12/0Z/04
MEDICARE CDNTRACTUAl ADJUSTMENT
MEDICARE CONTRACTUAL ADJUSTMENT
MEDICARE CONTRACTUAL ADJUSTMENT
MEDICARE PAYMENl
_ICARE rA~T() ~. Zr
,. ~l
r
/" .
/~ V' )
~/1 ;Z4 3 -] f{"/ ~
TAL
1O~a86.58
PArMBtTlAD.IUSlMENTS
1~a52.32
1..052.$2-
924.07
la~134.'5
10,134. '5-
REV-1513 EX+ (g.OO)
'*'
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Jumper, Erma F.
FILE NUMBER
21-05-0457
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 (a) (1.2)]
1. Robert L. Jumper, 240 Wertz Run Road, Carlisle, PA 17013 son 50%
2. Donald F. Jumper, 12 Springfield Ave, Newville, PA 17241 son 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 additional sheets of the same size)
I" \
~
LAW OFFICES OF
~TEPHEN J. HOGG
1<) S HANOVER STREET
SUITE 101
CARLISLE, PA 17013
WILL OF
ERMA F. JUMPER
I, Erma F. Jumper, of Carlisle, Cumberland County,
Pennsylvania, declare this to be my last Will and hereby revoke all
prior Wills and Codicils.
1. I direct that all my just debts, funeral expenses,
gravemarker and administrative expenses shall be paid
from my residuary estate as soon as practicable after my
death.
2. I direct that all inheritance, estate, transfer, succession
and death taxes of any kind whatsoever which may be
payable by reason of my death shall be paid out of my
residuary estate.
3. .\ direct that my entire estate be distributed as follows:
A. I leave everything to be divided in equal shares to
my sons, Donald F. Jumper and Robert L. Jumper.
Should either of my sons predecease me, their
share shall go to the survivor.
4. I appoint Donald F. Jumper as Executor of this my last
Will. If he should predecease me or cease to act in such
capacity, I appoint Robert L. Jumper as alternate.
5. The Executor of this Will shall have the power to
distribute my estate in kind or in cash, or partly in either.
6. I direct that no Executor acting under this Will shall be
required to enter bond in any jurisdiction.
IN WI~SS WHER~ I have hereunto set my hand this le'day
of "l/C(~1?1. ' 2004.
. . ;' r,
. '. ~ "'- .:~_/ ._- i~. ~.-
i. ..:. J I /vI..."'" \,. ;;::,..../...\j
Erma F. Jumpe{j ~
. "
LAW OFFICES OF
;TEPHEN J. HOGG
I') S. HANOVER STREET
SUITE 101
CARLISLE. PA \70\3
The preceding instrument consisting of this and one other page
was on the day and date hereof signed, published and declared by
Erma F. Jumper, as and for her last Will in the presence of us, who at
her request, in her presence and in the presence of each other have
subscribed our names as witnesses hereto.
/)~ ~~
Li :)
fTTNESS \
~l(~. I[.J,~; A~. '}LLJ)~ d c,---"
WITNESS v /
..
LAW OffiCES OF
,TEPHEN J. HOGG
Il) S. JlA NOVER STREET
SUITE 101
CARLISLE, PA 17013
ACKNOWLEDGMENT
State of Pennsylvania
ss
County of Cumberland
I, Erma F. Jumper, the 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 as my free and
voluntary act for the purposes therein expressed.
I.... " .,J
(.' )~_...J. ~ I
Erma F. Jumper
(
, .
) "::.j) .~- /
J / ,
-" ":. 1."''''-
Sworn to or affirmed and acknowledgectPe!9re me by ~r;na F.
Jumper, the testatrix, this / (; day of / V C.jAf.//c(d/] ,
( .,&
2004. / 4
, '~-"t; { i7;/-~
NOTARIA1. SEAL. I C7 (.
STEPHENJ.HOGG,NOTARYPUtll." ~ Notar'y' Public/Attorn
CARUSLE BORO. CUMBERLAND CC"1i (l
MY COMMISSION EXPIRES SEPn:M82A J. 2fjll5 ~,
~AFFIDAVIT
State of Pennsylvania
ss
County of Cumberland
Jfrc..t D eo. ;,l~ "r, \ f! '\
We, and ....1 (c 11/1(, - ~ l.;""" F'*), the
witnesses whose names e signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and say
that we were present and saw the testatrix sign and execute the
instrument as her last Will; that the testatrix signed willingly and
executed it as her free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of
the testatrix signed the Will as a witness; 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.
rJ/l() ~
I
..
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v.. .J. .
. ;~( C<c )L- > 1<, /(. ?; <--7 "j'L..L'-'
,.,. ,;~\;'-"lr.':7'l.L:,.;,j~..i:"l:..;:)!
NOTARIAL SEAL. ~
STEPHEN J. HOGG. NOTARY PLJ8U" ,'1
CARLISLE BORO. CUMBERI-AMO CO. p,~ ~
Y COMMISSION eXPIRES SEPTl::M9cflJ, 21:'\15 11
~