HomeMy WebLinkAbout11-17-06
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Rev.1500 EX + (6-00)
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OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUM~ER
II 06
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
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DECEDENrs NAME (LAST. FIRST. AND MIDDLE INITIAL)
Jumper, Ray K
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
204-30-6650
0772
NUMBER
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
~8-20-2006 09-02-1931
I (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST. FIRST AND MIDDLt: INITIAL)
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~ 1. Original Return
o 4. Limited Estate
I~ 6. Decedent Died Testate (Attach
'- copy of Will)
D 9. Litigation Proceeds Received
4a. Future Intere! I Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10 Spousal between
. 12-31-91
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
2. Supplemental Return
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NAME
Richard L Webber, Jr., Esquire
FIRM NAME (If applicable)
Weigle & Associates, P.C.
TELEPHONE NUMBER
717 -532-7388
COMPLETE MAILING ADDRESS
126 East King Street
Shippensburg, PA 17257
OFFICIA~SE ONLY
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(11 ) 8,925.15
(12) 57,830.44
(13) 0.00
(14) 57,830.44
-----_.~-
X .00 (15) 0.00
~------------
x .045 (16) 0.00
_.~---- --
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)
z 6. Jointly Owned Property (Schedule F) (6)
0 D Separate Billing Requested
i=
~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
:::) (Schedule G or L) D Separate Billing Requested
to-
n: 8. Total Gross Assets (total Lines 1-7)
oc(
u 9. Funeral Expenses & Administrative Costs (Schedule H) (9)
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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)
None
30.00
None
None
66,725.59
None
None
7,594.90
1,330.25
(8)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
66,755.59
0.00
8,674.57
8,674.57
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)
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15. Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
0.00
16. Amount of Line 14 taxable at lineal rate
0.00
17. Amount of Line 14 taxable at sibling rate
0.00
57,830.44
x .12 (17)
x .15 (18)
(19)
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2002 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00;
.
,
.' Decedent's Complete Address:
STREET ADDRESS
3157 Ritner Highway Newville, Pennsylvania 17241
CITY Newville
-I STATE PA
I ZIP 17241
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
8,674.57
8,240.84
433.73
Total Credits (A + B + C)
(2)
8,674.57
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + E)
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
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5) 0.00
(SA)
(58) 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: 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 ~
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 dedare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and
complete. Dedaretion of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Ruth Jumper
-^~
DATE
181 Crossroad School Road
Newville, PA 17241
If (, r( 06
ADDRESS
DATE
303 Harvest Lane
Shippensburg, PA 17257
) dls!;?/'
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS DATE
Richard L r'ebber, Jr., Esquire 126 East King Street /
~ rz. L----\ ~ Shippensburg, PA 17257 ,,/ C I () "
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 value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not 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 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.
, .
. '
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Jumper, Ray K 21-06-0772
Under penalties of perjury, 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.
Signature #3
--e
JoannFinkey n"Q J\ f\(} ~nt~
36 Maple Avenue ~
Name
Address1
Address2
City, State, Zip
Walnut Bottom, PA 17266
Date
1(((>lr)~
"
" Rev-1503 EX+ (6-98)
*
SCHEDULE B
STOCKS & BONDS
cot/MONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Jumper, Ray K
FILE NUMBER
21-06-0772
ESTATE OF
All property Jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 Cumberland Valley Cooperataive Association - 30.00
Common Stock - 3 shares @$10.00/Share
TOTAL (Also enter on Line 2, Recapitulation) 30.00
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA-1500 Schedule B (Rev. 6-98)
.' Rev.15G8 EX+ (6-98)
*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Jumper, Ray K
FILE NUMBER
21-06-0772
ESTATE OF
Include the proceeds of litigation and the date the proceeds were receiVed by the estate.
All property Jolntly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 1995 Dodge Van Motor Vehicle - VIN 2B4GH2533SR402901 2,800.00
2 Carlisle Propane - Refund 28.15
3 M&T Bank Checking Account #15004201618509 60.276.51
Accrued interest on Item 3 through date of death 7.43
4 Personal Property - Gross proceeds from public sale 3,433.00
5 Refund - Miscellaneous 113.00
6 The Sentinel - Subscription Refund 67.50
TOTAL (Also enter on Line 5, Recapitulation)
66.725.59
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule E (Rev. 6-98)
. . REV-1151 EX+ (12.99)
*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Jumper, Ray K
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-06-0772
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 2,390.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State Zip
-
Year(s) Commission paid
2. Attorney's Fees Weigle & Associates, P .C. 3,334.78
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 185.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 1,685.12
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 7,594.90
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
.' Rev-1502 EX+ (6-98)
*
SCHEDULE H-A
FUNERAL EXPENSES
continued
Cot./MONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Jumper, Ray K
IFILE NUMBER
21-06-0772
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Cumberland Valley Memorial Gardens - Tombstone and engraving
1,990.00
2
Ewing Brothers
400.00
Subtotal
2,390.00
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
.' Rev-1502 EX+ (6-98)
*
SCHEDULE H.87
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Jumper, Ray K
FILE NUMBER
21-06-0772
ESTATE OF
ITEM AMOUNT
NUMBER DESCRIPTION
1 Chamberlin-Wingert - toilet for public sale 75.00
2 Cumberland County Register of Wills - Short Certificates 8.00
3 Cumberland County Register of Wills - Filing fee for Inheritance Tax Return 15.00
4 Cumberland Law Journal - Legal advertisement 75.00
5 Food Expenses for laborers at public sale 26.25
6 Gasoline Expense - Van 50.00
7 Gerald M. Neal, Auctioneer - Commission for public sale 411.96
8 Janet Nimmon - Labor at public sale 50.00
9 Kyrin Zimmerman - Labor at public sale 25.00
10 Mike Zimmerman - Labor at public sale 125.00
11 Ryan Finkey - Labor at public sale 125.00
12 Scott Nimmon - Labor at public sale 100.00
13 The Sentinel - Advertising cost for public sale 199.68
14 The Sentinel - Legal Advertisement 173.33
15 Steven Finkey - Labor at public sale 125.00
16 Vehicle Inspection - Van 50.90
17 William Varner - Labor at public sale 50.00
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA-1S00 Schedule H-B7 (Rev. 6-98)
. Rev-1512 EX+ (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Jumper, Ray K
FILE NUMBER
21-06-0772
Include unrelmbul'1Ied medical expenses.
ITEM
NUMBER DESCRIPTION
1 Bernedette Gleim - Reimbursement for electric and phone paid on behalf of
decedent
VALUE AT DATE
OF DEATH
99.63
2 Blue Mountain Anestheologists 15.68
3 Blue Mountain Anestheologists 24.31
4 Carlisle Digestive 34.11
5 Carlisle Regional Medical Center 144.24
6 Central Penn MHT 22.58
7 Cumberland Pathology 24.40
8 David Bryant, MD 238.09
9 Embarq 43.63
10 Embarq 45.61
11 Embarq 44.57
12 Embarq 46.18
13 Graham Medical Center 220.85
14 Lane HMA 85.11
15 Moffitt Heart Associates 1.76
16 PP&L - Electric Bill 57.60
Total of Continuation Schedule(s)
See attached page
TOTAL (Also enter on Line 10, Recapitulation)
1,330.25
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule' (Rev. 6-98)
.. R8Y.1512 EX+ (6-98)
*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
continued
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Jumper, Ray K
FILE NUMBER
21-06-0772
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
17
PPL - Electric Bill
116.32
18
Richard Griffith, MD
44.57
19
Walnut Bottom Radiology
6.69
20
Wolfe Insurance - Auto insurance for Van
14.32
TOTAL (Also enter on Line 10, Recapitulation)
1.330.25
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
REV.1513 EX+ (9-00)
w
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Jumper, Ray K
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
aistributions, and transfers
under Sec. 9116(a)(1.2)]
I.
1
Joann Finkey
36 Maple Avenue
Walnut Bottom, PA 17266
2
Chester Jumper
303 Harvest Lane
Shippensburg, PA 17257
3
Ruth Jumper
181 Crossroad School Road
Newville, PA 17241
4
Janet Nimmon
75 Motter Drive
Shippensburg, PA 17257
RELATIONSHIP TO
DECEDENT
Do Not List Trusteetsl
Niece
Nephew
Sister-in-Law
Niece
FILE NUMBER
21-06-0772
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
One Third
One Third
One Fourth
One Twelfth
19,276.82
19,276.81
14,457.61
4,819.20
Total 57,830.44
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
Copyright (c) 2002 form software only The Lackner Group, Inc.
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Form PA-1500 ScheduleJ (Rev. 6-98)
0.00
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LAST WILL AND TESTAMENT
KNOW ALL MEN BY THESE PRESENTS, that I, RAY K. JUMPER, of
3157 Ritner Highway, Newville, Pennsylvania, being of sound and
disposing mind, memory and understanding, do make, publish and
declare this my Last Will and Testament, hereby revoking all
prior wills and codicils by me atrany time heretofore made.
FIRST: I direct the payment of all my legal debts, funeral
expenses including my grave marker and all expenses of my last
illness, state, federal estate and inheritance taxes,
administration costs, etc., shall be paid from my residuary
estate and shall not be charged or apportioned to any other
legatee, donee, beneficiary or joining tenant as soon as may be
conveniently done following my decease leaving all specific
bequests free of tax to the legatee.
SECOND: I give, devise and bequeath all my property, be it
real, mixed or personal, to Glenn Jumper, Ruth Jumper, Chester
Jumper and Joann Finkey, in equal shares, share and share alike,
per stirpes.
THIRD: I nominate and appoint Glenn Jumper, Ruth Jumper,
Chester Jumper and Joann Finkey, as the Executors of this my Last
will and Testament.
IN WITNESS WHEREOF, I, RAY K. JUMPER, to this my Last will
and Testament, set my hand and official seal, this I 7'i-L-, day of
January, 1997.
if( tu<-/ 71" jav/Jl'~~/
Ray ~ J'"umpjiT ;/
(SEAL)
""'''''!
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Sworn to and subscribed, d~clared and
published by Ray K. Jumper, as
his Last will and Testament, and SO:2 ('~ ~
done in the presence of we the fl ~~ "E;l "_
witnesses, who sign at hi~ request, .//~ ~ ~ #
and in his presence, and ln the ~f:...u~ j....-- /(;td~~
presence of each other. ./
COMMONWEALTH OF PENNSYLVANIA:
:SS
COUNTY OF CUMBERLAND
I, Ray K. Jumper, whose name is signed to the foregoing
instrument, having been duly qualified according to law, do
hereby acknowledge that I signed it willingly; and that I signed
it as my free and voluntary act for the purpose therein
expressed.
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Sworn to and acknowledged, before me,
by Ray K. Jumper, the Testator,
t~s I 7...J.h.. day of January, 1997.
G1CW-#~cS~
Notary Public .~
NarARIAL SEAL \
DAWN MARIE SHOOP. NOTARY PUBLIC
Sh sburQ. Cumberland County, PA
M =illion EJCPire. February 5. 2000 I
y -
J~,-~,~~", "
. '. ...~",_},ji1!i'!!i"tll'~c' OF PENNSYLVANIA..
,,-~ ....COMMONWEALTH
:SS
COUNTY OF CUMBERLAND
WE, H. Anthony Adams and Sharon Coleman Adams, the
witnesses whose names are signed to the foregoing instrument,
being duly qualified according to law, do depose and say that we
saw the Testator sign and execute the instrument as his Last Will
and Testament; that he signed willingly and that he executed it
as his free and voluntary act for the purposes therein expressed;
that each of us in the hearing and sight of the Testator signed
the Will as witnesses, and that to the best of our knowledge and
the Testator was at the time at least eighteen (18) or more years
of age and of sound mind and under no constraint or undue
influence.
~ ~ a:k~
,~MuV ~~ ~
Sworn to and subscribed before me by,
H. Anthony Adams and Sharon Coleman Adams,
the witnesses, this I~~ay of January, 1997.
f\ -
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NOTARIAL SEAL
DAWN MARIE SHOOP. NOTARY PUBLIC
Shippensburg. Cumberland County, PA
My Commission Expires February 5. 2000 r
!
PI M&fBank
499 Mitchell Road, MilIsboro, DE 19966 Mail COde DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
September 8, 2006
Weigle & Associates PC
Attorneys At Law
126 East King Street
Shippensburg, Pennsylvania 17257-1397
SEP" 1 1 2.9\1
Re: Estate of: Ray KJumoer
Social Securitv: 204-30-6650
Date of Death: Auvust 20. 2006
Dear Sir or Madam:
Per your inquiry dated August 31, 2006, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
1.
Type of Account
Savings Account
Account Number
015004201618509
Ownership (Names oj)
Ray K Jumper *
Opening Date
02/02/00
Balance on Date of Death
$60,276.51
Accrued Interest
$
7.43
Total
$60,283.94
Please be advised, there was no safe deposit box fOlmd for the above decedent.
* For further account information, regarding ownership, closures and/or reimbursement of funds, etc., please call
the High Street Carlisle Oftice # 717-240-4536.
Sincerely,
~~
Nancy Clagett
Records Management
I
FINAL SETTLEMENT
Date: I 0 } I~ J 04-
SELLER: K~ \Z :s u.'~ t~...~
Address:" \. _ , ()
Sale Location: 3\5>( R~~ \-lwl:j I '\L.U...U \)1' lU..., r'A.
Auctioneer: Dean Alleman AU# a'u, klP Clerk: S, ~'\~ Cashier: \). ~~o.p
G. Mark Neil AU# 27loct<1
PROCEEDS OF SALE:
Cash ...................... $ ~ f 3 4 ~ . F::::. [")
Checks ................... $---11 0 ~ ~. 5 0
.
Other...................... $
TOTAL PROCEEDS OF SALE $ .3, 4 ~~, DC)
Less Seller's Expenses: ~
Auctioneer's Fee .....1~.::..~........ $ 4 l { . Q (p
Other seDer's expenses:
Advertising costs:
-~ ~l\.lL
$ \ qCLto~
$
$
$
Miscellaneous expenses:
~~ ~ ~1~~c:
~~. ~5
$
$
$
Total SeDer's sale expense:
$ lP~[,~~
:;(,i4Z;-.\\
Total Net Proceeds to Seller:
$
I (we), the seller of goods, merchudise aad/or property sold at public auction on above date and
JoeaiioB, aeJmowledge aDd aeeept this settlement of proeeeds of sale. I (or we) agree to aeeept aU
responsibility for providing merchantable title to a!! g~gdsj mc!'chand:~e, and/or property sold, and {or
deliver of title to purchaser. .
l n Illll t"lp
(date)
> ji/,..e~ ~ ff..J
(Auctioneer's signature)
(Seller's signature)
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No.5001385
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MIDDLE INITIAL
LAST NAME (OR FULL BUSINESS NAME)
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PURCHA&fP, I
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1 ~11
ZIP CO~qDE) REFER TO COUNTY CODES
USTING ON REVERSE SIDE
(l'j' OF PINK copy
MIDDLE INIT1AlI ~C~~~~bREDI
D. LAST NAME (OR FULL BUSINESS NAME)
FIRST NAME
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PRICE
(See note on reverse)
LESS
TRADE-IN
TAXABLE
AMOUNT
,. Sales Tax Due
x 6% 1,061 or
~~ ~~ on reverse).
1A Exemption
Reason Code.(must
be a number fTom ,
to 23 or 0)
1 B First AasignrrJent
,
2. Title Fee
3. Lien Fee
4. Registration or
Processing Fee
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STREET COUNTY CODE 5. Duplicate Reg.
1 I Fee
No. of Cards_ . .
CITY STATE ZIP CODE REFER TO COUNTY CODES
UsnNG ON REVERSE SIDE 6. Transfer Fee
OF PINK COPY . .
MAKE OF VEHICLE I VEHICLE IDENTIFICATION NUMBER
7, Increase Fee
. .
MODEL YEAR I BODY TYPE (CP, TK, ETC.) 1 CONDmON
o GOOD o F~R D POOR 8. Replacement
Fee . .
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ORIGINAL PlATE .; Check One
o PlATE TO BE ISSUED BY
BUREAU (PROOF OF IN-
SURANCE MUST BE AT-
TACHED.)
EXCHANGE PlATE TO BE
ISSUED BY BUREAU
TEMPORARY PLATE
ISSUED BY FULL AGENT
D TRANSFER OF PREVIOUSLY ISSUED PlATE
D TRANSFER & RENEWAL OF PlATE
o TRANSFER & REPLACEMENT OF PlATE
D 1'.GRAND TOTAL
TRANSFER OF PLATE & REPlACEMENT OF STICKER (Add 9 & 10)
'.. REASON FOR REPlACEMENT
o LOST 0 DEFACED 0 STOLEN
DN~~C~~~~EW€b" block is checked apolicant must comol9t& Form MV-44.
IVlN
GMN4001 ,J:,)
83120 ']i
..' ...^ ............
EXPIRES
Month Year
TRANSFERRED FROM TITLE NO.
I
SlGNATU8E OF PERSON FRctA; ~SIGN HERE
WHOM PLATE IS BEING TRANS-
FERRED (IF OTHER THAN APPUCANT)
I Y.EV~t1lIG"'H"""'T I.NvFO..... ~,_,:c-:. , IWR I UNLADEN WEIGHT I REa. REG. GROSS WT. lREa. REG. GROSS COMB.
IIIF APPUCABLEJ INCLUDING LOAD wrr. (IF APPUCABLE)
'L:be~rM~luJ ~,. ( _j~~~~~g~) ~~ Ca~5_~ I~CYLf~i~o~ 1~~CY4.:i5~~~
ISSUING I bERTlFY THAT ON MO~ lJ \..,;{ DAY ~ YEAR....Q.ia- ISS.!.lING AGENT !f'RINT N.fAE) A r\.... ~ I'iJ; NO'1 "'" ""-
AGENT I HAVE CHECKED TO DETERMINE THAT THE VEHICLE IS INSURED AND r'\ r\iL (I ]:lr..'""t'\'"t:.VL. ~.A"\() '7",j - tC7"U
INFOR- ~~~~?~lt1E~~rk~ ~cit:~I~~vg/'~~ee'WC~ CODE IsS~ {I AGENT S1GNA~ /) ~ "" TE.[ PHO~IN?--- . IJd
MATlON AND DEPARTMENT REGULATIONS, j A.... - ---r~........ - (Cl tT\..fjl~"q
I/WE CERTIFY THAT IlWE HAVE EXAMINED AND SIGNED THIS FORM AFTER ITS COMPlETION AND THAT THE INFORMATION GIVEN IS TRUE AND CORRECT. IF AN EXEMPTION
IS CLAIMED. THE PURCHASER FURTHER CERTIFIES THAT HE/SHE IS AUTHORIZED TO CLAIM THIS EXEMPTION. I/WE ACKNOWLEDGE THAT IlWE MAY LOSE MY lOUR OPERATING
PRMLEGE(S) OR VEHICLE REGISTRATION(S) FOR F~LURE TO ~NT~N FINANCIAL RESPONSIBILITY ON THE CURREN1l.Y REGISTERED VEHICLE FOR THE PERIOD OF
REGlsm.cmON. IlWE ACKNOWLEDG~_ !H..E_"WE MAY BE SUBJECT TO A FINE NOT EXCEEDING $5.000 AND IMPRISONMENT OF NOT MORE THAN TWO YEARS FOR ANY
FALSE STATEMENT THAT IlWE MAKE ON/'11"l\:) FORM. ~
37rtur, of Firs~PU~~~Zed S~ner .... TELEPHONE NUMBER Signature of Seller Y'J .L II () Ck: I . 1"1.~ _ u..
1ST - '\ '" ... 7tlI -J ..: / \ .\. J ^ ^ h""\ l~ _ .Q-'ddU 'f'{ J' r.L '"\r '..r. ~
~~- Signatiie' of Co-Purchaser ITitle of Authorized Signer Il, ~ \ 1 !Signature of Co-Seller(~,,- Z- L""" fI(1;()I)1\I --j:, 111 {{ .v
J
2ND
ASSIGN-
MENT
Signature of Second Purchaser or Authorized Signer
TELEPHONE NUMBER
Signature of Co-Purchaser/Title of Authorized SIgner
TOTAL PAID
(Add 1 thru 8)
Signature of Seller
Signature of Co-Seller
.
Send One
Check in
This Amount
I RELATIONSHIP TO APPUCANT
ec
i/
NOTE: If a co-purchaser other than your spouse is listed and you want the title to be listed as "Joint Tenants With
Right of Survivorship. (On death of one owner, title goes to surviving owner.) CHECK HERE D. Otherwise, the title
will be issued as "Tenants in Common" (On death of one owner, interest of deceased owner goes to his/her heirs or
estate).
NOTE: IF THE VEHICLE IS TO BE USED AS A DAILY RENTAL OR LEASED VEHICLE, CHECK THIS BLOCK 0 ,IF BLOCK IS CHECKED. COMPLETE AND ATTACH FORM MV-IL.
MESSENGER NUMBER:
,. BUREAU ~ MOTOR ~HIC~S \{ ~M
-
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1 162 EX(1 1-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
WEBBER JR RICHARD L
WEIGLE & ASSOCIATES PC
126 E KING STREET
SHIPPENSBURG, PA 17257-1397
n_nn_ fold
ESTATE INFORMATION: SSN: 204-30-6650
FILE NUMBER: 2106-0772
DECEDENT NAME: JUMPER RAY K
DA TE OF PAYMENT: 11/17/2006
POSTMARK DATE: 11/17/2006
COUNTY: CUMBERLAND
DATE OF DEATH: 08/20/2006
NO. CD 007452
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $8,240.84
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$8,240.84
REMARKS:
CHECK#1028
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS