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HomeMy WebLinkAbout02-0066Register of Wills of Dauphin County, pennsylvania PETITION FOR GRANT OF LETTERS Estate' of also known as , Deceased , Social Security (COMPLETE "A" OR "B" BELOW:) [ A. Probate and Grant of Letters and aver that Petitioner(s) is/are the executor n~med in the Last Will of the Decedent, dated O~.To~£ ~' ~ ~,. *Zoo/ and codicil(s) dated State relevm~t rAr(;umstmaces, e.g.. renunciations, death of executo~, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: B. Grant of Letters of Administration Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: ~- '1 Name Relationship Residence ] (COMPLETE iN ALL CASES:) Attach additional ~;heets if necessary. Decedent was. domiciled at death i~""~'v residence at [o0' ~. ~[/~".~;~" Decedent, then ?~ years of age, died Decedent at death owned property with estimated values as follows: personal property .............................. (If domiciled in PA) All (If not domiciled in PA) Pers6nal property in Pennsylvania ............... · ....... $ (If not domiciled in PA) Personal property in County .......................... $ Value of real estate in Pennsylvania - .. ............................ : . . · .. ............ $ Total ................... ....................................... as follows: Real Estate situated County, Pennsylvania, with his/her last. family or principal (Location) Wherefore, Petitioner(s) respectfully .request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: ' Signature Typed or printed name and residence J Oath of Personal Representative Commonwealth of Pennsylvania County of Dauphin The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and correct to the best of.the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to and affir,~-ed: and subscribed before me this day of DECREE OF REGISYER Estate of (~E'cA,. TI~Tt~,.-SR,~;i ..... Deceased ~'-',i...-'.,., : ....... ... als° known as Social Security No: Date of Death: ,~Dec--~mbe~ ,1['.,Imt918 AND NOW, 5anua~'~¢ 18, , 20 02 , in consideration of the' Petition on the reverse side hereon, satisfactory proof having been presented before me, IT'IS DECREED that Letters [] Testamentary [] of Administration (c,t.a.; d.b31.c.t.; pendente lite; dulante absentla; dulante rninoritate) are hereby granted to JAy ,'~.~;, in the above estate and that the instrument(s), if any, dated October 23rd,2001 described in the Petition be admitted to probate and filed o~ record as the last Will of Decedent. FEES . ,, .. Letters .............. : ............ Short Certificate(s)..5. ....... Renunciation .................. Affidavit ( ) ................. Extra Pages ('4) ............ Codicil .... ' ...................... JCP Fee ........................ I'nventory & Tax Forms... Other ............................ TOTAL ................ 27015.00.00 / Re;iste, o/of Wills Mar~ C. Lewis 12.00 5.00 CALL A~PORNRY STEPHEN BAR~AUAG~-~Z', Attorney: I.D. No: Address: Telephone: DATE FILED: 105.805 REV 9~86 )=coog6 21-2002-0066 LAST WILL AND TESTAMENT OF DALE A. ROTZ, SR. I, Dale A. Rotz, Srl, of Etters, Pennsylvania, revoke my former Wills and Codicils and declare this to be my Last Will and Testament. ARTICLE I. IDENTIFICATION OF FAMILY I am currently a widower and not married to anyone. The names of my children are Jay A. Rotz, Dale A. Rotz, Jr., and Linda R. Miller. All references in this Will to "my children" are references to the above-named children. ARTICLE II PAYMENTS OF DEBTS AND EXPENSES I direct that my just debts, funeral expenses, and expenses of last illness be first paid from my estate. ARTICLE III DISPOSITION OF PROPERTY Residuar-~: Estate. I direct that my residuary estate be distributed to my children in equal shares. If-a child of mine does not survive me, such deceased child's share shall be distributed in equal shares to the children of such deceased child who survive me, by right of representation. If a child of mine does not survive me and has no children who survive me, such deceased child's share shall be distributed in equal shares to my other children, if any, or to their respective children by right of representation. If no child of mine survives me, and if none of my deceased children are survived by children, my residuary estate shall be distributed to my heirs-at-law, their identities and respective shares to be determined under the laws of the State of Pennsylvania, then in effect, as if I died intestate at the time fixed for distribution under this provision. Page 1 of 3 ARTICLE IV NOMINATION OF EXECUTOR I nominate Jay A. Rotz, of Etters, Pennsylvania, as the Executor, without bond or security. If such person or entity does not serve for any reason, I nominate Eileen C. Rotz, of Etters, Pennsylvania, to be the Executor, without bond or security. ARTICLE V EXECUTOR POWERS My Executor, in addition to other powers and authority granted by law 'or necessary or appropriate for proper administration, shall have the right and power to lease, sell, mortgage, or otherwise encumber any real or personal property that may be included in my estate, without order of court and without notice to anyone. My Executor shall have the right to administer my estate using "informal", "unsupervised", or "independent" probate or equivalent legislation designed to operate without unnecessary intervention by the probate court. ARTICLE VI MISCELLANEOUS PROVISIONS A. Paragraph Titles and Gender. The titles given to the paragraphs of this Will are inserted for reference purposes only and are not to be considered as forming a part of this Will in interpreting its provisions. All.words used in this Will in any gender shall extend to and include all genders, and any singular words shall include the plural expression, and vice versa, specifically including "child" and "children", when the context or facts so require, and any pronouns shall be taken to refer to the person or persons intended regardless of gender or number. B. Liability of Fiduciary. No fiduciary who is a natural person shall, in the absence of fraudulent conduct or bad faith, be liable individually to any beneficiary of my estate, and my estate shall indemnify such natural person from any and all claims or expenses in connection with or arising out of that fiduciary's good faith actions or nonactions as the fiduciary, except for such actions or nonactions which constitute fraudulent conduct or bad faith. C. Beneficiary Disputes. If any bequest requires that the bequest be distributed between or among two or more beneficiaries, the specific items of property comprising the respective shares shall be determined by such beneficiaries if they can agree, and if not, by my Executor. Page 2 of 3 IN WITNES. S WHEREOF, I have subscribed my name below, this ~l, ~arSay of be,r. ., 2.o01. Testator Signature:. Dale A. Rotz, Sr. We, the undersigned, hereby certify that the above instrument, which consists of three pages, including the pages which contain the witness signatures, was signed in our sight and presence by Dale A. Rotz, Sr. (the "Testator"), who declared this instrument to be his Last Will and Testament and we, at the Testator's request and in the Testator's sight and presence, and in the sight and presence of each other, do hereby subscribe our names as witnesses on the date shown above. Witness Signature: Name: City: State: Witness Signature: Name: City: State: Witness Signature: Name: City: State: Page 3 of 3 PENNSYLVANIA Self-Proving Clause COMMONWEALTH OF PENNSYLVANIA COUNTY OF · 0 ,~ I, Dale A. Rotz, Sr., the Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly and as my free and voluntary act for the purposes expressed in the instrument. Sworn to or affirmed and a~knowledged before me by Dale A. Rotz, Sr., the Testator, this ~ 3~"tday of 15} ~t~oj-* /' , q....ot,! . Testator Signature Dale ~. R~){~, Sr. c~:. ~ Signature of Seal and official capacity of officer NOTAffiAL SEAL pATR~CIA A. KNIPE, Notary Public Susclu~hanna Twp., Dauphin County, PA My COmmi$~°n E~ptms March 11, 2002 AFFIDAVIT COMMONWEALT~t OF PI~NNSYLVANIA COUNTY OF #~,~ ~lffa and ~'~.t')/I ~- I~de..b£T&e' , the witnesses whose names are signed to the a~ached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as the Testator's Last Will; that the Testator signed willingly and executed it as the Testator's free and voluntary act for the purposes expressed in it; that each of us in the hearing and sight of the Testator signed the Will as a witness; and that to the best of our knowledge the Testator was at that time 18 or mo.re years of age, of sound mind and under no constraint or undue influence. Sworn to_or affirmed and subscribed to before me by and ~~* ~ ~o~ and ~~] ~ W~~ , witnesses, this ~]~&day of ~~ , Witness Signature: ~ ~ Name: 'g~ ~., Ci~: Ly' S, '~ ~.~ ~ State: ~~S Witness Signature: Name: City: State: Witness Signature: Name: City: State: ,5'q,q/ 3ffzg ' - .,,oz,4 z P,4 / 7//)9 ' Signature Seal and official capacity of officer LCd: t a L I, ~[' 7_,0. ,to ~o~:O-'P~°°~8 ~00 ~(6~0) ~HARRISBURG, PA.17128-060.1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 I OFFICIAL USE ONLY REV-I'500 /?-3£'7 INHERITANCE TAX 'RETURN'I ' RESIDENT DECEDENT 'l--~':L__-- COUNTY CODE YEAR NUMBER Z UJ LU LU .-o8 Z 0 UJ 0 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) . DATE OF DEATH (MM,DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) oi'- oG- 2oo& /~.- t/- · .SOCIAL SECURITY NUMBER THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) ' SOCIAL SECURITY NUMBER ~ 1. Original Return [] 2. Supplemental Return- . .... [] 3.'Remai~d~ Re[urn (date of death prior to 12-13-82). [~] 4. Limited Estate [] 4a. Future Interest Compromise (d,te ofdea,h a,,r 12-12-82) E~ 5. Federal Estate Tax Return Required · X--~6. Decedent Died Testate (Attach copy of Will)[] 7. Decedent Maintained a Living Trust (^~ch c~py of Trust) , O 8. Total Number of Safe Deposit Boxes {~' 9. Litigation Proceeds Received E~ 10. Spousal Poverty Credit (d~to of de,th b.tw.., ~2-3~-9, a,d ~-~-gs) ['~ li. Election to tax under Sec. 9113(A)(Attach Sch O) FIRM NAME (IfApplicable) TELEPHONE NUMBER COMPLETE MAILING ADDRESS 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) i'~1 Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8, Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Cost~ (Schedule H) 10, Debts of Decedent, Mortgage Liabi!ities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. 14. (6) {~ (7) 0 (10) ~ ,/~ ?/./. ! OFFICt~L USE ONLY Charitable and Ggvemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) Net Value Subject to Tax (Line 12 minus Line 13) (~) k ql 7, bcs-, SEE INSTRUCTIONS ON REVERSESIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax' rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount o'f Line 14 taxable at collateral rate 19. Tax Bue 20. (19) Decedent's Complete Address: STREET ADDRESS Ioo mr, ,,¢'1/ ,,, 3ol Tax Payments. and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior'PaYments C. Discount STATE Total Credits ( A + B + C ) Interest/PenaltY if applicable .... D. Interest ..: ~ ' :~ O E. PenaltY ' ' Total Interest/Penalty D'+.E ) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. ... Check box on Page 1 Line 20 to request a refund If Line 1 + Line 3 is greater than Line 2, enter the difference. This is.the TAX DUE. A. Enter the interest on the tax due. . -" B. Enter the total of Line 5 .+ 5A. This is the BALANCE DUE. (1) ziP (2) 0 (3) O- (4) -- (5) .. o 5' (5A) O (5B) Make'. Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE. FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS IF THE ANSWER Did decedent make a transfer and: Yes a. retain the use or income o[the property transferred; ................................................. , ........ , .......................... .:... [] -b. retain the right to designate who shall use. the property transferred or its income; ................ i ........................... [] c. retain a reversionary interest; or .................................................................................................................. :.....L [] d. receive the promise for life of either payments, benefits or care? ......................................................... : ........ ;... [] If death occurred after December 12, 1982, did decedeni transfer property within one year of death without receiving adequate consideration? .............................................................................................................. [] Did decedent own an "in trust for" or payable upon death bank account or secudty at his or her death? .............. [] Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................................................... i.i ................ '.......' ............ '...' ~] No TO'ANY OF THE ABOVE QUESTIONS IS YES,~Y~U' MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF. THERETURN." Under penalties of perjury,- I declare·that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. ' · SIGNATURE OF PERSON RESPONSibLE FOR FILING RETURN '. ' DATE A. . ADDRESS ~ ' - .,-,- ~ ~:~ DATE A,,~D~ESS ~ Zo,l,,.j. Ac,.,,,,, £,,o¢,, / ?o:t_r' .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 survMng spouse is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net.value of transfers to or for the.useof.the surviving spouse is 0% [72 P.S. §9116 (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 return are still applicable even if -the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a'natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposedon the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers'to Or for the use of the decedenrs siblings is 12% [72 P.S. §9116(a)(l.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-1503 EX * (1-97} COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS A~ property jeintly-ewned wit~ dghtef s,,rvivorship m~st be discle~e~ o~ Sched,,~e F. FILE NUMBER ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line2, Recapitulation) $ ~/~,, ~,/J'", ~'J'"" (If more space is needed, insert additional sheets of the same size) ~e 1 of.2 FRANKLINoTEMPLETON. INVESTMENTS ;AT 02 214020 65844B1650A**3DGT I,,,llh,,I,,Ih,,,llhh,hh,,h,hhl,,hh,h,l,hl,h,,ll DALE A ROTZ C/O EILEEN ROTZ 45 S BEN HOGAN DR ETTERS PA 17319-9455 January 1,2001 - December 31, 2001 YEAR-END STATEMENT Asset Summary Number: 02z~0874 Franklin High Yield Tax-Free Income Fund - Class A Share Code-Account Number: 130-13011154498 Distributions: Dividends Reinvested, Capital Gains Reinvested Certificate Shares Held by You: 0.000 Year-to-date Summary Long-Term Capital Gains: Tax-Exempt Income Dividends: $0.00 $10,601.91 Account Transactions Date Transaction BALANCE FORWARD 01/01/01 01/22/01 DIV REINVEST 02/21/01 DIV REINVEST 03/21 JO1 DIV REINVEST 04/20/01 DIV REINVEST 05/21/01 DIV REINVEST 06/21/01 DIV RE INVEST 07/20/01 DIV REINVEST 08/20/01 DIV REINVEST 09/20/01 DIV REINVEST 10/19/01 DIV REINVEST $184,648.95 NASDAQ: FRHIX Dealer Number: 0632 Representative: 0809 FISERV SECURITIES INC FISERV INV SVCS, 91B Dollar Share Total Amount Price Shares Shares $10.47 17,636.003 $855.35 $10.53 81.230 17,717.233 $859.29 $10.49 81.915 17,799.148 $863.26 $10.56 81.748 17,880.896 $867.22 $10.46 82.908 17,963.804 $871.24 $10.49 83.054 18,046.858 $875.27 $10.56 82.885 18,129.743 $879.29 $10.63 ;.82.718 18,212.461 $883.30 $10.73 82.321 18,294.782 $905.59 $10.66 84.952 18,379.734 $909.80 $10.67 85.267 18,465.001 ge 2 of 2 FRANKLIN. TEMPLETON. INVESTMENTS DALE A ROTZ GlO EILEEN ROTZ 45 S BEN HOGAN DR ETTERS PA 17319 January 1,2001 - December 3i, 2001 YEAR-END STATEMENT Asset Summary Number: 02440874 Franklin High Yield Tax-Free Income Fund - Class A Share Code-Account Number: 130-13011154498 Distributions: Dividends Reinvesled, Capital Gains Reinvested Certificate Shares Held by You: 0.000 Account Transactions Date Transaction NASDAQ: FRHIX Dealer Number: 0632 91B Representative: 0809 FISERV SECURITIES INC FISERV INV SVCS, Dollar Share Total Amount Price Shares Shares 11/20/01 DIV REINVEST $914.02 $10.62 86.066 18,551.067 12/20/01 DIV REINVEST' $918.28 $10.48 87.622 18,638.689 ACCOUNT VALUE: $195,519.85 AT $10.49 PER SHARE AS OF 12/31/01 ACCOUNT COST BASIS: $205,993.49 Want your account statement faster? Look for it online instead of in your mailbox. sign up for electronic' delivery at . · , frankhntempleton.com today.." .' ' ..... :,.:/:.-. :..;:'i.. :'. ~'"';':::!i~" ':':,'.~ . ' ,'i,'.": '" .i :' ~' :' 'i ," . i..'~ i'" ' ~. · · Account ¢°si Basis is the -cumu oti~ (~ost'of a 'Sh'~res ~'ou'"°w,i If you'need Cost basis information to 'rep0d gains Or Io~ses on y°br ..: t~ re~rn(s), please rear to you~ Co~t Basis State~t ~[ vi~it f~nklinte~P[etq.n,com ~r m9[e iqfor~tion. ,:- ~'~,',.)~.'~:; .' '. - :, · :".,-~?' ~.' Tax. Free Income.` Fund -Class'A ' '- .... Share Code,AcEoUnt #: 130-1301115449.8 CIO EILEEN ROT~. ii;,T"- ' ~ 45 S BEN HOGAN'DR' ' - · 'ETTERSPA1731g.'". "': : "~ '' '~ . ?~v-: ; .]' ~,,.. " ~,_ ' .,', c; -.' .side if ~ang~ are'ne~b~ f0r~" "-' ] Dis~ibution Option Social S~uri~N 'AmoUnt EnclOsed: ($50 minimum) - ' -~:'.:~ :i-' ",,' .'~'~-7.. - . ?.-,- Franklin Templet~n I'ng~stmentis~ '~ ..'-:i., .,:~,-,'" ~' . ,.- . ' PO' BOX 33030 .' '?' i':. ?~,,;;~,L.;~.,~?,,.-~. :c,?.~.: St PeterSburg FL:33733:8030 :, '.-., ' ~.':: ",- "~. h,lh,,Ihh,,h,lh,,Ihl,,hll,,,,,ll,lh,,Ih,,I 001 000013011154498 130 100 123~s,, 0 COMMONWEALTH OF PENNSYLV~NIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E " CASH, BANK DEPOSITS, & MISC, PERSONAL'PROPERTY ESTATE OF Include the proceeds of litigation and the date the proceeds wet received by the estate. All property jointly-owned with the right of survivorship must'be disclosed on Schedule F. ITEM NUMBER DESCRIPTION TOTAL (Also entei on line 5, Recapitulation) ' VALUE AT DATE OF DEATH 7 (If more space is needed, insert additional sheets of the Same size) allfirst DALE A ROTZ 45 S BEN HOGAN DR E'I-rERS PA 17319-9455 I,,,lll,,,I,,Ih,,,lll,h,l,h,,I,,h hh,hh,l,,I,hhl,,,ll Page I of 2 Certificate of DepoSit Dale A Rotz January 1. 2002 thru June 30; 2002 Acct No 8-000-000-2539789 O allfirst.com 0 24'h°u; Fixed Rate CD Customer Service 1-800-533-4630 Activity Summary Interest rate · 2.08~, Beginning balance $1-49,162.65 Interest paid this statement 0835.1_6 Deposits and additions 85.~.16 Interest paid this year $835.1_6 Other activity -lqg,ggT.81_ Term (months) 13 Current value .00 Maturity date 02/0q/2003 Deposits and additions Date Description Amount 01/04 INTEREST CREDIT 01/07 INTEREST CREDIT $809.52 25.64 0835.16 Other activity Amount Date Description 01/07 CLOSING r149,997.81 - 149,997. $1 What your Icons mean O Customer Service ~) Credit to your account Important reminder ~ Charge to your account · Other banks' ATM transaction For questions about your statement or change of address information, please see page 2. 034315 0000-00000021779 001 allfirst DALE. A RoTZ 45 S BEN HOGAN DR E'FI'ERS PA 17319-9455 I,,,lll,,,h,lh,,,lll,h,l,h,,h,l,l,h,l,h,h,hhhl,,,ll Page :I of 6 'Relationship With Interest JanUary ~9, 2002 thru February 19, 2002 Dale A Rotz " ~,cct No 09109-6906-4 O allfimt.com ~ 24-hou;" .... Customer Service 1-800-533-4630 ACtivity Summary Number of images enclosed Annual percentage yield earned Avg. daily ledger balance Avg. daily collected balance Interest earned this statement Interest paid this statement Interest paid this year Days covered by this statement 1 0.26~ 0176.37 $352.7q .Oq .Oq .6q 16 Balance on 01/18 Deposits and additi~)ns Other activity $q70.$3 oq70.37 Balance on 02119 Deposits and additions Date Description Amount 02/01 INTEREST PAID .0q Othe~ ac~'.'lty Date Description Amount 01/31 CLOSING WITHDRAWAL -q70.$7 -q70,$7 End of Day Ledger Balance Account balances are updated in the section below on days when transactions posted to this account. Date Balance Date Balance Date 01118 $q70.$3 01/31 -.0q 02101 Balance .00 000983 0011-00273204732 001 PSEC4 P.O. Box 67013 (7i7) 234-8484 (Harrisburg) Harrisburg, PA 17106-7013 (800) 237-7328 (Nationwide) web$ite - http :/ /www. psecu.com PLEASE NOTE: BASED ON IRS CRITERIA THIS ACCOUNT DID NOT RECEIVE AN IHPORTANT TAX RETURN DOCUHENT HAPPY HOLIDAYS! h,,lll,,,l,,ll,,,,lll,l,,l,l,,,h,hhl,,hl,,I,,I,l,l,l,,,ll DALE A ROTZ 45 S BEN HOGAN DR ETTERS PA 17519-9455 JOINT OWNER JAY A ROTZ 8840126166 PAGE 1 [ ::!::.:.:.::+.::: :::::::::::::::::::::::::::::::::::::::::::::::::: :.:.:.: :.::.:,:,? :. ;.; ,.,.,; ...,;; ;;.;.....;...;; .,..,,..;;..,;;;.;.;.,,. ,; ,, ,, .. , , , ADDITIONAL JOINT OHNER: ETLEEN C ROTZ BASED ON AVERAGE DAILY BALANCE OF 601.79 [2/~[ ENDING BALANCE 602.9~ DIVIDEND YTD: YEaR ~O..DA~E ................. ~ ~.~[~_ ......... ~.~.~--...-:~ ................................ :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: J ANNUAL PERCENTA~EDAiLyYIELDBALANCEEARNED'oFi.O~ZllS.9~FRO~ 12/01/~1 THROUGH..I~/Sl/O1 J I BIsE VERI E . I J 1Z/~I ENDING BALANCE 116.~ I 4008560 EILEEN C. ROTZ, P/A 45 S BEN HOC. tltN DR ETTERS PA 17319-9455 h,,llh.h,lh.,llhh,hh.h,hhh,hh,h,hhhh.ll *** CHECKING *** FREE REGUIAR CHK ACCOUNT ~R 0001094028 0001094028 ,,, ACCOUNT NO. TAX ID ~R C~CLE-016 166-01-9336 4,370.78 6,755.34 500.00 10,626.12 *** ~CK~S~C~I~IONS *** SERIAL01/1DATE4 AMOUNT SERIAL 102 500.00 DATE AMOUNT *** CHECKING ACCOUNT TRANSACTIONS *** lDO2TE2/4 . DESCRIPTION ~ AC-DFAS-~~d~D -RET NE~ 12/27 DEPOSIT J ~ 12~31 AC-PATREASURY DEPT-ANNUITANT 01/02 AC-DFAS-CLEVELAND -RET NET~ ~ 01~03 AC-US TREASURY 303 -SOCSEC~----~ 01/07 DEPOSIT DEBITS CREDITS 34.80 102.47 390.96 1,798.35 828.00 3,600.76 *** BALANCE BY DATE *** 12115 4,370.78 12124 01/02 6,697.36 01/03 ,405.58 12/27 ,525.36 01/07 4,508.05 .12/31 11,126.12 01/14 1~,899'01 ,626.12 .' -,'-.' ':~ NOTE:":!'SEE REVERSE'~!DE FOR!IMpOR. TANT INFORMATION : '" h,,lll,,,h,ll,,,,lll,l,,I,h,,I,,M,l,,I,l,,I,,I,l,l,l,,,ll 12/15/01 0001532068 NO. *** C~ECKING *** VNB TREASURY MMDA ACCOUNT NL~BER 0001532068 PREVIOUS S~ BALANCE AS OF 11/15/01 .. ..' PLUS 1 DEPOSITS AND OTHER CREDITS 2212222112122222222 LESS 0 CHECKS AND O/HER DEBITS ...................... CORREN~ STA~I~4ENT BAIJ~CE AS OF 12/15/01 ......................... NI24BER OF DAYS IN ~-IIS ST.P~I~4EN~ PERIOD 30 CYCLE-016 BEGINNING RATE 2.69000 TAX ID NIR. tBER 166-01-9336 10,076.7'6 15.49 .00 10,092.25 *** C~ECKING ACCOUNT TRANSACTIONS *** 11~_~6 DESCRIPTION RATE CHAN~E TO 1.87000 12/15 INTEREST DEBITS CREDITS .00 15.49 *** BJtLANCEBYDATE *** 11/15 10,076.76 12/15 10,092.25 PAYER FEDERAL. ID~ER INTEREST PAID YEARTO DATE 23-0510610 42.25 *** INTEREST EAItNED THIS S~ PERIOD *** m~s IN P~.RIOO . 30 INTEREST EARNED :i::i:i::iiliiii::ilili: 15.49 "'":~ ' .NOT E!': SEE'REVER$*E'$1DE'FOR'iMPORTANT INFORMATION· . . . . ::'i'-- ~ '<' =' R~-1510 EX * (1~7) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NoN.P~,OI~AT~ PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-i500 COVER SHEET ~s/es. DESCRIPTION OF PROPERTY % OF ITEM INCLUDE THE NAME OF THE TRANSFEREE. THBRRELATIONSHIPTODECEDENTANDTHE OATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH A COPY OF THE DEED FOR REAL ESTATE, NUMBER VALUE OF ASSET INTEREST {IF APPLICABLE) £..o. Cox TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) L'zj 0 H 0 © 0 0 ~ 0~ ~ ~0~ '' ~0~000 ~000~ ~o~o~ 0 0 Z 0 o Z m COMMONWEALTH OF PENNSYLVANIA STATE EMPLOYEES' RETIREMENT SYSTEM 30 NORTH THIRD sTRE~~'' ~-~)-' BOX 1147 HARRISBURG, PENNSYLVANIA 17108-1147 TOLLFREE: 1-800-633-5461 www.sers.state.pa.us June 25,2002 JAY ROTZ 45 S BEN HOGAN DR ETTERS PA 17319 Member SSN: 166-01-9336 Beneficiary SSN: 178-50-3649 Dear Beneficiary: ' A check in amount of $26.06 will be mailed to you within two (2) weeks from the date of this letter. The a'm0unt of $0.00 was withheld for Federal Withholding Taxes. If you have elected to rollover then the taxable portion of $0.00 has been transferred to your qualified plans. ' This payment represents your designated share of 33.'33% in the Final settlement of the Account of DALE A ROTZ with this retirement system. If the individual listed above was a member of the Retirement system before JanUary 1, 1982, their contributions prior to that date were taxed as part of their gross income at that time. Therefore, no taxes are being withheld on that portion of their contributions. The difference between the amount of your payment and your share of the deceased member's non-taxable contributions, if any, is taxable for federal income tax purposes. This payment has been reported to the Internal Revenue Service. Ifa 1099R form is not enclosed with this letter, you will receive one prior to January 31 of next year, with the necessary tax information regarding this payment. Under current law there are no Pennsylvania state or local taxes on any benefits paid from this system. This letter and the 1099R form that you receive should be kept in a safe place, as you will need the information when filing your Federal Income Tax Return. This is the only notice you will receive. There is a $5.00 charge for each request of duplicate information. Sincerely, Linda M. Miller, Director Benefit Determination Division BEN31FSL I III!11 IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII! IIIII IIII IIII EV-1511 EX+ (12-99) ~' COMMONWEALTH OF PI:NNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF · . FILE NUMBER Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION FUNERAL EXPENSES: /~,o I ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) ~"'0,,,.,/ /~,- Po 7"Z.-- Social Security Number(s)/EIN Number of Personal Representative(s) / ~, j~ Street Address Y,.~'"" ,~, /'~e.,.-~ HOo~c.','x City ,~ T 'r-~.e'-$ State Year(s) Commission Paid: ~ O0 ~. Attorney Fees 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 Probate Fees ~., ~ ~ ~ ~/~..,... Accountant's Fees Tax Return Preparer's Fees ?oo / ?'-/~,2. ~, AMOUNT ~'01 o, & ?,,l. o o ?s,,5..,-/ i' ?o .,¢ 5"f. o o TOTAL (Also enter on line 9, Recapitulation) $ 3/ b'~.5/,' (if more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION 1, FILE NUMBER TOTAL (Also enter on line 10, Recapitulation) AMOUNT /'/, ?.S".r" . oo (If more space is needed, insert additional sheets of the same size) REV.-1513 EX+ (9-00~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF 0.,.-. I~... /~ FILE NUMBER J~o.. ~*-, S"r. / . RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING I~ROPERTY Do Not List Trustee(s) OF ESTATE I 1. II 1. TAXABLE DISTRIBUTIONS [include outiight spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A, SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART H- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If more space is needed, insert additional sheets o~ the same size) LAST WILL AND TESTAMENT OF DALE A. ROTZ, SR. I, Dale A. Rotz, Sr., of Etters, Pe~msylvania, revoke my former Wills and Codicili and declare this to be my Last Will and Testament. ARTICLE I IDENTIFICATION OF FAMILY I am currently a widower and not married to anyone. The names of my children are Jay A. Rotz, Dale A. Rotz, Jr., and Linda R. Miller. All references in this' Will to "my children" are references to the above-named children. ARTICLE II PAYMENTS OF DEBTS AND EXPENSES I direct that my just debts, funeral expenses, and expenses of last illness be first paid from my estate. ARTICLE III DISPOSITION OF PROPERTY Residuar,rt. Estate. I direct that my residuary estate be distributed to my children in equal shares. If a child ofmine does not survive me, such deceased child's share shall be distributed in equal shares to the children .of such deceased child who survive me, by right of representation. If a child of mine does not survive me and has no children who survive me, such deceased child's share shall be distributed in equal shares to my other children, if any, or to their respective children by right of representation. If no child of mine survives me, and if none of my deceased children are survived by children, my residuary estate shall be distributed to my heirs-at-law, their identities and respective shares to be determined under the laws of the State of Pennsylvania, then in effect, as if I died intestate at the time fixed for distribution under this provision. '-- Page 1 of 3 ARTICLE IV NOMINATION OF EXECUTOR I nominate Jay A. Rotz, of Etters, Pennsylvania, as the Executor, without bond or security. If such person or entity does not serve for any reason, I nominate Eileen C. Rotz, of Etters, Pennsylvania, to be the Executor, without bond or security. ARTICLE V EXECUTOR POWERS My Executor, in addition to other powers and authority granted by la:,,, or necessary or appropriate for proper administration, shall have the ri'ght and power to lease; sell, mortgage, or otherwise encumber any real or personal property that may 'be included in my estate, without order of court and without notice to anyone. My Executor shall )ave the right to administer my estate using "informal", unsupervzsed , or ~ndependent probate or eqmvalent legislation designed to operate without unnecessary intervention by the probate .court. ARTICLE VI MISCELLANEOUS PROVISIONS A. Paragraph Titles and Gender. The titles given to the paragraphs of this Will are inserted for reference purposes only and are not to be considered as forming a part of this Will in interpreting its provisions. All words.used in this Will in any gender shall extend to and include all genders, arid any singular words shall include the plural expression, and vice versa, specifically including "child" and "children", when the context or facts so require, and any pronouns shall be taken to refer to the person or persons intended regardless of gender or number. B. Liability of Fiduciary. No fiduciary who is a natural person shall, in the absence of fraudulent conduct or bad faith, be liable individually to any beneficiary of my estate, and my estate shall indemnify such natural person from any and all claims or expenses in connection with or arising' out of that fiduciarY's good faith actions or nonactions as the fiduciary, except for such actions or nonactions which constitute fraudulent conduct or. bad faith. C. Beneficiary Disputes. If any bequest requires that the bequest be distributed between or among two or more beneficiaries, the specific items of property comprising the respective shares shall be determined by such beneficiaries if they can agree, and if not, by my Executor. Page 2 of 3 1N WITNESS WHEREOF, I have subscribed my name below, this ~,.3rSay of t,e - , 2,,oI' .' Testator Signature: DaleA. Rotz, Sr. ' "(L~" ~' ' We, the undersigned, hereby certify that the above instrument, which consists of three pages, including the pages which contain the witness s. ignatures, was signed in our sight and presence by Dale A. Rotz, Sr. (the "Testator"), who declared this instrument to be his Last Will and Testament. and we, at the Testator's request and in the Testator's sight and presence, and in the sight and presence of each other, do hereby subscribe our names as witnesses on the date shown above. Witness Signature: Name: State: Witness Signature: Name: City: State: Witness Signature: Name: City: State: Page 3 of 3 PENNSYLVANIA Self-Proving Clause COMMONWEALTH OF PENNSYLVANIA COUNTY OF 0 ,'x I, Dale A. Rotz, Sr., the Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly and as my free and voluntary act 'for the purposes expressed in the instrument. Sworn to or affirmed and asknowledged before me by Dale A. Rotz, Sr., the Testator, this ~"tdayof i~c.7"o,3.~' , ~..o~>! . Testator Signature Dale ](. Rotz, Sr. ~.. ' Signature of officer Seal and official capacity of officer Public AFFIDAVIT · CONIMONWEALTkI OF P[NNSYLVANIA COUNTY OF ~/a, .-~ AL,~ and ~'~tZ I ¢. ~ebtT&r , the witnesses whose names are si~ed to the a~ached or foregoing instrument, being duly qualified according to law, do depose and say ·that we were present and saw the Testator sign and execute the instrument as the Testator's Last Will; that the Testator signed willingly and executed it as the Testator's flee and voluntaw act for the purposes expressed in it; that each o¢ us in the hearing and sight of the Testator signed the Will as a witness; and that to the best otour knowledge the Testator was at that time 18 or more years age, of sound mi.nd and under no constraint or undue influence. Sworn to_or affirmed and subscribed to betbre me by and ~~ ~ ~o~ and .9~ ~/ 'K W~f , witnesses, this ~day of 0o~~ , Name: ~¢~ State: ~~$ Witness Signature: Name: City.: State: Witness Signature: Name: State: Signature Seal and official capacity of officer COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 001847 BARCAVAGE STEPHEN J ESQUIRE 37 LOGANS RUN ENOLA, PA 17025 -' ...... fold ESTATE INFORMATION: SSN: 166-01-9336 FILE NUMBER: 2102-0066 DECEDENT NAME: ROTZ DALE ASR DATE OF PAYMENT: 11/15/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 01/06/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $16,896.03 TOTAL AMOUNT PAID: 916,896.03 REMARKS: JAY A ROTZ C/O STEPHEN J BARCAVAGE ESQ SEAL CHECK# 124 INITIALS: SK RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG,'PA 17128-0601 ' RECEIVEDJFROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ' ROTZ JAY A 45 SOUTH BEN HOGAN DRIVE ETTERS, PA 17319 DUPLICATE ........ fold ESTATE INFORMATION: SSN: 166-01-9336 FILE NUMBER: 2102-0066 DECEDENT NAME: ROTZ DALE ASR DATE OF PAYMENT: 01/22/2003 POSTMARK DATE: 01/21/2003 COUNTY: CUM BERLAN D DATE OF DEATH: 01/06/2002 ACN ASSESSMENT CONTROL NUMBER REV-1162 EX(11-96) NO. CD 002065 AMOUNT 101 $915.41 TOTAL AMOUNT PAID: $915.41 REMARKS: JAY A ROTZ SEAL CHECK# 1 34 INITIALS: CW RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVEI~FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 002065 ROTZ JAY A 45 SOUTH BEN HOGAN DRIVE ETTERS, PA 17319 DUPLICATE ........ fold ESTATE INFORMATION: SSN: 166-01-9336 FILE NUMBER: 21 02-0066 DECEDENT NAME: OTZ DALE ASR DATE OF PAYMENT: 01/22/2003 POSTMARK DATE: 01/21/2003 COUNTY: CUM BERLAN D DATE OF DEATH: 01/06/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $915.41 TOTAL AMOUNT PAID: $915.41 REMARKS' JAY A ROTZ SEAL CHECK//1 34 INITIALS: CW RECEIVED BY: REGISTER OF WILLS DONNA M. OTTO DEPUTY REGISTER OF WILLS · ' CERTIFICATION OF NOTICE :UNDER RULE 5.6(a) Name of Decedent: Date of Death: Will bio. To the Register: Adm. No. ,~, o o ~,-- 00066 I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on ~ / b/~.oo g, : Name Address · : ..':.: ~ ( ~ ...... ,,~ .... Notice has now been given to all persons entitled thereto under Rule 5.6a) except: · Date: Telephone (Z.'?) Capacity: Personal Representative Counsel for Personal Representative BUREAU OF INDIVIDUAL TAXES ,INH£RITAHCE T~ DIVISION DEPT. 280601 HARR/SBURG, PA 17128-060! COMMONNEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISENENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX REV-J547 EX AFP C01-05) STEPHEN J BARCAVAGE :57 LOGANS RUN ENOLA ~c ...... ':: ?. '['; ' ~;. , ii .C~i DATE 01 - 06 - 200:5 :{'¢. :.. ':. ',', ESTATE OF ROTZ DATE OF DEATH 01-06-2002 FILE NUMBER 21 02-0066 '03 JAN !] ;~ 8 :'0~OUNTY CUMBERLAND ACN 101 PA Amount Remitted DALE A MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF NILLS CUMBERLAND CO COURT HOUSE fl CARLISLE, PA 1701:5 CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS ~ REV-lB47 EX RFP C01-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF ROTZ DALE A FILE NO. 21 02-0066 ACN 101 DATE' 01-06-200:5 TAX RETURN WAS: ( ) ACCEPTED AS FILED C X) CHANGED SEE ATTACHED NOTICE' RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate CSchedule A) C1) 2. Stocks and'Bonds CSchedule B) C2) $. Closely Held Stock/Partnership Interest (Schedule C) ($) 4. Nortgages/Notes Receivable (Schedule D) (4) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 6. Jointly Owned, Property CSchedule F) 7. Transfers CSchedule G) C7) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/M/sc. Expenses (Schedule H) (9) lO. Debts/Mortgage Liabilities/Liens CSchedule I) (10) 11. Total Deductions 12. Net Value of Tax Return 246t615.85 .00 171~069.99 .00 .00 NOTE: To insure proper credit to your account, submit the upper portion · 00 of this form with your tax payment. :55,857.22 61361.35 c11) 42.2]fl.~7 REVERSE SIDE OF THIS FORM IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. 15. 14. NOTE: ASSESSMENT OF TAX: 15. Amount of L/ne I4 at Spousal rate C15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16). 17. Amount of Line 14 at Sibling rate C17) 18. Amount Of Line 14 taxable at Collateral/Class B rate C18) 19. Pr/nc/ ~al Tax Due TAX CREDITS: PAYMENT RECEIPT DISCOUNT C+) DATE NUMBER INTEREST/PEN PAID (-) 11-15-2002 CD001847 . O0 INTEREST IS CHARGED THROUGH 01-21-2005 AT THE RATES APPLICABLE AS OUTLINED ON THE reflect figures that include the total of ALL returns assessed to date. · O0 x O0 = 39:5,048.:52 x 045 = · O0 x 12 : .00 x 15 : C19)= AMOUNT PAID 16,896.0:5 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE Charitable/Governmental Bequests; Non-elected 9115 Trusts CSchedule J) C15) Net Value of Estate Sub3ect to Tax C14) :595,048.52 If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will .00 .00 17,687.17 .00 .00 17,687.17 16,896.03 791.14 124.27 915.41 ( IF TOTAL DUE IS LESS THAN ~1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CA), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) 17t581.05 c8) 455,266.89 RESERVATION= PURPOSE ~F NOTICE=, PAYMENT= REFUND OBJECTIONS= ADMIN- ISTRATIVE CORRECTIONS= DISCOUNT= PENALTY= iNTEREST= Estates of decedents dying on or before December 12, 1982 -- if'~ny future interest in the estate is transferred* in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 25 of 2000. (72 P.S. Sectioh Detach the top portion of this Notice and submit with your payment to the Register Of Hills.printed on the reverse side. --Hake check or money order payable to= REGISTER OF N/LLS, AGENT ~ refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application ..for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications are available at the Office of the Register of Wills, any of the 25 Revenue District Offices, or by calling the s~ecial 2q-hour answering service for forms ordering= 1-800-$62-2050; services for taxpayers with special hearing and / or - speaking needs= 1-800-~47-3020 (TT only). Any party in interest not satisfied with the appraisement, allowance, or disall'o~ance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by= --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA I7128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered.on this assessment should be addressed in writing to= PA Department of Revenue, Bureau of Individual Taxes, ATTN= Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" ~REV-1501) for an explanation of administratively correctable errors. If any tax due is paid within three ¢$) calm*rider months after the decedent's death, a five percent (5~) discount of the tax paid is allowed. ~he, 15~ tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before Januar~ 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (I) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6X) percent per annum calculated at a daily.rate of .000164. All taxes which became delinquent on and after· Januar~ 1, 1982 ~ll bear interest at a rate which will var~ from calendar year to calendar year ~ith that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2003 are= Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 1982 20~ .000548 1987 9~ · .0002~7 . 1999 7~ .000192 1983 16~ .000458 1988-1991 11~ .000301 2000 8~ .000219 1984 11~ .000501 1992 9~ .000247 2001 9~ .000247 1985 i3~ .00035~ 1995~1994 7~ .000192 2002 6~ .000164 1986 lO~ .000274 1995-1998 9~ .000247 2005 5~ .000137 --Interest is'calculated as follows= ZNTEREST = BALANCE OF TAX UNPAZD X NUHBER OF DAYS DELTNI;~UENT X DATL¥ ZNTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. REV-1470 EX (6-88)  INHERITANCE TAX EXPLANATION COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE CHANGES BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 DECEDENT~S NAME FILE NUMBER ROTZ SR,DALE A 2102-0066 REVIEWED BY ACH . Kathryn Harbilas 101 ITEM SCHEDULE NO. EXPLANATION OF CHANGES G 1 Annuities are fully' taxable with no exclusion. ROW Page 1 ~z~ ~o ~o~ ~m ~z mz ~ ~ ~m zm°m~ ~ o m~<Z ~ o~X m~ '03 JAN 22 .~2:11 IREAu OF ' ZNDZVZDUAL iERZTAHcE TAX D TAXEs 'T._280601 ZV-ZsZON .... ZNHERZTANc STATEHEN~ ~. E TAX ....... ~ ACCOUNT ROTE DATE OF DEATH 01 ~7 LOGANS RUN ENOLA PA 2 7025[~5:.~v. ' ACN CUHBERLAND *-n~RZ~==--- '*uN FOD v .... -o ror~ With qENT ZS PROVZD ~~z~ ,. ~. '-.~-, o~ ~o~'--~ ................ DALE A / ?-03 /~,-'- 8 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280681 HARRISBURG, PA 17128-0601 STEPHEN J BARCAVAGE 37 LOGANS RUN ENOLA PA 17025 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT REV-1607 EX RFP (P1-OS7 DATE 02-18-2003 ESTATE OF ROTZ DALE A DATE OF DEATH 01-06-2002 FILE NUMBER 21 02-0066 COUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this fore with your tax payment. CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1607 EX AFP (01-03) ~~* INHERITANCE TAX STATEMENT OF ACCOUNT *** ESTATE OF ROTZ DALE A FILE N0. 21 02-0066 ACN 101 DATE 02-18-2003 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 01-06-2003 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): 17,687.17 PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID C-) AMOUNT PAID 11-15-2002 CD001847 .00 16,896.03 01-21-2003 CD002065 124.27- 915.41 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. ^ IF PAID AFTER THIS DATE, SEE REVERSE I TOTAL DUE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) 17,687.17 .00 .00 .00 PAYMENT: Detach the top portion of this Notice and submit with your payment made payable to the name and address printed on the reverse side. -- If RESIDENT DECEDENT make check or money order payable to: REGISTER OF WILLS, AGENT. -- If NON-RESIDENT DECEDENT make check or money order payable to: COMMONWEALTH OF PENNSYLVANIA. REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-13137. Applications are available at the Office of the Register of Nills, any of the 23 Revenue District Offices or from the Department's 24-hour answering service far forms ordering: 1-800-362-2050; services for taxpayers with special hearing and / ar speaking needs: 1-800-447-3020 (TT only]. REPLY T0: questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601, phone (7177 787-6505. DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%l discount of the tax paid is allowed. PENALTY: The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9l months and one (17 day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six (6%7 percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2003 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 1982 20% .000548 1987 9% .000247 1999 7% .000192 1983 16% .000438 1988-1991 11% .000301 2000 8% .000219 1984 11% .000301 1992 9% .000247 2001 9% .000247 1985 13% .000356 1993-1994 7% .000192 2002 6% .000164 1986 10% .000274 1995-1998 9% .000247 2003 5% .000137 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUlIBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen C151 days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. Name of Decedent: STATUS REPORT lPqDER RULE 6.12 Date of Death: Will No.: Admin. No.: P.I oil. - oo~,b ' Pursuant to Rule 6.12 of the Supreme Court Orphans'. Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: . Yes 2. If the answer is No, state when the persOnal representativ?.reasonably/believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: Did the personal representative file a final account with the Court? Yes_ No [] b. The separate Orphans' Court No. (if any) for the personal representative's accoUnt is: Date: c. Did the personal repres.entative'stat9 an accoUnt inf6i[mally th' the parties in interest? Yes ~-] No .: [-]' Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the. Orphans' Court and may be attached to this report. ~ame Address (?/-)) ds-')- s'$"og" Telephone No. Capacity:I {-'] ~;'~rsonal Representative ~-] Counsel for personal representative