HomeMy WebLinkAbout97-00754
PETITION FOR PROnATE and GRANT OF' U~TTERS
No. ..,_&J::-_9.'J~_S!l:
To:
h:'Itl/I' (!( ...Kar.en..L.. ...BuslL,_________'..
,,1.\0 known as ______....._..___.__.__._ -----.~-
...._..,........,........ ,...._______,..._'_' Register of Wills for the
__" " DI'''msl'd. County of Cum her 1 i'lnn in the
So,.;ol SI',,"r;IY No. ..2,Q,4..:=AO..:.52.64 Commonwealth of Pennsylvania
The petilion of the undersigned re,pectfully repre'enls thai:
Your pelitioner(,), who Klare IN years of age or older an Ihe exe<'ut..or...&-c.n-"lC"c:ut.ollUmed
in Ihe last will of the ahove decl'dent, daled __Januar,YJ,-19JU ,19_
and cmlicil(s) dmed
(~liUl: Tell-\am cir':lIl1l\wnCl'\, ....l!. Il'111111ci,llioll. death of C\CCllIOr, cle.)
Decendent was domiciled m dealh in -.--C.uIDberlan.~ County, Pennsylvania, with
h pr last family or principal residen~.2.1 1 ~~6::~;Y New cumberland.
-1lanns.y.J..va~ 7070 "'-~- .IvA'?d "
(I.'l slrccl. Ilumher nnd llltlnl.'ipaliIY)
Deeendent,lhell 47 years of age, died January 17 , ,19 97
m,_Uni.v:er.siJ:.y-Hospi.tal.-H.ershey MedicaL.Center \-Tp,....lJey PII
Except as follows, deeedenl did nol marry, was not ~ivorced and did not have a child born' or adopted
after execulion of the will offered for probate; was notlhe victim of a killing and was never adjudicated
incompC'tcnt:
Dccendcnl at death owncd property wilh estimated values as follows:
(If domiciled in Pa.) All personal properlY
(If not domiciled in Pa.) Personal property in Pennsylvania
(I I' not domiciled in Pa.) Personal property in County
Vahl\,.' or real ~statc in Pennsylvania
situUII:d as follows:
$....1JlJl,OOO_OO
$
$
$
WHEREFORE, pelilioner(s) respectfully request(s) the probate of the last will and eodicil(s)
presented hcrewilh and the granl of lellers.-tes.taIDenti'lry
, (ll'\t.llllclltary: adlllini'lrUlillll ~.l.a.; adminislrntion d.b.n.c.l.a.)
Iheron.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH 01>' PENNSYLVANIA
COli NTY 01>' ....cUMBERLAND
I
.r 88
SWOrtl In or affirmed and
~befOr" Ille this 5TH
. EMBER
_ ,. __~ r.v...u:J.&.~
RY LEWIS
\ b - ;;:>O~ - 8
The petitioner(s) ahovc-named sIVearls) 01' affirm(s) that Ihe statements in the foregoing petition are
true alld ,orrect 10 Ihe hcst of the knowledge and belief of pelitioner(s) and thaI as personal represen-
wt;ve(s) of Ihe ahove decedem pelitioner(s) will well and Iruly administer the eslate according to law,
~~d~
subscribed
d ~of
19 [I
j,) Oldl," r; F"", P:l:'4
I
en
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RegiSlt
No. 21 - 97 - 754
Estale of
KAREN L. BUSH
, Deceased
DECREE OF PROBATE AND GRANT Of' LETTERS
AND NOW SEPTEMBER 16. 19-9-1-, in consideration of the petition on
the reverse side hereof, salisfactory proof having heen presented hefore me,
IT IS DECREED thai the instrumenl(s) dated_.IanuaQL.1.,....1..997
described therein he admitted 10 prohale and filed of record as lhe last will of Karen L. Bush
. d.I I . '
and Letters T9sta.m~mtilry
arc hereby granted to pnnprt- T
'Rile" ~11d..-.Do"n;:to.J' Kp,..kl pr r ,..f""l_pY~t"'l1tnrs
~.
FEES
200.00
6.00
Charles E. Friedman. ID #07175
ATTORNEY (Sup. Ct. 1.0. No.)
Filed
$
$
$
$ 21 . 00
5.eO
TOTAL _ $ ?1R,OO
SEPTEMBER 16 1997
.....................'..............
(717) 232 9925
PHONE
Probate, Letters, Ete, .........
Short Certificates(2) . . . . . . . . . .
Renunciation ................
X-Pages
JCP
305 N_ Front st.. Harrisburq, PA 17108
ADDRESS
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Mailed letters and order to attorney on 9-16-97.
21 - 97 - 754
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21 - 97 - 754
REGISTER OF WILLS OF
OATH OF SUBSCRIBING WITN ,
codicil
(each) a subscribing wit~ess to the will presented herew'
law, depose(s) and say(s) 'that
-
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'-"
, (each) being duly qualified according to
present and saw
the testat , sign the same and'ihat
'.
request of testa! in h presence' an
other subscribing witness(es)),
signed as a witness at the
, (in the presence of each other) (in the presence of the
Sworn to or affirmed and subscribed be ore
me this ay of
"
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'- (Name)
''-,
",-
Register
(Address)
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(Name) ~,.
(Address)
REGISTER OF WILLS OF (IA"'" M"'/a-... j COUNTY
OATH OF NON.SUBSCRIB NG WITNESS
f2...:,bert .:r, e,IAJ4 afl.J .Don~" J. Jc:<cK/('r
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
-rN-ct t:I rc familiar with the signature of !La r<:.... L. a"" <. '"
cmttctr
testa! r..)( of (ell_ uf d," ,ubscnbln~ "itllme, -to) the will presented herewith and
"b ,.. ./1 J. I r codicil
that 1'-,;1 0.1-, ,,,<//4 I OOA/JII . 1.:::'...rl4Mieves the signature on the will is in the handwriting of
I4A rt:.. L. 6.. $l
to the best of 'f1v ,1/" knowledge and belief.
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Sworn to or affirmed and subscribed before
me this
day of (Name)
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Register /Uk"AU'J i) fu- ffiJ:..QA
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CERTIFICATION OF NOTICE UNDER RULE 5.6Ia)
Name of Decedent:
Karen L. Bush
Date of Death:
January 17, 1997
Will No. 21-97-754
To the Register:
I certify that the notice of beneficial interest required by
RUle 5.6(a) of the Orphans' Court Rules was served on or mailed to
the following beneficiary of the above-captioned estate on
September 17, 1997
~
Address
Robert I. Bush, 211 Reno Avenue, Apt. 1, New Cumberland, PA 17070
Donna J. Keckler, 485 Goldenville Road, Gettysburg, PA 17325
Barbara Sunderlin, RD 2, Box 316, Morrisdale, PA 16858
Carmen Finnigan, RD 3, Box 70, Philipsburg, PA 16866
Marlene Dixon, 1117 Normandale Drive, Dothan, AL 36301
Linda Weitosh, P.O. Box, Hawk Run, PA 16840
Tara Weld, c/o Pamela Weld, RD 1, Box 537A, Osceola Mills, PA 16666
Amy Yavorosky, 1020 Donna Road, Orwigsburg, PA 17961
Margaret Hrenko, 527 Lewisberry Road, New Cumberland, PA 17070
Pamela Weld, RD 1, Box 537A, Osceola Mills, PA 16666
Notice has now been given to
Rule 5.6'(a) except - NOlie.
all persons entitled thereto under
~f2R
Charles E. Friedman, Esquire
FRIEDMAN & HOCH, p.e.
305 North Front street
P.O. Box 885
Harrisburg, PA 17108-0885
(717) 232-9925
Counsel for Personal Representative
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Date: september 17, 1997
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Register of Wills of cumberland County, Pennsylvania
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INVENTORY
EstatB of
Karen L
'Rll'=.h
No, 1997-00754
also known as
Date of Death 01 /1 7 /97
Social SecuritY No, 204-40-5264
, Deceased
i'e(sonal ~eDre5.,ntatlv"lsl ot the deave :stace. .iltceasea. 'Jl""'" tnat the Items 3cpeatlng In the following InvdntQr'llnCluae all
0; ::'1" personal assets .....ne'ev'" 31{U8t8 dnd elll or (ne reel estate In Che C.)mmonwealtn of P"nnsVIV8nl8 at salC C~c~oent. ~na[
the vaiudtlon placed .:lDCOS.te c!3cn I:am of said Inventorv reotesenC$ ItS talr '1alue as of Ii'll! aace at che O.,ct=oent'i \Jutn, ana
that J.,Cl!oenc owned no tealdstata cut:iICd or the C..:mmonw"aIC:'l or P'mnS'JlvanI8 exceD! that ....,nlen ,JDCdsrs In d rT\"lTIo:lranC:ul"'"
at [:'I" ~nc1 Qt thiS ,nventorv. l/We vet.fY eMat the statements maae In 0"5 Inv"ntor'l afd crUd and com~ct. liWe ',Jnoer~tano ~:'lar
ralSd :;ratemdntS nereln Jre mace iUOldct :0 :ne penaltldS Jt ~ a ;:23. C.3. S~ctlon ':'90~ r"latlnlj to 'Jniworn ~i'I:l'lIo.;dllon :0
.1ulnor!!leS,
?~rsonal Rdor~:it!nt,)l,vd:
Nam" 0'
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~th. ~ k'uJllA. ~b~_rt_~ Bush
0' J -9 b Don~:._~.:...Keckler
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Charles E. Friedman
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07175
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~05 N. Front st.. P.O.
Box BA5
OateCl
Harrisburg, PA 1710B-0885
;0'00000<; (717) 232-9925
Vai;.;::
OdscnotlOn
Real property:
None
personal prop~rty:
Fulton Bank Checking Account
1988 Ford Tempo Automobile
proceeds from settlement of class action
litigation.
$17 .00
$600.00
$102,111.01
Miscellaneous Personal property
$625.00
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Total: $103,353.01
(Attach Additional Sheets ,f necessaryl
NOTE: The Memorandum of (e:lll estoJ!e outSIde tne Commanwe.1ltn oJ ?enns'Ilval1ia may. olt the etee:IQlI ~t Inlt personal tegresellutl'.e ,I\C~Uae
tne ..,.Iue ot eaeh item. but suen tiqu'''s -;Mould not be .,del1dl'tO inlO IMe total ot to., In"I!ntor't,
~ >- BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND TO RECHECK MATH -<-<
Under penalties of perjury. I declare that I ha....e examined this return, including accompanying schedules and slalements, and 10 the best of my knowledge and belief,
" is True, correct and complete. I daclors that all real estors has been reportea at true market value. Declaration of pre parer other than Ihe personal representati....e is
based on all information of which preparer has any knowledge.
ilC AT RE ~E N R PONSl8lE FOR FIliNG RETURN ADDRESS DATE
211 Reno AV!'IDue, New Cumberland, PA 17070
5 DATE
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
'OR DATlSO' DIAlH Ann 12/31/91 CHIC~I
IF A SPOUSAL
POVIRTY CRIDll IS CLAIMID 0
FILl NUMSIR
COUNTY CODE
CI)\
Cf7
YEAR
7~-1
NUMBER
COMMONWEALTH Of PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HAU1S8URO. PA 17128_0601
DeCeDtNT'!. NAMe lLAST. P1RST. .AND MIDDU INITIAL)
DtCtDeNT'S COMPlUf ADORUS
211 Reno Avenue
New CUmberland, PA
Karen L. Bush
SOCIAL neURITY NUMItR
204-40-5264
DATf O' BIRTH
DATE O' DeATH
01/17/97
OS/25/49
Counl
f IN!.TRUCTlONSI
AMOUNT R IV
I" A""!CAllll $U~v,v'HO $POUSI'S NAMllLAsr. fllSt AND MIODLt INITIAll
$26
873.52
o 3. Remainder Return
(10' do... of deoth prior '0 12.13.821
o S. Federal Estate Tax Return Required
Bush
ail.
04.
162-36-9137
o 2. Supple menIal Relurn
Robert I.
Original Relurn
o 40. Future Interest Compromise
(for dote, 01 deo,h aher 12,12.821
o 6. Decedent Died Testate 0 7. Deceden, Maintained a living TrusI
(Altoch copy of Will) (Altoch copy of T,u,')
ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPlETE "IAllINQ ADORES!.
limited Estate
.....a. 8. Tolal Number of Safe Oeposil Boxes
Charles E. Friedman
TELtPHONE NUMBER
Es uire
305 North Front street
P.O. Box 885, Harrisburg, PA 17108
232-9925
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1. Reol Estate {Schedule AI
2. Stock, ond Bond, (Schedule BI
3. Clo,ely Held S.ocklPortne"hip In.ere,t (Schedule C)
4. Mortgages and Notes Receivable (Schedule 0)
5. Cash, Bank Oeposits & Miscellaneous Personal Property
(Schedule E)
6. Join.ly Owned Properly (Schedule F)
7. Tron,le" {Schedule Gi (Schedule l)
8. TOlal Gross Assets (total lines 1-7)
9. Funeral Expenses, Administrative Costs, Miscellaneous
E'pen.e, (Schedule H)
10. Debrs, Mortgage Liabilities, Liens (Schedule II
11. Total Deductions (total Lines 9 & 10)
12. Nel Value of Estate (Line 8 minus Line 111
13. Charitable and Governmental Bequests (Schedule J)
14.. Nel Value Sublect to Tax (line 12 minus Line 131
15. Spousal Transfers (far dates of dealh after 6.30.94)
See Instructions for Applicable Percentage on Reverse
Side. (Include values from Schedule K or Schedule M.J
,
16. Amount of line 14 taxable ot 6% rate
(Include values from Schedule K or Schedule M.l
17. Amount of Line 14 toxable al 15% role
(Include values from Schedule K or Schedule M.l
18. Principal lax due {Add tax from Lines 15, 16 ond 17.1
19. Credits Spousal Poverty Credit Prior Payments
+
20. If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMENT.
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21. If Une 18 is greater Ihen Line 19, enter the difference on Line 21. This is the TAX DUE.
A. Enter the inlerest on the balance due on Line 21 A.
B. Enter the Iota I of line 21 and 21A on Line 218. This is Ihe BALANCE DUE.
Make Check Payable to: Register of Wills, Agent
5.751.64
{lll 12,816.25
(121 qO.536 7F.
(13)
(14)
x. JL= _n_
X .06 = ---1...531 .91
3.219.73
{15} 26.873.52
{16} 42,198.41
(17) 21,464.83
Discounl Inlerest
+
X .15 =
(1BI
5.751.64
(191
{201
5,751.64
(21)
(21A)
(21BI
SENTATIVE
ADDRESS
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305 N. Front st. P.O. Box 885
Harrisburg, PA 17108-0885
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Act '48 of 1994 provide. for the reduction of the tax rate. Impolld on the net value of transfer. to or for
the u.a of the .pou.e. The rate. a. pre.crlbed by the .tatute will be: .
e 30/0 (.03) will be applicable for e.tate. of decedent. dying on or after 7/1/94 and before 111196
e 20/0 (.02) will be applicable for estate. of decedents dying on or after 1/1196 and before 111197
. 1% (.01) will be applicable for e.tate. of decedents dying on or after 1/1197 and before 111/98
. Spou.al transfers occurring on or after 1/1198 will be exempt from inheritance tax.
PLEASE ANSWER THE FOLLOWING QUESTIONS
BY PLACING A CHECK MARK (.....) IN THE APPROPRIATE BLOCKS.
YES NO
1. Did decBdent make a transfBr and:
x
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a. retain the use or income of the property transferred, .......................................................
b. retain the right to designate who shall use the property transferrBd or its incomB, ...............
x
Ix
Ix
Ix
Ix
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c. rB aIR a reversionary Interest; or ...................................................................................
d. receive the promise for life of either payments, benefits or care? .......................................
2. If death occurrBd on or before DecBmber 12, 1982, did decBdent within two years preceding
death transfBr property without recBiving adequate considBration? If death occurred after
December 12, 1982, did decedent transfer property within one yeor of death without recBiving
adequate consideration?",..,.....",.,..,.,."",.,..,...."...,',.....,',...," ........".....".,...",.."..,..,."...
3, Did decBdent own an 'in trust for' bank account at his or her deathL....................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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SCHEDULE E
CASH, BANK DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
Pleose Print or T e
FILE NUMBER
21-97-0754
COMMONWEALTH OF PENNSYWANIA
INHIIITANCI TAX R(TURN
RISIDINT DICEDINT
ITEM
NUMBER
1.
2.
3.
4.
Karen L. Bush
(All property lolntly-owned with the Right of Survivorship mUlt b. dllclol.d an Sch.dul. F)
ESTATE OF
VALUE AT
DATE OF DEATH
DESCRIPTION
Fulton Bank Checking Account
$17.00
$600.00
1988 Ford Tempo Automobile
Proceeds from settlement of class action
litigation (See attached explanation and
documentation.)
$102,TTL01
Miscellaneous Personal Property
$625.00
TOTAL (Also enter on line 5, Recopitulotionl S 1 03 353.01
(Anach additionaI8Y%" x 11" sheels if more space is needed.)
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COMMONWEALTH Of PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCEllANEOUS EXPENSES
ESTATE OF
ITEM
NUMBER
PI'la.e Print or Tvpe
FILE NUMBER ·
Karen L. Bush
DESCRIPTION
1.
A. Funeral Expenses:
Heath Funeral Home
2.
3.
B.
1.
2.
3.
A.
C.
1.
2.
3.
A,
5.
6,
7.
a,
cremation society of pennsylvania
Cue tara-Hi Ie Memorial Center
Administrative Costs:
Personal Representative Commissions
Sociol Security Number of Personal Representotive:
Year Commissio,1s paid
\
I Attorney Fees
I
\ Family Exemption
Claimon!
Relotionship
Address of Claimon! at decedent's deoth
Street Address
City
StOle
Zip Code
Probate Fees
.'
I Miscellaneous Expenses:
, Sentinel
Cumberland Law Journal
Copy of Birth certificate
Friedman & Hoch, P.C. - Miscellaneous Expenses
TOTAL (Also enter on line 9, Recopitulation)
(If mare space is needed, insert additional sheets of same size.)
AMOUNT
$900.00
$1,030.00
$125.00
$6,850.00
$238.00
$76.50
$60.00
$11.00
$4.80
$9,295.30
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INH(lIT"NCI 'A. mUltf.l
ltU!O!NrO!CIDfNr
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES AND LIENS
Plea.e Print ar Tvpe
FILE NUMBER
21 - 97- 0754
ESTATE OF
Karen L. Bush
ITEM
NUMBER
DESCRIPTION
AMOUNT
1.
Internal Medical Association
$1,247.80
2.
3.
University Physicians
$61.50
$128.48
$30.17
Lamps 'N' stuff
4.
Southeast Alabama Medical Center
5.
Margaret Hrenko - Loan for payment of automobile
$1,000.00
$1,053.00
6.
Margaret Hrenko - Loan for payment of funeral
expenses for Decedent's son
"
TOTAL (Also enter on line 10, Recopitulo,jon)
(If more space ;s needed, insert additional sheets of same s;ze.)
53,520.95
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COMMOJ'4WtAlTH 0' HNNsnVANIA
INMUllAHet TAX RnullN
IIIIDINT DlelOINT
SCHEDULE J
BENEFICIARIES
FILE NUMBER
ESTATE OF
Karen L. Bush
21-97-0754
ITEM
NUMBER
NAME AND ADDRESS OF BENEFICIARY
RELATIONSHIP
AMOUNT OR
SHARE OF ESTATE
A. Taxable Bequests:
1.
See Attached
ITEM
NUMBER
NAME AND ADDRESS OF BENEFICIARY
AMOUNT OR
SHARE OF ESTATE
B. Charitable a.,"d Governmental Bequests:
1.
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) S
(If more space is needed, insert additional shuts of same size)
SCHEDULE J
BENEFICIARIES
ESTATE OF: Karen L. Bush
FILE NO.: 21-97-0754
NAME AND ADDRESS
OF BENEFICIARY
RELATIONSHIP
AMOUNT OR
SHARE OF ESTATE
1. Robert I. Bush
211 Reno Avenue
New Cumberland, PA 17070
Husband
$26,873.52
($80.00 + 30% of
residue)
2. Donna J. Keckler
485 Goldenville Road
Gettysburg, PA 17325
sister
$4,465.59
(5% of residue)
3. Barbara Sunderlin
R.D.2 Box 316
Morrisdale, PA 16858
Aunt
$4,465.59
(5% of residue)
4. Carmen Finnigan
R . D . 3 Box 70
Philipsburg, PA 16866
Aunt
$4,465.59
(5% of residue)
5. Marlene Dixon
1117 Normandale Drive
Dothan, AL 36301
None
$4,465.59
(5% of residue)
6. Linda Waitosh
P.O. Box 171
Morrisdale, PA 16858
None
$893.12
(1% of residue)
7. Tara Weld
R.D.1 Box 537A
Osceola Mills, PA 16666
Grandaughter
$10,957.41
($240.00 + 12% of
residue)
8. Amy Yavorsky
1020 Donna Road
Orwigsburg, PA 17961
Sister
$2,709.35
($30.00 + 3% of
residue)
9. Margaret Hrenko
527 Lewisberry Road
New Cumberland, PA 17070
Mother
$4,172.47
($600.00 + 4% of
residue)
10. Pamela Weld
R.D.1 Box 537A
Osceola Mills, PA 16666
Daughter
$27,068.53
($275.00 + 30% of
residue)
Note:
The dollar amounts are the value of personal property
designated in the will.
. "
"
THE
SETTLEMENT
LAW GROUP
611 WEST SIXTH STREET
SUITE 2120
Los ANGELES
CALIFORNIA 90017.3127
TELErHONEI (800) 790.1877
FAC5IMtLE: (213) 833.0204
ATTORNEYS AT LAW
October 3, 1997
Re: Factor Concentrate Litil?ation Settlement
Dear Claimant:
This letter is being sent regarding claims in the Factor Concentrate Litigation,
The claim of your claimant Group has been approved. Your Claimant Group members are
listed on Exhibit A to the enclosed Release by name or relationship to the HIV -positive person.
I have been selected to serve as Special Settlement Counsel to expedite payment
of your claim, My staff will be available to assist you, without cost, concerning questions
about the settlement payment process and to help you with filling out the necessary forms, My
toll free number is 1-800-790-1877. Of course, you also are free to consult with any attorney of
your choice, at your own expense,
The Fractionators have already deposited the settlement funds into a trust
account. MetLife Trust Company (an affiliate of Metropolitan Life Insurance Company) is the
Trustee. The settlement amount for your Claimant Group will earn interest in that trust account
at the annual rate of 4,8% beginning on August 28, 1997, until the settlement funds are
transferred to the account(s) of the Claimant Group members. Those accounts also will earn
interest at a competitive money market rate, which presently is higher than 4.8%, No interest
will be paid on the trust account after February 27, 1998; by that date, the settlement process
should be virtually compl.ete,
For you and any other members of your Claimant Group to receive the money
being paid under this settlement, you will need to get some signatures on the enclosed legal
papers. We want you to know that, if you need it, help is available to assist you with filling out
the papers. We will try to make it as easy as possible for you to fill out the forms and receive
the settlement money,
1. RELEASE
In accordance with the terms of the Settlement Agreement, the Fractionators and
Class Counsel have agreed on a form of Release. That Release is enclosed. THE RELEASE
IS AN IMPORTANT LEGAL DOCUMENT. Each person who signs the Release should
read it carefully and completely so that he or she understands its terms. All members of your
Claimant Group must sign the Release for the claim to be paid, After signing the Release, any
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THE
SETTLEMENT
LAW GROUP
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pending lawsuit(s) will be dismissed as to the Fractionators, and no new lawsuits may be
brought against any of the Fractionators relating to the Incident described in the Release,
All members of your Claimant Group must sign a Release. We have enclosed
as Exhibit A to the Release a list showing the persons identified in the claim form who are
members of your Claimant Group and who need to sign the Release. Exhibit A also shows
categories of persons who may be part of your Claimant Group who need to be identified and
who also need to sign the Release. Please fill in any names for categories listed on Exhibit A if
you know of persons in those categories and return Exhibit A with the signed Release,
Please arrange to have all persons listed by name or by category on Exhibit A
sign the Release. If the HIV-positive person is deceased, the signature for that deceased person
must be by the legally designated personal representative (executor or administrator) of the
estate, If any signature is required for a minor, a parent or a coun-appointed guardian must
sign. In some instances, a member of a Claimant Group may need to sign more than once: for
example, on his or her own behalf, and on behalf of any minor child or estate,
Although you need to get signatures for all persons listed on Exhibit A, they do
not all need to sign the same copy of the Release, We are enclosing extra copies of this letter
and the Release. If one or more of the persons who must sign the Release cannot sign the
Release for any reason or refuses to sign, contact my office, We realize that it may be difficult
or impossible to get some of the signatures for persons listed by name or by category on Exhibit
A, Please call if you are having difficulty, and we will try to assist you. Where necessary, we
will try to get permission for you to submit the form without a required signature,
If you have special circumstances that make it impossible to get a necessary
signature notarized, plea~e contact my office.
2. REIMBURSEMENT AND STJBROGATION CLAIMS
The Fractionators have entered into agreements with the federal government,
and with most state governments and private insurers, Those agreements prevent the
government and private insurers from making a claim against your settlement amount for past
or future expenses that they have paid for mv or AIDS care. We have enclosed a list of the
states and private insurers that have entered into those agreements. My office has copies of
those agreements.
If the HN-positive person has received benefits for HIV or AIDS medical care
from a private insurer that is not on the enclosed list, please call my office, In many cases, an
insurer which does not appear on the list actually is listed under a different name, and we can
provide you with that information.
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SETTLEMENT
LAW GROUP
AnO'MUS AT l"""
If the HIV -positive person received benefits for HIV or AIDS medical care from
one of the few state governments which has not yet entered into a waiver agreement regarding
this settlement, please call my office.
3, ELECTION FOR FORM OF PAYMENT
At the time the completed and signed Release is returned. your Claimant Group
needs to decide how the payment will be received, Our office is available to assist in choosing
payment options. The following options are available:
A, Lump Sum, If your Claimant Group elects to receive the settlement
amount (generally 5100,000, plus any accrued interest) in a lump sum, an interest-bearing
account or accounts will be established with Metropolitan Life Insurance Company. The
account balance will earn interest at a floating interest rate from the date the settlement amount
is transferred into the account until all ofthe funds are withdrawn, The name(s) on each
account will be listed in accordance with directions on the Claimant Lump Sum Election Form
(enclosed). Check books will be sent to the account holders once the completed Release and
Claimant Lump Sum Election Form have been received, One or more checks can be written
from each account, until the entire settlement amount, and interest earned, have been
withdrawn. The entire amount in each account may be withdrawn at any time, There are no
service charges on these accounts for ordinary activity.
If your Claimant Group elects the lump sum payment option. each member of
the Claimant Group must sign and return the enclosed Claimant Lump Sum Election Form,
along with the signed Release. All persons who must sign the Release must also sign a
Claimant Lump Sum Election Form if you choose this payment option.
Your Claimant Group may also specify what percentage of the settlement
amount will be controlled by each Claimant Group member. For example, your Claimant
Group may decide to give 100% to one person; or to put 100% of the money into ajoint
account under the control of more 'than one person; or to divide the total, for example, 50% to
one person and 50% to another. If only one or two members of your Claimant Group will be
receiving all of the settlement money in a lump sum payment, follow the instructions on the
enclosed Claimant Lump Sum Election Form. If more than two Claimant Group Members will
be sharing the settlement payment, please contact my office for assistance, If you and your
Claimant Group wish to have a lump sum payment but cannot agree how the money should be
divided, feel free to contact my office before sending in your Claimant Lump Sum Election
Form.
3
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THE
SETTLEMENT
LAW GROUP
~
ATTOIlHITIAr UW
If members of your Claimant Group do not want a lump sum payment or wish to
have only a portion of the payment made in a lump sum, with the remainder received as a
Structured Settlement or through a Special-Needs Trust, please dlumt complete the Claimant
Lump Sum Election Fonn; instead, please contact my office for assistance,
8, Structured Settlement. If you are interested in receiving the settlement as
periodic payments in the future, you may wish to consider a Structured Settlement, which for
some people may have certain tax and economic benefits, Please call my office if you would
like to obtain additional details about a Structured Settlement.
C. Special-Needs Trust. If you are receiving Medicaid, Supplemental
Security Income (US,S,!. U), Section 8 housing, food stamps, general assistance, or any other
governmental benefit, I suggest you call our office to discuss your situation before you choose
how to receive your settlement amount. You may lose certain of those benefits unnecessarily if
you elect to receive your settlement amount directly, rather than using a Special-Needs Trust.
We are prepared to advise you concerning Special-Needs Trusts and other options you may
have to preserve those benefits,
4, SUMMARY OF DOCUMENTS TO RETURN
You should return:
· The fully signed Release, including signatures for all Claimant Group members.
· Exhibit A to the Release, signed by one member of the Claimant Group and with names
filled in for Claimant Group members who were identified by category rather than by name,
(You do not need the signatures of all Claimant Group members on this document; one
signature is enough, ~nce all of the blanks have been filled in.)
· The signed, enclosed medical records authorization fonn (Exhibit 8 to the Release). You
may have signed a similar fonn when you filed your claim, However, in order to process
your claim we need a current medical records authorization, As noted in the authorization
fonn, any infonnation which is obtained wiII be treated as strictly confidential. It may be
used only in connection with implementation of this settlement.
· The completed and signed Claimant Lump Sum Election Fonn, if that is the method your
Claimant Group has selected for receiving your payment.
I
I
I'
!
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I
Return mailing labels are enclosed for your use in returning these documents,
4
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Enclosures
,....
THE
SETTLEMENT
LAW GROUP
~
ATTOINITI AT LAW
Please feel free to call for assistance at 1-800-790-1877, It will assist us greatly
in answering your questions if you identify your Claim Number whenever you call or write us,
Since we are sending this letter and enclosures to thousands of eligible claimants, please be
patient if our line is busy, We look forward to assisting you with questions you may have,
Very truly yours,
David M, Higgins
Special Settlement Counsel
~
5
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FACTOR CONCENTRATE LITIGATION
RELEASE
FOR CLAIM NUMBER(S): 80003107
FOR HIV-POSITIVE PERSON: BURNS, TIMOTHY W. (DECEASED)
THIS RELEASE (hereafter the "Release") is entered into as of the date of the last
signature below by and between all individuals who have signed this Release (including but not
limiled to all Releasors identified on Exhibit A attached), (these individuals, including all
Claimants and other members of the Claimant's Group, collectively referred to as "Releasors")
and ALPHA THERAPEUTIC CORPORATION, GREEN CROSS CORPOR..l"TION OF
A.l'v1ERICA and THE GREEN CROSS CORPORATION (collectively, "Alpha"), ARMOUR
PHARMACEUTICAL COMPA.l'\"{, RHO!\TE-POULE~C RORER INC. (collectively,
". '" D' v~-R 'J- ~'~HC \ D- CORPOD \ -10", dB ^ ""'-R ""~-R'" -10" \ L
.""1..."1'110Ur ).~.'-\J\.1'::' nt..~.L...l .'""\....[\..::. I'\..........1:" ::m .'""\..."-.l.!: l~'\.i"::' _'....\1 .".u...
INC. (collectively. "Baxter"; which shall also refer to Travenol Laboralories, Inc.. and Hyland
Therapeutics, a division of Baxter Healthcare Corporation), BAYER CORPOR..l"T10N and
BAYER A.G. (collectively, "Bayer"; which shall also refer to Cutter Laboratories. Inc" Cutter
Laboratories. a division of Miles. Inc.. Miles Laboratories, Inc., Miles, Inc. and Miles Inc,)
[Alpha. Armour. Baxter and Bayer are hereafter referred to as the "Fractionators" or "Released
Parties"). Releasors and Released Parties are colleclively referred to as "the Parties."
WHEREAS, some or all of Releasors may have certain claims arising under their
own individual suits (if any) against one or more of the Released Parties and/or any purported
class actions including. but not iimited to, the class action suit styled Walker \'. Baver Com.. et
al.. filed in the United Slates District Court for the Northern District of II1inois. as Civil Action
No, 96C 5024 (these individual and class actions collectively referred to as the "Litigation"); and
WHEREAS, the Litigation agains; Released Parties seeks damages allegedly
sustained by one or more of Releasors as a result of an alleged infection with the HIV virus and
other viruses related 10 plasma factor concentrates and derivalives used for the treatment of
hemophilia during Ihe period 1978 Ihrough 1985 (hereafter "FaClOr Concentrates") processed or
distributed by any or all of the Released Parties (hereinafter referred 10 as the "Incident"); and
WHEREAS, Released Parties have denied and continue to deny that they have
any liability to Releasors as a result of the Incident or with respect to any claims asserted in the
Litigation; and
WHEREAS. the government of the United States of America, certain relevant
state governments, and certain private health insurance providers have agreed to release certain
rights those governments or insurers have or may have had 10 reimbursement/subrogation from
Releasors and Released Parties for payments made on behalf of any ofReleasors to medical
treaters through Medicare, Medicaid and/or certain other federal and state funded health care
plans and private insurance programs; and
WHEREAS, the Parties, having been provided with notice of and agreeing with
and accepting the terms and provisions of the Factor Concentrate Litigation Settlement
Agreement (the "Agreement" with the terms as defined therein being applicable in this Release)
BURNS, TIMOTHY w. (OECEASEOJ/8000310711013191/PENNSYLVANIA
rev 9197
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approved by The Honorable Judge John Grady in the Litigation currently pending in the United
States District Coun for the Nonhem District of Illinois, Eastern Division; and
WHEREAS, Releasors, voluntarily and with full knowledge of their rights and the
provisions of this Release, and having had the opponunity to obtain the benefit of the advice of
counsel, now wish to settle, compromise, and dispose of the above-described claims and the
Litigation, and any other claims that they have Or might have against Released Parties related to
the Incident upon the terms and conditions set forth below; and
WHEREAS, in the absence of a fully executed Release from Releasors, Releasors
will nol receive payment under the Agreement or be entitled to any of the other benefits of the
settlement. Furthem10re, Releasors acknowledge that as to a Claimant or Claimant Group
member who does nOI sign this Release and who pursues a lawsuit against the Fractionators
related to the Incident. the Fractionators may assert. and a court may decide. that any such
lawsuit is barred by the failure of the '-Iaimant o. Claimant Group member to exdude himself
from the settlement (10 "opt out") prior to October 15, 1996; and
WHEREAS, Released Parties, without any admission ofliability, now desire to
settle, compromise, and dispose of the above-described claims and the Litigation upon the terms
and conditions sel fonh below.
NOW, THEREFORE, in consideration of. and intending to be legally bound by,
the above premises and Ihe mutual covenants, as well as in consideration of the Settlement
Consideration set fonh below, the Panies enter into the following agreement:
I. Releasors, for themselves, and their heirs, personal representatives.
common law and statutory beneficiaries, survivors, successors, subrogees and assigns do hereby
forever remise, release, acquit, and discharge Released Parties, and all of their present and former
corporate parents. subsidiaries, affiliales, partners and joint venturers, as well as all suppliers to
Released Parties and distributors for Released Panies, as well as all directors, officers,
employees, agents. shareholders, insurers and counsel of each of the foregoing as well as their
predecessors and successors, from any and all causes of aClion and damages (including without
limitation damages for emotional injuries), and olher liability or relief of any nature whatsoever,
past, present or future, whether known or unknown, foreseen or unforeseen, whether in law or in
equity, that Releasors ever had, now have, or hereafter may have, by reason of or arising out of
any maller, cause, or event occurring on or prior to the date of this Release, arising out of or in
any way relating to the Incident. It is expressly understood and agreed by Releasors that this is
a full and final release of all malleI'S whatsoever relating to the Incident as to Released Parties
and is intended to and does embrace not only all known and anticipated damages and injuries,
but also unknown and unanticipated damages, injuries, or complications that may later develop
or be discovered, including all effects and consequences thereof.
2, It is the intention of the Parties and is understood by Releasors that this
Release will forever bar Releasors and anyone claiming through them from maintaining any
action or claim whatsoever against any and all Released Parties which arose or which might arise
in the future from any acts, omissions, agreemeills, or other occurrences relating to the Incident.
BURNS. TIMOTHY w. (DECEAsEoya0003107110131971PENNSYlVANIA
rev 9197
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The Parties intend that Released Parties obtain through this Rclease total and final peace,
satisfaction and protection from any liability arising from any and all claims of Releasors and
anyone claiming through them, whether or not previously asserted, and from any and all claims
for joint tort feasor liability, contribution or indemnity, including claims by any subrogees or
assignees of any of Releasors, asserted by any person or entities arising from the Incident or
which was or could have been asserted in the Litigation, The Parties further intend to exercise
their best effom to obviate the necessity and expense of Released Parties appearing in and
defending any action commenced by any of the Releasors and anyone claiming by or through
them asserting claims against any other person or entity arising from the Incident, or which could
have been asserted in the Litigation. (Such other unreleased persons or entities are hereafter
referred to, along with all subrogees and/or assignees ofReleasors, as "Third Parties".)
3. The intent of the Parties is to protect Released Parties 10 the maximum
extent possible, from any liabilily for contribution or indemnification claims that might
otherwise be assf-:ed by Third Parties wilo have been sued or may in the fmure be sued by
Releasors for the Incident. The effect of this Rc;lease shall be to reduce any judgment obtained
by any Releasor against any such Third Party by the amount of the consideration paid under this
Release, or the percentage or share of liability assigned 10 any or all of the Released Parties,
whichever is greater. This provision is specifically designed to bar, discharge and/or release
under the applicable law any claims for contribution or indemnificalion againsl Released Parties
arising from or related 10 the claims. In the event that any Releasor obtains a judgment against a
Third Party and such Third Party obtains a judgment over, in whole or in part, against one or
more of Released Parties for contribution or indemnification arising from the claims, then
Releasors will be required 10 reduce or remit any judgment or portion thereof obcained from the
Third Parties by Ihe amounl of the judgment over against Released Parties. To the extent a
judgment oblained against any Third Party for the Incident would result in the imposition of
liability for contribulion or indemnification against the Released Parties, Releasors agree not to
enforce any such judgment. In the event Releasors reach a settlement with Third Parties,
settlement documents between Releasors and Third Parties shall provide Ihat the Third Parties
relinquish any claims for contribution or indemnification for the Incident against Released
Parties.
4. Excepl as sel forth in Paragraph 5 below, Releasors reserve the right to
assert claims against all'l'hird Panies, including any of the non-released defendants in the
Litigation. and reserve also the right to assert claims that those Third Parties. and not the
Released Parties, are solely liable for damages arising from Ihe Incident.
5. Releasors agree to waive, release, and discharge any and all rights they
may have to assert claims, causes of action, and administrative or other proceedings arising out
of Claimant's use of Factor Concentrates, as defined in the Agreement, including, but not limited
to, the use, administration, regulation, processing, and distribution of Factor Concentrates,
against Ihe United Stales of America, ils federal employees, representatives, agents, agencies,
and instrumentalities, and each and every individual State, Commonwealth, Territory or
Possession which by agreement with the Fractionators has released its claims against Releasors
to reimbursement and subrogalion related to the Agreement. Releasors do not, however, waive
BURNS. TIMOTHY W, (OECEASED)/B0003107l10f3197/PENNSYLVAN1A
rev 9/97
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any rights that they may have to any entitlement or right to compensation which may be provided
after May I, 1997 by the legislature of any state. federal or other government.
6. As consideration for this Release, Released Parties will provide as
described under Paragraph 7 below compensation to Releasors collectively in one of the
following ways: (i) in the amount of One Hundred Thousand Dollars ($100,000) or in such
lesser amount as Releasors may be entilled to receive under the Agreement paid to the Total
Control Account for Releasors; or (ii) in periodic payments that shall have a total cost to
Released Parties of One Hundred Thousand Dollars ($100.000) or such lesser amount as
Releasors may be entitled to under the Agreement; or (iii) in the amount of One Hundred
Thousand Dollars (5100,000) or such lesser amount as Releasors may be entitled to receive paid
to the trustee of an "A" or "C" special needs trust for the benefit of Releasors; or (iv) in some
combination of (i). (ii) and (iii) having a total cost to Released Parties of One Hundred Thousand
Dollars (5100,000) or such lesser amount as Releasors ma\' be entitled to receive under the
Agreement (such lu:-np-sum amount and such cost of periodic payments. or such combination
thereof, are hereinafter referred to as the "Settlement Consideration"),
The Settlement Consideration provided by the Released Parties to the
Releasors as set forth in Ihis Paragraph is not being credited to the account of any Releasor nor
being set apart for the Releasors. nor otherwise made available to Releasors so that they may
draw upon it at any time. Ralher, Releasors' receipt of such Ihe Settlement Consideration is
conditioned upon the certificalion by Special Settlement Counsel that appropriate documentation.
including this Release, has been provided by, or on behalf ofReleasors to that Special Settlement
Counsel. along with court approvals where necessary.
7. Released Parties shall pay Ihe Settlement Consideration in accordance
with the terms of the Factor Concenlrale Litigalion Settlement Grantor Trust (hereinafter the
"Settlement Grantor Trust"). This Release shall be effective with respect to the Releasors upon
the first to occur of the following Iransfers:
a) The transfer from Metropolitan Life Insurance Company, as issuer
of a guaranteed interest contract ("GIC") owned by the Settlement Grantor Trust, to a Total
Control Account@ for the benefit of Ihe Releasors of the sum of One Hundred Thousand Dollars
(5100,000) or such lesser amount as Releasors may be entilled to receive under the Agreement,
plus interest thereon in accordance wilh the terms of the Settlement Grantor Trust.
b) The transfer from (i) MetLife Trust Company, National
Association, as trustee of the Setllement Grantor Trust, to Metropolitan Insurance and Annuity
Corporation of the sum of One Hundred Thousand Dollars (5 I 00,000) or a lesser amount in
accordance with the terms of the Agreement for a Qualified Assignment Agreement and Release,
and (ii) to Metropolitan Life Insurance Company, as issuer of a guaranteed interesl contract
("GlC") owned by the Settlement Grantor Trust, to a Total Control Account@ for the benefit of
the Releasors, of the excess of the amount to which Releasors are entitled under the Agreement
over the amount Iransferred under (b )(i), and the interesl on the amounts transferred under (b )(i)
and this (b )(ii) in accordance with the terms of t.he Settlement Grantor Trust.
BURNS. TIMOTHY W. (DECEASEOjI8000310711013197IPENNSYLVANIA
rev 9/97
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c) The transfer from MetLife Trust Company, National Association,
as trustee of the Sctllcment Granlor Trust, to MctLife Trust Company, National Association, as
trustee of the "A" or "C" trust for the benefit of the Releasors, of the sum of One Hundred
Thousand Dollars ($ 1 00,000), or such lesser amount as Releasors may be entitled to under the
Agreement, plus interest thereon in accordance with the terms of the Settlement Grantor Trust.
8. Payment of the Settlement Consideration pursuant to the terms of
Paragraph 7(a), (b) or (c) above constitutes full and final settlement payment to Releasors.
Following such payment, no further payment or consideration of any kind in connection with the
termination and settlement oflhe Litigation is contemplated or required by Releasors. Released
Parties bear no responsibility or liability for any failure on the part of the Special Settlement
Counsel and/or the Trustee of the Settlement Grantor Trust to properly allocate among members
of a Claimant Group or distribule the Settlement Consideralion. The execution of this Release
by Releasors is a material inducement to the Released Panies in paying the Settlement
Consideration pu~'suant to the tem!s o~ the A..gree:-ne:1t :.lnd,'or the Rele~se.
9, The Panies agree 10 execute any and all required supplemental documents
and to take all steps which may be reasonably necessary to give full force and effect to the terms
of this Release and to effecI dismissal of all claims and actions against Released Panies,
including the Litigalion.
10. Except as otherwise set fonh in the Agreement, the Panies shall bear their
respective costs and attorney fees. The monetary obligations of Released Parties to Releasors'
attorneys are expressly limited to the court approved costs and fees as set forth in the Agreement.
11. Releasors represent and warrant that they have full power and authority to
make, execute, and deliver this Release, and that to their knowledge and belief no other
individual related to the Releasor has a claim against Released Panies arising out of the Incident
related to the undersigned Releasors or which could have been raised in the Litigation, which is
not here released,
12. Releasors represent and warrant thai they have not sold, transferred,
conveyed, assigned, or hypothecated any of their rights. either collectively or individually. in
whole or in part, in any of the matters released herein.
13. Releasors represent and warrant that they have had an opportunity to
consult attorneys of their own choice to advise them fully of their rights under Ihis Release and
the meaning and effects of this Release and that if any Releasor has not consulted an attorney,
that Releasor has knowingly and voluntarily elected not to do so.
14, Releasors represent and warrant that they understand that il is their
decision and their decision alone whether or not to sign this Release. Releasors further represent
and warrant that in agreeing to the tem1S of this Release, they have not relied on any finding of
the fairness of the terms of the Agreement and/or Ihis Rdease by any Coun, including any
determinations made by the Court in the Walker v. Baver Corp. et. al action in the United States
District Court for the Northern District of Illinois or in the MDL proceedings pending in that
BURNS, TIMOTHY W. (DECEASED)/B0003107110l3l97/PENNSYLVANIA
rev 9191
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same Court. Rather, Releasors have reached their own deeisions as to the fairness of the
Agreement and this Release in consultation with counsel of their choice or have voluntarily
elected not to consult with such counsel. Releasors also represent and warrant that they are not
relying on the Court's order barring the filing or pursuit of individual claims and they would
agree to the tenns of this Release even if the Agreement were not part of a class settlement but
rather a eompletely private settlement.
15, Releasors represent and warrant that to their knowledge and belief, there
are no liens or claims of any kind which have not been discharged by a prior agreement and
which could be assened or made against the Settlement Consideration or against Released Parties
as a result of any HIV - or AIDS-related medical treatment provided to any Releasor, other than
those private or public subrogees who have agreed to waive their claims and are identified in the
notice sent with this Release to Releasors, If there are any such outstanding liens, Releasors
agree to satisfy those liens from the Settlement Consideration.
16, Ifany provision or any pan of any provision of this Release shall for any
reason be held 10 be invalid, unenforceable, or contrary to public policy or any law, then the
remainder of this Release shall not be affected, provided Ihat the portion which is held invalid,
unenforceable, or contrary to public policy or law does not constitute a material pan of the
consideration of one of the Parties,
17, Releasors state that they have carefully read this Release. have signed it as
their own free act, and intend to be legally bound thereby. This Release is not subject to any
assenion of mistake offact or law.
18, Releasors declare and understand that no promises, inducements, or
agreements not herein expressed have been made to them and that this Release contains the entire
agreement among the Panies hereto and that the tenns of this Release are contractual, and not a
mere recital. Releasors further represent that they are under no legal disability material to their
ability to execute this Release.
19, In conjunction with the signing of this Release, Releasors shall also
execute the medical reJe~se attached as Exhibit B to this Release ("the Medical Release") which
wiII authorize the release of certain medical records necessary for the finalization of the
settlement. The Medical Release shall be subject to all of the strict confidentiality provisions of
the Agreement, and wiII be used for no other purpose than the implementalion of this settlement.
20. Because this Release applies to persons throughout the United States, to
ensure unifonnity in interpretation and to take advantage of a highly developed body of law
familiar to the court presently presiding over In re Factor VIII or IX Concentrate Blood Products
Litigation, MDL-986, No, 93-C7452 (N.D. 111.) and Walker v. Baver Corp. et a!., No. 96C 5024
(N,D, II!.), which has jurisdiction over al1 of the Panies, this Release was negotiated with counsel
in those cases and shall be construed and interpreted in accordance with the laws of the State of
IlJinois (excluding Il1inois choice ofIaw rules).
BURNS. TIMOTHY w. (CECEASED)/S0003107/1013197/PENNSYlVANrA
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rev 9197
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21, This Release may be executed in counterparts, each of which is to he an
exact copy of the original Release ami each of which shall constitute an original, and all of which
shall constitute one and the same instrument. This Release shall become effective and binding,
subject to all conditions set forth herein, when it has been executed, in counterparts or otherwise,
by all Releasors,
IN WITNESS WHEREOF, and intending to be legally bound hereby, the
) . ~
BURNS. TIMOTHY w. (DECEASEOVB0003107/1013197IPENNSYLVANrA
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rev 9197
Releasors have executed this Release as of the date of the last signature,
PLEASE READ ENTIRE AGREEMENT BEFORE SIGNING
Releasors
Signature
I, the undersigned, a notary public in and for said county
in said slate, hereby certify that
whose name is signed to the foregoing Factor
Concentrate Litigation Release and who is known to me,
acknowledged before me on this date, thaI helshe had the
opponunity to read the Release. and being informed of
lhe contents of the same. heishe exccutcd the same
\'oluntJrily on this date.
:"ame (Print or Type)
Social Security Number
DJt~ Signed
Notaty Public
Stale of
My Commission Expires:
Signarure
I. the undersigned, a notary public in and for said county
in said state, hereby certify that
whose name is signed to the foregoing Factor
Concentrate Litigation Release and who is known to me,
acknowledged before me on this date, that he/she had the
opponunity to read the Release, and being informed of
the contents of the same, he/she executed the same
voluntarily on this date.
Name (Print or Type)
Social Security Number
Date Signed
Notary Public
Slate of
My Commission Expires:
BURNS, TIMOTHY w. (OECEASEOY80003107J1013197IPENNSYLVANIA
rev 9197
- 8 -
Signature
~
I, the undersigned, a notary public in and for said eounty
in said stale, hereby cenify that
whose name is signed to the foregoing Factor
Concentrate Lingatlon Release and who is known to me,
acknowledged before me on this dale, thai he/she had the
opponunity to read the Release, and being informed of
the contents of the same, he/she executed Ihe same
voluntarily on this date.
Namc (Pnnt or Type)
Social Security Number
Dale Signed
SlJ;r:.::mue
Notary Public
Slale of
My CommiSSion Expires:
1. th~ und::rsIgned. ~ no:ary publi~ in and fa:, SJid :ount)'
in said stme, hereby cenify that
whose name is signed to the foregoing Faelor
Concentrate Liligation Release and who is known 10 me,
acknowledged before me on this dale, Ihat helshe had the
opportUni~' 10 read the Release, and being informed of
the contenlS of the same. he/she executed the same
voluntarily on this date.
Name (Pnnt or Type)
Social Security Number
Date Signed
Notary Public
State oi
My Commission Expires:
BURNS, TIMOTHY W. (OECEASED)/B0003107/10f3/97fPENNSYlVANIA
rey9/97
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4, Deceased Parent(s) ofHIV-positive person who were living when the HIV-
positive person died.
Write in the names of any deceased parents who died AFTER the HIV positive
person died (even if the name is pre~printed above), or write "none,"
"
J.
All Brothers and Sisters ofa deceased HIV-positive minor BUT ONLY if the
HIV. positive person was a minor at the date of death AND at that date resided in
one of the following states:
Alabama
Alaska
California
Delaware
Iowa
Louisiana
Massachusetts
Nebraska
Nevada
New Mexico
North Dakota
Ohio
South Dakota
Utah
Fill in name(s) (even if the name is ~re-printed above), or Wnte "none,"
Instructions for Signing the RELEASE
All Claimant Group Members identified above must sign the RELEASE.
· Living HIV-positive person:
· If an adult, then that person must sign the RELEASE.
· If a minor, then the parent (or, if there is no parent, the guardian) must sign,
Guardians must submit a certified copy of the judicial appointment as guardian,
BURNS, TIMOTHY W. (OECEASEDVB0003107/1012197/PENNSYLVANIA
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· Deceased HIV-positive person:
. The judicially-appointed legal representative (administrator or executor) must
sign the RELEASE and submit a certified copy of the appointment.
· Spouses:
· Living spouses must sign the RELEASE,
· Deceased spouses: The judicially-appointed legal representative (administrator or
executor) of deceased spouse must sign and submit a certified copy of the
appointment. or call David Higgins' office to request a waiver of the required
signature,
· If obtaining the signature of a spouse presents unusual circumstances, call David
Higgins' office.
. Children of the HIV-positive person:
. All living adult (over the age of majority) children of the HIV-positive person
must sign the RELEASE.
. If the living HIV-positive person signs the RELEASE, then no additional
signature is required for any minor child of the HIV -positive person,
. If the HIV-positive person is deceased, the surviving parent (or. if there is no
surviving parent, the legal guardian) of a living minor child must sign on behalf of
each such minor child. Guardians must submit a certified copy of the judicial
appointment as guardian.
. If the child ofan HIV-positive person died afierthe HIV-positive person's death,
call David Higgins' office to request a waiver of the requirec signature,
. Parents of the HIV-positive person:
. All living parents oflhe HIV-positive person must sign the RELEASE.
. If the HIV positive person (or the judicially-appointed legal representative of the
HIV-positive person's Estate) signs the RELEASE. then no additional signature is
required for any deceased parent of the HIV-positive person EXCEPT those
identified in Item #4 above. If the deceased parent is identified in Item #4 above,
call David Higgins' office to request a waiver of the required signature.
.
The following instruction applies ONL Y if the deceased HIV-positive person was a
millor at the date of death AND at that date resided in one of the states listed in Item
#5 (Alabama, Alaska, Califomia, Delaware, Iowa, Louisiana, Massachusells,
Nebraska, Nevada, New Mexico, North Dakota, Ohio, South Dakola. Utah).
.
Brothers and sisters of the HIV-positive person:
· All adult brothers and sisters of the deceased HIV -positive person must sign the
RELEASE.
BURNS, TIMOTHY W. (DECEASEO)J80003107/1012197/PENNSYLVANIA
-4-
I ., .
A
· The parent (or, if there is no parent, the legal guardian) ofeaeh minor brother and
sisler must sign on behalf of each minor brother or minor sister. Guardians must
submit a certified copy of the judicial appointment as guardian.
· If a brother or sister of an HIV -positive minor died after the death of the HIV.
positive minor, call David Higgins' office to request a waiver of the required
signature.
*
*
*
*
*
*
We understand that there may be some <;ircumstances where it will be extraordinarily
difficult - ifnot impossible - to obtain all of the required signatures. In those
circumstances, please contact David Higgins' office 10 explore possible alternatives.
The phone number of David Higgins' office is: 1/800/790-1877.
The above information contained in this Exhibil A to the RELEASE,
including the additional names listed and confirmation that there is no
one else in those categories, is true, complete and correct. I declare and
verify under penalty of peIjury that the foregoing is true and correct. (28
V.S.C. ~ 1746)
Exe~uted on [date:] November 6
,19 97
Print Name: Robert T _ Ru~h
Signature: ~,L..-~~
BURNS. TIMOTHYW. (OECEASED)/B0003107/1012197/PENNSYLVANIA
-'5 -
~.' '
I. I' .
The RELEASE must be signed in accordance with "Instructions for Signing the
RELEASE" set forth below. If you believe'that any of the pre-printed information is
incorrect or if you want to request a waiver of a required signature, please call
David Higgins' office (Phone: 1/800/790-1877).
If you know of any other members of your Claimant Group in any of the
following categories, you need to write down their names. They also must sign the
RELEASE in accordance with the "Instructions for Signing the RELEASE" set forth
below. If you do not know of any additional persons, then you must write "none" on the
appropriate blank line. THERE MUST BE SOME RESPONSE FOR EACH
CATEGORY BELOW.
1. Spouse(s) of HI V-positive person:
None
Fill in name(s), or write "none," or write "all listed above"
2. All Children of HI V-positive person:
None:
Fill in name(s), or write "none," or write "all listed above"
3. Living Parent(s) ofHIV-positive person:
Mother is deceased. The HIV-positive person was illegitimate and his
father was never legally determined and is unknown.
Fill in name(s), or write "none," or \yrite "all listed above"
BURNS. TIMOTHY W. (OECEASEOVB0003107/10121971PENNSYLVANIA
COUft(n
~FiPAFir
- 2-
C(l~NTERPART
. ,
constitute one and the same instrument. This Release shall become effective and binding, subject to all
conditions set forth herein, when it has been executed, in counterparts or otherwise, by all Releasors,
IN WITNESS WHEREOF, and intending to be legally bound hereby, the
Releasors have executed this Release as of the date of the last signature.
PLEASE READ ENTIRE AGREEMENT BEFORE SIGNING
Rele:Jsors
~ ~ ~ !, the undersigned, a nolary public in and for said county
Signarure in said Sl:1te, hereby certify that Robert I. Bush
~"'N>T"t T l'lll~h. ('n-Rxecutor of the whose name is signed to the foregoing Factor
Name (Print or Type) Est. of Karen'L. BushConcentr:lte Litigation Rele3Se:md who is known to me.
162-36-9137 DQc..:ilioo acknowledged befote me on this date, tlw.t he/she had the
Socia! Security Number opporronity to read the Rele3Se, and being infonned of
J '1. '5 I C; 7 the contents of the same, heishe executed the same
Date'Signed voluntarily on this date.
'-1\ lL' c ,-,', L.,/ "\.
Nolary Puhlic
Slate of __.c.. i...
My Commission Ex
L... 0- t.-.I'-..
es'--' MOT , ~ \
MAU~o;:N "" ~",.4. .",,1.:., ?1Ja I ~
Low... Paxton Twp., DauphIn Co., P"
f) j/ J /} "" C::lmmlulon Elq>iret March 20, 2OCO
~ 0 ~...-t4 I, the undmigned, a .. ,.. .or sala county
Signarure / in said Sl:1te, hereby certify that Donna J, Keckler
Donna J. Keckler, Co-Executor of thEl,yhose name is signed to the foregoing Factor
Name (print or Type) Est. of Karen L. _ Concentmte Litigation Rele3Se :md who is known to me.
171-46-9156 Bush, Decease<:: ac:c::owiec'l~d ':o:;m::::e on ~'i: .:!:;" 'bt heishe had the
- .. " "~-,"~,_'I""~"I -.'" ...."_U' :1'!~ ~"."_"'~"'... ._....,; 'o"_'-~= lIU' 'onn-d ot-
.:;t:.~:::'i .;c:c::;::'/ ~ il.:.....::.:r:: . ..4., ... __.. __ '-... ...
i,r, !::::-: c; '~'.I the contents of the same, he/she executed the same
D~e ;Signed voluntarily' on this date.
1\ '\-
'-i L.Q'-'...U,_L>I- YJ., (,~.L.-,r--..
Notary Public . '
State of-Pc..C- L-\~) OLC<>'- LLn.
My Commission Expires:
NOTARlAl. su,L
IAAURl!EH X. BltAHH. Hot<Iry \lIJbll4
Lower Paxton Twp.. Dauphl~ C~I' p~
My Commlulon !xpl... March 20, 2000
yuao3/u7
{jC,jv w'S
LAW OFFICES
FRIEDMAN & 1I0ell, p.e.
306 NOfUIl FRONT STREET
SUITE 402
P.O. BOX BB6
HARRISBURG. PENNSYLVANIA 1'110R-0886
CHARLES E, FRIEDMAN
KENNETH D, HOCH
June 9, 1998
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Re: Estate of Karen L. Bush
Dear Sir/Madam:
TELEPHONE (111) 2]2.9925
FAX (111) 2]2.9946
I am enclosing an Inventory and two copies of an Inheritance
Tax Return for the above estate.
Charles E. Friedman
CEF/bw
cc: Mr, Robert I. Bush
Ms. Donna J. Keckler
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF JNOIYIDUAl TAXES
OEPT 280601
HARRISBURG. PA 17128.0601
.
NO. AA 2 i 0191 REV II., EX ('....,
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
RECEIVED FROM:
r
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
CHARLES E FRIEDMAN ESQUIRE
POBOX 885
HARRISBURG, PA 17108
1 nl
~~17~1 1-.4
FOlDHEnE
ESTATE INFORMATION:
FILE NUMBER
21-1997-0754
NAME OF DECEDENT (LAST)
BUSH KAREN I
DATE OF PAYMENT
FOLD HERE -
SSN 204-40-52/,4
(FIRST)
IMI)
POSTMARK DATE
6/10/1998
COUNTY
CUMBERLAND
DATE OF DEATH
TOTAL AMOUNT PAID
$5,751,64
cw
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REMARKS CHARLES E FRIEDMAN ESQUIRE
RECEIVED BY //"r,', I C;,
.,
MARY c. LE.111 S
REGISTER OF WILLS
sEA~HECK# 431
fiicGlsn:n Of' WILLS
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
nEPT. Z&D6Dl
HARRISBURG, PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
'EV~U41 n UP l"-'m
r
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
08-24-1998
BUSH
01-17-1997
21 97-0754
CUMBERLAND
101
KAREN
L
~
CHARLES F FRIEDMAN ESQ
305 N FRONT ST
PO BOX 885
HARRISBURG PA 17108
AMount Rellitted
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 ~
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COMMONWEALTH OF PENNSYLVANIA
OEPAHTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT280G01
HARRISBURG, PA 17128-0601
d>~
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO, AA 296589 fl'V.l162 EX (1'96)
RECEIVED FROM:
I
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
FRIEDMAN CHARLES E
FRIEDMAN & HOCH P C
POBOX 885
HARRISBURG, PA 17108-0885
101
!>7/' 7::1
fOlD HERE
FOLD HERE -~
ESTATE INFORMATION:
FILE NUMBER
21 1997-0754
NAME OF DECEDENT (LAST)
B H KAREN L
DATE OF PAYMENT
SSN 204 40-5264
(F)RST)
(Mil
POSTMARK DATE
8/25/1998
COUNTY
CUMBERLAND
DATE OF DEATH
TOTAL AMOUNT PAID
$76,73
REMARKS CHARLES F FR I EDMAN ESO,
SEALCHECK# 123
r"EGISlER or' WILLS
:::-::---------. _.- ~-- -- - ---- ~- --- ------ -- - - ---------- --------~._--_--...:
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
~REAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128.0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT. ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUItBER
COUNTY
ACN
08-24-1998
BUSH
01-17-1997
21 97-0754
CUMBERLAND
101
Allount Re.11 tted
CHARLES F FRIEDMAN ESQ
305 N FRONT ST
PO BOX 885
HARRISBURG PA 17108
*
1...114111." f".n.
KAREN
L
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 ...
iiEY:isitj-EX-"FP-ioij':97riiciiicE--OF-YHHEifiTANCE-TAin-ppiiAisEiiEiii"~--"ll-oWANCE-iiR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BUSH KAREN L FILE NO. 21 97-0754 ACN 101 DATE 08-24-1998
TAl< RETURN WAS: I I ACCEPTED AS FILED I XI CHANGED SEE ATTACHED NOTICE
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Reel Estete (Schedule AI
2. Stocks IIl1d Bonds ISchedule BI
3. Closely Held stock/Partnership Interest (Schedule C)
4. Hortgages/NotMs Receivable (Schedule DJ
5. C.sh/8ank Deposits/Misc. Personal Property (Schedule EJ
6. Jointly Owned Property ISchedu1e FI
7. Transfers (Schedule G)
8. Total Assets
III
121
131
(41
151
(6)
(7)
,00
.00
.00
.00
103,353.01
.00
.00
181
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule Xl
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. N.t Value of Estate Subject to Tax
I~ an assessment was issued previoUSly, lines 14, 15 and/or 16, 17 and 18 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. ^-ount of Line 14 .t SpouSB1 r.te 1151
16. Am~t of Line 14 taxab1D at Lineal/Class A rate (16)
17. AMount of Line 14 taxable .t Collateral/Class B rate (17)
18. Princip.l rax Due
NOTE:
TAX CREDITS:
PAYHENT
DATE
04-17-1998
06-10-1998
RECEIPT
NUHBER
WRITEOFF
AA270191
DISCOUNT 1+)
INTEREST/PEN PAID I-I
.00
.00
9,295.30
3.520.95
Ill)
1121
1131
(141
(91
(10)
26,873.52 X .00=
42,198.41 X .06=
21.464.83 X .15=
1181
AHOUNT PAID
258.55
5,751.64
BALANCE OF UNPAID INTEREST/PENALTY AS OF 06-11-1998 TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax paYllenta
103,353,01
1;>,816 ;><;
90,536.76
.00
90,536.76
.00
2,531. 91
3,219.73
5,751.64
t
f
t
t
5,751.64
.00
76.73
76.73
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
I IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. I
RESERVATION: Estllt.. of declldents dying on or before Dee...r 12, 1982 -- If IIflY future interest in the estllte is tr....f.rrad
in poiseS' Ion or enjo~t to Clllss B (collllterlll) beneficiaries of tho decedent efter the expiretlon of any estllte for
life or for yeer., the eo.onwealth hereby expressly raserves thG right to IIPpre1se end assess transfer Inherltllnce Taxes
lit the lewful Cless B (collateral) rete on any .uch future interest.
PURPOSE OF
NOTICE:
To fulfill the raquire.ants of Section 2140 of the Inheritance and Estate Tax Act, Act 21 of 1995, (72 P.S.
Section 9140).
PAYMENT:
Detllch the top portion of this Notice and sut.it with your PBYMnt to the Register of 'U11s printed on the reverse side.
--HIlke check or .aney order payable to: REGISTER OF MILLS, AGENT
REFlIOJ (CR):
A refund of a tax credit, which was not requested on the Tax Return, .ay be requested by c~leting an "Appl1C11tion
for Refund of Pennsylvania Inheritance and Estate Tax" (REY~1313). AppliClltions are available lit tho Office
of the Register of Wills, any of the 23 Revenue District Offices, or by calling the special 24~hour
answoring service nu.bors for for.s ordering: In PennSYlvania 1~800~362~2050, outside Pennsylvania IInd
within local Harrisburg Brea (717l 787-8094, TDD' (717) 712~2252 (Hearing I~aired Only).
OBJECTIONS: Any party in interest not satisfied with the IIpprais..ent, IIllowance or disallowance of deductions, or assas~nt
of tax (inclUding discount or Interest) liS shown on this Notice .ust object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Depart.ent of RevonuG, Board of Appeals, Dept. 281021, HarriSburg, PA 17128~1021, OR
-~R1ect1on to have the ntter deter.ined at audit of the account of the personal representative, OR
--appeal to the Orphans. Court.
ADMIN
ISTRATIYE
CORRECTIONS:
Factual errors discovered on this 8SSeSs.ent should be addressed in wrIting to: PA Depart.ent of Revenue,
Bureau of Individual Taxes, ATTN: Post ASS8ss..nt Review Unit, Dept. 280601, Herrisburg, PA 17128~0601
Phone (711) 781-6505. Soe page 5 of the booklet "Instructions for Inherltenca Tux Return for 0 Resident
Decedent" (REV~1501) for an explanation of e~inistr8tively correctable errors.
DISCOUNT:
If any tax due is peld within three (3) celendar ~nths ofter the decedent.s death, a five percent (S~) discount of
the tex paid is allowed.
PENALTY:
The 15~ tax 88nOsty non.perticipation penalty is co.puted on the totol of tho tax and interest assessed, end not
paid before Januery 18, 1996, the first dey ofter the and of tho tax aanesty periOd. This non~participation
penalty is appealable in the s8lle .enner end in the the s8lle ii.e period as you would appeel the tax and interest
that has been essessed as indicated on this notice.
INTEREST:
Interest is charged beginning with first dey of delinquency, or nine (9) .onths ond one (1) day fro. the date of
death, to the date of pe~ent, Taxes which becaae delinquent before Januery 1, 1982 bear interest at the rllte of
six (67.) percent per en~ calculoted at a deily rate of .000164. All taxes Mhich beceee delinquent on and after
Januery 1, 198Z will baar interest at a rate which will vary fro. calendar year to calendar year with that rate
announced by the PA Depertaent of Revenue. The applicable interest rates for 1982 through 1998 lire:
'!!!r Interest Rate Daily Interest Factor ~ Interest Rata Dally Interest Factor
1982 20~ .000548 1987 91- .000247
1983 16:': .000438 1988-1991 11Z .000301
1984 11Z .000301 1992 97. .000247
1985 137- .000356 1993.1994 TI. .000192
1986 107- .000274 1995~1998 9Z .000241
~-Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Hotlce issued ofter the tax boco.es delinquent will reflect an interest celculotion to fifteen (15) deys
beyond the dete of the IIsses...nt. If pa~ent is aade after the interest co.putotion date shown on tho
Hotice, additionel interest aust be calculoted.
,
/b' ;)0,)-9
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
'*
BUREAU OF INOIUIOUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURC, PA 171Z8~D601
In.ln1U'" UJ.U'
CHARLES F FRIEDMAN ESQ
305 N FRONT ST
PO BOX 885
HARRISBURG PA 17108
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
09-28-1998
nUSH
01-17-1997
21 97-0754
CUMBERLAND
101
KAREN
L
Allaunt R...l tt.d
-i
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE. PA 17013
NOTE: To insure proper credit to your account, sub.it the upper portion of this for.. with your tax pay..ent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS .....
ii"Ev:i60TEX-AFii-m-:97r-----iiiiii-iNHEiii'fANCE-;:;.X"sriifEiiEN;:-OF-;.Ccouiif--iiiii------------------- --
ESTATE OF BUSH KAREN L FILE NO. 21 97-0754 ACN 101 DATE 09-28-1998
THIS STATE"~NT IS PROVIOED TO AOVISE OF THE CURRENT STATUS OF THE STATED ACH IN THE NAHED ESTATE. SHDWN BELOW
IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE. AND, IF APPLICABLE.
A PRDJECTEO INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 08-17-1998
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
04-17-1998 WRlTEOFF .00 258.55
06-10-1998 AA270191 .00 5,751.64
08-25-1998 AA296589 76 .73- 76.73
TOTAL TAX CREDIT
5,751.64
INTEREST AND PEN.
.00
.00
BALANCE OF TAX DUE
TOTAL DUE
.00
. IF PAlO AFTER THIS OATE, SEE REVERSE
SIDE FDR CALCULATION OF AODITIONAL INTEREST,
( IF TOTAL DUE IS LESS THAN $1,
ND PAYHENT IS REQUIREO,
IF TOTAL OUE IS REFLECTED AS A "CREOIT" (CRI,
YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FDRH FOR INSTRUCTIONS. I
PAYJEHT:
Detach the top portJon of thJs Notice and sub.it with your pay.ant .ade payable to the na.e and addre..
printed on the rever.e .Ide.
If RESIDENT DECEDENT .ake check or .,ney order payable to: REGISTER OF WILLS, AGENT.
If NOH-RESIDENT DECEDENT .ake check or .oney order payable to: COMMONWEALTH OF PENNSVLVANIA.
REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, .ay be requested by co.pleUng en
-application for Refund of Pennsylvania InheritancG and Estate Tax" (REY-1313). Applications are available at
the Office of the Regi.ter of Wills, any of the 23 Rovenue DIstrIct OffIces or fr~ the Depart.ent"s 24-hour
an....ring service ~ors for for.s ordering: In Pennsylvania 1-600-362-2050, outside Pennsylvania
end withIn local Harri.burg arua (717) 767-6094, TDDI (717) 772-2252 (HearIng I.paired only),
REPLY TO:
Questions regarding errors contained on this notice should be addressed to: PA Depart.ent of Revenue, Bureau
of Individual Taxes, ATTN: Post Assess.ent Review Unit, Dept. 280601, HarriSburg, PA 17128-0601, phone
(717) 767-6505.
DISCDUNT:
If any tax due is paid within three (3) calendar .onths after the decedent's doath, a five percent (5~) discount
of the tax paid is allowed.
PENALTY:
The 15~ tax ..nesty non-participation penalty is co.puted on the total of the tax and interest assessed, and not
paid bofore January 18, 1996, the first day after the end of the tax a.nesty periOd.
INTEREST:
Interest is charged bQginning with first day of dOlinquency, or nino (9) .onths and one (1) day fro~ the date of
death, to the date of pay..nt. Taxes which boca.e delinquent before January 1, 1982 bear interest at tho rate of
six (6Z) percent per annum calculated at a dally rate of .000164. Ail taxes which beca.o delinquent on and after
January 1, 1982 will bear interest at a rate which will vary fro. calendar yellr to calendar year with that rate
announcod by the PA Depart.ent of Revenue. The applicablo Interest rates for 1982 through 1998 are:
\/ear Interest Rate Dally Interest Factor
Daily Interest Factor
Vear
Interest Rate
1982 207- .000546 1987 9Z .000247
1963 167- .000438 1968-1991 117- .000301
1984 117- .000301 1992 9% .000247
1985 13i! .000356 1993-1994 n .000192
1986 10% .000274 1995-1998 9Y. .000247
--Interest is calculetod os follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
M-Any Notice issued after tho talC beco.lIs delinquent will reflect an interest calculation to fifte.n US) days
beyond the date of the ft5Ses..ent. If payment is .ado after the interest co_putation date shown on the
Notice, additional interest .ust be calculated.