HomeMy WebLinkAbout10-22-08 (2)y a
REV-1500 EX * (&00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Z Johnson E. Catherine a/k/a Johnson Catherine E.
~ DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year)
04/08/2008 12/28/1925
Q (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL}
OFFICIAL USE ONLY
FILE NUMBER
2 1 -0 8 0 4 4 8_
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
0 9- 1 2- 7 3 9 5
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
w ®1.Original Retum ^ 2. Supplemental Retum
~ a Y ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date or death after 12-12-e2)
_ ~ ~ 6. Decedent Died Testate (Attach copy or WIIQ ^ 7. Decedent Maintained a Living Trust (Attach copy orrrusq
vam 0
~ ^ 9. L'Itlgation Proceeds Received ^ 1 O. SpoUSal POVerty Credft (date of death between 12.31.91 and 1-1-95)
^ 3. Remainder Retum (date of death priorto 12-1382)
^ 5. Federal Estate Tax Retum Required
1 8. Total Number of Safe Deposit Boxes
^ 11. Election to tax under Sec. 9113(A) (Attach sch o)
F
Z
i
y
~ THI8 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND COO?F ~E MA LING ADDR SORMATION 5tivuLU rat urrce~ r w ~ v:
NAME
Joel R. Zullin er Es uire 14 North Main Street, Suite 200
FIRM NAME (If Applicable)
Zullin er Davis P.C.
TELEPHONE NUMBER p 17201
717 264-6029 Chambersbur
1. Real Estate (Schedule A) (1) C:~ ~ OF
. ~ ^r;7
~t FIC SE ONLY . )
t~ ~ -~
~
2. Stocks and Bonds (Schedule B) (2) ;= % r ~ r.~
3. Closely Held Corporation, Partnership orSole-Proprietorship (3) ~ ~ rV i
~ -;
4. Mortgages 8 Notes Receivable (Schedule D) (4) J '
` ~' ~~
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 118,267.30 ._ ~~
--t ='~ I"ti7 ~ -
(Schedule E) ~
trt
Z
O
6. Jointly Owned Property (Schedule F) (6) i
^ Separate Billing Requested
52,728.46
~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
F- (Schedule G or L)
995.76
170
a
Q 8. Total Gross Assets (total Lines 1-7) (6) ,
V
9. Funeral Expenses & Administrative Costs (Schedule H) (9) 21,167.32
~ 317.76
Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
10
. 485.08
21
11. Total Deductions (total Lines 9 & 10)
(11)
,
510.68
1
49
12. Net Value of Estate (Line 8 minus Line 11)
(12)
.
,
13. Charitable and Governmental BequesLslSec 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
(14) 149, 510.68
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
Z
O 15. Amount of Line 14 taxable at the spousal tax
0.00 x (15) 0.00
rate, or Vansfers under Sec. 9116 (a)(1.2)
a
~
16. Amount of Line 14 taxable at lineal rate 0.00 x
(16) 0.00
52,728.46 x .12 (17) 6,327.42
(1 17. Amount of Line 14 taxable at sibling rate
~
O
18. Amount of Line 14 taxable at collaterel rate 96,782.22 x .15 (18) 14,517.33
V
(19) 20,844.75
K
Q 19. Tax Due
20. l
> > BE`SURE TO ANSWER ALL' QUESTIONS ON REVERSE'SIDE AND RECHECK MATH `< <
~~
Decedent's Com
STREET ADDRESS 46 RUS
Address:
Drive
STATE PA I ZIP 17257
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments 19.548.55
C, Discount 1.028.87
(1) 20.844.75
Total Credits (A + B + C) (2) 20, 577.42
3. InterestlPenalty if applicable
D. Interest
E. Penalty Total InterestlPenalty (D + E) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 0.00
Check box on Page 7 Line 20 to request a refund
267.33
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)
(5B) 267.33
B. Enter the total of Line 5 +5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes No
1. Did decedent make a transfer and: X
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 "intrust 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? ....................................................................................................... 0 ^
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 penaltles of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all mfonnabon of which preparer has any knowledge. DATE
OF PERSO RESPUNSIbsI_t run riu V RC 1 VRI`I ~ Q//~/O
~/ .y / !J i ~ fl _
Harold E. Heefner PA 1725
27 Lantern Lane Shi ensbur DATE
~REPARER OTHER TkiAN gEPRESENTATIVE /_
R. Zullinger, E~~ujre ^^^ ,~__~__..~.,.,. PA 17201
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 does not exemat a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-0ne 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°h (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 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 12% p2 P.S. §9116(a)(1.3)]. 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 + (8-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT FILE NUMBER
ESTATE OF 21 Og 0448
~ ~ th rin
Include the proceeds of Ifiga4on and the date the proceeds were received by the estate
ht of survNorshlp must be disclosed on Schedule F.
ith ri
d
g
w
All property jointly-owne VALUE AT DATE
ITEM DESCRIPTION
NUMBER OF DEATH
13,041.95
Certificate of Deposit #31003914606933, M&T Bank,
~
.
including interest accrued to date of death
2. Certificate of Deposit #31003916126111, M&T Bank,
35,071.87
including interest accrued to date of death
3. Checking Account #97324078, M8~T Bank, including
13,608.76
interest accrued to date of death
4,458.50
4, Gross proceeds from sale of personal property by
Dan Hershey Auction Service, LLC
175.00
5. Cash
2,200.00
6, Proceeds from private sale of decedent's
automobile
14.08
7. Cash from lockbox
86.00
8. Sale of coins found in lockbox
15.37
g, Refund, Comcast
387.70
10. Refund, Nationwide Insurance
33.07
11. Refund, Embarq
250.00
12, Rebate, Commonwealth of Pennsylvania
600.00
13. U.S. Treasury, Stimulus Rebate
47,500.00
14. Gross proceeds from sale of mobile home to
Tanya Brown
15. Tanya Brown, reimbursement of prepaid lot rent
825.00
10/08 thru 12/08, sale of mobile home
(If more space is needed, insert addttional sheets of the same size)
..
REV-1510 EX + (8-98)
SCHEDULE G
INTER•VIVOS TRANSFERS &
COMMONWEALTH OF PENNSYLVANIA MISC. NON-PROBATE PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT FILE NUMBER
ESTATE OF
Inhncnn F Catherine a/k/a J ` `' ~herine E 21 08 0448
1J1111aU11 VGI tI
This schedule must be completed and filed 'rf the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDETHENAMEDFTHETRAN6FEREE,THEIRRELATIDNSHIPTODECEDENTAND DATE OF DEATH %OFDECD'S EXCLUSION TAXAUEE
NUMBER THE DATE OF TRAN6FER ATTACHACDPY OF THE DEED FDR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE}
52,728.46 100. 52,728.46
1. Annuity Contract#W0021458981, Western-Southern Life,
named beneficiary, Harold E. Heefner, brother of decedent
TOTAL (Also enter on line 7 Recapitulation) ~ 3 52,725.46
(If more space is needed, insert additional sheets of the same size)
REV-1511 FJC + (12-99)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT FILE NUMBER
ESTATE OF
th rin 21 08 0448
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A, FUNERAL EXPENSES: 9,807.00
~, Fogelsanger-Bricker Funeral Home, funeral services
g, ADMINISTRATIVE COSTS:
~ Personal Representative's Commissions 0.00
Name of Personal Representative (s)
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address
Ctiy State ZIP
Year(s) Commission Paid:
6,200.00
2.
Atlomey Fees Joel R. Zullinger
00
0
g, Fatuity Exemption: (If decedents address is not the same as claimants, attach explanation)
.
Claimant
Street Address
Ctiy State ZIP
Relationship of Claimant to Decedent
s Letters 260.00; will 15.00; codicil 15.00; short certificates 20.00;
F
t
b
340.00
4. ee
e
a
Pro
JCP fee 10.00; automation fee 5.00; filing return 15.00
5 Accountants Fees
g, Tax Retum Preparers Fees
179.68
7, Repair of mobile chair prior to sale 300.00
8. Ausherman Bros., appraisal of mobile home 30.00
g. Carl L. Spidel, appraisal of coins 113.00
10. News-Chronicle, advertise letters 53.62
11. PPL Gas Utilities, gas service to residence 75.00
12. Cumberland Law Journal, advertise letters 16.68
13. Penelec, utilities 41.97
14. PPL Gas Utilities, gas service 34.11
15. Penelec, utilities 37.06
16. Borough of Shippensburg, water and refuse service 26.81
17 PPL Gas Utilities, gas service 414.94
.
18, Vivian F. Co ,Tax Collector, taxes due on mobile home
TOTAL (Also enter on line 9, Recapitulation) S 21,167.32
If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
21 08 0448
Johnson, E. Catherine, alk/a Johnson, Catherine E. page 1 File Number
Decedent's Name
Schedule H -Funeral Expenses & Administrative Costs - B7.
ITEM DESCRIPTION AMOUNT
NUMBER
26.81
19. PPL Gas Utilities, gas service 60.84
20. Penelec, utilities 216.50
21. Nationwide, insurance on mobile home 43.32
22. Penelec, utilities 27.35
23. PPL Gas Utilities, gas service 25.10
24. Penelec, final utilities 37.06
25. Borough of Shippensburg, final water and refuse 1,560.47
26. Dan Hershey Auction Service, LLC, commisson on sale of personal property 1,500.00
27. Country Side Village Homes, commission on sale of mobile home
SUBTOTAL SCHEDULE H•B7 I 3,497.45
REV-1512 EX + (6-98)
SCHEDULE 1
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT FILE NUMBER
ESTATE OF
rl I hnson C ine E 21 08 0448
Include unreimbursed medical expenses.
VALUE AT DATE
ITEM DESCRIPTION OF DEATH
NUMBER 44.15
1, Embarq, telephone service due at death
115.60
2. PPL Gas Utilities, gas service due at death
3. ~Penelec, utilities due at death
23.26
83.61
4. WSEMS-Chambersburg ALS/BLS, ambulance
transport
51.14
5. Chambersburg Imaging, medical services
TOTAL (Also enter on line 10, Recapitulation) I S 31
(If more space is needed, insert addfional sheets of the same size)
REV-1513 EX + (°s^~
SCHEDULE)
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
aGCinFNT nFCEDENT
ESTATE OF FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
F ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) O
I TAXABLE DISTRIBUTIONS [include outri ht spousal distributions, and transfers under
Sec. 9116 (a~ (1.2)]
1. Harold E. Heefner Sibling 52,728.46
Item 1 on Sch. G
27 Lantern Lane
Shippensburg, PA 17257
2. Mark A. Coy Collateral
one-seventh of residue
501 Brenton Street
Shippensburg, PA 17257
3. Andrew J. Coy Collateral
one-seventh of residue
31 Nelson Drive
Carlisle, PA 17013
4. Michael E. Heefner Collateral
one-seventh of residue
314 Whitmer Road
Shippensburg, PA 17257
5. Margaret J. Bowman Collateral
one-seventh of residue
8396 Rice Road
Shippensburg, PA 17257
6. Gregory B. Heefner Collateral
one-seventh of residue
87 Curtis Drive
East Berlin, PA 17316
7. Joseph W. Heefner, Jr. Collateral
one-seventh of residue
Lindsay Lot Road
Shippensburg, PA 17257
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, O N REV-1500 COVER SHEET
II,
1. 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 I S
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Johnson, E. Catherine, a/k/a-Johnson, Catherine E. 21 08 0448
Page 2 File Number
DacBdent's Name
Schedule J -Beneficiaries -1
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS (include outright spousal distributions)
8. Douglas Swartz
P.O. Box 117
Gratz, PA 17030
9. Betty Martin
15 Dead End Lane
Shippensburg, PA 17257
RELATIONSHIP TO DECEDENT I AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
Collateral
one-half of aone-seventh
share of residue
Collateral
one-half of aone-seventh
share of residue
JRZ - 5.1 johnson.2 July 23, 1999
LAST WILL AND TESTAMENT
I, E. Catherine Johnson, also known as Catherine E. Johnson,
of 46 Rustic Drive, Shippensburg, Pennsylvania, being of sound and
disposing mind, memory and understanding, do hereby declare this to
be my will, hereby revoking any and all former wills and codicils
theretc by me heretofore made.
I.
I d1rP_Ct treat all my just debts and funeral expenses,
including all expenses of my last illness, shall be paid from my
estate as soon as practicable after my decease as a part of the
expense of the administration of my estate.
II.
I give, devise and bequeath the residue of my estate of every
nature and wherever situate as follows:
p,, One-third thereof to my husband, John H. Johnson, if he
survives me. In the event my said husband, John H.
Johnson, predeceases me, his share shall be distributed
under subparagraph B of this paragraph II.
g, Two-thirds thereof to my following named nieces and
nephews: Mark A. Coy, Andrew J. Coy, Michael E. Heefner,
Margaret J. Bowman, Gregory B. Heefner, Joseph E.
Heefner, and one equal share to Betty Martin and Douglas
Swartz, Jr., jointly or to the survivor of them. Should
any of the above-named beneficiaries predecease me, their
share shall be distributed equally among the remaining
beneficiaries with the exception of the death of Betty
Martin or Douglas Swartz, Jr. , prior to me, their portion
of one equal share shall be distributed to the remaining
beneficiary as set forth above.
III.
pny fiduciary under this will shall have the following powers
in addition to those vested in them by law and by other provisions
of my will applicable to all property whether principal or in.r_ome,
including property .,held for minors, exercisable without Court
approval, and effective until actual distribution of all property:
A. To retain any and all of the assets of my estate, real or
personal, without regard to any principle of
diversification of risk.
g. To invest in all forms of property including stock,
common trust funds and mortgage investment funds without
restriction to investments authorized for Pennsylvania
fiduciaries as they deem proper, without regard to any
principle of diversification of risk.
C. To sell at public or private sale, to exchange or to
Page 2
lease for any period of time any real or personal
property and to give options for sales,.. exchanges or
leases, for such prices and upon such terms or conditions
as they deem proper.
D. To allocate receipts and expenses to principal or income
or partly to each as they from time to time think proper.
g. To compromise any claim or controversy.
g. To distribute in cash or in kind or partly in each.
G, To hold property in their names without designation. of
any fiduciary capacity or in the name of a nominee or
unregistered.
IV.
I direct that all taxes that may be assessed in consequence of
my death of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate as a part of the expense of
the administration of my estate.
V.
I appoint Grace E. Coy and Harold E. Heefner as co-executors
of this my will.
Page 3
vI.
No bond shall be required of any fiduciary hereunder in any
jurisdiction.
IN WITNESS yJEiEREOF, I hereunto set my hand and seal to this my
of five typewritten pages, 'the
last will and testament, consisting
first three of which bear my signature
purpose of identificatior_
~~~~ 19 ~ -
this
in the margin for the
-/~~ day of
(° ~GL ~ %~-°~-~'`~~""~ ( SEAL )
(> (SEAL)
Signed, sealed, published and declared by the above-named
testatrix 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 set our hands as attesting witnesses.
~ ~ ~ ,
~~a ~ ~
We, E. Catherine Johnson, also known as Catherine E. Johnson,
6 ~ I~ Z~. ~ I~ ~r fill and ~~'T ~ ~ , L ~fr~-1 the
testatrix and the witnesses respectively, whose names are signed to
Page 4
first duly sworn, do
oing instrument, being
the attached or foreg that the testatrix
hereby declare to the undersigned authority
executed the instrument as her last will and testament
signed and act for the
and that she executed it as her free and volunta~nesses, in the
urposes therein expressed and that each of the wi
P signed the will as
presence and hearing of the said testatrix,
said signer was at
witnesses and to the best of their knowledge'sound mind and under
that time eighteen years of age or older, of
no constraint or undue influence.
~.
Testatrix
~ - ~°
Testatrix ~
Subscribed, sworn to and acknowl egeand
before me by the above-named sig
subscribed andtnessestthisf o I3~''ed Y ofe
above-name~~ 1 l~ .
N t ry ublic
papT~AL SrAt
R~
t3t3~A~~~~ ~ ~., PA
~~ ommialo~+ Ex~ ~Y B'
Page 5
JRZ - 5.1 johnson November 4, 2005
CODICIL
I, E. Catherine Johnson, a/k/a Catherine E. Johnson, of 46
Rustic Drive, Shippensburg, Pennsylvania, being of sound and
disposing mind, memory and understanding, do hereby declare this to
be a codicil to my will dated August 13, 1999.
I.
I hereby revoke paragraph V of my said will which reads as
follows
" I appoint Grace E . Coy and Harold E . Heefner as
co-executors of this my will."
IN LIEU THEREOF, I direct that the following be substituted:
"I appoint Harold E. Heefner and Margaret Bowman as
co-executors of this my will."
II.
In all other respects I hereby ratify, confirm and republish
my will dated August 13, 1999, together with this codicil as and
for my will.
IN y11~Eg5 WHEREOF, I have hereunto set my hand and seal this
2 CC
IC~~'~ day of ~;~(,'?~2rP~l.~c'r' ~ ~~ .
E. Catherine ohnson
,~2Z`~ :<~~ ~` ;~`7~~w1~ SEAL)
Catherine E. Johnson
Signed, sealed, published and declared by the above-named
testatrix as and for her codicil to last will and testament in our
resence
presence, who in her presence, at her request and in the p
of each other have hereunto set our hands as attesting witnesses.
-----~ ,
~--,
i
n ,~ ,,~,
'~,~ ///~ f~ ~ ~
We, E. Catherine Johnson, also known as Catherine ~. Johnson,
and a.~LtrJC ~' (Y1 `i~ ~-~ _, the
testatrix and the witnesses respectively, whose names are signed to
do
instrument, being first duly sworn,
the attached or foregoing
hereby declare to the undersigned authority that the testatrix
signed and executed the instrument as her codicil to her last will
and testament and that she executed it as her free and voluntary
Page 2
act for the purposes therein expressed and that each of the
witnesses, in the presence and hearing of the said testatrix,
signed the codicil as witnesses and to the best of their knowledge,
said signer was at that time eighteen years of age or older, of
sound mind and under no constraint or undue influence.
~.~~~ ~
Testatrix
Testatrix /
Witness~~ ~
-~ ~
~' 'Witness ~~
Subscribed, sworn to and acknowledged
before me by the above-named signer and
subscribed and sworn to before. me by the
above-named witnesses this 2;'C C~ da of
N ~:.
Notary P' lic
Notarial Seal
Tricia L. Bailey, C°~ ~Couztty
South Middleton'Itxp•.•
My Commission Expues Sept. 24, 2006
Page 3
O 1VI8TBank
Apri124, 2008
Law Offices
Zl~llinger-Davis
Professional Corporation
14 North Main Street, Suite 200
Chambersburg, PA 17201
499 Mitchell Street, Millsboro, DE 19966
RE: Estate of Catherine Johnson
Date of Death: April 8, 2008
Social Security Number: 209-12-7395
Dear Mr. Zu]linger:
In response to your request, please be advised that at the time of death, the above-
named decedent had on deposit with this bank the following accounts.
Certificate of Deposit
1. Account Type ...........................
...... 31003914606933
Account Number .................
Ownership (Names ofl......... • • • • • Ellen Catherine Johnson
Opening Date .......................... .05 / 08 / 98
Balance on Date of Death_........ .$13,000.00
Accrued Interest $ 41.95
Total ..................................... ..$13,041.95
.... Certificate of Deposit
2. Account Type .......................
Account Number ....................... 31003916126111
Names o Ellen Catherine Johnson
Ownership ( ~ ..............
Opening Date ...........................01 / 10 / 07
Balance on Date of Death .........$35,000.00
Accrued T + ~+ $ 71.87
1! LLG
Total .......................................$35,071.87
April 24, 2008
• Page 2
Checldng Account
3. Account Type ...........................
Account Number ....................... 97324078
Ownership (Names oj~. • • • • • • • • • • • • • Ellen Catherine Johnson
Opening Date ...........................01 / 28 / 80
Balance on Date of Death.........$13,608.48
Accrued Inte ~ + $ 0.28
Total .......................................$13,608.76
The above named decedent did not have a safe deposit box.
* If upon reviewing the information above, you believe there are additional accounts not
referenced, please provide us with an account number and/or the name of any possible
joint account holder. For any additional information on the above accoulease contalctg
ownership and any changes, closures and/ or reimbursement of funds, p
our Walnut Bottom Branch at 28 Walnut Bottom Road, or # 717-532-2414.
Sincerely, --~'
~~
Charlene Warrington, Records Management
1-888-502-4349
UCTION SERVICES LLC
j~ArT I-jERSHEY A
790 West High Street
~""fy Carlisle, PA 17013
(717) 532-4647
Steve Ege 717-385-5438 Cell Chris Bream 717-226-1920 Cell L~' ~,x,
1•~r
. t~, ~~~~r~~?~fi ~~~~~i' i~.;~ _~~~~~h ~ '~C'-~ DATE ~' ,y.
~^ ~ '~ ~ 4 ( '',
SELLERS NAME ~ , ~W ~ ~ ~, ~ ~~,~
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ADDRESS ._ ~ ,C~.S~~.t<<~`.:a :.~. ~ .~ ~.. ~ ~ 4
`b.,~ ~~ :., r ~ ta~ ~ ~f",~.; r ` ,,~ ~;~ b{'~~ .~ ~ Y,~. ~r ~~ ~„`~ ~*~ AUCTIONEER %~-`-` -
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AUCTION DATEILOCATIO ~ ''n '" _
P I` / F .r `k ..... fir, , '~.E.. `..4„n~ r f ,."`~}'r~` i
r ~ f~ ~ ° `~ k `- `" ~. a~•a~ .t DESCRIPTION OF MERCHANDISE ~~<'4~ '~ ~;
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I Commission the Auctioneers to sell t e merchandi t th ~gthat Ilamethe owner orauthox~zedrrepresen--~
to be sold as is & grouped as necessary to obtain bids. I cert fy
tative of the merchandise, goods and or property and have good title and the right to sell and that they are free
from all incuinbrances. I agree to acc haramhlessthe Auct oneers againsgany claims of the natt}re referred to n
title to the purchaser. I agree to hold ~ ~,.,,
this agreement. ~/ .,,„fir ~ o.;
^~~~-~""`~ ~-'' SELLERS SIGNATURE
AUCTION SIGNATURE o
a "~'
TotaY Sales 1Clerking Tickets Attached) ~
Less Sale Expense:
,~ :~ % Commission Auctioneer $ ~ a ~~ ~' ~ ~ ~
__ % Commission Clerks $
OTHER:
TOTAL SALE EXPENSE DEDUCTED $
.~ ~~
~' ~ S~LLERS NET $ '= ~~~ 4~ ~'• ~'~ ~
•, r
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~' AUCTION SIGNATURE
SELLERS SIGNATURE
CLOSE OUT SHEET FOR 46 RUSTIC DRIVE
'THE ESTATE OF E. CATHERINE JOHNSON
SALES PRICE OF HOME $47,500.00
COMMISSION TO COUNTRY SIDE $1,500.00
VILLAGE HOMES
TOTAL $46,000.00
REIMBURSMENT OF PREPAID LOT RENT
FOR OCTOBER THRU DECEMBER $825.00
($275 PER MONTH)
TOTAL AMOUNT TO THE ESTATE OF $46,825.00
E. CATHERINE JOHNSON
~6d~a.99'i! 1 i~~ ~~®~ i19LA..P°~~~ i~i®~~~'Y"!t~•
31 Walnut Bottom Road
~U9~CH~~~ (717) 532-6643 GToIEFreeY(888)1745-2797
A~"y~E~1~EE~9~
IN THIS CONTRACT, "BUYER" REFERS TO THE PERSON(S) NIJHO'S NAPIiE APPEARS BELOW.
"SELLER" REFERS To COUNTRY SIDE VILLAGE HOMES, INC. _
SUB.fECT TO THE TERMS AND CONDfTIONS ON BOTH SIDES OF TH RED HOOP EsAND ANY REfUI OR AHY COMBINA"f10N OF rrEMS DESCRIBED ~ QURGHAS
THE FOLLOWING "UNI'T°' WHICH IdIEANS THE NIOBILE/PIIAPIUFACTLI PHO 2 ~,_ ~~.{,~ (Q ~ O Z f Z~d~'
BUYER(S) •~•~(~. > ~~ T SALESP~BSO~NI~
ADDRESS t GG ~~~ ~c. ~`J~~'~ P~
~~~ADDRESS IV ~ C cl i~Q~riiJ~iJ' uL~~ Q~
S ~~- fl'a YEAR BD. ROOMS FLOOR SIZE HITCH SIZE STOCK NUMBER
MAKE & MODEL _ ~ L "'l L{P O W WZ
~rc iP ~ ~ ~~ .~ COLOR PROPOSED DELIVERY DATE KEY NUMBERS
SERIAL NUMBER ~k15'~. ~~ ~4
222 ~~'3O ^ NEVII ~ED t,..,.~~1 ~TZ~
OPTIONAL E®I,.IlO:'MENT, LABOR Atd® ACCESSORIES BASE PRICE 01= UNIT $ ,
OPTIONAL EQUIPMENT
Wheals, axfes & hitches not included but avaitable in future $ SUB-TOTAL $
~ no charge for moving of home to new location.
~~ 5 NON-TAXABLE ITEMS _
~~ ~~
I l VARIOUS FEES AND INSURANCE ~
1. CASH PURCHASE PRICE $
TRADE-IN ALLOWANCE $
LESS BAL. DUE on above ~
NET ALLOWANCE $
CASH DOWN PAYMENT $ ~~
CASHASAGAEEDseeReMaRKS $ ~
2. LESS AL EDITS $ ~~,
SUB- TAL $
w
n id an a of h le Pri e $ ' ~~~
INSYLVA S AS BEE PAID ON THIS HOME
THE SEL S REGIUIRE BY ACT 23 01= 2000.
RELEA CAN TO COU UPY HSIDE VILLAGE HOMES,SINCE
BALANCE CARRIED TO OPTIONAL EQUIPMENT $ R IS MUTUAL-i-Y UNDER~~D ~ ~ ~ ~ Subje~
slzE m necessary moons, and adlustrrlents concemin9 des
YEAR x ~ ~In t0 tle made at the tl[rie ~ ~~
DESCRIPTION OF TRADE-IN In net I
BEDROOMS
MAKE O E
COLOR
TITLE NO. E IA N .
AMOUNT OWING TO WHOM • • • • ` • •
~ ' _
^ BUYER ^ SELLER WILL PAY THE DEBT OWED ON THE TRADE-IN. T
O ~~~. BUYER
B
SIGNED X
SELLER 1 1
COUNTRY SIDE VILLAGE HOMES, INC. SOCIAL sE R
an or anAuthorizedAgent BUYER
Not Valid nless Signed and Adept b Officer of the Cornp Y SIGNED X
SOCIAL SECURITY NO.
`(-, 1 '
BY Approved A PLAIN LANGUAGE PURCHASE AGREEMENT 05!02
Copyright m1983 JENKINS BUSINESS FORMS MASCOUTAH, IL 62258
nRM ~00NIPA ~® _ _ ___ _ f1RIC;INAI _ _
PURCHASE AGREEMENT
THE BUYER(S) ~ ~' ~ ~~~~
OFFERS AND AGREES TO PURCHASE THE FOLLOWING MOBILE HOME
CATED AT
~.-SAC- ~~Z-I ~ ~ S `~<
A
LO
BEWG A \~~ ~~~~~ s M EL SIZE
YEAR MAKE
FOR THE AMOUNT OF $
.ITEMS INCLUDED IN PRICE:
~~ DATE: ~ ~ ~Z' ~ ~ g
BUYER: ~ r ~- ~ ~`"
X
DATE:
BUYER:
THE SELLER.HEREBY ACCEPTS THE ABOVE OFFER:
F E.
' ~ DATE: ~ ~ "e~`~~~
SELLER: t
BY:
'~kl~ ESTIR~ CUT ~-CL-t~~tti~ ~ - J'7~ ~'-~~5 r`3
'N ~
~"
AD~E]YDi11i~f TO CONTRACT
q~~Zl~~
ADDENDUM TO RETAIL INSTALLMENT CONTRACT i)ATF.,T)„~.,,..-.{-.-.------
BY AND BETWEEN ~~~c- ~F~tn a (Seller). 1 f~F~ w~"'
114ANUFACTURER 2~ph1~~v MODEL S~-rnax:,~'~.-t~~ SIZE
SERLAL NT1To.L'~}ER f- ZZZ t-~-~"~
Buyers are aware of tho fact that this rnohile home has been
used. Buyers also acknowledge that they are purchasing this
mobile home in an "AS IS CONDITION" and they have inspected
the mobile home, and will not have any right whatsoever to
request the seller or Country Side Homes TO MAKE ANY REPAIRS,
CHANGES OR IMPROVEMENTS, other than those set forth hereon,
(Sellers agree that before buyers take possession. of this mobile home,
the heating, plumbing and electrical systems are to be in
working condition.)
~~
R}
(SELLER) ~~ ~ 5~:~ G = C.~-~~..t2-«~ .E .
:~,Frn.~S~ `..b
(BUYER) (SELLER)
tswo ~ - ~
BY:
FOR Country Side i age Homes, lnc.
~~
Western-Southern Life~~
Date: 05/01!2008
ZULLINGER - DAVIS
14 NORTH MAIN ST
SUITE 200
CHAMBERSBURG, PA 17201
ATTN: JOEL ZULLINGER Re: Contract Number W0021458981
Dear Mr. Zullinger:
Please accept our condolences on the death of Ellen Catherine Johnson. We are here to serve
you during this difficult time. I hope you will find the following information helpful:
1. This contract is an annuity and the reference number is W0021458981
2. The annuity was opened on February 13, 2008
3. This annuity was held solely by Ellen Catherine Johnson. She was the owner and the
annuitant.
4. The balance of this annuity as of April 8,.2008 was $52;728.46 `'
5. The interest earned on this account (to date) since it was opened with Western Southern
Life is $447.67. Please note that Ms. Johnson was withdrawling her interest on a
monthly basis. As such the interest in this annuity as of today's date is $46.17.
As a designated beneficiary, .Harold E. Heefner;is entitled to receive payment on the Western-
Southern Life annuity referenced above. Payment of benefits under the contract is the obligation
of, and is guaranteed by, Western-Southern Life Assurance Company, Cincinnati, Ohio. The
following settlement options are available to him:
Lump sum. You can ct to tax Westerln-Southern Life enlcouragesnyouato (seek tax or legal
contract may be sub~e
advice before selecting this option.
If you choose this option, Western-Southern Life will automatically establish a Proe~ ~ lent
Account in your name. This interest-bearing account provides you immediate,
access to your Pr{ Authorizationhfo mcand ebum t with theulcla m form.lease sign the
enclosed Accoun
Income payments. You can receive a stream of guaranteed income payments. If you
choose this option, a variety of options are available. Some guarantee you an income for as
long as you live, others spread your distribution out over the number of years that you
choose. You must select this option within 1 year of the annuitant's death. Payments from
qualified annuity contracts will be taxable when you begin receiving payments. Additional
information will be provided if you select this option.
Defer five years. You ow aax-deferred unti you select a settlement optyon.rOnceeselectedt
value will continue to gr
this option cannot be changed.
Member Western & Southern Financial Group®
Annuity OperatPhone (800) 926 B 70291Fax (513} 629 799 ~ 45201-2918