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Home My WebLink About01-17-08 --.J 15056051058 REV-1500 EX (06-05) PA Department of Revenue '*' Bureau of Individual Taxes . PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY ~O~~ty~ode Year 21 06 File Number 1035 Date of Birth 175-40-5713 10/03/2006 01/22/1952 Decedent's Last Name Suffix Decedent's First Name MI Wagner Stephen J (If Applicable) Enter Surviving Spouse's Information Below Last Name Suffix MI J 178-40-8147 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C8:l 1. Original Return c:::) 2. Supplemental Return c:::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c::) 4. Limited Estate c:::) c:::) 4a. Future Interest Compromise (date of death after 12-12-82) c:::) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c:::) 10. Spousal Poverty Credit (date of death c:::) 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE ~CTED TO: NameDaytirneTelep~eNumberg . i (717) 232-4~ ( .. :._'_:.'::-::.--:.::'::-:-:---:':':-:::::~:~::3'~:{d:::::'. .~::~:~~:-. REGISTER O"--$-\.s USe.eNLY .' - .--; -oJ 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received mQ 8. Total Number of Safe Deposit Boxes Michael Cherewka, Esq Firm Name Law Offices of First line of address <) J ~._) !( .1 624 North Front Street Second line of address L:...:..; __J _..~ 1'-) or Post Office DATE FILED ZIP Code Wormleysburg 17043 Correspondent's e-mail address:mcestateplanlaw@earthlink.net Under penalties of pe~ury, I declare 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. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG ATURE OF 0 RE PONSIBLE FOR FILING RETURN DATE . 71 i;)~:;)f..e -0 Y) ,.~4 17v ~ {' ADDRESS (, Ztj II./. ~f :5~ DATE 12-ZI,-61 tuPYIl1u.,s~ P.q /7rJll3 PLEASE E ORIGINAL FORM ONLY L 15056051058 Side 1 15056051058 --.J --.J 15056052059 REV-1500 EX Decedent's Social Security Number w..........__..._......._.._......_.__......._..............__.....'..'...".._..__.__,.,..""..".......... Decedent's Name: Stephen J Wagner 175-40-5713 RECAPITULATION .._-"->>--~~~~-~~....,.-~-~---~~-~"~ 1. Real estate (Schedule A). ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 95,940.00 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Properly (Schedule E) . . . . . . .. 5. 6. Jointly Owned Properly (Schedule F) c=> Separate Billing Requested. . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (Schedule G) c=> Separate Billing Requested. . . . . . .. 7. 4,325.27 0.00 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 99,265.27 14,179.78 0.00 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10).... . ...... . .... . ...... ............ 11. 14,179.78 85,085.49 0.00 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subjectto Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal lax rate, or transfers under Sec. 9116 (a)(1.2) X .0 00 16. Amount of Line 14laxable at lineal rate X.O 45 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14laxable at collateral rate X. 15 85,085.49 15. 0.00 16. 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 68.77 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT c=> L 15056052059 Side 2 15056052059 --.J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME Stephen J Wagner STREET ADDRESS 424 South York Street iEi!9J!lIm!l.t.L .._m_~.~~._.~~ .1035 DECEDENTS SOCIAL SECURITY NUMBER 175-40-5713 CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 68.77 0.00 0.00 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) 0.00 Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2.72 0.00 A. Enter the interest on the tax due. (5A) (5B) 2.72 0.00 68.77 2.72 71.49 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 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 [i] b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 [i] c. retain a reversionary interest; or.......................................................................................................................... 0 iii d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 iii 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 [i] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [i] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 [i] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent [72 P.S. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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 zero (0) percent [72 P.S. 99116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to orforthe use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-9W COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF Stephen James Wagner FILE NUMBER 21-06-1036 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 424 South York Street, Mechanicsburg, Cumberland County, Pennsylvania VALUE AT DATE OF DEATH 94,940.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert addKional sheets of the same size) 94,940.00 REV-1503 EX+ (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Stephen James Wagner FILE NUMBER 21-06-1035 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH Ameriprise Account #00065191314-7-021 10,125.00 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 10,125.00 --"-'1;..,.",_",,;,-- ~.'-Y_"_' ' '-""1'-- ~ .-eb Mail Printable Message ~l('D)~~ ~--co 00(20264958 8 021 IRA - beneficiary designated 00(33286063 4 021 IRA - beneficiary designated 00C65191314 7 021 Individual - TOO Am0riprise ONE Financial Account Account Number Ownership 00020263869 8 021 Joint Tenancy With Right Of Survivorship Ameriprise Brokerage Account Acc::mnt Number 00020264958 8 021 00033286063 4 021 00065191314 7 021 Total Value $126,028 .15 ~NO ft..l-.F<U- $16,577.68/ $10,125.00 Ameriprise ONE Financial Account Acc,)unt Number 00020263869 8 021 Total Value $20,753.92 The date of death values provided are for estate tax. purposes and are not a value to be paid. Accounts may be subject to market fluctuation as governed by each product. Please note that thevalues indicated for any Life Insurance product(s) reflect the1gross death benefit at date of death, not the cash value. Values for any proprietary mutual funds include accrued dividends as app:.icable. Values provided for brokerage .products are manuaHycalculated, and should be used as estimates only. The prices used to_provide values are esLmates obtained from outside sources believed. to be reliable . Ameripiise . Financial provides these values as a service to. its:clien.ts. Actual values used in preparation of tax returns or for planning purposes should be verified by your legal and accounting advisors. We c.ppreciate the opportunity to be of service to you'. Please contact us if you have any questions. Sincerely, Jim Mattacola Death Settlements Processing Team 70100 Ameriprise Financial Center Minneapolis, MN 55474 1-800-862-7919, Option 5,1 (Embedded image moved to file: pic21538.jpg) (Embedded image moved to file: pic16118.jpg) (Emb':!dded image moved to file: pic02082. jpg) (Emb,~dded image moved to file: pic22929.jpg) > > > > > > > > Jame~; E Mattacola I Claims Analyst Estat:e Settlements Client Account Administration Ameriprise Financial Services 7010C Ameriprise Financial Center I Minneapolis, MN 55474 http://webmail.pas.earthlink.net/wam/printable.jsp?msg~d= 1 0363 7&x=~ 116580566 Page 2 of3 08/09/07 REV-1507 EX+ (6-98) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF Stephen James Wagner FILE NUMBER 21-06-1036 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. None VALUE AT DATE OF DEATH 0.00 TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed. Insert additional sheets of the same size) 0.00 REV-1508 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Stephen James Wagner FILE NUMBER 21-06-1036 Include the proceeds of Inigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. 1993 Ford Tempo GL Sedan, Fair Condition 350.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert addnional sheets of the same size) 350.00 .... .~~~ . ...... advertisement .. Send to Print 1993 Ford Tempo GL Sedan 4D BLUE BOOK~ TRADE-IN VALUE - advertisement - Condition Value Excellent $600 Good $500 ." Fair $350 (Selected) Average Consumer Rating (2 Reviews) Read Reviews ....'tJ 4 out of 5 Review This Vehicle Vehicle Highlights Mileage: Engine: Transmission: Drivetrain: 100,000 4-Cyl. 2.3 Liter Automatic FWD Selected Equipment Standard Air Conditioning Power Steering AM/FM Stereo Blue Book Trade-In Value Trade-in Value is what consumers can expect to receive from a dealer for a trade-in vehicle assuming an accurate appraisal of condition. This value will likely be less than the Private Party Value because the reselling dealer incurs the cost of safety inspections, reconditioning and other costs of doing business. Vehicle Condition Ratings Excellent Ul'lf.'I'YJIU $600 "Excellent" condition means that the vehicle looks new, is in excellent mechanical condition and needs no reconditioning. This vehicle has never had any paint or body work and is free of rust. The vehicle has a clean title history and will pass a smog and safety inspection. The engine compartment is clean, with no fluid leaks and is free of any wear or visible defects. The vehicle also Close Window http://www.kbb.com/KBB/UsedCarslPricingReport.aspx?ManufacturerId= 15& Y earId=1993& Ve... 7/25/2007 has complete and verifiable service records. Less than 5% of all used vehicles fall into this category. Good axD''} $500 "Good" condition means that the vehicle is free of any major defects. This vehicle has a clean title history, the paint, body and interior have only minor (if any) blemishes, and there are no major mechanical problems. There should be little or no rust on this vehicle. The tires match and have substantial tread wear left. A "good" vehicle will need some reconditioning to be sold at retail. Most consumer owned vehicles fall into this category. ." Fair (Selected) 8f.10;';;;; $350 "Fair" condition means that the vehicle has some mechanical or cosmetic defects and needs servicing but is still in reasonable running condition. This vehicle has a clean title history, the paint, body and/or interior need work performed by a professional. The tires may need to be replaced. There may be some repairable rust damage. Poor N/A "Poor" condition means that the vehicle has severe mechanical and/or cosmetic defects and is in poor running condition. The vehicle may have problems that cannot be readily fixed such as a damaged frame or a rusted-through body. A vehicle with a branded title (salvage, flood, etc.) or unsubstantiated mileage is considered "poor." A vehicle in poor condition may require an independent appraisal to determine its value. Kelley Blue Book does not attempt to report a value on a "poor" vehicle because the value of cars in this category varies greatly. * Pennsylvania 7/25/2007 http://www.kbb.com/KBB/UsedCars/PricingReport.aspx?ManufacturerId=15& Y earId=1993& Ve... 7/25/2007 REV-1509 EX+ (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Stephen James Wagner 21-06-1035 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SCHEDULE F JOINTLY-OWNED PROPERTY SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Mary J. Wagner 424 South York Street Mechanicsburg, PA 17055 Spouse B. Henry Philip Wagner 424 South York Street Mechanicsburg, PA 17055 Son C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 07/12/02 PSECU Savings Account #8805027284 1,504.17 50% 752.09 2. A 07/12/02 PSECU Checking Account #8805027284 396,71 50% 198.36 3. A 01/14/85 PNC Bank, Savings Account #5030065115 3,693.05 50% 1,846.52 4. A 1 0/28/93 PNC Bank, Savings Account #5080016899 4,584.90 33% 1,528.30 5. A Ameriprise Account #00020263869-8-021 20,753.92 50% 10,376.97 TOTAL (Also enter on line 6, Recapitulation) $ 14,702.24 (If more space is needed, insert additional sheets of the same size) -...'''.",;:l'',-,.~ ,.. ~,"" .~" .,.~ , eb Mail Printable Message ~~)~~ ~---co 00C20264958 8 021 IRA - beneficiary designated 00C332.86063 4 021 IRA - beneficiary designated 00C65191314 7 021 Individual - TOO Ameriprise ONE Financial Account Account Number Ownership 00020263869 8 021 Joint Tenancy With Right Of Survivorship Ameriprise Brokerage Account Acc::mnt Number 00020264958 8 021 00033286063 4 021 00065191314 7 021 Total Value $126,028 .15 ~fo.tO JU-.f<U- $16,577.68 / $10,125.00 Ameriprise ONE Financial Account Acc)unt Number 00020263869 8 021 Total Value $20,753.92 The date of death values provided are for estate tax-purposes and. are n~t a valCle to be paid. Accounts maybe subject to market fluctuation as governed by each product. Please note that the values indicated for any Life Insurance product(s) reflect the' gross death benefit at date of death, not the cash value. Values for any proprietary mutual fund$,include accrued dividends as app.icable. Values provided for brokerage .products . are manually CflJ,culated; ,and should be used as estimates only. . The prices used to provide values are esLmates obt.ained from outside sources be~ieved_ to. be:r:e.liable.Ameripiise. Financial provides these values as a service to its clients. Actual values used in preparation of tax returns or for planning purposes should be verified by your legal and accounting advisors. We c.ppreciate the opportunity to be of service to you'. Please contact us if you have any questions. Sincerely, Jim Mattacola Death Settlements Processing Team 70lCO Ameriprise Financial Center Minneapolis, MN 55474 1-800-862-7919, Option 5,1 (Embedded image moved to file: pic21538.jpg) (Embedded image moved to file: pic16118.jpg) (Embedded image moved to file: pic02082.jpg) (Emb=dded image moved to file: pic22929.jpg) > > > > > > > > Jame~, E Mattacola I Claims Analyst Estat:e Settlements Client Account Administration Ameriprise Financial Services 70100 Ameriprise Financial Center I Minneapolis, MN 55474 http://webmaiLpas.earthlink.net/wam/printable.jsp?rnsgi4=10363 7 &x=-116580566 Page 2 of3 08/09/07 , DEC. 13. 2007 2:08PM I NO. 976 p, 2 t~J~~ December 13, 2007 J\cco~t*SS05~ MICHABL CHBRBWKA 624 NORTH FRONT ST WORMSLEYSBiJRG, P A 17043 V1A FACSIMlLB 717-232-4774 Dear MR. CHERE'WKA The following is the status of STBPHEN 1. WAGNER's account with PSECU as of the date of death. Joint Owner's Name Date orDeath Date orBUth MAllY JANB WAGNER-ADDED 07,12.2002 AS JOINT TENANT WIROS 10.03.2007 01.22.1952 Share SOl S04 DescriptioD Regular Shares Checking Open date 07.12.2002 08.07.2002 Balance $1,504.07 395.70 Accrued Dividend $0.10 0.01 The dividend eamed from January 1. 2007 tb:ro\lgb the date of death was $20.30. The decedent had no loans with us. We do not have safe deposit boxes for our medlen. If yon have any questions, please call 234-8484 in HmisbW'g 01 Ow toU-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, ~AJ~J" :e~:J) 1 Menber Service Repre.seDtative Finance Support Unit Pannsylvcmia Slote Employees Credit Union i Mgjn Addl'tu; 1 Credit Uniol1 PIQ~, HorrisbvTg, PA 17110.2990. 717.234.8484 . 800.237.7323 I 'i}.__m_- ___~____~ailin9. Addl'lu; P.O. Box 67013~~!9u~ PA 17106.7Q.!.!.:.!.17.777.21 00 tTP-PJ..:. 800.472.1967 .lIP.~ ~ T~is credit \,Inion i$ fQqQ1'\l11y iMufed by 1111 NmioAaI Credit Union AdrninlslrclHon. EQlJCll Opporlvnily lender ww\V.pHClI.com Dec. 11. 2007 2:27PM PNC BANK 412-705-2747 ~ PNCBAN< The Thinkll'lg Behind The Money Deeember II, 2007 Law Offices of Michael Cherewka Attn: Leslie 624 N Front St WonnJeysburg, PA 17043 RE: Stephen James Wagner (Deceased) SSN: 175-40-5713 000: 10.03-2006 Dear Sir or Madam: No, 6825 p, 1/1 In response to your request for Date of Death balances for the customer noted above, our records show the following: Savings Account Aecount# 5030065115 STEPHEN JAMES WAGNER MARY J WAGNER DOD balance: $3,692.94 + 0,11 aeemed interest Account /I 5080016899 HENRY PHILIP W AGJ\TER STEPHEN J W AGJ\'ER MARY JWAGNER DOD balance: $4,584.75 + 0.15 accrued interest Established 01-14-1985 E..qablished 10-28-1993 P1ellse note that this office only provides date of death balances for deposit accounts (IRAs. CDs. Checking and Savings accounts). We do Dot process aay tinaaeial tralllllCtioas or provide statements. If you need assistance with any of these items, please calI1-88S.PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, ~ ~.~dv/. Colleen Crowder 1-800-762-177S P7 -PFSC-04-F 500 Pirst Ave Pittsburgh, PA 15219 Page 1 ofl Member FDIC REV-1511 EX+ (12-99. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Stephen James Wagner FILE NUMBER 21-06-1035 Debts of decedent must be reported on Schedule L ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Myers Funeral Home, Inc. Weis Markets, Funeral Reception 5,049.40 176.79 2. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City . State Zip Year(s) Commission Paid: 2. Attomey Fees 2,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's. attach explanation) Claimant Mary J. Wagner Street Address 424 South York Street 3,500.00 City Mechanicsburg State PAZip 17055 Relationship of Claimant to Decedent Spouse 4. Probate Fees 249.00 5. Accountant's Fees 2,500.00 6. Tax Return Preparer's Fees 0.00 7. Legal Notices - The Sentinel and Cumberland Law Journal 204.59 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 14,179.78 Myers Funeral Home, Inc. Boyd L. Myers Jr.. Supervisor 37 East Main Street Mechanicsburq, Pennsylvania 17055 (717) 766-3421 105 Fax (717)795-7291 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are only for those items that you selected or that are required. Ifwe are required by law or by a cemetery or crematory to use any items, we will explain in writing below. If you selected a funeral that may reqUIre embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as direct cremation or immediate burial. Ifwe charge you for an embalming, we will explain why below. For Services of Stephen James Wagner Charge to Mary J. Wagner Name A. CHARGE FOR SERVICES SELECTED: 1. PROFESSIONAL SERVICES Services of Funeral Director and Staff Embalming Casketing, dressing, cosmetology Other Preparation of body Hairdresser / Barber Autopsy Remains SUB-TOTAL PROFESSIONAL SERVICES 2. USE OF FACILITIES AND SERVICES For visitation / wake service $ For funeral ceremony $ For memorial service $ Equipment & services for graveside servi~ $ , $ SUB-TOTAL FACILITIES AND EQUIPMENT 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home Hearse (Casket Coach) Flower Car / Floral Distribution Family Car Lead Car / Clergy Car Utility Car Out of town transportation $ $ $ $ $ $ $ $ SUB-TOTAL AUTOMOTIVE EQUIPMENT TOTAL SERVICES, FACILITIES, AUTOMOBILE B. CHARGES FOR MERCHANDISE SELECTED Casket $ Other Receptacle Cardboard Cremation $ Outer Burial Container $ Acknowledgment Cards $ Register Book $ Memorial Folders $ Prayer Cards $ Temporary Grave Markers $ Burial Clothing $ Other Clothing $ Cremation urn $ Temporary $ $ Date Of Death 424 South York Street Address $ $ $ $ $ $ $ 1895.00 95.00 $ $ $ $ $ $ $ :--$ $ $ SUB-TOTAL OF CASH ADVANCED D $ We charge you for our services in obtaining the following: NONE October 3, 2006 Date of Contract Mechanicsburg, Pa. Clly State C. SPECIAL CHARGES Forwarding Remains to other Funeral Hom~ $ Receiving Remains form other Funeral Hom~ $ Immediate Burial $ Direct Cremation $ $ SUB- TOTAL OF SPECIAL CHARGES D. CASH ADVANCED Opening Grave/Crypt Newspaper Patriot Newspaper Clergy / Mass Offering Certified Copies of Death Certificate 24 Family Flowers Coroner's Authorization Fee Transporation Organist 17055 Zip C$ 325.40 . 125.00 100.00 144 25.00 80.00 100.00 899.40 SUMMARY OF CHARGES TOTAL ABOVE ITEMS (A,B.C.D) $ 5,049.40 Sales Tax (if App) @ % $ 0.00 TOTAL OF ALL SECTIONS $ LESS: Payment Made $ LESS: Credits Pending . $ LESS: Credits granted Package Price Discount $ BALANCE DUE Jan 30,0001 $ 5,049.40 A late charge of 1.5% per month on the outstanding balance (annual rate of 18%) will be added to the balance. 1,815.00 3,234.40 REASON FOR REQUffiED SERVICES OR MERCHANDISE I DISCLAIMER OF WARRANTIES Our funeral home makes no representations or warranties regarding caskets or outer burial containers. The only warranties, expressed or implied, granted in connection with goods sold with the funeral service are the express written warranties, if any, extended by the manufacturer thereof. No other warranties including the implied warranties of merchantability or fitness for particular TOTAL MERCHANDISE SELECTED B $ 245.00 purpose are extended by the seller. I agree that I have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requested. I acknowledge receipt of a copy of this Statement of Funeral Goods and Services Selected. I represent that I have sufficient funds available for payment of the cash price for the goods and services selected. I also agree to make payment of $ 3234.40 within 30 days. I agree to be jointly and severally liable with anyone else who signs below. A LATE CHARGE of 1.5% per month (18% per annum) Will be applied to the unpaid balance beginning 30 days after the date of this contract. I will also pay the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts I owe under tnis agreement. Those costs may include attorney fees and court costs. Any items requested after the date of this agreement will be considered part of this agreement and will be reflected on tne final bill. (Seal) Purchaser (Seal) Purchaser Al$ 1,990.00 525.00 450.00 395.00 A2 $ 1,370.00 350.00 195.00 A3 $ A$ 545.00 3,905.00 150.00 95.00 1 25, 21):)7 ; (;: i 3t~;'/ 7q 69' 970C 11.('111 ""\111 I n~~ ';IHltif1l1l'J WI \'., 1\~lImll'. 1I1'J', l'III:!IIlNldllIIlUj. (lll i:: I ~ [i I I.,." IJII 'oI'lllNIJ wi I IlliI it Ill) ,1110; "I'lil! 1:1 J" I ! ,~1I' I, ~m 1llltlNl,l illll ~I{'I llHlll'll.! "tll WI! '..1'1/[ NI, ,II II II (I ',I 111M III1 tllJIIHi 'II I I I; ~l', 1'\ II i" , \ r~ I Nil \ IlId "II,' ,'ullI! It. 1'1 If I I 11'<1,) ~II."I' f'1 ill: ( Ii I I. ,J I iiI, 1'1 III II U lHX 7.11 RRL i\C 2558 p,'j ~e WI. '). <19 r iJCI t;'; il lJe 1 i,cJ Ii <1i)')'1 \ I Vlll:i hJnera l fuep+l(.'vt €f-Pe nC e ~ ill'" " ~ .: Ii Ill',,: '1'\ I) lJ hi: I '.ll't ,. lIlI.. Cd"!' U1AN(JE ~el~ ~lub 5~vi~w~ folal. ','Ilur 101,,1 !;j1vi"!f:\ nre 1.33). )(JI U'J/1Jl, .\" i1l'1 i'I"')\;)(. liOOf, " I,IJ 'I i, 'J :\ 'b 1'1 'Jl) I I;! . 'j'j r b I 'I') 0 'j IJ 'I 'J II \'(6. '('J 1[\0.00 :I.ZI ,2.'S!; 2 ~ll "nl WI I , Mil" ~ 'I: I I'll, ~, Mill(IU. r 'J ~1Ii1.1l\ 1111 '.MIl ',', tin i I r.Il'; I j I I" I I". \. I I) I I II I'll I I i I I I.' I 11. II t I wi"- J~, J :jjlNlt 1,11111 J N~J r'I"!~Jtil{I't'1! ~Ii! IH; lItlt r te,l) litH! ITlIWd I. ~ J r' i t ,Ir/l: I. \1 p 1 ! I , , 2 r ;" "': '. U ' J' 201) 7 i;): 13 AM 717 691 9700 h 2558 F 13 RECEIPT FOR PAYMENT ------------------- -------------~----- GLENDA FARNER STP~SBAUGH Cumberland Cduntv - Reqister Of Willa One Courthouse S~uare - Carlisle, PA 170'13 Rece pt Date: Rece ot Time: Rece pt No. : 11/21/2006 16:12:36 1046431 WAGNER STEPHEN JAMES Estate F'ile No. : Paid By Remarks: 2006-01035 MARY WAGNER JA Fee/Tax Description PETITION LTR8 ADM AUI'OMATION FEE SHORT CERTIFICATE JCP FEE Receipt Dlstribution ------------------------ Payment Amount Payee Name 210.00 CUMBERLA}Tn COUNTY GENERAL FUN 5.00 CUMBERLAND COUNTY GENERAL Ft~ 24.00 CUMBERL~~DCOUNTY GENERAL FUN 10,00 BUREAU OF RECEIPTS & CNTR jl.1. D Check# 131 Total Received ~249.00 :;;249.00 iJ~L ~,. ..... .~.....< ~"~:S , ' , ! i~ I it I' ,.j' I ;.iiI : ,f,}. ~.~ ". ",11# '+ -. ~ - - .. - - - ,... . . - - - t 'I t - :) .4 .it <{ a.. C> 0:: ::> CO (/) - 0::: c:: <( J: ~~ (,f en (j C) (\I to r-i z c:( ..., ~ 0- I ,.... 1'0 ....... <( 0.. CO ~ :J ~ (I) J::: .... .... '" .....c .- II >> ,. .. - . I , . .. II .."....... 41 ''I'i~. ... ~ f{If I II " .- III j' I - " . ~ II I j - ,_) I "Lr),fS !J'. . v'.; '- . ('\~~ .-' t[}.tI to... .'" - ~ ,.., i ' ,I I T'12, C', <lJ Ul ;:J o ..c .j.J ~ ;:J o U<lJM ~...... Ul >'C\lO r-i.j.J;:Jr-.. r-i ~ t::r...... OM ;:J Cf) ~ 0 U<lJ<j 4-l Ul P-< o '0 ;:J ., ~ 0 " ... C\l..c <lJ <lJr-i.j.Jr-i .j.J ~ ~ Ul Ul <lJ ;:J OM OM ,0 0 r-i OOI3U ~ <lJ;:J C\l o=:U......U Law Offices of Michael Cherewka 624 North Front Street Wormleysburg, Pennsylvania 17043 (717) 232-4701 (717) 901-3770 Fax (717) 232-4774 December 26, 2007 C) -'.;H (.".. --.l Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, P A 17013 ~~. r-0 RE: Estate of Stephen J. Wagner Our File No. 2606.00 Enclosed please find Original and one copy of REV 1500, Inheritance Tax Return for Resident Decedent, Inventory and check No. 420 in the amount of $71.49 representing payment of the Pennsylvania Inheritance Tax, Interest and Penalty in the above referenced Estate. Also enclosed is check #419 in the amount of $25.00 to cover the cost of filing the Inventory and the Return. We have enclosed a copy of the front page of the return and a copy of the Inventory. We ask that you time-stamp the copies and return them to us in the enclosed stamped envelope. If you have any questions, please call the undersigned. Thank you for your consideration in this matter. Happy Holidays, '-fI'k-~ (fJ/u'iiuff:J l Michael Cherewka..:~-}X-- .( , MCIlI Enclosure