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HomeMy WebLinkAbout06-02-0815056041147 REV-1500 EX 06 05 ( - ) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes county rode Year File Number PO 60X.280601 INHERITANCE TAX RETURN 2 1 0 8 0 0 0 9 2 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 183 12 1672 O1 04 2008 05 15 191~i Decedent's Last Name Suffix Decedent's First Name MI FORTENBAUGH DOROTHY M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DIUPLICATE WITH THE REGISTER OF VNILLS FILL IN APPROPRIATE OVALS BELOW X^ 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ qa. Future Interest Compromise ~ 5. 1=ederal Estate Tax Retum Required (date of death after 12-12-82) 6 Decedent Died Testate ~ (Attach Copy of Will) ~ Decedent Maintained a Living Trust 1 8. 'total Number of Safe De osit Boxes (Attach Copy of Trust) p 9. Litigation Proceeds Received ~ 1 p. Spousal Poverty Credit (date of death 11.1=lection to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) ~ I;Attach SCh. 0) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytilme Telephone Number EDMUND G. MYERS (7:L7) 761 4540 Firm Name (If Applicable) JOHNSON, DUFFIE, STEWART & First line of address 301 MARKET STREET Second line of address PO BOX 109 City or Post Office State ZIP Code LEMOYNE PA 17043 Correspondent's a-mail address: RE131STER OF WILLS USE ONLY r`J G7 © CJC ~ ~7 C... t`r1 ~ ~ C rn C t ?~~ ~ DATT 3 T -_, ~~; _~ ~-=~3 .~ j Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. S NA UR F PERSON RES NSIBL~E Ff~ FILING R N DATE . l~~ ~%z ~ RICHARD A. FORTENBAUGH S~ jC3- U g 213~ALL OAK DRIVE, New Cumberland, PA 17070 IG T RE OF Pf~EP/,~ gT)iER THAN REPRESENTATIVE EDMUND G. MYERS 301 MARKET STREET, Lemoyne, PA 17043 ~,~o ~ Side 1 15056041147 15056041147 J 15056042148 REV-1500 EX Decedent's Social Security Number oecedenrSName: DOROTHY M. FORTENBAUGH 1. 8 3 12 16 7 2 RECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 1,234.28 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 3. 4. 5. 6. 7. 8. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)........ Mortgages & Notes Receivable (Schedule D) ........................................................ Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............ Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............ Total Gross Assets (total Lines 1-7) ...................................................................... .. 3. .. 4. . 5. . 6. . 7, . g• 1,322,442.80 $ 9 , g 4 5 7 3 1 , 4 13 , 5 2 2 8 1 9. Funeral Expenses & Administrative Costs (Schedule H) ........................................ . 9. 70,740.19 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. .. 10. 8,647.79 11. Total Deductions (total Lines 9& 10) .................................................................... .. 11. 7 9, 3 8 7 9 8 12• Net Value of Estate (Line 8 minus Line 11) ........................................................... .. 12, 1 , 3 3 4 , 13 4 . 8 3 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................ . 13. 5 , 0 0 0 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................ . 14• 1 , 3 2 9 , 13 4 8 3 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, of transfers under Sec. 9116 (a)(1.2) X .00 0 0 0 15. 0 0 0 16. Amount of Line 14 taxable 1, 3 1 9, 13 4 8 3 at lineal rate X .045 16. 5 9, 3 6 1 0 7 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 0 0 0 18. Amount of Line 14 taxable at collateral rate x .15 1 0, 0 0 0. 0 0 18. 1, 5 0 0. 0 0 19. Tax Due .................................................................................................................... . 19. 6 0, 8 6 1. 0 7 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 15056042148 151]56042148 J REV-1500 EX Page 3 norarlant's Cmm~lete Address_ File Number 21-08-00(192 DECEDENT'S NAME DOROTHY M. FORTENBAUGH STREET ADDRESS MESSIAH VILLAGE CITY STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 60,861.07 2. Credits7Payments A. Spousal Poverty Credit g, Prior Payments 56,000.00 C. Discount 0.00 Total Credits (A +8+~) (2) 56,000.00 3. InteresUPenalty if applicable D, Interest E. Penalty Total InteresUPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 4, 861.07 q, Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) t~ ~ $ s ~ . Q 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 :.................................................................................. ^ b. retain the right to designate who shall use the property transferred or its income :.................................... ^ 0 c. retain a reversionary interest; or .................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? .............................................................. ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...................................................................................................................... ~ ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or heir death?......... ^ 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...................................................................................................................... ~ ^ 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, 1 y54 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. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use: of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)J. The statute does not exemat a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent,. whether by blood or adoption. ~ a ~OOp~ Last Will and Testament of DOROTHY M. FORTENBAUGH I, DOROTHY M. FORTENBAUGH of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, ~iereby revoking and making .void any and all Wills or Codicils at any time heretofore made by me. ARTICLE I DEBTS AND TAXES I direct the payment of my legally enforceable debts and the expenses of my last illness from my Estate as soon after my death as conveniently may be done. I direct that all taxes that may be assessed as a consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my Estate. ARTICLE II SPECIFIC BEQUESTS A. I give and bequeath the sum of F IVE THOUSAND DOLL~:I:S ($S,COO.CO) u:lto my friends, ROBERT ORMSBEE and LEE ANN ORMSBEE, 4134 Venus Avenue, Hamsburg, Pennsylvania, provided at least one of them survives me; B. I give and bequeath the sum of FIVE THOUSAND DOLLARS ($5,000.00) unto my friends, KENNETH L. SHOAFF and NANCY SHOAFF, 4424 Venus Avenue, Hamsburg, Pennsylvania, provided at least one of them survives me; and C. I give and bequeath the sum of FIVE THOUSAND DOLLARS ($5,000.00) unto GOOD SHEPHERD LUTHERAN CHURCH, 3200 Rutherford Street, Harrisburg, Pennsylvania. ARTICLE III TANGIBLE PERSONAL PROPERTY I give and bequeath my automobile(s), household and personal effects and other tangible personalty of like nature (not including cash or securities), together with any existing insurance thereon, unto my son, RICHARD A. FORTENBAUGH, provided he sun~ives me. ARTICLE IV REST, RESIDUE AND REMAINDER I give, devise and bequeath all the rest, residue and remainder of my Estate, of whatsoever nature and wheresoever situate, in equal shares, one unto my son, RICHARD A. FORTENBAUGH, and one unto each one of my grandsons, BRIAN R. FORTENBAUGH, SCOTT M. FORTENBAUGH and ANDREW R. FORTENBAUGH, subject to the provisions of Article V. ARTICLE V TRUST FOR THE BENEFIT OF BENEFICIARY UNDER THE A(SE OF THIRTY. If, at the time of my death, a beneficiary has not achieved the age of thirty (30), I give and bequeath the share of such beneficiary unto LeTORT MANAGI~MENT & TRUST COMPANY, in SEPARATE TRUST, to hold, manage, invest and reinvest the share so received, and to distribute the income at least as often as quarterly unto such beneficiary, and to use and apply so much of the principal as, in Trustee's discretion, may be necessary or appropriate for such beneficiary's support and education (including post-graduate and professional education), taking into account such beneficiary's other readily-available resources, or to make payment for these purposes without further responsibility to sucf~ beneficiary. When such beneficiary shall achieve the age of thirty (30) years, Trustee shall dislribute the balance of principal unto the beneficiary, at which time the trust as to that beneficiar~r shall terminate. In 2 the event any beneficiary dies before receiving his final distribution hereunder, the Trust as to that beneficiary shall terminate and the balance of principal shall be paid to or in trust for such persons or organizations -other than such beneficiary's estate, his creditors, or the creditors of his estate - as the beneficiary may appoint by will containing a specific reference to this power. Any principal not effectively appointed by such beneficiary shall bf~ distributed to such beneficiary's then-living issue, per stirpes, or if there be a failure of same, then unto my surviving grandsons or their then-living issue, per stirpes, as the case may be. If any beneficiary to whom Trustee is directed to distribute a share of Trust principal is, in the sole opinion of my Trustee, incapable of properly managing his own affairs, his share shall then vest in interest in him indefeasibly, but the Trustee shall continue to hold such beneficiary's share in further TRUST, with all of the powers granted to it as Trustee herc;in, and with authority to use both income and principal for the beneficiary's health, education, maintenance and support until in the Trustee 's sole judgment no further incapacity exists, at which time Trustee shall distribute such share to the beneficiary absolutely. ARTICLE VI SPENDTHRIFT PROVISION I direct that the interest of the beneficiaries shall not be subject to anticipation or to voluntary or involuntary alienation. ARTICLE VII POWERS OF PERSONAL REPRESENTATIVE AND TR'.USTEE My Personal Representative and Trustee shall have the following :powers in addition to those vested in them by law and by other provisions of my Will applicable to all property, whether principal or income, including property held for minors, exercisable without court approval and effective until actual distribution of all properly: A. To make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as they may determine. B. To retain any or all of the assets of my estate, real or personal, without restriction to investments authorized for Pennsylvania fiduciaries, as they deem proper, without regard to any principle of diversification or risk. 3 C. To invest in all forms of property without restriction to investments authorized for Pennsylvania fiduciaries, as they deem proper, without regard to any principle of diversification or risk. D. To sell at public or private sale, to exchange, or to lease for any period of time any real or personal properly and to give options for sales, exchanges or leases, for such prices and upon such terms or conditions as they deem proper. E. To allocate receipts and expenses to principal or income or partly to each as they from time to time think proper. F. To compromise any claim or controversy. a G. To make such elections, decisions, concessions and settlements in connection with all income, estate, inheritance, gift, generation skipping or other tax refunds and the payment of such taxes as my Personal Representative and/or Trustee sh~dl deem appropriate, without obligation to adjust the distributive share of any person thereby affected. H. To combine, without prior court approval, any Trust contained in my Will with any other Trust with substantially similar provisions, although such Trust may have been created by separate instrument. I. To resign any time, for any reason whatsoever, without court approval. ARTICLE VIII COlYIPENSATION Trustee shall be entitled to reasonable compensation for its service;, in accordance with its standard schedule of fees as may be adjusted from time to time w~ule the services are performed hereunder. 4 ARTICLE IX PERSONAL REPRESENTATNE I name, constitute and appoint my son, RICHARD A. FORTENBAUGH, Executor of this my last Will and Testament. Should my son, RICHARD A. FORTENBAUGH, fail to qualify or cease to so act, I name, constitute and appoint LeTORT :MANAGEMENT & TRUST COMPANY, alternate Executor to complete the administration of my Estate. I direct that no fiduciary appointed herein shall be required to post bond for the faithful administration of the duties required in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this f ~L day of , 2007. a..~i . ~~~ (SEAL) DOROT M. FORT'ENBAUGH Signed, sealed, published and declared by the above-named Testatrirc, as and for her Last Will and Testament, in the presence of us, who at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. ~~~~~~wy ---- 5 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND . ss. We, DOROTHY M. FORTENBAUGH, '~,(V1~,1.~L~.L y Nl'~..~ ~°.~~- and ~(l. ~,! ~~',' ~~i_/ ~) ~(1'S~-s~ _ _, the Testatrix and the witnesses, respectively; whose names are signed to the attached or foregoing instn:iment, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she had signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and that: to the best of his/her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. DORO HY M. FORCE AUGH ~~~~ ~~ ~ Witness < S~~I~Y~/L' Witness Subscribed, sworn to and acknowledged before me by DOROTHY M. FORTENBAUGH, Testatrix, and f~ \~_~ ~+ Lu1~~~~, . ~~1~~~-' and I(~t . ,~.~ 'tj.~',~ , (>i~} 4C.~ ,witnesses, this (~ T'o'day of --- '{1.,~J- , 2007. - \a ~ ( ~ ~j . ~~ ~~`~~ ' ; Notary u lic My Commission Expires: :298148v2 COMMONWEALTH OF PENNS`(LVANIA Nataria4 Seat Dana L Wieseman, Notary P1>b6c Lemoyne Born, CLmberland Gxa~ly My Commissdon Expires Nov.15, 2008 ti Member, Pennsylvania Associati9n G~f Notaries Rev-1507 FJt+ (8.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 All property jointly-owned with light oT survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 21 Shares - MetLife Inc. @ $58.775 per/share' 1,234.28 TOTAL (Also enter on Line 2, Recapitulation) 1,234.28 tlr more space Is needed, aodltional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev1508 EX+ (6.98) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF (FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 InGude the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly-owned with the rtght of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 2001 Oldsmobile Alero -Date of death value. 3,535.00 2 Household Goods -Appraised Value 2,620.00 3 Jewelry -appraised value 3,680.00 4 Messiah Village -Refund -Apartment -purchase. 68,045.00 5 Miscellaneous foreign coins/currency/ Misc. coins in safe deposit box -Appraised 93.00 value. 6 Nationwide Bank -Account No. 100000043861 2,356.23 7 Nationwide Bank -Account No. 100000137056 1,426.86 8 PLM Equipment Growth 8~ Income Fund VII - 250 Depositary Units - (Dissolved and 0.00 cancelled in second quarter of 2007) 9 PNC Bank -Checking Acct. No. 50-0488-2461 -Date of death balance, plus accrued 13,806.28 interest. 10 PNC Bank -Money Market Acct. No. 50-0488-3501. -Date of death balance, plus 6,045.52 accrued interest. 11 Wachovia Securities -Investment Account No. 3303-6519 - (Mutual 1,220,834.91 Funds/Bonds/Money Market -See attached) TOTAL (Also enter on Line 5, Recapitulation) I 1,322,442.80 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) APPRAISAL COO L~~ Pers ,,a~~Property of ~lCy,~~, ~D,~T~.U.13~-G~.~ .~~ST~T~ /'2~~ss/~~l~I llrc_.L~-.yF, Appraised by Chuck E. Bricker AU094-L Date ~ //~-/ ~ ~' ITEM VALUE ITEM VALUE h'vy ~%~/ sic ~ r~~s K ~o, r! ~ GGt/~-~t'S G /~- p~5 ~t~. ~ .~,~ sus ,~~ 1G~, i;o ~`'~!~ S'~ ~ ~U, U GU ~ ~ c' f3 ~,c~E l G G , ~~' L ~~ T f3c=~ ~D, D' ~ ll~s~ T 9D vv ~ ?~ ~ /,3G'i7~12 G u D OL Nl. ~ - ~ ENE ~~ 1~ , ~v -Gi~l~~, R.Gc,~E ~ ;UJ i3 ~L Diti~~ ~ ~T' ' G, va ~ /`Z P~ I ~, ~ ,~, DG ~ I N ~ ltd, LL U1.(~ ~ b l~,Gc~ T iZ~-cK 3~, ~~~ G ~/i [,GK'S i2 D cK ~1~ ~D, G'~ ~~-h~~ ~a ~ ~~ v, v~ J SS( ~ ~1 S ~nc~ ~ ~I~._,v ;~. G~~ Tv~ Des K 7~, ~ ~ L/~i~-'~C LzT Cf2L~5 ~ 1, L G~ o ~S~/iU~L fZC~/~EJZ ~-[i,6C 5_~i ~ ~~sl~Es-- Pr/~.s -P'J ~~:J ETC. b~G I~~ ~ , D i F}om the desk of.• Bryon Fertenbaugh Hasko Jewelers 215 Third Street New Cumberland, PA 17070 717-7747280 02119/2oos Richard Fortenbaugh 502 Bridge Street New Cumberland, PA 17070 t~ a p~ Phone: 'T17-7747280 Fax 71~T-7742732 Email: hasko}ewelersCverizon.net The following information is of the opinion of the Jeweler based on personal knowledge and industry standards. The only jewelry listed are the pieces that I can evaluate fairly and accurately. 1 700.00 14kt y/g charm bracelet w/ bell ,jade fish, dog, palm tree 2 175.00 14kt y/g 2.Omm. french rope 18" chain 3 325.00 14kt y/g 8x3 mm oval cameo pin/pend 4 170.00 14kt y/g fancy herringbone chain 4,Omm 24" chain 5 400.00 14kt y/g large bow-tie pin with 2-diamonds 6 150.00 14kt y/g tooth, 7.4dwt 7 100.00 14kt y/g ladies jade ring 8 350.00 14kt y/g ladies round emerald surrounded by 7- dia ring 9 75.00 14kt y/g antique emerald seed pearl ring 10 100.00 14kt y/g ladies single cultured pearl ring 11 65.00 14kt y/g ladies 8-emerald 1-diamond single earring 12 150.00 14kt y/g ladies pair of pearl earrings 13 95.00 14kt ylg ladies pair of knot earrings 14 75.00 14kt y/g 2-child head charms 15 75.00 14kt y/g islands charm 16 25.00 s/silver circle pin 17 25.00 s/silver sandal on chain 1 DBzSCOINS 224 FOURTH STREET NEW CUMBERLAND, PA. 17070 (717) 774-4182 Customer's Order No. _ DATE G- " G- ~ C~GL= L; BOUGHT/SOLD TO r'%~ ~~ f-~ ~'~'~`~ ~%~~~' ~~ ADDRESS u ~: ~`~. PAYMENT METHOD - CASH CHECK QUAN. DESCRIPTION PRfCE AMOUNT T b tt~ ~ y~ ~ .,y„ ~, S, ~ `l~n~ ~ ~i l~r~ .~ i \ ~~ :,r ~ - / f 1 J ~.r.~~,_-, ~~ r .~ ~_ .. `~3 ~ ALL Claims and Returned Goods MUST be accompanied By This Bi{f SIGNATURE Wachovla Securities. l1C 1250 Broaacast;ng F2DaQ Post OffiG~e BoX 6347 Wyomissing, PA 14610 Tel 610 376.1700 Fax 610 4781352 800 z832a37 i`~~ Dorothy M Fortenb~ugh account 3303-6519 DATE OF DEATH VALUAT JANUARY 4, 2006 Quan #ity Description 3,553.43 CAPITAL INCOME BLDR CL-A 1,971.66 CAPITAL INCOME BLDR CL-C 3,639.09 INCOME FD OF AMERICA CL~A 11,119.39 1NGOME FUND AMER ING CL-C 4,631.08 DAV1S N Y VNTR CL GL A 3,358.24 WASH MUTUAL INVS FD CL-C Gusip Symbc 140193103 CAIBX 140193301 GIBCX 453320103 AMEC; 453320301 IFACX 2390801 D4 NYVT} 939330304 WSHC 2,300 FIRSTENI=RGY CORD 337932107 FE 50 IMPERIAL TOB GROUP PLC F 453142101 ITY 5,000 BLAIR CO 6.90% 7/1/200$ 092840AS6 15,000 HARRISBURG 5.0%.9!112017 41475$GN6 25,000 HARRSBRG PA 5%7/15/2024 41473MGA5 30,000 PA ST TPK 4.75%17J1/2027 709221 CFO 5,000 PHIL.A PA 525% 7/1/2011 717$1EAN5 15,000 WILLIAMSPORT 3.3% 1/1/11 970191ER9 Money Market 'IY~TAL ~~~ O ~_... op~ ION WAf~O`G7CA t~ cac-sr~rr~,~ NAV Value 61.65 219,068.84 61.65 121,552.96 19.00 69,142.65 1$.85 209,600.41 38.41 177, 879.59 32.28 108,403.92 High Lover Clase 75.05 72.33 74.32 170,936.00 105.33 104.27 104.27 5 , 213.50 Accrued Bid [n#erest 101.911 2.88 5, 098.43 105.975 256.25 16,152.50 105.163 586.81 26,877.56 100.926 130.63 30,408.43 101.863 2.19 5,095.34 100.014 4.13 15,006.23 40,398.55 $1,220,834.91 The summary ofiprices/quotes/sta~isiics has been obtained fra~ sources believed to be re[iabie, but is not necessarily complete and cannot b guaranteed. ~~ Rev-1510 EXr (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 This schedule must be completed antl filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIP~ N PR PE INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 PNC Bank -Certificate of Deposit No. 15,167.33 15,167.33 31400319835 -Decedent ITF - Richard A. Fortenbaugh, Son -Date of death balance, plus accrued interest. Established 1011112007. 2 Wachovia Securities -IRA Account No. 74,674.78 74,674.78 3303-6460 - 3,972.063 shares -Amer Balanced Fd CL-C @ $18.80 p/sh. Beneficiary: Decedent's Estate 3 Wachovia Securities -IRA Account No.3303-6460 3.62 3.62 - Money Market -Cash Beneficiary: Decedent's Estate TOTAL (Also enter on Line 7, Recapitulation) I 89,845.73 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1151 EX+ (12.99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A- FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees JOHNSON, DUFFIE, STEWART 8~ WEIDNER 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 7,381.75 40,000.00 18,000.00 4. Probate Fees 760.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 4,598.44 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 70,740.19 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1602 EX+(6.98) , ~. . SCHEDULE H-A FUNERAL EXPENSES continued ESTATE OF (FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1b02 EX+ (6.98) SCHEDULE H-B1 PERSONAL REPRESENTATIVE'S COMMISSIONS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continued RESIDENT DECEDENT ESTATE OF FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 Copyright (c) 2002 form software only The Lackner Group, Inc. Farm PA-1500 Schedule H-B1 (Rev. 6-98) r ~ Rev-1502 EX+(6.98) gCHEDULE H-B2 ATTORNEY'S FEES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-62 (Rev. 6-98) ,~ Rev-1502 EX+(6-98) gCHEDULE H-B4 PROBATE FEES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-64 (Rev. 6-98) Rev1502 EX+ (6-98) r ~~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 ITEM NUMBER DESCRIPTION AMOUNT 1 Chuck Bricker -Household Goods Appraisal 120.00 2 Comcast -final cable charges. 5.54 3 Cumberland Law Journal -Legal Advertisement 75.00 4 Hasko Jewelers -jewelry appraisal 79.50 5 John Wesley/Smart Move Makers, Inc. -packing 8r removing furniture -lfrom 3,620.00 decedent's residence -Messiah Village - 826 Oak Oval 6 PNC Bank -Counter Check Fee 8r Check Printing Fee -Estate Account 55.20 7 PP&L -final electric service charges. 18.18 8 Register of Wills -Cumberland County -Additional Probate charges 150.00 9 Register of Wills- file Inventory 81 Inheritance Tax Return. 30.00 10 Reserve for close-out costs. 275.00 11 The Patriot-News -Legal Advertisement 141.24 12 Verizon -final telephone charges 28,78 Subtotal I 4,598.44 Copyright (c) 2002 form software only The Lackner Group, Inc. Farm PA-1500 Schedule H-B7 (Rev. 6-g8) Rev1b12 EX+ (6.98) K ~ ~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAx RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF - (FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 Include unrelmbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Central PA Pulmonary -balance not covered by insurance. 11.73 2 Checks that cleared after death - PNC Account No. 50-0488-2461 - PPL - $30.67; 149.44 Visa - $53.77; Nationwide -Apt. Insurance - $65.00 3 Messiah Village -charges -January -March 31, 2008 -contents - removed from 3.117.65 residence - 3/31/2008 4 Moffitt Heart 8~ Vascular -balance not covered by insurance. 123.27 5 Nationwide Insurance -Automobile insurance 264.55 6 PA Department of Revenue -tax due -decedent's 2007 PA 40 978.00 7 PP&L -electric service charges 35.79 8 Quantum Imaging -balance not covered by insurance. 23.71 9 T-Mobile -final charges 38.65 10 United States Treasury -tax due -decedent's 2007 -Form 1040 3,355.00 11 Waggoner, Frutiger 8~ Daub -Accountants -preparation of decedent's - 2007 550.00 Federal and State income tax returns. TOTAL (Also enter on Line 10, Recapitulation) I 8,647.79 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1513 E7(+ (8-00) ~ + SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER FUKItNE3AUGF1, D~ROTNY M. 21-08-00 092 NUMBER NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSON(S) RECEIVING PROPERTY Do Not Llet Trustee s (1Nords) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal . distributions, and transfers under Sec. 9116(a)(1.2)] 1 Richard A. Fortenbaugh Son 25% Residue; 213 Tall Oak Drive Tangible Pers. New Cumberland, PA 17070 Prop. 2 Andrew R. Fortenbaugh Grandson 25% Residue 925 Bellair Ave. Apt. Z-212 State College, PA 16801 3 Brian R. Fortenbaugh Grandson 25% Residue 115 Juniper Street Middletown, PA 17057 4 Scott M. Fortenbaugh Grandson 25% Residue 20 White Birch Lane Etters, PA 17319 5 Kenneth & Nancy Shoaff Friend 5,000.00 4424 Venus Avenue Harrisburg, PA 17112 See continuation schedule attached Continuation 5,000.00 Total 10,000.00 Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropri ate, on F;ev 1500 cove r sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS See continuation schedule(s) attached 5,000.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 (:OVER SHEET 5,000.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) t ~ ' SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: DOROTHY M. FORTENBAUGH 01/04/2008 183-12-1672 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Word;:) ($$$) 6 Robert & Lee Ann Ormsbee Friend 5,000.00 4434 Venus Ave. Harrisburg, PA 17112 Total 5,000.00 Rev-1502 EX+ (6-98) „/ c ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J-IIB CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS continued ESTATE OF FILE NUMBER FORTENBAUGH, DOROTHY M. 21-08-00092 pyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J-IIB (Rev. 6-98) INVENTORY REGISTER OF WILLS OF COMMONWEALTH OF PENNSYLVANIA COUNTY of CUMBERLAND RICHARD A. FORTENBAUGH Personal Representative(s) of the Estate of EDMUND G. MYERS deceased, depose(s) and say(s), that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate In the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Attorney - (Name) (Firm) (Address) (Telephone) CUMBERLAND } SS } File Number DOROTHY M.FORTENBAUGH (Su~~reme Court I.D. No.) 20558 JOHNSON, DUFFIE, STEWART 8~ WEIDNER 301 MARKET STREET, Lemoyne, PA 17043 (717)761-4540 DATE OF DEATH LAST RESIDENCE MESSIAH VILLAGE DECEDENTS SOC. SEC. NO. 01/04/2007 836 OAK OVAL 183-12-1672 FIGURES MUST BE TOTALED Personal Property Cash ............................................................................................... Personal Property ......................................................................... Stocks/Listed ................................................................................. Stocks/Closely Held ...................................................................... Bonds ............................................................................................. Partnerships and Sole Proprietorships ..................................... Mortgages and Notes Receivable ............................................... All Other Property ......................................................................... Total Personal Property ......................................... Total Real Property ................................................ ,F- L~~{'~ 1,322,442.80 1,234.28 74,678.40 1,398,355.48 Total Personal and Real Property ......................... r--1,398,355.48 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal repre;>entative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S. § 3301(b)) Fo~rn RW-09 Rev. ~o-13-20os RICHARD A. FORTENBAUGH °> PE1~'LVAt~ COUNTY _`` < ~ , . , ~, : ~- t N r ±. ~~~ ~ t ~ ~~ 3 21-08-0092 ~ ~" °''= r~= -~ INVENTORY REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND } SS File Number 21-08-OC1092 DATE OF DEATH LAST RESIDENCE MESSIAH VILLAGE DECEDENT'S SOC. SEC. N0. 01/04/2007 836 OAK OVAL 183-12-1672 Personal Property 2001 Oldsmobile Alero -Date of death value. 3,535.00 Household Goods - Appraised Value 2,620.00 Jewelry -appraised value 3,680.00 Messiah Village -Refund -Apartment -purchase. 68,045.00 Miscellaneous foreign coins/currency/ Misc. coins in safe deposit box - 93.00 Appraised value. Nationwide Bank -Account No. 100000043861 2,356.23 Nationwide Bank -Account No. 100000137056 1,426.86 PLM Equipment Growth 8~ Income Fund VII - 250 Depositary Units - (Dissolved 0.00 and cancelled in second quarter of 2007) PNC Bank -Checking Acct. No. 50-0488-2461 -Date of death balance, plus 13,806.28 accrued interest. PNC Bank -Money Market Acct. No. 50-0488-3501. -Date of death balance, plus 6,045.52 accrued interest. Wachovia Securities -Investment Account No. 3303-6519 - (Mutual 1,220,834.91 Funds/Bonds/Money Market -See attached) Total Personal Property 1,322,442.80 Stock /Listed 21 Shares - MetLife Inc. @ $58.775 per/share' 1,234.28 (Attach additional sheets if necessary) Total Personal Property and Real Estate 1,398,355.48 INVENTORY REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA } SS COUNTY OF CUMBERLAND } DATE OF DEATH LAST RESIDENCE MESSIAH VILLAGE DECEDENT'S SOC. SEC. NO. 01/04/2007 836 OAK OVAL 183-12-1672 Total Stock /Listed All Other Property Wachovia Securities -IRA Account No. 3303-6460. Beneficiary -Decedent's Estate. Date of death value. Total All Other Property Fide Number 21-08-OC1092 1,234.28 74,678.40 74,678.40 -2- r ~~ ~-"~ ~°~ " ~. Ap 3 kR ~ ~~'1 :.,.1 .; ~~^\ '~ L. ~r~'.1 ~~ `~~t4Vtl _ , C, ~~ t.=.1 . ~'~ `^~ 1._.) '~'i (x- Cr7 ~- ~-~ ss ~. U ti Q~ ~~ ss a. 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