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Home My WebLink About03-0982 PETITION FOR PROBATE and GRANT OF LETTERS Estate of Donna A. Facr, m~. No. t~./-t~,.~- t~¢'~O..~ also known as ' To: Register of Wills for the Social Security No. 172-32--,~-~ D~clsed. County of Cumberland in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the executr5 x named in the last will of the above decedent, dated January 17 and codicil(s) dated ,1-9-__21302 (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in. Cumber]and County, Pennsylvania, with h er last family or principal residence at 355 S. ~qnow~cincs l-Ii 11 ge] #2. Mechanicsburg: PA ] 7050 ' ~ : (list street, number and muncipality) Decendent, then 90 __ years of age, died Nove~nber 17, , 1-9_.2003 at Holy .qrfi r5 t l-ln.qni fa]. ~._ Penn,boro Township, Cumber] and County i Except as-follows, dec~dent did not marry, was not divorced-and did not have a child born or adopted after execution of the will offered t'or probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) A!I personal property $ 485. 000. 013 (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania situated as follows: N/A $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters Test~nentary theron. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) ~ ~ Donna B. Bohn ~.~ 2140 Market Street, B 201 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF f ss The petitioner(s) above-named swear(s) or 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 represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirm,~_/.,~and subscribed ~ ~c ~t,4n~ be~'o~ me this _,.~.~ day of [ ' ~,,~eJ~Registe~ [ NO. Estate Of Donna A. FaCvniq , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW ~PE/~/zzz/,O~ 19' 2003, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated January 17, 2002 described therein be admitted to probate and filed of record as the last will of Donna A. Facynic . and Letters Testamentary are hereby granted to Donna B. Bohn FEES Probate. Letters, Etc .......... ~~ E. Robert Elickert II 01572 g(-/O,~.~~nort t.-ertlncates( ) ...' ....... - '~'~-- 20 ~tone bprlng $ ~. ti,cz, ~, AT~OP. NEY (~l~t. I.D. No.) Renunciation ................ $ Camp Hill, PA 17011 ~ $ /t~, t:~ ~:~ ADDRESS ~ ~L~... TOTAL $ ~//'3/, . .~..~./. ~ .~ ......... 717-240-6535 Filed PHONE This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~ Date H105 143 Rev 2/87 COMMONWEALTH OF PENNSYLVANIA ° DEPARTMENT OF HEALTH ° VITAL RECORDS TYPE/PR,NT CERTIFICATE OF DEATH PERMANENT Donna Anders Facynic I I I ~. C~berland I~. Camp H~ll I,~.MO/~ ~l~/J~/~/ [,. [,0 ~te ,.. Supervisor ~ ~.State Gover=ent I~. I,,. 12l I,~. Widowed Country Meadows I~gV~ME ~.. s,~t~ Pennsylvania dec~,qDid 1lc. ~ Yes. dec~ent '},edin Hampden 355 South Sporting Hill Road (s.~,.~,~.=,~.. C~berland Iownship?liveina 17d.~ wilhinactuaHi,ngsofN°' decedenllived 16~h~nj oRh,,r~ PA ] 7~5~ ~on omer side) 17b. County cily/b~o ~,. Charles F. ~ders ~,. Bertha C. Donahey ~0~. Donna B. Bohn m=0,' ziqomarKet Street, B-ZOl, Camp Hill, PA 17011 METHOD OF DISPOS~TmON DATE OF D[SPOSITmoN m PLACE OF D~SPOS)TION- Name ol Ceme~e~, Crematory mLOCATION - Cil~/Yown, State Zip CoOe . ~.~, c~em~,~, ~ =~, November ~ D ...... ~ ~ ~ ...... I ,rom State ~ ( .............. ) or Other Place UC,.Sa.UR ~o~ooa~sso,~c,m~refz & Bowser F~eral ltome Inc <~ z=,. FB-O] q6741, [n.. 114 West Main Street. H~elsto~. PA 1 7036' CAUSE (Disease or inju~ ~ c. r~uRing on death ) LAST d. WERE AUTOPSY FINDINGS MANNER OF D~TH DATE OF INJURY TIME OF iNJURY Jbuild,ng.P~CE .,cOF(spec,,.)INJURY' A ..................... , , .ice I LOCATION (S ...... Ci 'PRONOUNCING AND CERTIFYING PHYSICIAN (Physician bolh pronouncing death and certifying to cause of death} / LICENS~NUMBER [ D~TE SIGNED (Mgnth. Day. Year) ~ To the best ot my k,owledge, death ...... dattheflme, d ...... dp ........ duelolh ....... (s) and ............. d ...................... ~ 31c. ' ~00/gYS~~5 NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH LAST WILL AND TESTAMENT OF DONNA A. FACYNIC I, DONNA A. FACYNIC, of Hampden Township, 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 hereby revoking and making void any and all wills by me at any time heretofore made. 1. I direct that all my debts and funeral expenses be paid as soon as practicable after my death by my Executrix hereinafter named. 2. I give, devise, and bequeath all the rest, residue, and remainder of my estate, real, personal, and mixed, and wheresoever the same may be situate to the church and persons named below, the church and individuals each receiving one eighth (1/8) of the residuary estate: The Tree of Life Lutheran Church, Susquehanna Township, Dauphin County, Pennsylvania, absolutely; My niece, Jane A. Kapsa, absolutely; My nephew, Thomas A. Boyer, absolutely; My niece, Donna B. Bohn, absolutely; My nephew, Jack E. Boyer, absolutely; My sister-in-law, Helen Sass, absolutely; My sister-in-law, Anne F. Zerbe, absolutely. In the event any of the aforementioned persons predecease me and have spouses surviving, I direct that the share of the deceased person shall pass to the surviving spouse. If both the named beneficiary and spouse have predeceased, then the equal share of the named beneficiary shall pass equally to the children of the beneficiary and deceased spouse. If there are no children surviving, then the share of the deceased named beneficiary shall pass in equal shares to the church and persons surviving above named. 3. The remaining one eighth (1/8) of the residuary estate shall be divided equally between the four (4) children of Mary K. Kuzovich, namely, Paula Daniels, absolutely; Patricia Nauditt, absolutely; Nicholas Paul Kuzovich, absolutely; Cecelia Kuzovich, absolutely. In the event any of the aforementioned children of Mary F. Kuzovich predeases me, I direct the share of such deceased person shall pass in equal shares to the persons surviving above named in this paragraph. 4. I hereby nominate, constitute, and appoint my niece, DONNA B. BOHN, as Executrix of this my Last Will and Testament, but should she predecease me or fail to qualify, then in such event, I nominate, constitute, and appoint my great niece, SUZANNA J. POSAVEC, as Executrix of this my Last Will and Testament. 5. No fiduciary acting hereunder shall be required to post bond or enter security for the faithful performance of her duties in any jurisdiction. IN WITNESS WHEREOF, I, DONNA A. FACYNIC, have hereunto set my hand and seal this /74~ day of DONNA A. FACYNIC SIGNED, SEALED, PUBLISHED and DECLARED by DONNA A. FACYNIC, the Testatrix above named, as and for her Last Will and Testament, in our presence, who, in her presence, at her request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. SEAL) COMMONWEALTH OF PENNSYLVANIA: : SS: COUNTY OF CUMBERLAND : We, DONNA A. FACYNIC, E. ROBERT ELICKER, II, and TRACI J. COLYER, the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament, and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes herein 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 or her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind, and under no constraint of undue influence. Testatrix Witness Subscribed, sworn to and acknowledged before me by DONNA A. FACYNIC, Testatrix, and subscribed and sworn to before me by E. ROBERT ELICKER, II, and TRACI J. COLYER, witnesses, this / '7~ day of ~,/~._~ 2002. ~N~o t~a~ Public TERRY J. F~LL, [",~;~,J P~blic Carlisle Bom, C.~rn~d,a~ C~unty_ My ~mmission ~ ~ 6, CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Donna A. Facynic Date of Death: November 17, 2003 To the Register: I certify that notice of (beneficial interest) .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 December 1, 2003: The Tree of Life Lutheran Church, 1492 Linglestown Road, Harrisburg, PA 17110; Jane A. Kapsa, 4297 Brixton Drive, Stow, Ohio 44224; Thomas A. Boyer, 418 Haldeman Avenue, New Cumberland, PA 17070; Donna B. Bohn, 2140 Market Street, B-201, Camp Hill, PA 17011; Jack E. Boyer, 813 Cross Street, Port Royal, PA 17082; Helen Sass, P.O. Box 64, 424 Center Street, Wisconisco, PA 17097; Anne F. Zerbe, 127 Shartlesville Road, Bernville, PA 19506; Paula Daniels, 34 Algonquion Drive, Natick, MA 01760; Patricia Nauditt, 11515 SE 178th Place, Renton, WA 98055; Nicholas Paul Kuzovich, 415 Fourth Avenue N., Renton, WA 98001; Cecelia Kuzovich, 3027 Edmunds Road, Lafayette Hill, PA 19444. Date Signature E. Robert Elicker, II Attorney at Law 20 Stone Spring Lane Camp Hill, PA 17011 Telephone (717) 240-6535 Counsel for personal representative E. ROBERT ELICKER, II Attorney at Law 20 Stone Spring Lane Camp Hill, PA 17011 (717) 240-6535 November 26, 2003 Mark Pacella Chief Deputy Attorney General Charitable Trust Section 14th Floor, Strawberry Square Harrisburg, PA 17102 RE: Estate of Donna A. Facynic, 2003-00982, Cumberland County, Pennsylvania Dear Mr. Pacella: I represent the above referenced estate. The Will has been filed with the Register of Wills of Cumberland County (a copy of which is enclosed) providing for a bequest to Tree of Life Lutheran Church, 1492 Linglestown Road, Harrisburg, Pennsylvania 17110. Letters testamentary were issued on November 26, 2003, to Donna B. Bohn, 2140 Market Street, B-201, Camp Hill, Pennsylvania 17011. It is my understanding that upon completion of the final account and schedule of distribution, a copy should be provided to your office. Very truly yours, E. Robert Elicker, II Attorney at Law : Enclosure (Will) ? COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 003496 ELICKER E ROBERT II 20 STONE SPRING LN CAMP HILL, PA 17011 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold 101 $40,000.00 ESTATE INFORMATION: SSN: 172-32-2265 FILE NUMBER: 21 03-0982 DECEDENT NAME: FACYNIC DONNA A DATE OF PAYMENT: 01/30/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 11/1 7/2003 TOTAL AMOUNT PAID: $40,000.00 REMARKS: INITIALS: JA " SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS ~.. REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 003531 ELICKER E ROBERT II 20 STONE SPRING LN CAMP HILL, PA 17011 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold .......... .- 101 $6,000.00 ESTATE INFORMATION: SSN: 172-32-2265 FILE NUMBER: 2103-0982 DECEDENT NAME: FACYNIC DONNA A DATE OF PAYMENT: 02/05/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 11 / 17/2003 "~:~ TOTAL AMOUNT PAID' 86,000.00 'REMARKS: INITIALS: JA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV- 1500 PENNSYLVANIA ,a~:~~% DEPARTMENT OF REVENUE r~~'"'t~l DEPT. 280601 INHERITANCE TAX RETURN .ARRIS.URC, PA 7 28-060 RESIDENT DECEDENT 21 _ 03 __ 098.__2__ COUN~F CODE YEAR NUMBER -- DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I-- Facynic Donna A. Z 172-32-2265 ~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR THIS RETURN MUST BE FILED IN DUPLICATE WITH THE LU 11/17/2003 05/04/1913 0 REGISTER OF WILLS III (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ,,, ~[~.~ 1. Original Return [] 2. Supplemental Return [] 3. Remainder Retum (da~ of death pr~r to 12-13.82) ~-~ [] 4. Limited Estate [] 4a. FuturelnterestComprom,se(~ofdea~a,~2.~2-~2) [] 5. Federal Estate Tax Return Required o,, ~a [] 6. Decedent Died Testate (^~ach copy ol Will)[] 7. Decedent Maintained a Living Trust (^,a~ copy of T~st) 8. Total Number of Safe Deposit Boxes < [] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit {da~e of death beb~en 12-31.91 and 1-1.951 [] 11. Election to tax under Sec, 911~(A)(Altach S~ O) I- Z "' NAME c~ COMPLETE MAILING ADDRESS z E. Robert Elicker, II, Attorney ~0 FIRM NAME (lfApplicablei 20 Stone Spring Lane ,,, Camp Hill, PA 17011 TELEPHONE NUMBER o (717) 240-6535 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) .... 1,663.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Modgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Properly (5) 411,310.46 (Schedule E) 6. J.oi_n. tly Owned Properly (Schedule F) (6) ~'-'~ Separate Billing Requested ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) I"- (Schedule G or L) ,~ 8. Total Gross Assets (total Lines 1-7) (8) 412,973.46 LLI 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 38,184.69 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)(10) ............................ 615._8_0 11. Total Deductions (total Lines 9 & 10) (11) 38,800.49 12. Net Value of Estate (Line 8 minus Line 11) (12) 374,172.97 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been {13) 4_~6 771.62 made (Schedule J) · 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 327,401.35 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount o[ Line 14 taxable at the spousal tax ~'_ rate. or transfers under Sec. 9116 Ia)(12) x .0 (t5) ~--- 16. Amount of Line 14 taxable at lineal rate x .0 (16) ~; 17. Amount o~' Line 14 taxable at sibling rate x .12 (17) __ O 327 401.35 x .15 (1~) 49,110.20 (,1 18. Amount of Une 14 taxable at collateral rate X ~ 19. Tax Due (19) 49,110.20 20. [] Decedent's Complete Address: Count Mead ws ~orting Hill Road CITY . - Mechanicsburg Tax Payments and Credits: ~ 1. Tax Due (Page 1 Line 19) 2. Credits/Payments (1) A. Spousal Poverty Credit 49,110.20 B. Prior Payments Szl'O'O00'O0 ( 1/ ~X}.O0 (2/5/1~) C. Discount 2,420.98 3. InteresCenaity if applicable Total Credits (A + 8 + C ) (2) D. Interest 48,420.98 E. Penalty Total Interest/Penalty ( D + E ) (3) 4. if Line 2 is greater than Line 1 + Line 3, enter the diffemnca. This is the OVERPAYMENT, Check box on Page I Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 689.2? A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58) 689.2'~ Make Check Payab/e 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: a. retain the use or income of the property transferred; ...................................................................................... Yes No b. retain the right to des gnate who sba I use the property transferred or its incoma; ............................................ [] [] 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, d d decedent transfer properly within one year of death without receiving adequate consideration? ................................................ 3. D d decedent own an 'in trust for" or payable upon death bank account or security at his or her death? .............. 4. Did decadent own an Individual Retirement Account, annuity, or other non-probete property which [] [] contains a beneficiary designation? IF THE ANSWER TO ANY OF THE ABOVE Q ESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Declaration of Ixeparer other l~an the peca3na/mpm~enla~ve b 13a~d on d in~llon of ~ ~ ~ ~y ~, , It b b'~e, connect and complete. SIGNATUR/E~F PERSON RESPON~BLE FOR~FILINO RETURN , A ~'~"?~--'- ~',.,,,~~ -~...~J.~v_/~',, , D. ATE ................................... .... ~pr ng Lane, Cam Hi ..... -./-- ..................................................... ~ II, PA 17011 ~ ........................................ 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 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 use of the surviving spouse is 0% [72 P.S. {}9116 (a) (1.1) (ii)]. The statute ~ a transfer to a sun/Mng spouse from tax, and the statutory requimmants for disdosuro of assets and filing a tax ratum are still applicable even if the surviving spouse is the only bener~Jary. 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 stepparant of the child is 0% F2 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedenrs lineal benetidaries is 4.5%, except as noted in 72 RS. §9116(1.2) [72 RS. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or fa' the use of the decedent's siblings is 12% [72 RS. §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. REV-1503 EX+ 16-9,~;~,8~ SCHEDULE B ~O~,.,ONV,,E^.T~ O~ .EN~,S¥.¥.',~.^ STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH I. Prudential Financial - 18 shares at $28.44 per share $511.92 2. Met Life - 35 shares at $32.8881 per share $1,151.08 TOTAL (Also enter on line 2, Recapitulation) $ 1,663.00 (If more space is needed, insert additional sheets of the same size) REV-~50S Ex. (6.ss) e,,3,,~ I SCHEDULE E CO. MONWEALTH OF PENNSYLVAN.A /CASH, BANK DEPOSITS, & MISC. INHERITANCE T~ R~URN / PERSONAL PROPER~ RESIDENT DECEDENT I FCKbUNAL PRO Include ~e proceeds of litigation and the date the pr~eeds were received by the es~te, 21-03-0982 ITEU All pmpe~y jointly-owned with right of suwlvomhlp must be disclosed on Schedule F, NUMBEF DESCRIPTION VALUE AT DATE 1. Count~ Meadows Retirement Home - refund D~TH credit balance 2. BELCO $14,447.76 Regular Savings, Account No. 759310 Money Market, Account No. 759310 34.49 Ce~ificate of Deposit, Account No. 34759 101,272.70 22,072.82 3, M&T Bank - checking, Account No. 32048645 8,388.47 4. PSECU Account No. 0172322265 Regular share S1 Checking share S4 78,137.10 7,077.51 5. Fideli~ and Guamn~ Life Insurance Company Annuitant - Donna A. Facynic, Policy No. 3079721, beneficia~ estate 179,153.84 6. Met Life - Dividend replacement check from 12/05/00 to 11/15/02 21.35 7. Verizon - refund 8. Comcast - refund 2.54 15.88 9. Insurance policy on tangible pemonal pmpe~y - refund 186.00 10. Tangible personal prope~ in room in retirement home 500.00 TOTAL (Also enter on line 5, Recapitulation) $ 411,310.46 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (6-98) SCHEDULE G COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS & INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is ;'es. DESCRIPTION OF PROPERTY ITEM INCLUDETHE NAME OF THE TRANSFEREE, THEIRRELATIONSHIPTODECEDENTAND DATE OF DEATF % OF DECD'S EXCLUSION TAXABLE NUMBEF THE DATE OF TRANSFER. ATrACHACOPYOFTHEDEEDFORREALESTATE. VALUE OFASSET INTEREST (IFAPPLICABLE) VALUE 1. Nationwide Life and Annuity Insurance Co. - Contract No. 07 - 1078383 See attached beneficiary designation form SEPARATE Billing Requested 80,497.62 100% $80,497.1~ 2. Met Life - life insurance proceeds to estate, Policy No. 2697758M 2,226.07 100% 100% - £ 3. Prudential Financial - life insurance proceeds to estate, Policy No. 067617931 3,468.92 100% 100% - C TOTAL (Also enter on line 7 Recapitulation) $ 80,497.6; (If more space is needed, insert additional sheets of the same size) FIDELITY AND GUARANTY LIFE INSURANCE COMPANY 201 Brookfield Pkwy, Ste. 301 Greenville, SC 29607 1.800.638.2255 December ! 8, 2003 Robert Elicker 20 Stone Spring Lane Camp Hill, PA 17011 Fax: 717-697-3050 Re: Annuitant - Donna A. Facynic Policy No - 3079721 Beneficiary - Estate of Donna A. Facynic Dear Mr. Elicker: We are providing you with the following information and ask that you forward it along with the forms provided to the beneficiary listed above. On behalf of Fidelity and Guaranty Life Insurance Company, I want to extend to the family our sincere condolences on their recent loss. As beneficiary of an F&G Policy, the executor may choose from several different ways to receive the funds. The most convenient of these is through an F&G Asset Account. The personal Asset Account is an interest-bearing checking account established in the estate's name. We will mail them a personalized checkbook and whenever they want to access the funds, they simply write a check. We will also send them monthly statements from the account, just like a bank. It's a convenient way to keep track of the funds. All the executor will need to do is select this option. We handle the rest. The executor may defer distribution for up to 5 years from the date of death. ShOuld you desire to defer payment, please complete the Defer Payment request form enclosed. Finally, they may also elect to receive the entire balance in a single disbursement. Question #9 on the enclosed claim form enables the executor to select which of the above options they may prefer. Please have them complete this form in its entirety, have it witnessed, and return it to the Claim Departments attention with an originaI Certified death certificate and the original policy. The date this policy was issued is 08/06/2002. The value as Of 11/17/2003 was $179,153.84. If you should have any questions, please contact our office at 1-800-638-2255. ADMlN 5184 (10-2003) W W W . O m f n . c o m Sincerely, FIDELITY AND GUARANTY LIFE INSURANCE COHPANY PO BOX 1157 BALTTHORE) MD 2i203-11S7 ANNUTTANT: ESTATE OF DONNA FACYNIC DRAFT DATE: 02/13/04 PAYEE: POLTCY NIJHBER: 3079721 ESTATE OF DONNA FACYNIC 21q0 MARKET ST B-201 CAMP HILL PA 17011 DESCRIPTION OF CHECK DZSBURSENENT: DEATH BENEFIT ,~ CHECK NO. 0000529631 FIDELITY AMD GUAI LIFE INSURANCE CONPANy PO BOX 1157 ~,ALTIINORE, HO 2X20$-I~s~ ' 02/13/04 PAY ONE TO THE ORDER OF · ' .' CHECK. ANOUNT ESTATE OF DONNA FACYN*rC ' ~166)4.~.85 2140 HARKET ST Bi20! CANP HTLL PA 17011 ' '. CONTRACT NUMBER 0710783~ ACCOUNT CHANGE FORM NATIONWIDE LIFE AND ANNUITY INSURANCE COMPANY INDIVIDUAL INVESTMENT PRODUCTS P.O. BOX Ie2449 ' COLUMBUS, OHIO 4321S.244g 1-8e~-~21.11 O0 NON-FINANCIAL CHANGES BY SIGNING BELOW, I AM CERTIFYING THAT I AM AUTHORIZED TO MAKE T~I8 REQUEST AND REQUE INSURANCE COMPANY MAKE THE CHANGES AS INDI ANY OTHER PARTY TO THE CATED IN THE NON-FINAN . STING THAT NATIONWID CONTRACT, TO REVI CIAL CHANGES SE T E LIFE NO CONFIRMATION, TO REVIEW T EW ANY WRI_T.?EN CONFIRMATION RES C ION. I AGREE FOR MYSELF AND AS PRACTICAL OF ANY . HE NEXT QUARTERLY__~TATEMENT FOR THI ULTING FROM TH~ REQUEST, OR IF THE ERRORS APPEARI S CONTRACT AND I RE IS SUCCESSORS A NG THEREON WHICH RELAT , WILL NOTIFY NATIONWIDE® ND ASSIGNS, TO RELY O E TO THIS REQUEST, AS SOON THE CONFIRMATION OR ON THE QUAI:rI'~R~yN~TFAATI~UMREENTO. F SUCH NOT, IFIOATION AS A RATIFICATION ~FATU~R~AZi~IG~T~OEFNLE~ET~i~ ACTIVITY CURRENT INFORMATION CHANGE TO OWNER* DONNA A FAcyNIc ' .. NAME & ADDRESS 2140 MARKET ST APT B201 CAMP HILL PA 17011-4731 · A COMPLETED IRS FORM W-9 WITH THE NEW .... OWNER'S SOCIAL SECURITY NUMBER & SIGNATURE ...... · THE NEW OWNER'S DATE OF BIRTH · . ,, ~ AN OWNERSHIP CHANGE MAY BE A TAXABLE · .... EVENT, PLEASE CONSULT YOUR TAX ADVISOR BEFORE EXECUTING SUCH A REQUEST. ANNUITANT* DONNA A FACYNIC NAME & ADDRESS 2140 MARKET ST APT B201 CAMP HILL PA 17011-4731 i'F CHANGING THE ANNUITANT, PLEASE INCLUDE= · A SIGNED ANNUITANT MEDICAL QUESTIONNAIRE · A COMPLETED IRS FORM W-9 WITH THE NEW ANNUITANT'S SOCIAL SECURITY NUMBER & SIGNATURE · THE NEWANNUITANT'8 DATE OF BIRTH PRIMARY BENEFICIARY* AS ~TATED ON APPLICATION CHANGED F,¥y~,. CONTINGENT BENEFICIARY* AS STATED ON APPLICATION UNLESS OTHERWISE __ _ "]0, CHANGED % PLEASE ATTACH ADDITIONAL INFORM~,TION IF THERE 18 MULTIPLE BENEFICIARIES OR COMPLEX DETAIl.8 INVOLVEB, * Contract rights sire reserved to the Contract Owner see the Contriiot Data Page) unless delegated to this Annuitant o another piirty. Such delegiition is only. effective If Nallonwlda r to ease of contracts Issued to qulillfied plans and oartlln ..... ®_,h_?e ra?sivad and r?co.rdad the delegation In Its re ~m,,u~t.~aut..horlz. e moat transiictlons "Certiiln ~-t .... _w ,u .e_t _g l p. la~._l_t..~llllI oonluh with vour Plan ,4--~,.~ ....... ~,ords. In t.h.e :o_n_t_r?.u.t,on,.~. aha other 403(b) ~llns eOver4nOe3d(~,~..~"..","-_'n~o_~_uae .ERISA 403(b) plains ~ol~erii,u ,,.A~I_,,;,.~|.,~.,_a_~,; WnO generally ~ el....~. ~ ,/= unless ou ~ii . ·wale from qualified Irene or Y n..o?_~.e,r,mltted, to. cha. nge either the owner or the lnYno-,*.l.,v~l-I-l-Pl-?-t?-d--f.r°.m.~-ervi°,l with the lpOnlOPfln. ._.4,°.3.~_(~.) p,.li, nl are c3ena;~c~ary eas~gnations on such oontriicts m-.- J-::'-'::E|:'-Y':-~"uu'n-;r"eT ne;~ unoer ii qulillfied i~lln ,_l~j,~y_.;, .I.t IS generally -x "- -uuiwgT TO ilmltl or reeulrem--, .... .,_..L--" '.' "~..3tu~ annuity, or an IRA WR-0064 (11/2000) Rosalie O. Boyer R. D #1, Box 308 New Bloomfield, PA 17068 Jane A. Kapsa 4297 Brixton Drive Stow, OH 44224 Donna B. Bohn 2140 Market Street, B-201 Camp Hill, PA 17011 EV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Tree & Bowser Funeral Home, Inc. 114 West Main Street, Hummelstown, PA - funeral goods and services $10,693.90 2. Tree of Life Lutheran Church - funeral luncheon 150.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 12,500.00 Name of Personal Representative(s) Donna B. Bohn Social Secudty Number(s)/EIN Number of Personal Representative(s) 164-30-7285 Street Address 2140 Market Street, B-201 City Camp Hill State PA Zip 17011 Year(s) Commission Paid: 2004 2. Attorney Fees 12,500.00 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 4. Probate Fees 401.00 5. Accountant's Fees 750.00 6. Tax Return Preparer's Fees 7. Register of Wills - short certificates 15.00 8. Advertising letters - Cumberland Law Journal 75.00 9. Advertising letters - The Patriot News 99.79 10. Reserve for filing account, county inventory, notary fees, releases and miscellaneous costs 1,000.00 TOTAL (Also enter on line 9, Recapitulation) $ 38,184.69 (If more space is needed, insed additional sheets of the same size) ,~ SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Reimbursement - The State Employees' Retirement System $594.73 2. AT & T - balance due, telephone charges 21.07 TOTAL (Also enter on line 10, Recapitulation) $ 615.80 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEAL'rH OF PENNSYLVANIA BENEFI(:IARIE$ INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Jane A. Kapsa 4297 Brixton Drive Niece 1/8 of residuary estate Stow, Ohio 44224 2. Thomas A. Boyer 418 Haldeman Avenue Nephew 1/8 of residuary estate New Cumberland, PA 17070 3. Donna B. Bohn 2140 Market Street, B-201 Niece 1/8 of residuary estate Camp Hill, PA 17011 4. Jack E. Boyer 813 Cross Street Port Royal, PA 17082 Nephew 1/8 of residuary estate 5. Helen Sass P.O. Box 64,424 Center Street Wisconisco, PA 17097 Sister-in-Law 1/8 of residuary estate GO TO PAGE 2 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET I! 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 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) REV-.1513 EX+ (9-00) ~i:'..~i~ PAGE 2 COMMONWEALTH OF PENNSYLVANIA BE N E FI(:IARI ES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 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)] 6. Anne F. Zerbe 127 Shartlesville Road Bemville, PA 19506 Sister-in-Law 1/8 of residuary estate 7. Paula Daniels 34 Algonquion Drive 1/32 of residuary Natick, MA 01760 Niece estate 8. Patricia Nauditt 11515 SE 178th Place 1/32 of residuary Renton, WA 98055 Niece estate 9. Nicholas Paul Kuzovich 15195 Sunwood Blvd., #13 Nephew 1/32 of residuary Seattle, WA 98188-7767 estate 10. Cecelia Kuzovich 3027 Edmunds Road 1/32 of residuary Lafayette Hill, PA 19444 Niece estate ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 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. The Tree of Life Lutheran Church 1492 Linglestown Road 1/8 of residuary estate Harrisburg, PA 17110 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 46,848,60 (if more space is needed, insert additional sheets of the same size) Inventory of the real and personal estate of Donna A. Facynic, deceased Personalty 1. Country Meadows Retirement Home - refund credit balance $ 14,447.76 2. BELCO Regular Savings, Account No. 759310 34.49 Money Market, Account No. 759310 101,272.70 Certificate of Deposit, Account No. 34759 22,072.82 3. M&T Bank- checking, Account No. 32048645 8,388.47 4. PSECU AccountNo. 0172322265 Regular share S 1 78,137.10 Checking share S4 7,077.51 5. Fidelity and Guaranty Life Insurance Company Annuitant- Donna A. Facynic, Policy No. 3079721, Beneficiary estate 179,153.84 6. Met Life - Dividend replacement check from 12/05/00 to 11/15/02 21.35 7. Verizon - refund 2.54 8. Comcast - refund 15.88 9. Insurance policy on tangible personal property - refund 186.00 10. Tangible personal property in room in retirement home 500.00 11. Prudential Financial - 18 shares of stock at 28.44 per share 511.92 12. Met Life- 35 shares of stock at 32.8881 per share 1,151.08 13. Nationwide Life and Annuity Insurance Co. - Contract No. 07-1078383 (Reported on Schedule G as a non probate asset) 80,497.62 Total personalty $ 493,471.08 NO REAL ESTATE )MMONWEALTH OF PENNSYLVANIA ~ ss: )UNTY OF CUMBERLAND J Donna B. Bohn i.g duly sworn accord;.9 t0 ~aw, deposes a.d says that ~he is the EXecutrix of the Estate of Donna A. Facynic- · e of ~TLa151.~Lderi .Township , Cumberland County, Pa., deceased and that the thin is an inventory made by Donna B. Bohn ~. the said Executrix the entrre estate of said decedent, cons;sfincj of all the personal property and real estate, except real estate outside ~ Commonwealth of Pennsylvania, and that +he figures opposite each item of the Inventory represent it's fair value of the date of decedent's death. Sworn and subscribed before me, February ~/ 1~ 2004 Exacutor Adm;nistrator Donna B. Bohn, Executrix 2140 Market Street, B-20]. Camp Hill, PA 17011 Address ate of Death 17 1 1 0 3 Day Month Year INSTRUCTIONS An inventory must be filed within three months after appointment of personal representative. A supplement inventory must be filed within thirty days of discovery of additional assets. Additional sheets may be attached as to personalty or realty See Article IV, Fiduciaries Act of 1949. , COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT QF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 003541 ELICKER E ROBERT II 20 STONE SPRING LN CAMP HILL, PA 17011 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold .......... _ ....... 101 $689.22 ESTATE INFORMATION: SSN: 172-32-2265 FILE NUMBER: 21 03-0982 DECEDENT NAME: FACYNIC DONNA A DATE OF PAYMENT: 02/06/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUM BERLAN D DATE OF DEATH: 11/17/2003 TOTAL AMOUNT PAID: $689.22 iREMARKS: DONNA BBOHN CHECK# 1001 INITIALS: AC SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS · '.~,~. '~ PENNSYLVANIA ,,~~~. DEPARTMENT OF REVENUE ~~tA~ DEPT. 280601 INHERITANCE TAX RETURN HA SBU ,PA 7 28-O O RESIDENT DECEDENT _ 03 o982 COUN~ CODE Y~ NUMBER DECEDENTS NAME (~ST~ FIRST, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER Facynic Donna A. 172-32-2265 DATE OF DEATH (MM-DM.YEAR) DATE OF BIRTH (MM-DM-YEAR) - 11/17/2003 05/04/1913 TH~S RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS [[~"~[i~B[-~) ~-~-~-G-~U'~;~~ FIRST, AND MIDDLE INITIAL) ' SOCIAL SECURIW NUMBER w [] 1. Original Return [] 2. Supplemental Return [] 3. Remainder Retum (d~e of death pdor Io 12-13.82) v~ [] 4. Limited Estate [] 4a. Future Interest Compromise (da~e ofdaatha~te~ ~ ~ ~ [] 5. Federal Estate Tax Return Required ~: ~o ~ [] 6. Decedent Died Testate (Atlach copy o, wil,] [] 7. Decedent Maintained a Living Trust (Altech cop,,, o~' o ~ 8. Total Number of Safe Deposit Boxes < ~ 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit I~.te of Ueath b~wc~n ~2-3~.91 and ,-1.eS) ~ 11. Election to tax under Sec. 9113(A)(^~ch S.~ O) ~ NAME z E. Robed Elicker II, Attorney COMPLETE MAILING ADDRESS Camp Hill, PA 17011 O u (717) 240-6535 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 1,663.00 ~.,:? 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) ~ 5. Cash, Bank Deposits & Miscellaneous Personal Properly (5) 398,630.47 ("';.~ . O 6. Jointly Owned Properly (Schedule F) (6) ~ [.~ Separate Billing Requested '-1 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) I--' (Schedule G or L) ,~ 8. Total Gross Assets (total Lines 1.7) C,1 (S) 400,293.47 LLJ 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 38,184.69 rY · 10. Debts of Decedent. Mortgage Liabilities, & Liens (Schedule ~}(10) 615.80 11. Total Deductions (total Lines 9 & 10) (11) 38,800.49 12. Net Value of Estate (Line 8 minus Line 11) (12) 361,492.98 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) 45~ 186.62 made (Schedule J) ........ 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 316,306.36 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z O 15. Amount or Line 14 taxable at lhe spousal lax ~ ra~e. or transfers under Sec. 9116 (a)(1.2) ............................................................................... x .0 ..... (15} ~ 16 Amounl of Line 14 taxable at lineal rate ::::3 x .0 (16) ~; 17. Amount ol Line 14 taxable at sibling rate x .12 (17) O (,..3 18. Amount of Line 14 taxable at collateral rate 3!6~30.6:36 x .15 (1~) 47,445.95 ~ 19. Tax Due (19) 47_~_445,95 Decedent's Complete Address: __ _C o__u_o_t ~¢__M e a d ows ........ ~_5~_S_ou___th Sporting Hill Road CITYMechanicsburg J STATEpA ' ZiP 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments (1) 47,445.95 A, Spousal Poverty Credit B. Prior Payments Sz[O, 000.00 ( 1/30/00, ) ,' ~:~6,000.00 ( 2/5/0~ ) C. Discount 2r420.98 3. Interest/Penalty if applicable Total Credits (A + El + C ) (2) 48,420.98 D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. 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 (4) 975.03 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 * 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT . ~ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS ......... 1. Did decedenl 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. D d decedent own an" n trust for" or payab e upon death bank account or secudty 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. Under penalties of per'ju~, I dc=dare that I have examined mis relum, including accompanying schedules and slatements, and to the bast of my kno~edge and belief, il is true. correct and complete. Deciaralion of preparer other than the personal representalive is based on all Informalion of which preparer has any knowledge. SIGNATURE OF P,.~RSON RESPONSIBLE FOR FILING RETURN DATE / 2140 Market Street, B720!~ Camp Hill, PA 17011 SIONAT~ OF PREPARER O~-IER TI'~N 'R'EPRE~'~-i:i'~'i~ D ;'rE 20 Stone Spring Lane, Camp Hill, PA 17011 ........................................................................................................................................................................... : .................. ~'~' 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 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates o¢ 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 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 imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 RS. §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 12% [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, REVo1503 EX+ (6-98~ · SCHEDULE B coM,.o,~,,,,,~^,-'r, o,: .,:NNS¥'-V^N'^STOCKS & BONDS INHERITANCE TAX RETURN RESIOENT DECEDENT FILE NUMBER ESTATE OF 21-03-0982 Donna A. Facynic All property jointly-owned with right of survivorship must be disclosed on Schedule F. VALUE AT DATE iTEM OF DEATH NUMBER DESCRIPTION 1. Prudential Financial - 18 shares at $28.44 per share $511.92 2. Met Life - 35 shares at $32.8881 per share $1,151.08 TOTAL (Also enter on line 2, Recapitulation) $ 1,663.00 (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) I ,~ SCHEDULE E I COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 Include the proceeds of litigation and the dale the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Country Meadows Retirement Home - refund credit balance $14,447.76 2. BELCO Regular Savings, Account No. 759310 34.49 Money Market, Account No. 759310 101,272.70 Certificate of Deposit, Account No. 34759 22,072.82 3. M&T Bank - checking, Account No. 32048645 8,388.47 4. PSECU Account No. 0172322265 Regular share S1 78,137.10 Checking share S4 7,077.51 5. Fidelity and Guaranty Life Insurance Company Annuitant - Donna A. Facynic, Policy No. 3079721, beneficiary estate * 166,473.85 6. Met Life - Dividend replacement check from 12/05/00 to 11/15/02 21.35 7. Verizon - refund 2.54 8. Comcast - refund 15.88 9. Insurance policy on tangible personal property - refund 186.00 10. Tangible personal property in room in retirement home 500.00 * Date of death value reported by letter was $179,153.84. This was the value reported on original return. When death benefit check received by estate, it was in the amount of $166,473.85. After inquiring about the difference in the amount on the letter and check, Fidelity and Guaranty Life Insurance Co. reported that there was a penalty charged for cashing in the annuity within five years of date of purchase, leaving a net check with interest of $166,473.85. This information about the penalty was not disclosed on the application or date of death value letter. Copy of documents and check attached. TOTAL (Also enter on line 5, Recapitulation) $ 398,630.47 (If more space is needed, insed additional sheets of the same size) FIDELITY AND GUARANTY LIFE INSURANCE COMPANY 201 Brookfield Pkwy, Ste. 301 Greenville, SC 29607 1.800.638.2255 December 18, 2003 Robert Elicker 20 Stone Spring Lane Camp Hill, PA 17011 Fax: 717-697-3050 Re: Annuitant - Donna A. Facynic Policy No - 3079721 Beneficiary - Estate of Donna A. Facynic Dear Mr. Elicker: We are providing you with the following information and ask that you forward it along with the forms provided to the beneficiary listed above. On behalf of Fidelity and Guaranty Life Insurance Company, I want to extend to the family our sincere condolences on their recent loss. As beneficiary of an F&G policy, the executor may choose from several different ways to receive the funds. The most convenient of these is through an F&G Asset Account. The personal Asset Account is an interest-bearing checking account established in the estate's name. We will mail them a personalized checkbook and whenever they want to access the funds, they simply write a check. We will also send them monthly statements from the account, just like a bank. It's a convenient way to keep track of the funds. All the executor will need to do is select this option. We handle the rest. The executor may defer distribution for up to 5 years from the date of death. Should you desire to defer payment, please complete the Defer Payment request form enclosed. Finally, they may also elect to receive the entire balance in a single disbursement. Question #9 on the enclosed claim form enables the executor to select which of the above options they may prefer. Please have them complete this form in its entirety, have it witnessed, and return it to the Claim Departments attention with an original Certified death certificate and the original policy. The date this policy was issued is 08/06/2002. The value as of 11/17/2003 was $179,153.84. If you should have any questions, please contact our office at 1-800-638-2255. ADMIN 5184 (10-2003) W w w . o m f n . ¢ o rn Sincerely, r~uCLlJy AND GUARANTY LZFE ZNSURANCE CONPANY PO BOX 1137 8ALTTNORE~ HD 21203-1157 ANNUTTANT: ESTATE OF DONNA FACYNTC DRAFT DATE: 02/13/0fi PAYEE: POLTCY NUHBER: -~079721 ESTATE OF DONNA FACYNIC 2140 MARKET ST B-201 CAMP HILL PA 17011 DESCRIPTION OF CHECK DZSBURSEHENT: DEATH BENEFZT CHECK #0. FIDELZT¥ AND GUAR~ 000052963! LIFE IMSURANcE COHPAM¥ .' PO BOX 1137 B*L~Z,OeE. ,D 2Z2OS-ZZ3? .. ': . . 02/13/04 PAY ONE "'O000 52qr= 3 ;~,. m:O 53 &OqOEil. m: E~732 REV.-1510 EX+ (6-98) ~ SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 This schedule must be completed and filed if the answer to any of questions 1 through 4 on lhe reverse side of the REV-1500 COVER SHEET is es. DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S :XCLUSION TAXABLE ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND NUMBEF THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET NTEREST IF APPLICABLE) VALUE 1. Nationwide Life and Annuity Insurance Co. - Contract No. 07 - 1078383 See attached beneficiary designation form SEPARATE Billing Requested 80,497.62 100% $80,497.62 2. Met Life - life insurance proceeds to estate, Policy No. 2697758M 2,226.07 100% 100% - 0 - 3. =rudential Financial - life insurance proceeds to estate, Policy No. 067617931 3,468.92 100% 100% - 0 - TOTAL (Also enter on line 7 Recapitulation) $ 80,497.6 (If more space is needed, insert additional sheets of the same size) CONTRACT NUMBER 0710783E~ ACCOUNT CHANGE FORM NATIONWIDE LIFE AND ANNUITY INSURANCE COMPANY INDIVIDUAL INVESTMENT PRODUCTS P.O. BOX IS244g COLUMBUS, OHIO 4321S-2449 1.see-221.11 oo NON-FINANCIAL CHANGES BY SIGNING BELOW, lAM CERTIFYING THAT I AM AUTHORIZED T~IS REQUEST AND REQUESTINe THAT NATIONWIDE LIFE INSURANCE COMPANY MAKE THE CHANeEB AS INDICATEO IN THE 'NON-FINANCIAL CHANGES" SECTION. I AGREE, FOR MYSELF AND ANY OTHER PARTY TO THE CONTRACT, TO REVIEW ANY WRITTEN CONFIRMATION RESULTING FROM THIS REQUEST, OR IF THERE IS NO CONFIRMATION TO REV EW THE NEXT QUARTERLY STATEMENT FOR THIS AS PRACTICAL OF ANY ERRORS APP CONTRACT, AND I WILL NOTIFY NATI EARING THEREON WHICH RE ONWfDE® AS SOON SUCCESSORS AND ASSIGNS, TO RELY ON ANY FAILURE OF SU H Nt3?I~L~I~',nTO~ ,T~H~..R_~._Q.U_E.S_T,__ [ AUTHORIZE NATIONWIDE® ITS THE CONFIRMATION OR ON THE QUARTERLY STATEMENT. C ................ o ~ ~/I~Ir~ATION OF THE CHANGES REFLECTEI~ ON SIGNATURE ~ DATE ~:~L~_ ACTIVITY CURRENT INFORMATION CHANGE TO OWNER* DONNA A FACYNIC NAME & ADDRESS 2140 MARKET ST APT B201 CAMP HILL PA 17011-4731 IF CHANGINO THE CONTRACT OWNER, PLEASE INCLUDE; · A COMPLETED IRS FORM W-9 WITH THE NEW · ' ' OWNER'S SOCIAL SECURITY NUMBER & " SIGNATURE ' '.i a THE NEWOWNER'S DATE OF BIRTH . ... AN OWNERSHIP CHANGE MAY BE A TAXABLE EVENT. PLEASE CONSULT YOUR TAX ADVISOR BEFORE EXECUTING SUCH A REQUEST. ANNUITANT* DONNA A FACYNIC NAME & ADDRESS 2140 MARKET ST APT B201 CAMP HILL PA 17011-4731 IF CHANGING THE ANNUITANT, PLEASE INCLUDE: · A SIGNED ANNUITANT MEDICAL QUESTIONNAIRE · A COMPLETED IRS FORM W-g WITH THE NEW ANNUITANT'S SOCIAL SECURITY NUMBER & SIGNATURE · THE NEWANNUITANT'S DATE OF BIRTH PRIMARY BENEFICIARY* AS STATED ON APPLICATION UNLESS OTHERWISE CONTINGENT BENEFICIARY* AS STATED ON APPLICATION L UNLESS OTHERWISE CHANGED . % . PLEASE ATTACH ADDITIONAL INFORMATION IF iTHERE IS' MULTIPLE BENEFICIARIES OR ~COMPLEX DETAIL8 INVOLVED. · Contract rights are reserved to the Contract Owner (.ee tho Contract Data Pa e unl ' anothe.r part. y..Su.ch delegation is only effective If Natlon~,~.~-~ ~. ........... _g..)___ as~s .delegated to. tha.An, nultsnt or to ..... ..-...,~.,v.g ina reooruea the delegation In Itl reoord,. In the ease o~ eontrems ieeued to qualified 131an, and certain 403(b plan, mus. t .authorize mcat traneactlona 'Certain · . _ .13 .__?.o. nl.ult wi. th your Plan Administrator. w contrlcutlona) and cth-- ~e~-' '-' ..... 40$.(b.) plan. s in. elud~ ERIBA wua[ol ol&nl manaeellu .......... ho generally · -~,...-,u .,gm service w.n ;ne sponsoring em Icy.r. It Is generally not permitted to change either the owner or the annuitant on a contract held under a u ' Beneficiary designations on ouch contracts ma be sub eot to II q alined plan. a 403~1~ annuity or an IRA. Y J mits or I'equlrementa under the employer's plan. if any WR-0064 (11/2000) Rosalie O. Boyer R. D #1, Box 308 New Bloomfield, PA 17068 Jane A. Kapsa 4297 Brixton Drive Stow, OH 44224 Donna B. Bohn 2140 Market Street, B-201 Camp Hill, PA 17011 EV- . E×+ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facyni¢ 21-03-0982 Debts of decedent must be reported on Schedule ]. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Trefz & Bowser Funeral Home, Inc. 114 West Main Street, Hummelstown, PA - funeral goods and services $10,693.90 2. Tree of Life Lutheran Church - funeral luncheon 150.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 12,500.00 Name of Personal Representative(s) Donna B. Bohn Social Security Number(s)/EIN Number of Personal Reprosentative(s) 164-30-7285 Street Address 2140 Market Street, B-201 City Camp Hill State PA Zip 17011 Year(s) Commission Paid: 2004 2. Attorney Fees 12,500.00 3. Family Exemption: (If decedenrs address is not the same as claimant's, attach explanation) Claimant Street Address City State __ Zip Relationship of Claimant to Decedent 4. Probate Fees 401.00 5. Accountant's Fees 750.00 6. Tax Return Preparer's Fees 7. Register of Wills - short certificates 15.00 8. Advertising letters - Cumberland Law Journal 75.00 9. Advertising letters - The Patriot News 99.79 10. Reserve for filing account, county inventory, notary fees, releases and miscellaneous costs 1,000,00 TOTAL (Also enter on line 9, Recapitulation) $ 38,184.69 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (6-98) I ,~ SCHEDULE I COMMO.WE^LT. OF PENNSYLV^NI^ I DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH i. Reimbursement - The State Employees' Retirement System $594.73 2, AT & T - balance due, telephone charges 21.07 TOTAL (Also enter on line 10, Recapitulation) $ 615.80 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALT' OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. JaneA. Kapsa 4297 Brixton Drive Niece 1/8 of residuary estate Stow, Ohio 44224 2. Thomas A. Boyer 418 Haldeman Avenue Nephew 1/8 of residuary estate New Cumberland, PA 17070 3. Donna B. Bohn 2140 Market Street, B-201 Niece 1/8 of residuary estate Camp Hill, PA 17011 4. Jack E. Boyer 813 Cross Street Port Royal, PA 17082 Nephew 1/8 of residuary estate 5. Helen Sass P.O. Box 64,424 Center Street Wisconisco, PA 17097 Sister-in-Law 1/8 of residuary estate GO TO PAGE 2 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET 11 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 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) REV-1513 EX+ (9-00) t'~ PAGE 2 SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT (DECEDENT ESTATE OF FILE NUMBER Donna A. Facynic 21-03-0982 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) (12)] 6. Anne F. Zerbe 127 Shartlesville Road Bernville, PA 19506 Sister-in-Law 1/8 of residuary estate 7. Paula Daniels 34 Algonquion Drive 1/32 of residuary Natick, MA 01760 Niece estate 8. Patricia Nauditt 11515 SE 178th Place 1/32 of residuary Renton, WA 98055 Niece estate 9. Nicholas Paul Kuzovich 15195 Sunwood Blvd., #13 Nephew 1/32 of residuary Seattle, WA 98188-7767 estate 10. Cecelia Kuzovich 3027 Edmunds Road 1/32 of residuary Lafayette Hill, PA 19444 Niece estate ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET I1 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. The Tree of Life Lutheran Church 1492 Linglestown Road 1/8 of residuary estate Harrisburg, PA 17110 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) 03/17/2004 15:55 FAX 7178973050 WADI)ELL AND REEl) ~]02 HRR-17-2084 15: 3~ P, FIOEL~Y AND GUARANTY UFE IN~RAMCE C~PANY ' 2Cl ~r,)o~iol~ p~ Sm 301 RO~ Bicker 20 S~ne Spring ~ne ~mp Hill PA [70]] .. Re: Policy No: 307972t Annuitant: Donna Facyni¢ D~ar MI'. EIIck~r: As requested, we are furnishing the following information on this policy. The value on November 17, 2003 was $179,153:8,1. The value on the date of I~ayrnent, February :ti, 200,t was $181,26S.89. The penalty amount on the policy was $14,792.04. We paid a benefit in the amount of $166,473.8~. We hope this Information is of assistance I~ you. If you have further concerns, please ~10 not hesitate to con~act this office. Sincerely, ~,~ Examiner : ~C 7 :. ......~,~j TOTRL. P, 02 CONNONNEALTH OF PENNSYLVANZA BUREAU OF INDIVIDUAL TAXES DEPARTHENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 NOTICE OF INHERITANCE TAX HARRISBURG, PA 17128-060! APPRAISEHENT, ALLO#ANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSNENT OF TAX REV-1;4?EXAFP(OI-OS) R~C~ ~"! DATE 05-29-200~ ~ :~ ESTATE OF FACYNZC DONNA A DATE OF DEATH 11-17-2005 FILE NUNBER 21 05-0982 'OZ~ AP~-5 p}:05 COUNTY CUMBERLAND E ROBERT ELZCKER Z! ATTY ACN 101 ZO STONE SPRZNG LN I Amount RemAttad CAHP HZLL PA HAKE CHECK PAYABLE AND RENZT PAYNENT TO: REGISTER OF NILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE I1~ RETAIN LONER PORTION FOR YOUR RECORDS REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSENENT, ALLONANCE OR DZSALLONANCE OF DEDUCTIONS AND ASSESSNENT OF TAX ESTATE OF FACYNIC DONNA AFZLE NO. 21 05-0982 ACN 101 DATE 05-29-200~ TAX RETURN HAS: ( ) ACCEPTED AS FILED (X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL AND SUPPLEHENTAL RETURN NO. 01 1. Real Estate (Schedule A) (1) .00 NOTE: To Ansure proper 2. Stocks and Bonds (Schedule B) (2) 1;66~.00 credAt to your account, $. Closely Held Stock/Partnership Interest (Schedule C) ($) .00 subeAt the upper portion ~. Hortgages/Notas Racelvable (Schedule D) (~) .00 of thAs fora wAth your $. Cash/Bank Daposits/Hisc. Personal Property (Schedule E) (5) $98z650.~7 tax payeant. 6. JoAntly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 8. Total Assets (8} ~00,295.~7 APPROVED DEDUCTIONS AND EXENPTZONS: ~8,18~.69 9. Funeral Expanses/Ada. Costs/Nisc. Expanses (Schedule H) (9) 10. Dabts/Hortgaga Liabilities/Liens (Schedule Z) (10) 615.80 11. Total Deductions (11) 12. Nat Value of Tax Return (12) $61,~92.98 15. Char/table/Governmental Bequests; Non-elected 9115 Trusts (Schedule J} (15) ~5,186.6Z 1~. Nat Value of Estate Subject to Tax (1~) $16,S06.$6 NOTE: Zf an assessment ,as issued prev/ously, lines 14, 15 and/or 16, 17, 18 and 19 ~ill re~lect ~lgures that include the total o~ ALL returns assessed to date. ASSESSNENT OF TAX: O0 x O0 .00 15. Amount of L/ne 1~ at Spousal rate (15) ' = 16. Aeount of Line 1~ taxable at LAneal/Class A rata (16) . O0 X 0~ = .00 17. Amoun~ of LAne lfi at SAbling rate (17) .00 x 12 = .00 18. Amount of LAne 1~ taxable at Collateral/Class B re~e (18) 516,506.56 X 15 = ~7,q~5.95 19. Pr/nc] ~al Tax Due (19)= ~7, ~R5.95 TAX CREDZTS: PAYMENT RECEIPT ~ DISCOUNT (+) AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) 01-$0-200~ CD005~96 2,105.26 ~0,000.00 02-05-Z00~ CD005551 267.0~ 6,000.00 02-06-200~ CD00~5~1 .00 689.22 TOTAL TAX CREDIT i ~9,061.52 BALANCE OF TAX DUE] 1,615.57CR TNTEREST AND PEN. I .00 i TOTAL DUE ] 1,615.57CR ZF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE TS LESS THAN $1, NO PAYHENT IS RE{)UTRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU NAY BE DUE A REFUND. SEE REVERSE STDE OF THIS FORN FOR INSTRUCTIONS.) :~EV-1470 EX (6-88) INHERITANCE TAX EXPLANATION COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES DEPT, 28O6O1 HARRISBURG~ PA 17128-0601 FILE NUMBER DECEDENTS NAME Donna A Facynic 2103-0982 ACN REVIEVVED BY Sandra J Eslinger 101 ITEM EXPLANATION OF CHANGES SCHEDULE NO. Accepted revised return ROW Page 1 RESERVATION: Estates of decedents dying on or before December 1Z, 1982 -- if any future interest in tho 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 Commonaealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such futura interest. PURPOSE OF NOTICE: To fulfill the requirements of Section ZlfiO of the Inheritance and Estate Tax Act, Act Z3 of 2000. (7Z P.S. Section 9140). PAYMENT: Detach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side. --Make check or money order payable to: REGISTER OF HILLS, AGENT 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-1313). Applications are available at the Office of the Register of Nills, any of the 23 Revenue District Offices, or by calling the special Z4-hour answering service for forms ordering: 1-BOO-36Z-ZOSO; services for taxpayers eith special hearing and / or speaking needs: 1-800-447-30Z0 (TT only). OBJECTIONS: Any party in interest not satisfied aith the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object uithin sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17liB-lOll, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: 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. la0601, Harrisburg, PA 171Z8-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-IS01) for an explanatlon of administratively correctable errors. DISCOUNT: If any tax due is paid aithin three (3) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is alloaed. PENALTY: The 1SZ 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 and of the tax amnesty period. This non-participation penalty is appaalabla 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: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) 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 (6g) percent par annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January 1, 198Z mill bear interest at a rate which Nil1 vary from calendar year to calendar year ,ith that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through ZOO4 ara: Interest Daily Interest Daily /ntarest Daily Year Rate Factor Year Rate Factor Year Rate Factor ~ ZGZ .000548 ~T~-1991 1ix .000301 ~ 9Z .goal47 1983 16Z .000438 199Z 9Z .000Z47 ZOOZ 6Z .000164 1984 11Z .000301 1993-1994 7Z .00019Z 2003 5Z .000137 1985 I3Z .000556 1995-1998 9Z .000247 2004 4Z .O001lO 1986 IOZ .000Z74 1999 7Z .O0019Z 1987 IOZ .000Z74 ZOO0 7Z .OOO19Z --Interest is calculated as folloes: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent a111 reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date sheen on the Notice, additional interest must ba calculated. CONNONNEALTH OF PENNSYLVANZA BUREAU OF ZNDZVZDUAL TAXES DEPARTNENT OF REVENUE ZHHERITANCE TAX DZVZSZOH 0£PT. Z8060~ ZNHERZTANCE TAX HARRZSOURG, PA 17128-0601 STATEMENT OF ACCOUNT RE¥-I&O7 EX AFP DATE 05-05-200~ ESTATE OF FACYNZC DONNA A DATE OF DEATH 11-17-2005 FZLE NUMBER 21 05-0982 '0,~ :'i/i'[ 24 '~ ~ .I~UHTY CUMSERLAND E ROBERT ELZCKER Z! ATTY ACN Z01 Z0 STONE SPRZNG LN I Amoun~ Remi~ed CAMP HILL PA 17011 HAKE CHECK PAYABLE AND RENZT PAYNENT TO: REGZSTER OF NZLLS CUMBERLAND CO COURT HOUSE CARLZSLE, PA 17015 NOTE: To insure proper credJ~ ~o your account, subei~ ~he upper por~ion of ~his form wi~h your ~ax payeen~. CUT ALONG THZS LZNE ~"' RETAZN LONER PORTZON FOR YOUR RECORDS ~,~ REV-1607 EX AFP (01-03) -~ ZNHERZTANCE TAX STATEMENT OF ACCOUNT ESTATE OF FACYNZC DONNA A FZLE N0.21 05-0982 ACN 101 DATE 05-05-200~ THZS STATEHENT ZS PROVZDED TO ADVZSE OF THE CURRENT STATUS OF THE STATED ACN ZN THE NAHED ESTATE. SHONN BELO# ZS A SUHHARY OF THE PRZNCZPAL TAX DUE, APPLZCATZON OF ALL PAYHENTS, THE CURRENT BALANCE, AND, ZF APPLZCABLE, A PROJECTED ZNTEREST FZGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 05-22-200~ PRZNCZPAL TAX DUE: ........................................................................................................................................................................................................................... ~7,~5.95 PAYMENTS (TAX CREDZTS): PAYNENT RECEZPT DZSCOUNT (+) ANOUNT PAZD DATE NUMBER ZNTEREST/PEN PAZD (-) 01-30-200~ CD005~96 2,105.26 ~O,O00.OO 02-05-200~ CD005551 267.0~ 6,000.00 02-06-200~ CDO0$5~I .00 689.22 0~-12-200~ REFUND .00 1,615.57- TOTAL TAX CREDZT q7, qq5.95 BALANCE OF TAX DUE .00 ZNTEREST AND PEN. .00 ZF PAZD AFTER THZS DATE, SEE REVERSE TOTAL DUE . O0 Si'DE FOR CALCULATTON OF ADDZTI'ONAL ZNTEREST. ZF TOTAL DUE ZS LESS THAN $1, NO PAYHENT ZS REI;IUTRED. ZF TOTAL DUE TS REFLECTED AS A "CREDZT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SZDE OF THZS FORH FOR ZNSTRUCTZONS. ) PAYNENT: Detach the top portion of this Notice and submit eith 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 NILLS, AGENT. -- If NON-RESIDENT DECEDENT make check or money order payable to: COHHON#EALTH OF PENNSYLVANIA. REFUND (CR): A refund of e 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-IS13). Applications ars available at the Office of the Register of Nills, any of the 25 Revenue District Offices or free the Department's 2~-hour ansaering service for forms ordering: 1-D00-362-Z050; services for taxpayers with special hearing and / or speaking needs: 1-800-~q7-3020 (TT only). REPLY TO: Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Past Assessment Revise Unit, Dept. 280601, Harrisburg, PA 17128-0601, phone (717) 787-6505. DISCOUNT: If any tax due is paid eithin three (3) calendar months after tho decedent's death, a five percent (SI) discount of the tax paid is allowed. PENALTY: The 152 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 (9) months and one (1) 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 (62) percent per annum calcuLated at a daily rate of .00016~. 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 ZO0~ are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 1982 202 .0005~8 1988-1991 llZ .000301 ZOO1 9X .0002~7 1983 162 .000~38 1992 92 .0002~7 Z002 62 .00016~ 1984 llZ .000301 1993-199~ 77. .000192 2003 52 .000137 1985 13Z .000356 1995-1998 92 .0002~7 ZO0~ ~Z .000110 1986 lOZ .000Z7~ 1999 7Z .00019Z 1987 97. .000247 2000 87. .000219 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY XNTEREST 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, additionaI interest must be caIculated. 03/17/2004 15:$$ FAX 7175973050 WADD~,LL AND REED H~h ~7, 20~ Ro~ ~lcker 20 S~ne Spring ~mp Hill PA Re: Policy No: 3079721 Annuitant: Donna F~cynic D~ar Mr. Flicker: As requested, we are fLsrnishlng the following inrormaUon on this policy. The value on November 3.7, 2003 was $179,153:8~L The value on the date of payment, February 11, 200,t on the policy was $14,792.04. We aid a _was $18.1,2_65.89. The na a P benefit in th .............. P~ Ity mount · a,,,vura ur We hope this informaUon is of assistance to you. Zf you have further concerns, Please do not hesitate to contact this of Rce. Sincerely, ~ Examiner--- ESTATE NO. 21-03-0982 FIRST AND FINAL ACCOUNT AND STATEMENT OF PROPOSED DISTRIBUTION OF AND BY DONNA B. BOHN, EXECUTRIX OF THE ESTATE AND UNDER THE LAST WILL AND TESTAMENT OF DONNA A. FACYNIC, DECEASED, LATE OF THE TOWNSHIP OF HAMPDEN, CUMBERLAND COUNTY, PENNSYLVANIA Donna B. Bohn, Executrix as aforesaid and Accountant herein, avers as follows: DATE OF DECEDENT'S DEATH: November 17, 2003 DATE LETTERS TESTAMENTARY ISSUED: November 26, 2003 DATES EXECUTRIX'S NOTICE ADVERTISED: Cumberland Law Journal December 12, 19, 26, 2003 Patriot- News Co. December 16, 23, 30, 2003 FIRST AND FINAL ACCOUNT PERSONALTY - PRINCIPAL ACCOUNT DEBITS The Accountant charges herself with the receipt of the Decedent's personalty, goods and chattels as set forth below: 1. PSECU, Account No. 0172322265 Regular shares (S 1) Balance and accrued dividends $ 7~162 79 Checking shares (S4) Balance and accrued dividends 7,078.39 2. BELCO, Account No. 759310 Regular savings 34.49 Money market Balance and accrued dividends 101,336.38 Certificate of Deposit, No. 34759 Balance and accrued dividends 22,090.30 3. M&T Bank Checking Account No. 32048645 8,361.47 4. MET LIFE Dividend replacement check 21.35 35 shares of stock at 32.8881 per share 1,151.08 Life insurance proceeds 2,226.07 5. Prudential Financial Life insurance proceeds 3,468.92 18 shares of stock at 28.44 per share 511.92 6. Cumberland County Veteran Widow Benefit refund 100.00 7. Country Meadows Associates, refund 14,447.76 8. Comcast Cable, refund 15.88 9. Verizon, refund 2.54 10. Fidelity and Guaranty Life Insurance Company, annuity, Policy No. 3079721 166,473.85 11. Insurance policy on tangible personal property, refund 186.00 12. Tangible personal property in room in retirement home 500.00 13. US Treasury income tax refund 164.00 14. PA Treasury Department, income tax refund 284.00 TOTAL, PERSONALTY, PRINCIPAL ACCOUNT, DEBITS: $406,617.19 PERSONALTY - PRINCIPAL ACCOUNT CREDITS The Accountant claims credit for the payment of the following items from Decedent's Personalty Principal Account: 1. Trefz & Bowser Funeral Home, Inc. - funeral expenses $ 10,693.90 2. Tree of Life Lutheran Church, luncheon 150.00 3. Register of Wills - probate fees and short certificates 401.00 4. Cumberland Law Journal - advertising letters 75.00 5. The Patriot-News (Metro West) - advertising letters 99.79 6. AT&T final bill 21.07 7. Checks for estate checking account 15.55 8. Register of Wills, Agent payment on account of PA Inheritance Tax - 1/30/04 40,000.00 payment on account of PA Inheritance Tax - 2/5/04 6,000.00 payment on account of PA Inheritance Tax - 2/6/04 689.22 (payment of tax during discount period resulted in a savings of $2,372.30) 9. Register of Wills - filing fee, county inventory 16.00 10. Register of Wills - filing fee, PA Inheritance Tax return and supplemental inheritance tax return 30.00 11. Register of Wills, additional short certificates 15.00 12. The State Employees' Retirement System reimburse state for overpayment of November 2003 payment prorated from date of death of recipient 594.73 13. Donna B. Bohn, Executrix's commission 12,500.00 14. E. Robert Elicker, II, Attorney fees 12,500.00 15. Whitcomb's tax and fmancial services 2003 final income tax return preparation 395.00 16. Reserve for additional accountant fees, filing fees, notary fees, and miscellaneous costs 1,500.00 TOTAL, PERSONALTY, PRINCIPAL ACCOUNT, CREDITS: $85,696.26 PERSONALTY - INCOME ACCOUNT DEBITS The Accountant charges herself with the receipt of the following income from the investment of Personalty Principal: 1. M&T Bank, interest and November 2003 payment from State Employees' Retirement System $1,374.38 2. BELCO accounts, interest 157.99 3. PSECU accounts, interest 122.49 4. Interest - estate checking account (as of 3/25/04) 12.89 5. Interest- estate savings account (as of 3/25/04) 841.07 TOTAL, PERSONALTY, INCOME ACCOUNT, DEBITS: $2,508.82 PERSONALTY - INCOME ACCOUNT CREDITS The Accountant claims credit for the payment of the following items from the Personalty Income Account: NONE TOTAL, PERSONALTY, INCOME ACCOUNT, CREDITS: NONE NO REAL ESTATE RECAPITULATION PERSONALTY: PRINCIPAL ACCOUNT: Debits $ 406,617.19 Credits $ 85,696.26 Balance $ 320,920.93 INCOME ACCOUNT: Debits $ 2,508.82 Credits $ - 0 - Balance $ 2,508.82 NO REAL ESTATE ACCOUNT TOTAL FOR DISTRIBUTION: $ 323,429.75 COMMONWEALTH OF PENNSYLVANIA ) : SS: COUNTY OF CUMBERLAND : Donna B. Bohn, being duly sworn according to law deposes and says: that she is the Executrix of the Estate and under the Last Will and Testament of Donna A. Facynic, Deceased; that she is the Accountant herein; that the foregoing is a true and complete accounting of her administration of said Estate; that the attached list or schedule (*) contains the names, addresses and amounts due unpaid creditors who have given proper notice of their claims; that the attached list or schedule (**) contains the names and addresses of all persons interested in the distribution of said Estate; and that the facts set forth herein are true and correct to the best of her knowledge, information and belief. Donna B. Bohn, Executrix Sworn to and subscribed before me this /',~'~- day of ~ 2004. / [ Bridget Ann Con:oran, Notary Public ! Carlisle Boro, Cumberland County ;~pires June 10, 2006 Momber, ~er~ns.ylvan~ation of Notaries * UNPAID CREDITORS: NONE ** PERSONS INTERESTED IN DISTRIBUTION OF ESTATE: 1. James A. Kapsa 4297 Brixton Drive, Stow, Ohio 44224 2. Thomas A. Boyer 418 Haldeman Avenue, New Cumberland, PA 17070 3. Donna B. Bohn 2140 Market Street, B-201, Camp Hill, PA 17011 4. Jack E. Boyer 813 Cross Street, Port Royal, PA 17082 5. Helen Sass P.O. Box 64, 424 Center Street, Wisconisco, PA 17097 6. Anne F. Zerbe 127 Shartlesville Road, Bernville, PA 19506 7. Paula Daniels 34 Algonquion Drive, Natick, MA 01760 8. Patricia Nauditt 11515 SE 178th Place, Renton, WA 98055 9. Nicholas Paul Kuzovich 15195 Sunwood Blvd., #13, Seattle, WA 98188-7767 10. Cecelia Kuzovich 3027 Edmunds Road, Lafayette Hill, PA 19444 11. The Tree of Life Lutheran Church 1492 Linglestown Road, Harrisburg, PA 17110 STATEMENT OF PROPOSED DISTRIBUTION Donna B. Bohn, Executrix and Accountant herein, proposes to distribute the balance of the Estate of Donna A. Facynic, Deceased, to wit: $323,429.75 in accordance with the Last Will and Testament of said Decedent as follows: 1. The Tree of Life Lutheran Church 1/8 of residuary estate as a tax free bequest in accordance with the non-taxable distribution report on Schedule J of the inheritanace tax returned and Line 13 of the approved charitable bequests as shown on the Notice of Inheritance Tax Appraisement, Commonwealth of Pennsylvania, Department of Revenue $ 45,186.62 2. Anne F. Zerbe, 1/8 of residue 39,749.02 3. Thomas A. Boyer 1/8 of residue 39,749.02 4. Donna B. Bohn 1/8 of residue (tangible personal property in kind $500.00 and cash $39,249.02) 39,749.02 5. Jack E. Boyer 1/8 of residue 39,749.01 6. Helen Sass 1/8 of residue 39,749.01 7. Jane A. Kapsa 1/8 of residue 39,749.01 8. Paula Daniels 1/32 of residue 9,937.26 9. Patricia Nauditt 1/32 of residue 9,937.26 10. Nicholas Paul Kuzovich 1/32 of residue 9,937.26 11. Cecelia Kuzovich 1/32 of residue 9,937.26 TOTAL DISTRIBUTION: $323,429.75 COMMONWEALTH OF PENNSYLVANIA ) : SS: COUNTY OF CUMBERLAND ) Donna B. Bohn, being duly sworn according to law, deposes and says that the facts set forth in the foregoing Statement of Proposed Distribution are true and correct to the best of her knowledge, information and belief. Donna B. Bohn, Executrix Sworn to and subscribed before me this /~ day of ~ 2004. ]"--~-'-'---- Notarial Seal Bridget Ann Corcoran, Notary Public Carlisle Boro. Cumberland Count Memb~ ~ ~ ~ ~ ~0 ever~ o~hGr per,on ~nown ~o ~ ~ 1o In~ve or ct~m ~n Glenda Farner Strasbaugh ~'~,~~,~ Register of Wills & ~ One Courthouse Square Clerk of the Orphans' Court Carlisle, Pa. 17013 Marjorie A. Wevodau First Deputy (717) 240-6345 FAX (717) 240-7797 Kirk S. Sohonage, Esquire Solicitor OFFICES OF · egi ter of tills anb Cle of toe ® ban ' Court t~ount~ 0f Cunrl~erlan~ NOTICE IS HEREBY GIVEN TO ALL PARTIES INTERESTED IN THE FOLLOWING ACCOUNT: FIRST AND FINAL ACCOUNT AND STATEMENT OF PROPOSED DISTRIBUTION OF AND BY DONNA B. BOHN, EXECUTRIX OF THE ESTATE AND UNDER THE LAST WILL AND TESTAMENT OF DONNA A. FACYNIC, DECEASED, LATE OF THE TOWNSHIP OF HAMPDEN, CUMBERLAND COUNTY, PENNSYLVANIA FACYNIC 21-2003-0982 E.ROBERT ELICKER, ESQ. 1. James A. Kapsa 4297 Brixton Drive, Stow, Ohio 44224 2. Thomas A. Boyer 418 Haldeman Ave, New Cumberland, PA 17070 3. Donna B. Bohn 2140 Market St, B-201, Camp Hill, PA t 7011 4. Jack E. Boyer 813 Cross Street, Port Royal, PA 17082 5. Helen Sass P.O. Box 64 424 Center St, Wiconisco, PA 17097 6. Anne F. Zerbe 127 Shartlesville Rd, Bemville, PA 19506 7. Paula Daniels 34 Algonquion Drive, Natick, MA 01760 8. Patricia Nauditt 11515 SE 178th Place, Renton, WA 98055 9. Nicholas Paul Kuzovich 15195 Sunwood Blvd., #13 Seattle, WA 98188-7767 10. Cecilia Kuzovich 3027 Edmunds Road, Lafayette Hill, PA 19444 1 1. The Tree of Life Lutheran Church 1492 Linglestown Road, Harrisburg, PA 17110 Due to the inability to get this matter published in a timely fashion, the confirmation hearing has been rescheduled from the June 22na date to June 29, 2004 at 9 am in courtroom one. cc: Commonwealth E. Robert Elicker, Esq. NOTICE IS HEREBY GIVEN TO ALL PARTIES INTERESTED THAT THE FOLLOWING ACCOUNTS WITH STATEMENTS OF PROPOSED DISTRIBUTION HAVE BEEN FILED IN THE OFFICE OF THE CLERK OF ORPHANS COURT DIVISION IN THE COURTHOUSE AT CARLISLE, PENNSYLVANIA, BY THE ACCOUNTANTS HEREIN NAMED WHERE SAME MAY BE EXAMINED PRIOR TO BEING PRESENTED TO THE COURT OF COMMON PLEAS ORPHANS COURT DIVISION CUMBERLAND COUNTY PENNSYLVANIA FOR CONFIRMATION AND DECREES OF DISTRIBUTION AT 9:00 AM, ON JUNE 29, 2004 IN COURTROOM NO. 1 FACYNIC FIRST AND FINAL ACCOUNT OF DONNA B. BOHN, EXECUTRIX FOR 21-2003-0982 THE ESTATE OF DONNA A. FACYNIC, LATE OF HAMPDEN TOWNSHIP, CUMBERLAND COUNTY, PENNSYLVANIA, DECEASED E. ROBERT ELICKER, ESQ. Glenda Farner Strasbaugh Cleric of Orphans Court Cumberland County, Carlisle, Pennsylvania STATUS REPORT UNDER RULE 6.12 Date 0fDeath: ~,,-~'~[~'-~ r ?~ ;a,~, o ~ WillNo.: ~F--~ ~ - o ~ ~ A~n. No.: P~su~t to Rule 6.12 of the Supreme Cou~ OChmns' Com~ Rules, I repo~ the followMg wi~ respect to completion of the a~stration of ~e above-captioned estate: i. State whe~er admin~s~ation of the estate is complete: 2. If ~¢ ~swer is No, state when ~¢ personM representative reasonably ~at ~¢ ~flm~s~ation ~ be complete: 3. ~th¢ ~swer to No. 1 is Yes, state ~¢ follow,g: a. Did ~¢ personal representative file a ~al accost wi~ ~¢ Co~? YesX No ~ b.The ssp~at¢ O~h~' Co~ No. (if any) for the personal representative's aoco~t is: o.Did ~¢ personal representative state ~ accost ~o~ally to ~¢ p~ies ~ ~tsrest? Yes ~ No ~ 0. Copies of receipts, mle~es, jo~ders ~d approv~ of focal or ~o~al aoco~ts may be filed wi~ ~¢ Clerk of the O~h~s' Co~ ~d may be a~ached to t~s rspo~. · :~- .. Telephone No. .... Persona Rep, ~ Counsel for personal representative