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HomeMy WebLinkAbout09-19-08' , . ~ 15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN """''- ~`- '' ' " "~ PO BOX 280601 ' i ©i ~ © D 8' -~ ` Cj , Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ 9 '3 8 ~3 o s~s~ , ~9 ~ ~{ ~~ ~ 7 d ~~ ~~ 1~ ~ s: ~..~..~.. q, Decedent's Last Name Suffix Decedent's First Name MI (IfAppliCable) Enter Surviving Spouse's Information Below Spouse's Lasl Name Suffix Spouses First Name CAI .,/. Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numher ~> ..~ Firm Name (If Applicable) ~ ~-~~ <"7 REGISTER-~!F LLS USE~LY ~ ~ /~/! ~i t i i .,.1 ~..- r f- '. First line of address = ~-a"? ~t7 - ~ -` Second line of address '-~~~- J A J d ~ - - _ r~r-~ C1 City or Post Office State ZIP Code DATE FILED JN~C'HR-N/ ~S,Bt!/~G ~'f1 /7 osS"9735 Correspondent's a-mail address: Ce $~~ elals3 Q L~ollrl Cast net 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, co and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT ~`Py~~S.O/N Q~SP IB ~FORjFILING RETURN n ' n DATE ADDRE ICI~KN r~ ~ v!• /~~.~ /~"'/~IV `i R~/~'IYIS ~/ O SIGNATU PREP RER ER T ReS T TIVE DATEd 7 ADDRESS ~/~R~S y/~AS OSS'' PLEAS SE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 J 15056052048 REV-1500 EX Decedent's Socia l Security Number Decedent's Name: /•JI~LENi¢ L. f~/E7~Z ~ S ~j 3 ~ 3 O S`S' RECAPITULATION 1. Real estate (Schedule A) .......................................... ... 1. ~ p O 2. Stocks and Bonds (Schedule B) .................................... ... 2. ~ ~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. , O ~ 4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. D ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. ~ ~ ~ p s 2: 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. „ ~ ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. n t f% 0 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ~ , Q O 8 s ~ ~ (o 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 3 (0 6 ~ ~ ~ 7 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. ~ ,Z "] / q ~ p 2, 11. Total Deductions (total Lines 9 8~ 10) ................................. .. 11. ; oZ (0 3 ~' 8 . f 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ~ ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. ~ Q 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. r D ~ , TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 ~ ~ 15. ~ ~ 16. Amount of Line 14 taxable at lineal rate X .0'~ , Q Q 16 Q O 17. Amount of Line 14 taxable t ibli ~ ~ a s ng rate X .12 17. ~ D 18. Amount of Line 14 taxable at collateral rate X 15 ~ ~ . . 1 g. ~ D O 19. TAX DUE ....................................................... ..19. © ~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O _~~-~~ ~' '-~-' ~~~ 15056052048 Side 2 15056052048 J REV.1500 EX Page 3 File Number it ~- 07 '~ ~ 7 4 Decedent's Complete Address: HkLE'N~4 t . 1~iETz -- --_- STREETADDRESS -- ~ s---__GV.FSC~y Drr. aTY - - - _ i1'1 ~'CfI~FN ~ cS~ u~~ -- - - _. 1 STATE ~~T ZIP / 70 S S' Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) ` 2. CreditslPayments O A. Spousal Poverty Credit B. Prior Payments ~ C. Discount p 3. InterestlPenalty if applicable (1) ~ O Total Credits (A + B + C) (2) D. Interest D E. Penalty (~ O __ -- -- ota nteres 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) Q 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Q A. Enter the interest on the tax due. (5A) Q B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) ~ 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 : ............................................ ^ 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 her death? .............. ^ 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, 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. §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 spause is zero (0} percent [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 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)j. Asibling 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-1508 EX ~ 11-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF ~' ~ T Z~ f/ EL EN~Q- L . FILE NUMBER a /_ b7 _ ~, 4 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ 3Dn o97 ~l~y2 v~ 785.2!v PNC t3~r~/K , Cheek;r~ acct ~. rsec va~~r~/io., /~h`zi- Clt~actica~~ ~. /~~~ {u.rhrTU~1G Qnt.c1 Oil^C.~ ~2.C5oNQ.I'~ 1.0(t.S cli5~osee0 of ~~ .-.p .... e~,~r 1 nq h i g4Wr f e vP~l 4~'~ C~•-"G '~p.~,i 1 i 'lam . 3. ~// ii~'ins ~ (~~~~`~/ agora inch f wcrle g; vu~ a u~ 4.y n~o~. -- o -- on¢ year be~re d.o•d. ~J / ~~ ~CO/IOM~G c~T7•/~'1lL~US ~~ 3D0•BD TOTAL (Also enter on line 5, Recapitulation) I $ /~~ Q O S~ •~ 6 (If more space is needed, insert additional sheets of the same size) ~1 y~G,„ k ~~ i ~! ~~! 't October LZ, 2C~7 Charles E. Shield, lIi Attorney at Law 6 Clouse; Road Mechan.acsburg, PA 17{;55 RE: Estate of Helena L. Dietz, deceased SSN: 155-38-3055 DOD: °/14/2aa7 Dear iV1l. Shield: ~ ~ - 4 In response to your request for Date of Death balances for the custoa,,er noted above, our records show the iollowi~tg: ChYC~Ciilo I~CCOfIElE Account #saao~78642 Estzbiished o~; 2ai2aoo %IELENA L DlETZ DOD beisnce: $4,785.26 (Han-interest bsa_ring) Please Hate that this office only provides date of death baia,?ees for deposit accounts (?R~s, CUs, Chec?ung and Savings accounts). vVe de trot nsocess env #iaancial transactions or pravidc st~te~ents. If you need assistance wi#h any of these items, please cal! 1-888-PNC-Btl.rdl: (I-888-76Z-22b~) or stop by your local P2vC Banl: branch office. Sincerely, Fachelle wells I -$0~:1-76?-1775 P7-PFSC-O~-F 500 fast Ave. ?'ittsburgh P.q 15219 Vlcrnbcr FDIC REV-1511 EX+ (12-99) • ~, SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF ~ I ~ T Z ~ f-(E'L E'N/~ L- • FILE NUMBER ~ ~ _ ~ ,7~ ~y7~ Debts of decedent must be reported on Schedule I. 6 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,. Dyers ~;.t,ner~a.( Mome rrF ~Yl~ctian~ csbwt-~ fit, !fS~.72. d. ~u>n~ mea.l, ~• r~o• za 3• `['~;Iw~.ee n~ ~~ e,K ~-.nu^a~ flan ~l I o. /8 B. I ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) K/ f /2E/I/ /"~~~ ~$D'T, Z s Social Security Number(s)lEIN Number of Personal Representative(s) Street Add/r~ess a !? /YIlc~IG ~Ye. City C.Q/lt.d /y/~~ State I'~~ Zip l70!/ Year(s) Commission Paid: J 2. Attorney Fees C h at~GS E. `J~ll ele~s ~ ~ ~ ~ ~ D O.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant /1/'D Nom' EL/L/CiLF /NONE Street Address City State Zip Relationship of Claimant to Decedent 4. i /' Probate Fees QMl~ Of^! 4l Au.~ i 5 S GE p~ S~1ort CG't1 4'~•LafL.t Q ~-76 ~ a0 5. Accountant's Fees Jgr1G}' (3racKb'rlt , M ~R (31ocK, 11f1echanitsb~~ g87 DO 6. Tax Return Preparer's Fees ~~ /~Avcrf;s~n~ ;r~ Curnbu-land L.a.~ ~u--n4,J {~,~00 ~- A~/Ert~si~ :~ C'ar/~s/e ~S~ine/ y~ / 9 ,~ ~;n ~~ ~ ~~~5~ or 1~•~~s (~ i8 7z rls: vv /D• /~alr I!7 0/1~/ /diso ,6a~' ~ e T ~ D, 0 0 I/, ReilMbur' ~ Charles ~: Srri~elds u1 ~i,r poS'~et~c, ~fw~- 32. ~a C~p,es Cf',r"f'iTted ma. (~ ngs. , TOTAL (Also enter on line 9, Recapitulation} /7 $ 3, ~ 6 9'. (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) ' SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF ~EL ~N/~' L ~ FILE NUMBER ~ tc-~z, .u~a~- 819 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ C I a. M by Dept. o~ ~wbl~'c Gt1e ll~tre ~ r' re~inad ur (~tfCApri zeal Q S mee>l ~a//y /L~lltr~4 l,~Ji ~iin /Q tf S i X M,on his ~~{~K c~.o. ~l• (class 3 c._1ai:~) (ate C/a;•r~ tS~I~efs at`fx~~~ ~~ D3 9'. ~3 a. .rte fer;nal IQe/en ue e~i c t ~u . S. Treasury - ~~ i/!c l~axts) ~(~ . ~ p 3, ~e i~ V'- I I a.q~. (see b:llr~ a ~cli~tl~ ~~ 6 7.3, 3 9 0 d TOTAL (Also enter on line 10, Recapitulation) $ I o7 a, 7/ q. o ~- (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 November 13, 2007 CHARLES E SHIELDS, III CHARLES E SHIELDS, III 6 CLOUSER ROAD MECHANICSBURG PA 17055 Re: HELENA DIETZ CIS #: 560191125 SSN: 159-38-3055 Date of Death: 09/04/2007 Dear Attorney Shields: Please be advised that the Department of Public Welfare maintains a claim in the amount of $18,039.63 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $18,039.63, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $.00, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, r ~ ~ ~ ~~ r Kelly I. Wells TPL Program Investigator 717-214-1870 717-772-6553 FAX Enclosure I I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 November 13, 2007 STATEMENT OF CLAIM SUMMARY 'NAME Estate of DIETZ, HELENA ID 560 191 125 'MEDICAL GLASS-'3 CLASS B TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 18,039.63 .00 18,039.63 DRUG .00 .00 .00 s`REIMBURSEMENT TO DPW 18,039.63 .00 18,039.63 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 COMMONWEALTH OF PENNSYLVANIA , DEPARTMENT OF PUBLIC WELFARE November 13, 2007 STATEMENT OF CLAIM NAME DIETZ, HELENA ID 560 191 125 BETHANY VILLAGE RETIREMENT CENTER 325 WESLEY DR MECHANICSBURG PA 17055 DATE OF' SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 06!10107 - 06130107 00100100 00000000000000001 3,717.63 3,717.63 DIAGNOSIS 1 : ESTIM PROC CODE : W0305 CASE MIX 07/01/07 - 07/31/07 00100/00 00000000000000002 5,919.76 5,919.76 DIAGNOSIS 1 : ESTIM PROC CODE : W0305 CASE MIX 08/01/07 - 08/31/07 00/00100 00000000000000003 5,919.76 5,919.76 DIAGNOSIS 1 : ESTIM PROC CODE : W0305 CASE MIX 09/01107 - 09/04/07 00100100 00000000000000004 2,482.48 2,482.48 DIAGNOSIS 1 : ESTIM PROC CODE : W0305 CASE MIX .PROVIDER SUB TOTAL- BETHANY VILLAGE RETIREMENT CENTER 18,039.63 18,039.63 03 101750581 0003 ~~ ~T Bethany Village 325 Wesley Drive Mechanicsburg, PA 17055 A F ~. r ~ Statement Date Due Date Account # 12/7/2007 Upon Receipt 198 TOTAL BALANCE-:DUE: $0.00 AMOUNT PAID $ Please make check payable to: Bethany Skilled Nursing HELENA DIETZ clo KAREN PARKS 22 MAPLE AVENUE CAMP HILL, PA17011 Comments: Balance Forward Total Balance Due: Remit To: BETHANY VILLAGE 325 WESLEY DRIVE MECHANICSBURG, PA 17055 Please detached and return this portion with your remittance to the address above. $0.00 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER Bethany Skilled Nursing HELENA L. DIETZ 198 12/5/2007 Payment Check $4,673.39 ~~ T Bethany Village 325 Wesley Drive Mechanicsburg, PA 17055 Statement Date Due Date Account # 11/7/2007 Upon Receipt 198 TOTAL"BALANCE.QUE: $4,673.39 AMOUNT PAID $ Please make check payable to: Bethany Skilled Nursing HELENA DIETZ clo KAREN PARKS 22 MAPLE AVENUE CAMP HILL, PA17011 Comments: Remit To: BETHANY VILLAGE 325 WESLEY DRIVE MECHANICSBURG, PA 17055 Please detached and return this portion with your remittance to the address above. Date ' Description Da s/Units' Char e'' Payrrment/Ccedit 'Balance Balance Forward ($1,44S.ti1) 6/10/07-6/30/07 Resident Liability $1,534.25 7/01!07-7/31/07 Resident Liability $1,529.25 8/01/07-8/31/07 Resident Liability $1,529.25 9/01/07-9/30/07 Resident Liability $1,529.25 Total Balance Due: $4,673.39 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER Bethany Skilled Nursing HELENA L. DIETZ 198 Statement Date Due Date Account # 10/4/2007 Upon Receipt 198 TOTAL BALANCE`DUEs ($1,448.61 AMOUNT PAID $ Please make check payable to: Bethany Skilled Nursing HELENA DIETZ c/o KAREN PARKS 22 MAPLE AVENUE CAMP HILL, PA17011 Comments: Total Balance Due: Remit To: BETHANY VILLAGE 325 WESLEY DRIVE MECHANICSBURG, PA 17055 Please detached and return this portion with your remittance to the address above. ($1,448.61) FACILITY NAME RESIDENT NAME ACCOUNT NUMBER Bethany Skilled Nursing HELENA L. DIETZ 198 ~-~l~T Bethany Village 325 Wesley Drive Mechanicsburg, PA 17055 Statement Date Due Date Account # 9/7/2007 Upon Receipt 198 TOTAL.BALANCE DUE: $1,448.61) AMOUNT PAID $ Please make check payable to: Bethany Skilled Nursing HELENA DIETZ c/o KAREN PARKS 22 MAPLE AVENUE CAMP HILL, PA17011 Comments: 8/21/2007 8/28/2007 Balance Forward Beauty Shop Beauty Shop Total Balance Due: Remit To: BETHANY VILLAGE 325 WESLEY DRIVE MECHANICSBURG, PA 17055 Please detached and return this portion with your remittance to the address above. 1,501.61) $33.50 $19.50 ($1,448.61) FACILITY NAME RESIDENT NAME ACCOUNT NUMBER Bethany Skilled Nursing HELENA L. DIETZ 198 ~~ T Bethany Village 325 Wesley Drive Mechanicsburg, PA 17055 Statement Date Due Date Account # 8/7/2007 Upon Receipt 198 TOTAL BALANCE:DUE: $1,501.61 AMOUNT PAID $ Please make check payable to: Bethany Skilled Nursing HELENA DIETZ clo KAREN PARKS 22 MAPLE AVENUE CAMP HILL, PA17011 Remit To: BETHANY VILLAGE 325 WESLEY DRIVE MECHANICSBURG, PA 17055 Please detached and return this portion with your remittance to the address above. Comments: • ~ • ~ i l ~ Date Description ' DayslUnits ''Char e'` Pa' ment/Credit' Balance aaiance rorwara 6/10/07-6/30/07 Monthly Fee 7/01/07-7/31/07 Monthly Fee 7/31/2007 Tranfer A/L overpayment Total Balance Due: ~'I ;i, ~ti4.UU -21 ($5,397.00) -31 ($7,967.00) ($1,501.61) ($1,501.61) FACILITY NAME RESIDENT NAME ACCOUNT NUMBER Bethany Skilled Nursing HELENA L. DIETZ 198 REV-1513 EX+ (9-00) SCI~IEDt~LE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~~_ D 7- ~ 79 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ~/ 1. fiy ant! fhrda'~ ~iS R~CHA-!20 ~I~TZ S°~ ~ ~ i°o~, ~s~vi~ .~lE rz nle~harliesbu,r~q, a°•~ /~oso 9/S Greehbriar .Di: /!'le~l14ni esbury, Pi¢ /7oso 3. .~~ ~eE,v e. P.~•eks dad Y ~ `l~ J.~CQ~ /yt~eysf~z ~l'E~S ~rnfn.dso-, /g Ddb /,~e~~y~,~/ ~t yarr~s6~rry ~/t /7/05 , <~oNh'~~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) s~~E~ ~, c~~~ /~t~RY ELLEN /~E -o? ~-D_7- ~7 9 ~~..`y_hf~ - ------------- _-------- LAST WILL AND TESTAMENT OF HELENA L DIETZ I, HELENA L. DIETZ, currently of Bethany Village, Lower Allen Township, Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, shall be distributed into four (4) equal shares, one of which shall be given to my son, RICHARD C. DIETZ; one of which shall be given to my daughter, SANDRA E. KINDNESS; one of which shall be given to my daughter, KAREN C. ADAMS; and one of which shall be divided between my two grandchildren, JACOB MICHAEL NESS and 14IARI` ELLEN NESS, the children of my deceased daughter, Linda S. Ness. 3. I nominate, constitute and appoint my daughter, KAREN C. ADAMS, to be the Executrix of this my Last Will and Testament. In the event that she should predecease me or for any reason be unwilling or unable to act as such Executrix, I nominate, constitute and appoint my son-in-law, RONALD E. ADAMS, to be Executor in her place and stead. In the event that he should predecease me or far any reason be unwilling or unable to act as such Executor, I nominate, constitute and appoint my grandson, DAVID C. DiETZ, to be Executor in his place and stead. I further direct that they shall not be required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~,~ day of - ~ , A.D. 2001. I E ENA L. DIE (SEAL) Signed, sealed, published and declared by the above-named HELENA L. DIETZ as and for her Last Will and Testament, in the presence of tts, who at her request and in her presence, and in the presence of each other, have her~ut ubscnribed our names as witnesses. ~~~ CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG, PA 17055 GEORGE M. HOUCK (1912-1991) September 19, 2008 Register of Wills Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Helena L. Dietz No. 21-07-0879 Dear Register of Wills: TELEPHONE (717) 766-0209 FAX (717) 795-7473 Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Helena L. Dietz Estate as well as a Check in the amount of $15.00 for the filing fee and a Check in the amount of $30.00 for additional Probate. Thank you for your kind attention to this matter. Very truly yours, Gt Charles E. Shields III , , Attorney-At-Law ~ , ,, ..- ~ _ ~ ; o ~ _ cn ~ , ~ ~ - ~ n Enclosures ~ - `'-''~ - ~::~ %~~~~ z,. ~ ~' --~ a c, 0