HomeMy WebLinkAbout11-04-05
R;;V-1500 EX". ("0-00)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
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COUNTY CODE YEAR NUMBER
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Kirk
DATE OF DEATH (MM-DD-Year)
Ross R
DATE OF BIRTH (MM-DD-Year)
SOCIAL SECURITY NUMBER
1 76- 1 4 - 7 2 2 2
THIS RETURN MUST BE FILED IN 'DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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04/24/2005 12/09/1920
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST. AND MIDDLE INITIAL)
[Xl 1. Original Return
D 4. Limited Estate
[Xl 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 (dale of death prior to 12-13-82)
D 5. Federal Estate Tax Reiurn Required
8. Total Number of Safe~eposit Boxes
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D 11. Election to tax under $ec. 9113(A) (Attach Sch 0)
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THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE I ECTEO TO:
NAME COMPLETE MAILING ADDRESS
ROGER B. IRWIN, ESQUIRE 60 WEST POMFRET STREET
FIRM NAME (If Applicable) CARL ISLE PAl 7013
IRWIN & McKNIGHT
TELEPHONE NUMBER
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1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
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)
1
I
13,009.53
("
(8)
13,009.53
0.00 X _(15) 0.00
0.00 X _(16) 0.00
0.00 X .12 (17) 0.00
0.00 X .15 (18) 0.00
(19) 0.00
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)
9,724.63
28,068.74
(11)
(12)
(13)
37,793.37
-24,783.84
16. Amount of Line 14 taxable at lineal rate
(14)
-24,783.84
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
fiEV-1511' EX + (12-99)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Kirk
Ross
Debts of decedent must be reported on Schedule I.
R
1.
FILE NUMBER
05
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
0826
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Guss Funeral Home - Paid From Burial Fund at Juniata Valley Bank 8,143.14
2. Guss Funeral Home - Final Balance 262.49
3. Rice Memorial Works - Inscription 110.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name 01 Personal Representative (s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees Irwin & McKnight 750.00
3. Family Exemption: (II decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship 01 Claimant to Decedent
4. Probate Fees 79.00
5. Accountanfs Fees
6. Tax Return Preparer's Fees 350.00
7. Register of Wills - Filing Fee 30.00
TOTAL (Also enter on line 9, Recapitulation) $ I
9 724.63
(II more space is needed, insert additional sheets 01 the same size)
'REV-1512 EX + (6-98)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Kirk
Ross
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
R
Include unreimbursed medical expenses.
FILE NUMBER
1.
05
0826
ITEM VA UE AT DATE
NUMBER DESCRIPTION ::IF DEATH
1. Forest Park Health Center - Nursing 524.44
2. Cumberland-Goodwill Fire Rescue, Ambulance 96.75
3. Department of Public Welfare Claim 27,447.55
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TOTAL (Also enter on line 10, Recapitulation) $ I
I 28068.74
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (8-M\
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Kirk Ro!';!'; R 1 Ofi 082E
RELATIONSHIP TO DECEDENT M OUNT 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. Judith A. Rich Lineal 11/2 Remainder
20 Macintosh Drive
Newport, P A 17074 1112 Remainder
2. Edward R. Kirk Lineal
5531 Spring Road
Shermans Dale, PA 17090
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
.. ,
(If more space IS needed, Insert additional sheets of the same size)
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WILLIAM R. BUNT
ATTORNEY AT L.AW
109 5. CARLISLE 5T.
NEW BLOOMFIELD, PA.
17068
El (717) 582-8195
'." (7'7) 582-752'
LAST WILL AND TESTAMENT
OF
ROSS R. KIRK
I, ROSS R. KIRK, of Tuscarora Township, Juni ta County,
Pennsylvania, being of sound mind, memory and understa
hereby declare this to be my Last will and Testament, revoking
all former wills or writings in the nature thereof and ny
codicils thereto made.
FIRST:
I direct my hereinafter named Co-Exe
pay all of my just debts, funeral expenses, costs of
administration and inheritance taxes out of the corpus
estate as soon after my decease as is practicable to do
SECOND: I give, bequeath and devise all of m
wife, Catherine S. Kirk.
estate, real, personal and mixed and wheresoever situat , unto my
THIRD:
In the event that my wife, Catherine S. Kirk,
and devise all of my estate, real, personal and mixed a d
predeceases my decease, then and in that event, I give, bequeath
wheresoever situate, unto my two (2) children, Edward R Kirk and
Judith A. Rich, in equal shares, share and share alike.
In the event that either of my child en
predecease my decease, leaving a child or children to s~rvive the
Page 1 of 3 pages
WILLIAM R. BUNT
ATTORNEY AT LA.W
109 S. CARLISLE ST.
NEW BLOOMFIELD. PA.
17068
TEL. (7\7) 582-8195
F~x. (7\7\ 582-752\
II
same, then and in that event, I give, bequeath and dev'se the
share of said deceased child's share of my estate unto the child
or children of said deceased child, in equal shares, stare and
share alike.
In the event that either of my children
predecease my decease, failing to leave a child to sur~ive the
same, then and in that event, I give, bequeath and devise the
share of said deceased child's share of my estate unto my
remaining child surviving my decease.
FOURTH: Any person who shall have died within thirty
(30) days of my death, or under such circumstances that the order
of our deaths cannot be established by proof, shall be deemed to
have predeceased me.
FIFTH:
I name, constitute and appoint my tWD (2)
children, Edward R. Kirk and Judith A. Rich, as Co-Executors of
this my Last will and Testament.
My Co-Executors are hereby excused f~om the
posting of any bond or security notwithstanding any provisions of
the law to the contrary.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal to this my Last will and Testament this 13th day OF
September, 1993.
~~?^/'.-c.- rh"J ~i t(L (3EAL)
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Page 2 of 3 pages
WILLIAM R. BUNT
ATTORNEY AT LAW
109 S. CARLISLE ST.
NEW BL.OOMFIELD. PA.
17068
TEL. l717\ 582.-8195
F... 1717\ 582.-7521
signed, sealed, published and declared by the above
named Testator, as and for his Last will and Testament, in our
presence, who, in his presence, at his request and in the
presence of each other, have hereunto set our names as attesting
witnesses.
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THE JUNIA TA VALLEY BANK
'-)O.'-.!~I\~~r~ ACCOUNT #:
, BALANCE DOD:
ACCRUED INTEREST:
DOD VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
MIFFLlNTOWN PA 17059
c..htc"Gr~.G ACCOUNT #:
.J- BALANCE DOD:
ACCRUED INTEREST:
DOD VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP: '(J":,':;' K. \~,r
c~, :T (h A,
c ~., ACCOUNT #:
_.J BALANCE DOD:
ACCRUED INTEREST:
DOD VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
ACCOUNT #:
BALANCE 000:
ACCRUED INTEREST:
DOD VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
ACCOUNT #:
BALANCE 000:
ACCRUED INTEREST:
DOD VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
Decedent: I~csc) ~cl~~ l-<\\\~
Date of Death: A~ ~ d q , 8-CC' c",
SSN: \ ,-' L: - : <}.-).::j.
ACCOUNT #:
BALANCE 000:
ACCRUED INTEREST:
000 VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
ACCOUNT#:
BALANCE 000:
ACCRUED INTEREST:
000 VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
ACCOUNT #:
BALANCE 000:
ACCRUED INTEREST:
000 VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
ACCOUNT #:
BALANCE 000:
ACCRUED INTEREST:
000 VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
ACCOUNT #:
BALANCE 000:
ACCRUED INTEREST:
DaD VALUE:
INTEREST PAID YTD:
OPENING DATE:
MATURITY DATE:
OWNERSHIP:
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
September 30, 2005
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IRWIN & MCKNIGHT LAW OFFICES
ROGER B IRWIN ESQ
WEST POMFRET PROFESSIONAL BUILDING
60 WEST POMFRET STREET
CARLISLE PA 17013-3222
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Re: ROSS KIRK
CIS #: 900171621
SSN: 176-14-7222
Date of Death: 04/24/2005
Dear Mr. Irwin:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $27,447.55 against the above-mentioned estate. Thi
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.S. 1412, effective August 15, 1994, a
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 $21,730.94, was incurred
during the last six months of the decedent's life; therefore, it is a Clas 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 $5,716.61,
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,
)JIM/)"" a. ;JVd
Debra A. Wiest
TPL Program Investigator
717-772-6713
717-772-6553 FAX
Enclosure
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
September 29, 2005
STATEMENT OF CLAIM SUMMARY
Estate of KIRK, ROSS
900171 621
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
.00
5,662.82
53.79
.00
.00
20,609.52
1,121.42
.00
26,272.34
1,175.21
21,730.94
5,716.61
27,447.55
September 29, 2005
STATEMENT OF CLAIM
KIRK, ROSS
900 171 621
FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM RD
09/20/04 - 09/30/04 04/25/05 55051084084770001 1,695.98 1,206.88
DIAGNOSIS 1: 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 2989 PSYCHOSIS NOS
PROC CODE: 000000
10/01/04 - 10/31/04 04/25/05 55051084086560001 4,779.58 4,455.94
DIAGNOSIS 1: 2900 SEMLEDEMENTIAUNCOMP
DIAGNOSIS 2: 60000 ABORATION
PROC CODE: 000000
11/01/04 - 11/30/04 04/25/05 55051084086570001 4,625.40 4,293.96
DIAGNOSIS 1: 2900 SEMLEDEMENTIAUNCOMP
DIAGNOSIS 2: 60000 ABORATION
PROC CODE: 000000
12/01104 - 12/31/04 04/25/05 55051084086580001 4,779.58 4,455.94
DIAGNOSIS 1: 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 60000 ABORATION
PROC CODE: 000000
01/01/05 - 01/31/05 05/02/05 55051144581120001 4,779.58 4,339.68
DIAGNOSIS 1: 2900 SENILE DEMENTIA UNCOMP
DIAGNOSIS 2: 60000 ABORATION
PROC CODE: 000000
02/01/05 - 02/28/05 05/02/05 55051144581910001 4,317 .04 3,864.12
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 2989 PSYCHOSIS NOS
PROC CODE: 000000
03/01/05 - 03/31/05 05/02/05 55051144582630001 3,803.08 3,345.72
DIAGNOSIS 1: 3310 ALZHEIMER'S DISEASE
DIAGNOSIS 2: 2989 PSYCHOSIS NOS
PROC CODE: 000000
September 29, 2005
STATEMENT OF CLAIM
KIRK, ROSS
900 171 621
FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM RD
04101/05 - 04124/05
DIAGNOSIS 1: 8208
DIAGNOSIS 2: 2989
PROC CODE: 000000
05/16/05 20051304024540001
FX NECK OF FEMUR NOS-CL
PSYCHOSIS NOS
310.08
310.10
FOREST PARK HEALTH CENTER
03 100749488 0003
29,090.32
26,272.34
CONTINUING CARE RX
28 SOUTH SECOND STREET
September 29, 2005
STATEMENT OF CLAIM
KIRK, ROSS
900 171 621
09/20/04 - 09/20/04
DIAGNOSIS 1: 0
NDC CODE: 50458030250
09/20/04 - 09/20/04
DIAGNOSIS 1: 0
NDC CODE: 00078032644
09/20/04 - 09/20/04
DIAGNOSIS 1: 0
NDC CODE: 51672129003
09/22/04 - 09/22/04
DIAGNOSIS 1: 0
NDC CODE: 50458030250
09/22104 - 09/22/04
DIAGNOSIS 1: 0
NDC CODE: 00078032644
09/22/04 - 09/22/04
DIAGNOSIS 1 : 0
NDC CODE: 00025152051
10/08/04 - 10/08/04
DIAGNOSIS 1: 0
NDC CODE: 50111085101
12/24/04 - 12/24/04
DIAGNOSIS 1: 0
NDC CODE: 00536199553
01/31/05
25050035543670001
6.94
6.94
RISPERDAL 0.5 MG TABLET . ATARACTICS-TRANQUILIZERS
01/31/05
25050035544450001
6.33
6.33
EXELON 6 MG CAPSULE - PARASYMPATHETIC AGENTS
01/31/05
25050035557640001
42.23
6.00
HYDROCORTISONE 0.2% CREAM . GLUCOCORTICOIDS
01/31/05
25050035545760001
106.57
8.71
RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
01/31/05
25050035547440001
173.06
11.10
EXELON 6 MG CAPSULE - PARASYMPATHETIC AGENTS
01/31/05
25050035551590001
60.46
8.71
CELEBREX 100 MG CAPSULE . ANTIARTHRITICS
01/31/05
25050035548970001
64.30
6.00
BENZONATATE 100 MG CAPSULE - COUGH PREPARATIONS/EXPECTORANTS
01/31/05
25050035555890001
3.80
3.80
SELENIUM SULFIDE 1% SHAMPOO - ALL OTHER DERMATOLOGICALS
CONTINUING CARE RX
28 SOUTH SECOND STREET
September 29, 2005
STATEMENT OF CLAIM
KIRK, ROSS
900 171 621
01/17/05 - 01/17/05
DIAGNOSIS 1: 0
NDC CODE: 00078032644
01/20/05 . 01/20/05
DIAGNOSIS 1: 0
NDC CODE: 50458030250
01/20/05 - 01/20/05
DIAGNOSIS 1: 0
NDC CODE: 00078032644
01/20/05 . 01/20/05
DIAGNOSIS 1: 0
NDC CODE: 00025152051
02/19/05 . 02119/05
DIAGNOSIS 1: 0
NDC CODE: 50458030250
02/19/05 - 02119/05
DIAGNOSIS 1: 0
NDC CODE: 00078032644
02/19/05 . 02119/05
DIAGNOSIS 1: 0
NDC CODE: 00025152051
03/21/05 - 03/21/05
DIAGNOSIS 1: 0
NDC CODE: 00025152051
02114/05
25050175878560001
6.59
6.49
EXELON 6 MG CAPSULE - PARASYMPATHETIC AGENTS
02114/05
25050215611030001
103.16
99.20
RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
02114/05
25050215611050001
159.66
149.45
EXELON 6 MG CAPSULE . PARASYMPATHETIC AGENTS
02/14/05
25050215611070001
57.83
53.21
CELEBREX 100 MG CAPSULE - ANTIARTHRITICS
03/21/05
25050525745090001
103.16
99.20
RISPERDAL 0.5 MG TABLET - ATARACTICS.TRANQUILlZERS
03/21/05
25050525745120001
159.66
153.45
EXELON 6 MG CAPSULE . PARASYMPATHETIC AGENTS
03/21/05
25050525745170001
57.83
55.67
CELEBREX 100 MG CAPSULE . ANTIARTHRITICS
04/18/05
25050815648240001
57.83
55.67
CELEBREX 100 MG CAPSULE - ANTIARTHRITICS
II
September 29, 2005
STATEMENT OF CLAIM
KIRK, ROSS
900 171 621
CONTINUING CARE RX
28 SOUTH SECOND STREET
03/21/05 - 03/21/05
DIAGNOSIS 1: 0
04/18/05
25050815648280001
103.16
99.20
NDC CODE: 50458030250
RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
03/21/05 - 03/21/05
DIAGNOSIS 1: 0
04/18/05
25050815648310001
159.66
153.45
NDC CODE: 00078032644
EXELON 6 MG CAPSULE - PARASYMPATHETIC AGENTS
04101/05 - 04101/05
DIAGNOSIS 1: 0
04/25/05
25050915503130001
115.82
107.35
NDC CODE: 00025152551
CELEBREX 200 MG CAPSULE - ANTIARTHRITICS
04/01/05 - 04/01/05
DIAGNOSIS 1: 0
04/25/05
25050915505140001
70.76
64.09
NDC CODE: 50458030050
RISPERDAL 1 MG TABLET - ATARACTICS-TRANQUILIZERS
04/07/05 - 04107/05
DIAGNOSIS 1: 0
05/02/05
25050975849990001
35.71
21.19
NDC CODE: 57664049918
MIRTAZAPINE 15 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
CONTINUING CARE RX
24 100731447 0011
1,654.52
1,175.21
II
COMMONWEALTH OF PENNSYL VANIA
: SS
COUNTY OF CUMBERLAND
Judith A. Rich and Edward R. Kirk, being duly sworn according to law, deposes and says that they are the Co-Executod of
,
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the Estate of
Ross R. Kirk
, late of Carlisle Borough
, Cumberland County,
Pennsylvania, deceased and that the within is an inventory made by Judith A. Rich and Edward R. Kirk, the said Co-Exe utors of the
entire estate of said decedent, consisting of all the personal property and real estate, except real estate outside the Co rom nwealth
of Pennsylvania, and that the figures opposite each item ofthe Inventory represent it's fair value as of the date of decede t's death,
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COMMONWEALTH OF PENNS
November, 2005
/
20 Macintosh Drive
Sworn and subscribed before me,
t
4{T
this~ ' day of
Newport. PA 17074
Address
:VANIA
~~/ /&:A,
Edward R. Kirk, Co-Executor
Notarial Seal
Karen S. Noel, Notary PubIk
Carlisle Boro, Cumberland County
My Corrunission Expires Dec. 8 2007
'~.---....._", ,.
5531 Spring Road
Shermans Dale, PAl 7090
Address
Date of Death
24
Day
04
Month
2005
Year
,., "
INSTRUCTIONS
1. An inventory must be filed within three months after appointment of personal representative.
2. A supplement inventory must be filed within thirty days of discovery of additional assets.
3. Additional sheets may be attached as to personalty or realty.
4. See Article IV, Fiduciaries Act of 1949.
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Inventory of the real an personal estate of
ROSS R. KIRK
, deceased
1. Juniata Valley Bank - Savings Account $1,953.73
2. Juniata Valley Bank - Checking Account $2,456.19
3. Juniata Valley Bank - Irrevocable Burial Fund $8,143.14
4. Insurance Premium - Refund $350.00
5. Continuing Care - Refund $87.50
6. Valley Rural. Refund $1.00
7. Valley Rural- Dividend Income $17.97
TOTAL $13,009.53