The URL can be used to link to this page

Home My WebLink About02-0932 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of II\Il rI ~~l A2 HE Ju Ry also known as 0 ~ c, i!: No. ~ J-OtQ-Q3:J To: Deceased. Social Security No. J ~ 1 - 3> 4 - 4 9 Z/.5 Register of Wills for the County of~ cJ ,.., I"!P/~~NDin the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Your petitioner(s), who is/are 18 years of age or older, appl 1 6::S for letters of administration on the estate of Decendent was domiciled at death in (\ \ ~ VV\ ~ E. R ~ 14 WO County, Pennsylvania, with h I. ~ last family or principal residence at ')"" ( 7 7 e. T R I 1J \) L.S R 0 ~ {;1 Ii It 't:t (list street. nnmber and municipality) ./ clt/ (Wj Decendent, then ~ t\ years of ~e, died '].. ~ at rl~'-Y S I ~ IT Ii- 9Pll>4L <; Evfi it 2..eJ9 l'\A HILL' (),q. 17 , I Decendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property $ (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ '8' 7. ~ <JQ situated as follows: H AM.?r7Er-? "r1:Jtl~, (! lJ(VI.F?t'i3/J2. ~ JtJf> ()C1 t7~ (,: c, . ndO 0R . THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. ~ " u . " "0_ .t;;~ "" '"~ -g.g cu',o 3~ "- ZO ~ . ., iii c: ('L2 ~ '>-h $; sn7 e. TI1' I NDLF Kc])~' Irq F=C 1::1 Ii JUle5 Su ]':<G I ,..14. o .>() n -<1'5 - I OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBRRr .ANn } 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 representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to ~r affirmed and subscribed f d ~:;;::!::pK befo.I!:.\Il.J:thls 1htb day of ____~_ OC'l'OtlER I 2UU2 19_ E. Ai( ~ ~\)..~t% ~"' l ~ ~ ~ " .... = ~ oS " OIl i:i3 ..-.... ;:.~' . c5 !"'x; No. ~-oa.q3a. Estate of MARUl!N'HENRY BRETZ , Dec~sed GRANT OF LETTERS OF ADMINISTRATION I,.',", AND NOW OCTOBER 1 6. 2002 )<Il91L-, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that E . CARLA BRET Z is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to R. CARLA BRE'l'Z in the estate of MARLIN HRNRY BRR'l'Z ~"' "'(.-1"-' @r"'d '14"J Register of WtI s . FEES Letters of Administration ..... $ 235 . 00 Short Certificates( ).......... $ 1 2 . 0 0 Renunciation ................ $ ;cp $5.00 TOTAL _ $252.00 Filed. .1.Q:-.l. ?:;?.o.~f...... A.D. 19_ malleu to atty 10-16-2002 '-J J2 fl) R 'i F=_ (! lJ\f IJE ATfORNEY (Sup. Ct. J.D. No.) 3Qo'l Mf.'Rt<1?{ Sr. ADDRESS CAMl' FJ Il.l.-../ fqQ. )'7011 '72...2.7 PHONE tEL 7/*1-737-046 , JA.. S c.:y )AJ 0 0 ({),;z j""" H105.805 REV ')18(, This is to certify that the information here given is correctly copied from an original certificate of death duly filed w Local R~gistrar. The original certificate will be forwarded to the State Vital Records Office for permanent I\ling. me as WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for [his certificare, $2.00 p 8606794 No. IJ ,"," :~JH.. ;,'81 COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH. YITAl RECORDS CERTIFICATE OF DEATH sr"'if'~f"""_R SOCI"'~SECURlTY"UMllfR OM'EOfDE/lr";Mcn.,.u"" ... e ljrbi!'., JI.)('ol ,pE..pfh"r ," f'tRM.o."f..T !l~"'CKINK NAME Of OECfOf"lT Ihso M""'"'.l....' ~. I. Marlin Henry Bretz UNDEA 1 YfAA U_R I 11M ......... o.v- _,_ 81RTHI'LACE:C"Y....'" sw."'""''''9''Cou<'II'Y' 2.male I. 161 34 - 4845 Pl..ACEOf'OEMHIC"""."""'...... _"""""""''''''''__1 HOSPtv.t.; i$focrx! ,0 AGE,:,..'ll<r1"""vl 60 '" COUNTYOf' " CUlTiJerland E. ~ troUun OECEOEm's "'''''' ~""'"'" ...- ~-- ". 1l.,S- PA N - ~.. ClmIberlaril lu>mIIlip? I?".o:::"~=of MOTHEA'$NNI€,F."'M_,_$u/~ - * , . < i 5177 E. TriOOle Rd. It. Mechani PA 17055 FRHER'SNAIolE(f...M_. ~_, I.. Harvie A. Bretz ""ORMAHT'S 1UIMt; (T n-''''.... E. Carla Bretz loETtlOOOf'OISP'OSlTIOIt O eun..1E ~O -.-._s..,.0 QonM..... OlM<lSpoocIv' 2'.. SIGHATUREOf'FUNERAlSE , ~" ". 1NIF000000000T'SUAlIJ"IQoUIOflU8\SUM.CiIwfbon._.Zil::>~ _5177 East Trindle Rd PUCE Dl 1ON.,...,.OIc-r.C...-y ._- ~c;umrer land Valley Mem. N.o.IoIEAND.-DDAESSOl'FM:lUTV tClCR'lClM.~SI"'.lipCoc>> n. tlCENSEMUMIlER _ 011667 L 1i>".._of....,k_~.lM.."QCO.lI_..th8um..._on<l~S\_ (s.gna........rol/O) .. EORPERSOHM; dLXJ J I I I I I ~ " o \: ~~lI/cJp~ !;vv,-,>f 0-OUE ,AS.lCQNSt:OIJE qFl' 1_ P'Vt ac c. v~., OlJETOjOAAS.o.C(lNSEOUEf'.IC[Of)" OUflOlOAAS.o.CQNSEOIJENCEOFl __RQFOEATH OAJEOFllIUlJl\Y (Uon<h~,_, WEfIE""UTOPSYI'.,OIIiGS ~",1OR1O COMPl.ETIOl\IOf"CAUSE "''''''"'' )g o o ._.,INO '- (1-401"5+1 M#lRI1AtSWtIS.-..-d -_.- -- l~ied ntz Ih.K]......__in - 1 Gar.. 21.~" Pennsboro Twp. 8 Market Plaza W A zzi llCEMSEM\lIIlMR ,- :---- :.....-- i "....,.: TINEOF\MJ\JP.'I' \MJllR'I'M~1 DESCf\l8E11OW~FrIOCClJftAED -- p~~- o o DP\...lcEOf'INJuA'I'.All>Om..IaI..........r........,._ P\OIding,~.'Spec,,,,) _. .. -- ~- _ 0 NOJtJ ....0 - - CfRTlftEIII,o>$Cl<"""'''''''' .CEfITIfYINGl"HV&lCl..,.IPb~""'~cau-.oI_.."""....,......p/'l.""',..."".plonounco.:l~ea"'"""curnpiele<l".."2l) TollM_lol...y.......'"""'"'.dNthOCCy.........IO.,..~......................_. ~O CIwI<l_boOdo"""".- - ". .PROtlOUHClItG Am!ClIITlnlNGl"HYSlClloHiPtly"",...,,,,,,,, poOl1Oul\C",II"""...'OOOc......"".!IO"""..."''''''''''f To 1..._ol...,kno........._...occ............IIno..............pIM:...........'"1tI."...08ie)_....M.'...._,. .UEOICM. E.)I,AMlMi.RlCClROMEl'I On lhe ......ot..........uonandlOlinlr..I'9allon, In myopilllon, "".Ih ""...".d .......11"... d.t.. and pIX..;ln. du.lo1h. .."..1.)...., ....nne...~.led.. ,.... n_ l , 1..:11 i l.A11 I Jl ... 0 "",0 JO l- "j;l.J?u6 o /Fi<'/{C. R OIllEFtUD(M.".._Oay,_' Jot. ..,"51' 7 ")... ~ CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: MARLlN HENRY BRETZ Date of Death: 09-26-2002 Will No.: 2002-00932 To the Register: I certify that notice of beneficial interest 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 October 22, 2002: Name: Address: Mrs. E. Carla Bretz Ms. Wenty Bucher Ms. Robin Mentzer Mr. Brian Bretz 5177 E. Trindle Road, Mechanicsburg, P A 17055 2764 Peters Mountain Road, Halifax, P A 17032 5435 Wertzville Road, Enola, PA 17025 7073 Carlisle Pike, Lot No. 47, Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None COYNE & COYNE, P.e. Date: 7ZdC,.. ~ z-. . BY: Marie Coyne, Es 01 Market Street CampHilI,PA 17011-4227 (717)737-0464 Pa. Supreme Ct. No. 53788 Counsel for Personal Representative ',.j COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU Of INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYlVANIA INHERITANCE AND ESTAT OFFICIAL RECEIPT RECEIVED FROM: COYNE HENRY F 3901 MARKET STREET CAMP Hill, PA 17011 _n_n__ f"ld ESTATE INFORMATION: SSN: 161-34-4845 FILE NUMBER: 2102-0932 DECEDENT NAME: BRETZ MARLIN HENRY DATE OF PAYMENT: 12/26/2002 POSTMARK DATE: 12/24/2002 COUNTY: CUMBERLAND DATE OF DEATH: 09/26/2002 TOTAL AMOUNT REMARKS: CHECK#102 SEAL INITIALS: AC RECEIVED BY: REGISTER OF WILLS REV-1162 EX(11 } E TAX NO. CD 00199 ACN SSESSMENT AMOUNT CONTROL NUMBER _ _n 101 I $4,000.00 I I I I I I I I PAID: $4,000.00 DONNA M. OTTO DEPUTY REGISTER OF WillS ii I A lUN.'\5QQ~+\6-<<l\ *' REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT COMMONWEAlTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT.2B0601 HARRISBURG. PA 1712B-0601 ... Z W o W o W o DECEDENT'S NAME (LAST, Fr~ST, AND MIDDLE INITIAL) BRETZ, MARLIN HENRY DATE OF DEATH (MM.DD-YEAR) DATE OF BIRTH (MM-OD-YEAR) 09/26/2002 08/29/1942 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL) BRETZ, E. CARLA OF~ ICiAL(USE ONLY FILE NUMBER 21 2002 00932 OUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 161-34-4845 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER w ... ti~~ w~o zOO ufal. ~ " ,. Original Return 2. Supplemental Retum 0 4. Llmited Estate 0 48. future Interest Compromise (date of death after 12-12-82) 0 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach of Will) copy of Trust) 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (dale of death between 12-31-91llr\1i1-1-95 D 3. Rermlinder Relurn (dale of death prior to 12-13-82) D 5. Federal Estate Tax Return Required 8, Total Number of Safe Deposit Soxes D 11. Election 10 tax under Sec. 9113(A) (Attach Sell 0) .... mill ~O ~z 00 o~ ME Lisa M. Coyne, Esquire IRM NAME (If applicable) Coyne & Coyne, P.C. lEPHONE NUMBER 717/737-0464 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposlts & Miscellaneous Personal Property (Schedule E) . 6. Jointly Owned Property (Schedule F) ~ 0 Separate Billing Requested 5 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~ (Schedule G or L) ir. 8. Total Gross Assets (total Lines 1-7) Cl ~ 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (line 8 minus Line 11) COMPLETE MAILING ADDRESS 3901 Market Street Camp Hill, PA 17011-4227 (1) 90,000.00 Oi'"FICIAL USE ONLY (2) 57,371.58 g (3) None -,., rr1 (4) None Q:1 N " (5) None V1 (6) None , ~ C''': (7) -0- :0<: W (8) 147,371.58 (9) 39,700.12 (10) 3,087.73 (11) 42,787.85 104,583.73 (12) (13) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 104,583.73 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15.Amount of Line 14 taxable at the spousal tax rate, 52,291.87 x .00 (15) or transfers under Sec. 9116{a)(1.2) z 52,291.86 .045 (16) 0 16.Amount of Line 14 taxable at lineal rate x 0= ~ => (17) ~ 17.Amount of Line 14 taxable at sibling rate x .12 :& 0 0 ~ 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) 0.00 2,353.00 CHECK HERE IF YOU ARE REOUESTING A REFUND OF AN OVERPAYMENT. 2,353.00 20. 181 . :opyright 2000 form software only The Lackner Group. Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 5177 E. Trindle Road CITY I STATE PA I ZIP 17055 Mechanicsburg Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 4,000.00 118.00 Total Credits (A + 8 + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty TotallnteresVPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT 2,353.00 4,118.00 0.00 1,765.00 0.00 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes 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? ...... ..... ... ...... ... .... ....... ........ ..... ........... ... ...... .........-... ... ..- ... .......................... D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ... ........... ........ .............. ...... .... ..... ... ......................... ...... ...-.- .............. ...........0 No I 181 181 181 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 perjury. I declare that J have examined this return. including ac:c:ompanying schedules and statements. and to the best of my knowledge and belief. It is true, correct and complete. Declaratlon preparer other than the personal representative is based on all information ofwhich preparer has any knowledge. SIGNATURE OF PERSON RESPONSI FOR FILING RETURN ADORESS E. RE Z 5177 E. Trindle Road Mechanicsburg, P A 17055 DATE ~ dfJ d.EJo i- DATE ADDRESS DATE SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE Lisa M. Coyne, Esquire 3901 Market Street CampHill,PA 17011-4227 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. 99116 (a) (1.1) (i1)]. The statute does not exemOB 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. 99116 (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 .5. 99116 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% 172 P .5. 99116 (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. *' SCHEDULE A REAL ESTATE COMMON'NEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BRETZ, MARLIN HENRY I FILE NUMBER 21 - 2002 - 00932 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which Is jointly-owned with right of survivorship must be disclosed on schedule F. ITEM NUMBER I DESCRIPTION VALUE AT DATE OF DEATH 38,000.00 Tract One, Deed dated August 13, 1982, Recorded in Deed Book Z, Volume 29, Page 685 Cumberland County Recorder of Deeds Office, Pennsylvania (See Attached Settlement Sheet) 2 Tract Two, Deed dated August 13, 1982, Recorded in Deed Book Z, Volume 29, Page 685 Cumberland County Recorder of Deeds Office, Pennsylvania (See Attached Settlement Sheet) 52,000.00 TOTAL (Also enter on Line 1, Recapitulation) 90,000.00 ", .?ARTMENT OF HOUSING AND URBAN DEVELOPMENT ~UMt:lll L~Ul-Ulll~! L~Jj!.P~~~,[q'BM~;lir~~EME;,t:lT,~~m4'J~"E''t~_;tlt~4jf~I:X~1~~rr~;i}1'J;t~~i; ';)(S:l1;'.Z:ti~X::\S")e-,jit~~j;;::~~~,;)(,;.(;; {'\\:(~>fY'" , ., ~j,."; Type of Loan ] FHA 2.[] FmHA 3.[] Conv. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insurance Cas~ N.u~~er: 1\....,',- ] VA 5.[] Conv. Ins. '_ < .}.! NOTE: This form furnishes a\ statement of settlement costs. Amounts paid to and by the settlement agent are shown. Items marked 1.0.C.;' were paid outside the closing; they are shown for informational purposes and are not included in the totals. Name & Address of Borrower: E. Name, Address & TIN of Seller: F. Name & Address of Lender: $38,062.07 $2,785.00 $35,277.07 Summary of Borrower's Transaction O. Gross Amount Due from Borrower: 1. Contract sales price 2. Personal Property 3. Borrower's settlement charges (line 1400) 4. 5. Ijustments for Items paid by seller In advance 6. City/town taxes 519/03 to 12/31/03 7. County taxes to 8. Assessments to 9. SchoolTax 5/9/03 to O. 1. 2. 3. O. Gross Amount Due from Borrower O. Amounts Paid by or In Behalf of Borrower: 1. Deposits or earnest money 2. Principal amount of new loan(s) 3. Existing loan(s) taken subject to 4. 5. 6. 7. 8. 9. Ijustments for Items unpaid by seller O. City/town taxes to 1. County taxes to 2. Assessments to 3. to 4. 5. 6. 7. 8. 9. O. Total Paid By/for Borrower O. Cash at Settlement From/to Borrower 1. Gross amount due from borrower (line 120) 2. Less amounts paid by/for borrower (line 220) 3, Cash X from to Borrower 1,16ift]II)IBIIlIDGmIllD!ilYlSIIIIA'NStiI!fiMI(JJ1 '1- ~'i~ e information in Blocks E, G, H, I & line 401 (or, If line 401 is asterisked, line 403 and 404) Is important tax information and Is being -nished to the Internal Revenue Service. If you are required to file a retum, a sanction will be Imposed on you If this item is required to be Jorted and the IRS determines that it has not been reported. If this real estate Is your principal residence, file Form 2119, Sale Dr 'change Df Principal Residence, for any gain, with your income tax return; for other transactions, complete the applicable parts of Form 97, Form 6252 and/or Schedule D (Form 1040). You are required to provide the Settlement Agent (named above) with your correct (payer identification number. If you do not provide the Settlement Agent with your taxpayer Identification number you may be subject to 'iI or criminal penalties imposed by law. Under penalties of pe~ury, I certify that the number shown on this ;tatement is my correct (payer Identification number. (Seller) (Seller) ili 'liitle"!". ~.'" , ,. '0. Total Sales/Broker's Commission: (based on price) Division of Commission line 700 as follows: " $38,000.00 @ % Paid from Seller's Funds at Settlement $2,660.00 I $lDO' '1. '2. 13. Commission aid at Settlement to Cantu 21 at The Helm 14. Transaction Fees to Cantu 21 at The Helm 10. Items Pa able In Connection with Loan 11. Loan Or! ination Fee 12. Loan Discount 13. A ralsal Fee )4. Credit Re ort )5. Lender's Ins ection Fee 16. Mort a e Insurance A lication Fee 17. 18. 19. O. 1. 2. 3. 4. 10. Items Re ulred b Lender to Be Paid In Advance l1.1nterestfrom )2. Mort a e Insurance Premium for 13. Hazard Insurance Premium for 14. 15, , lQO. Reserves De osited with Lender 101. Hazard insurance 102. Mort a e Insurance 103. Ci ro art taxes 104. Count TO e taxes 105. Annual assessments IDe. 107. lOB. 109. re ate Accountin Ad'ustment 100. TItle Char es 101. Settlement/closin fee 102. Abstract/title search 103. Title examination 104. Title Insurance binder 105. Document ra aration to Co ne & Co ne 106. Nota fees 107. Attome s fees to Snelbaker, Brenneman & S are, P.C. includes above item numbers lOB. Title insurance to Keith O. Brenneman, A ent Canasta a Title Insurance Com an Includes above item numbers 1101 1104 109. lender's covera e 110. Owner's covera e $3B,000.00 111. 112. 113. !OO. Government Recordln and Transfer Char W1. Recordin fees: Deed 9 W2. eit !coun tax/stam s: W3. State tax/starn s: ~04. W5. ~06. 100. AddItional Settlement Char es W1.Surve m2. Pest Ins ection 103. 104. 105. me. 107. JOB. mo. Total Settlement Charges This Number Transfers to Lines 103 & 502 Above $ erda ~,,:,., ~- ""'~'" .~. -'-~--- .....,~:.,' er month er month er month er month er month er month ,''''w' .c. Deed Deed SeUer Borrower l Ihe best of Ive been 0 abel relz y knowledge the HUD-1 Settlement Slatement which f have prepared is true and accurate account f the funds which were received and I b he undersigned as part of the selllement of Ihis transaction, Selllement Agent May 9, 2003 Dale Keith O. Brenneman ~RNING: 11 Is a C1i",., 10 knowingly rmke false stale",.,nls to lIle United Slales,on,lhis or any olh!!r similar form. Penallles upon oonvfclion cen Indude a fine and 1"",lsonmenL For delalls see: Tille 18 U,S. ,deSecllon 1001 and$ecUon 1010. -~~ OMS NO. 2502-0265 ..... - B. TYPE OF LOAN: .. 1.oFHA 2.0FmHA 3. ~CONV. UNINS. 4.oVA 5.DCONv. INS. S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 6. FILE NUMBER: 17. LOAN NUMBER SETTLEMENT STATEMENT 200304185 8. MORTGAGE INS CASE NUMBER: . NOTE: This form is furnished to give you 8 statement of actual sattlement costs. Amounts paid to and by the setuement agent are shown. Items marked "(POC)" were paid outside the closing; they 8rs shown here for informational purposes and are not included in the totals. '.0 ~" (200304165.PFD/2003041651tt) . NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER: :;lBIN L. MENTZER ESTATE OF MARLIN H. BRETZ Orrslown Bank 3 Baden Powell Lane Mechanicsburg, PA 17050 PROPERTY LOCATION: H. SETTLEMENT AGENT: 25-1649506 l. SETTLEMENT DATE: 135 WERTZVILLE ROAD Bankers Settlement Services-Capltal Region, LLC \lOLA, PA 17025 January 14,2004 Jmberland County, Pennsylvania PLACE OF SETTLEMENT 4807 Joneslown Road, Suite 245 Harrisburg, PA 17109 J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION J. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 1. Contract Sales Price 52,000.00 401. Contract Sales Price 52,000.00 2. Personal Pro 402. Personal Pro e ,. Settlement Char es to Borrower Une 1400 2,049.75 403. I. 404. ;. 405. Ad"ustments For Items Paid B Seller in advance Ad'ustments For Items Paid B Seller in advance ,. CourrtVfrown Taxes to 406. Coun !Town Taxes to r. School Taxes 01/14/04 to 07f01/04 169.75 407. School Taxes 01f14/04 to 07101/04 169.75 ,. SewerfTrash 01/14/04 to 04f01/04 97.31 408. SewerfTrash 01f14/04 to 04/01/04 97.31 ,. 409. ,. 410. I. 411. I. 412. ,. GROSS AMOUNT DUE FROM BORROWER 54,316.81 420. GROSS AMOUNT DUE TO SELLER 52,267.06 J. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 1. De 0511 or earnest monev 501. Excess De osit See Instructions I. Princi al Amount of New Loan s 41600.00 502. Settlement Cha es to Seller Line 1400 635.00 I. Exislin loan s taken sub ect to 503. Existin loan s taken sub ecl to t. 504. Payoff of flrst Mortgage ;. 505. Pa off of second Marl a e ,. 506. r 507. I. Advance on Inheritance 12,713.27 508. Advance on Inheritance 12,713.27 l. 509. Ad'ustments For Items Un aid B Seller Ad'ustments For Items Un aid B Seller I. Coun !Town Taxes 01101/04 to 01f14/04 3.54 510. Coun iT own Taxes 01101/04 to 01/14/04 3.54 I. School Taxes to 511. School Taxes to I. SewerfTrash to 512. SewerfTrash to I. 513. t. 514. ;. 515. ,. 516. r 517. ,. 518. I. 519. ). TOTAL PAID BYiFOR BORROWER 54,316.81 520. TOTAL REDUCTION AMOUNT DUE SELLER 13,351.81 J. CASH AT SETTLEMENT FROMn'O BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER: I. Gross Amount Due From Borrower tLine 120 54316.81 601. Gross Amount Due To Seller Line 420 52267.06 1. Less Amount Paid 8 {For Borrower Line 220) ( 54,316.81) 602. Less Reductions Due Seller (Line 520 ( 13,351.81 l CASH ( FROM) ( TO) BORROWER 0.00 603. CASH ( X TO)( FROM) SELLER 38,915.25 ....... 113 undersigned hereby acknowledge receipt of a completed copy of pages 1&2 of this statement & any attachments referred to herein. Borrower Seller ESTATE OF MARLIN H. BRETZ, E. CARLA BRETZ, ADMqTRATRIX ~ 6 . BY, (IQl..e. A , ~'(M,...) \0. TOTAL-COMMISSION Based on Price Division of CommissiOn line 700 as Follows: 11,$ to 12, $ to 13. Commission Paid at Settlement ~. ~ 10. ITEMS PAYABLE IN CONNECTION WITH LOAN 11. Loan Ori inalion Fee % to 12. Loan O.lscount % to '3, Appraisal Fee to '4. Credit Report to '5. Lender's Inspelction Fee to '6. Mo 8 e Ins. . Fee to 7. Flood Certification Fee to 8. Underwriting Fee to 9. Document Preparation Fee to 0, " a.ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 1. Interest From 01/14104 to 02101/04 @ $ 2, Mort !l e Insurance Premium for months to 3. Hazard Insurance Premium for ars to 4, 5, 00. RESERVES DEPOSITED WITH LENDER 01. Hazard Insurance 02. Mae Insurance 03. Coun /Town Taxes 04. School Taxes 05. SewerlTrash 'S, ", 'B, 00. TITLE CHARGES )1. Settlement or Closlna Fee )2. Abstract or TItle Search )3. Title Examination )4. Titletnsurance Binder )5. Document Pre aralion 16. Nota Fees )7. Attorney's Fees includes above item numbers: )8. Tine Insurance includes above Item numbers: )9, Lender's Coverage 10. Owner's Coverage 11. Endorsements PA100/3001710/900 12, 13, 10. GOVERNMENT RECORDING AND TRANSFER CHARGES 11. Recording Fees: Deed $ 38.50; Mortgage $ 50.50; )2. Ci ICoun Tax/Stam s: Deed 520,00' Mort a e )3. State Tax/Stamos: Revenue Stam s 520.00: Mort ~, )5, lll. ADDITIONAL SETTLEMENT CHARGES )1. Survey 12. Pest Ins ection 13. Overni htFees 14. SewerfTrash 15, 10. TOTAL SETTLEMENT CHARGES Enter on Lines 103, Section J and 502, Sectioll kJ 2,049.75 signing P<'ge 1 QflhiSstalement.lhesign~lOrieSac:lcnOl'lO&clge""celPtolaCOmple1edropyotpage20flhi!;twopagar12 II J,fJVtJI /0 dv I L SETTLEMENT CHARGES "" % Orrstown Bank QrrstowlI Bank OrrstownBank Orrstown Bank Iday 18 days %) months months months months months months months months $ $ $ $ @ I $ @ $ $ moefu month month month month month moolh month "' "' "' , P" " P" 0", to to to to to to Amanda Sn der to to Bankers SetUemen Servlces-Ca ital Re ion LLC $ 41,600.00 $ 52,000.00 to Bankers Settlement Services-Capital Region, LLC Releases $ to to to Bankers Settlement Services-Ca ital Re ion, LLC to Ham den Townshi PAlO FROM BORROWER'S FUNDS AT SETT~EMENT 200.00 30.00 200.00 200.00 lrlified to be a true copy. Bankers sn\eme t SeN\ces.Capl\a1 RegIon, LLC setUemerfl,.Agent P81192 PAID FROM SELLER'S fUNOSAT smLEMENT 10.00 570.75 200.00 89.00 260.00 260.00 260.00 260.00 30.00 115.00 635.00 (200304165/200304165111) . SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVAN1A INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BRETZ, MARLIN HENRY I FILE NUMBER 21 - 2002 - 00932 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF NUMBER DEATH I 227 Shares of BP PLC ADR 41.40 9,398.00 2 175 Shares of CBRL Group, Inc 23.77 4,160.00 3 90 Shares of HealthSouth Corp. 4.23 381.00 4 100 Shares of Marathon Oil Corp. 23.07 2,307.00 5 150 Shares of Novell Inc 2.10 315.00 6 2,220.431 Shares of Prudential High Yield Fund 4.87 10,814.00 7 158.177 Shares of Sovereign Bancorp Inc. 13.37 2,115.00 8 200 Shares of Sunoco Logistics Partners 22.88 4,576.00 9 400 Shares of Sunoco Inc. 31.37 12,548.00 10 200 Shares of US I Industries .51 102.00 11 200 Shares of Verizon Conununications 29.66 5,932.00 12 108 Shares of Viacom Inc. Class B Shares 43.75 4,725.00 TOTAL (Also enter on line 2, Recapitulation) 57,373.00 .ITUE) 10:15 LEGG MASON CAMP H1LL TEL: 7177370800 P. 001 c FAX (717) 737-0800 214 Senate Avenue 7lh Floor Camp Hili, PA 17001-6853 Fax To: '~;b."} ~ Fnum Janet LOVlIe r_ 1 ?:ii ~ 51L.. I ...._ "2.. PhoIns 1-800-433-8186 o.t.: lt~\tt~o,- ~ ~~Q~. .~~&~ CJ Uts- 0 PIe_ RoIpIy via _' im/owelill_.co", . CoI.w.",,,"" If you have not received a total of -z... pages, including this cover . sheet. please contact Janet Lowe at the above number. <e-? 02 (TUE) 10:16 :. ~ LEGG MASON CAMP HILL Estate of Marlin I!lmz 363~88.16-JVT SK\lrtty N_ BP Pl.C AOR caRL C3ll1up Inc I l&dlti~ Colll Marathon 011 Corp N....11Ilc PIUdentIIIl High Yield Fd Saw!8ign BllIlCllrp Inc Sunoco I.cgIstIcs Partners Su""""lnc US 1 IndustriA Var120n CommunIcation. Vial:orn Inc CI e TOTAL Shares 2Z7 175 90 100 150 2220.431 158.177 2lXI 400 200 200 108 &h8I1I PI'ICll $41.40 123.77 $4.23 123.07 52.10 $4.87 $13.37 $22.88 $31.37 $0.51 $29.88 $43.75 TEL: 7177370800 P. 002 D8Ie ofDaath v..... Il2II2OO2. $9,397.90 $4,151l.75 $380.70 $2,307.00 $315.00 $10,413.50 52.114.8:>- ~.OO $12,548.00 $102.00 $5,932.00 S4,725.OC 557,311.58 *' SCHEDULEH RJNERAL EXPENSES & ADMINISTRATlVE COSlS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BRETZ, MARLIN HENRY I FILE NUMBER 21 - 2002 - 00932 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: 1. Malpezzi Funeral Home 7,746.81 2. Cumberland Valley Memorial Gardens-- Grave Openniog 900.00 3. Headstone and Engraviog 2,130.00 4. Mt. Zion Church-- Reception 260.00 B. ADMINISTRAT 7,369.00 1. Personal Repre E. CARLA B Social Security Street Address City Meehan Year(s) Comm 2. Attorney's Fees 8,000.00 3. Family Exempt 3,500.00 Claimant IVE COSTS: sentative's Commissions RETZ Number(s) I E1N Number of Personal Representative(s): 5177 E. Triadle Road icsburg ission paid 2003 Coyne & Coyne, P.C. State P A Zip 17055 ion: (If decedent's address is not the same as claimant's, attach explanation) E. Carla Bretz Street Address 5177 E. Triodle Road City Mechanicsburg State P A Zip 17055 Relationship of Claimant to Decedent Wife Probate Fees Cumberland County Register of Wills 4. 252.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Other Administrative Costs Postage 111.00 2 Cumberland Law Joumal-- Legal Advertisement 75.00 Total of Continuation Schedule(s) 9,358.00 39,700.12 TOTAL (Also enter on line 9, Recapitulation) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BRETZ, MARLIN HENRY ScheckJIe H Funeral Expenses & AdniIlb1lcdille Costs conliooed I FILE NUMBER 21 - 2002 - 00932 I 3 Patriot News-- Legal Advertisement 4 Filing Fee-- Inheritaoce Tax Retnm 5 Chartone, Inc. -- Medical Records 9 Nationwide Insurance Michael J. Bartell, M.D.-- Medical Records 100.00 15.00 71.00 25.00 65.00 28.00 600.00 530.00 2,000.00 823.00 2,785.00 250.00 1,000.00 639.00 308.00 15.00 98.00 6 Estate Checking Account 7 Transfer of Title 8 10 Waggoner, Frutiger & Daub, Accouoting--Dave Phillips 11 Legg Mason-- Commissions 12 Real Estate Taxes 13 Century 21 At the Hehn -- Commission 14 Appraisal-- Rey Woof 15 Reserves 16 Closing Costs-- Cabin Property 17 Hampden Twp. Sewer aod Trash 18 Filing Fee-- Inheritance Tax Returu 19 Execntor's Mileage @ $.325/mile Page 2 of Schedule H *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDE:NT ESTATE OF BRETZ, MARLIN HENRY I FILE NUMBER 21 - 2002 - 00932 Include unreimbursed medical expenses. ITEM NUMBER 1 Visa Charge-- PSECU DESCRIPTION AMOUNT 149.00 2 Miller Construction 1,300.00 3 Discover Card 1,639.00 TOTAL (Also enter on Line 10, Recapitulation) 3,088.00 REV.1513 EX+ (9-00) . SCHEDULE J BENEFICIARIES COMMONWEAL.TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BRETZ, MARLIN HENRY I FILE NUMBER I 21 - 2002 - 00932 RELATIONSHIP TO AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY n. ~;;~EDENT OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 E. Carla Bretz Wife 50% of Probate Estate 2 Robin Mentzer Daughter \116 of Probate Estate 5435 Wertzville Rd., Enola, PA 17025 3 Wendy Bucher Daughter '1/6 of Probate Estate 2764 Peters Mountain Rd., Halifax, PA 17032 \116 of Probate Estate 4 Brian Bretz Son 7073 Carlisle Pike, Lot 47, Carlisle, P A 17013 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: I A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE I I I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET BUREAU OF TNDZV/DUAL TAXES INHERTTANCE TAX DTVZSION DEPT. 280601 HARRTSBURG, PA 17128-060! COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLO#ANCE OR DZSALLO#ANCE OF DEDUCTIONS AND ASSESSMENT OF TAX LISA M COYNE ESQ COYNE & COYNE 3901 MARKET ST ~-;. CAMP HILL P~:~7011 DATE Oq-lZ-ZOOq ESTATE OF BRETZ DATE OF DEATH 09-26-2002 FILE NUMBER 21 02-0932 COUNTY CUMBERLAND ACN 101 Amount Rsm'i ~'l:od REV-lSd7 El( AFP (01-OS) MARLIN H MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BRETZ MARLIN H FILE NO. 21 02-0932 ACN 101 DATE Oq-12-200q TAX RETURN HAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Stock/Partnership Interest (Schedule C) (3) q. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits~Misc. Personal Property (Schedule E) ($) 6. Jo/ntly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Ada. Costs/Misc. Expanses (Schedule H) (9) 10. Debts/Mortgage L/ab/I/ties/Liens (Schedule Z) (10) 11. Total Deductions 12. Nat Value of Tax Return 90/000.00 57z$71 58 O0 O0 O0 O0 O0 NOTE: To insure proper credit to your account, submit the upper portion of th~s fore w~th your tax payment. (a) lq7,371.58 15. NOTE: 39,700.12 3,087.73 (11) 42.787.85 (12) 10q,583.73 Charitable/governmental Bequests; Non-elected 911:5 Trusts (Schedule J) (15) Nat Value of Estate Sub.~ect to Tax (lq) Zf an assesseent was issued prevlot;sly, lines 14, 15 and/or 16, 17, reflect ~:lgures that include the total of ALL returns assessed to date. .00 10q,583.73 ASSESSMENT OF TAX: 1.6. Amount of L/ne lq at Spousal rata 16. Amount of L/ne lq taxable at Lineal~Class A rate 17. Amount of L/ne lq at S/bl].ng rate 18. Amount of Line lq taxable at Collateral/Class B rata 19. Pr/nc/pal Tax Duo TAX CREDITS: PAYMENT i RECEXrl DISCOUNT (+) DATE NUMBER /NTEREST/PEN PA/D (-) 12-2~-2002 CD001993 117.65 18 and 19 will ZF PA/D AFTER DATE /NDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL /NTEREST. (15) 52,291.87 x O0 = .00 (16) 52,291.86 x Oq5= 2,353.00 (17) . O0 x 12 = . O0 (18) .00 x 15 = .00 (19)= 2,353.00 AMOUNT PAID q,O00.O0 TOTAL TAX CREDIT ~,117.65 BALANCE OF TAX DUEI 1,76~.65CR INTEREST AND PEN. .00 TOTAL DUE 1,76~.65CR ( ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR ZNSTRUCTZONS.) Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 8/03/2004 COYNE HENRY F 3901 MARKET STREET CAMP HILL, PA 17011 RE: Estate of BRETZ MARLIN HENRY File Number: 2002-00932 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS, COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent,s death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 9/26/2004 Your prompt attention to this matter will be appreciated. Thank You. CC;: File Personal Representative(s) Judge Sincerely, REGISTER OF WILLS STATUS REPORT UNDER RULE 6.12 Name of Decedent: MARLIN HENRY BRETZ Date of Death: _ September 26, 2002 Will No. 21-02-00932 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: State whether administration of the estate is complete: Yes No X 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: FEBRUARY 2005 3. If the answer to No. 1 is Yes, state the following: ao Did the personal representative file a final account with the Court? Yes No b. the separate Orphans' Court No. (if any) for the personal representative's account is: interest? c. Did the personal representative state an account informally to the parties in accounts may be filed with the Clerk of the Orphans' Court and may be attacheft to this ri~ort. F Yes No 9.~ d. Copies of receipts releases, joinders and approvalS. ~f formal 30.0'1 Market Street -- Camp Hill, PA 17011-4227 (717) 737-0464 Counsel for Estate Dated: BUREAU OF I'NDZVZDUAL TAXES TNHERTTANCE TAX DTVTSI'ON DEPT. 280601 HARRISBURG, PA 171Z8-0601 COMMONNEALTH OF PENNSYLVANTA DEPARTMENT OF REVENUE ZNHERZTANCE TAX STATEMENT OF ACCOUNT RE¥-1607 EX AFP (D1-$$) LISA M COYNE ESQ COYNE & COYNE $901 MARKET ST CAMP HILL PA 17011 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACM 05-17-Z004 BRETZ 09-26-2002 Z10Z-O9$Z CUMBERLAND 101 Amoun~ Rem'i 'l:'l:ed MARLIN H MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF MILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17015 NOTE: To insure proper credi~ ~o your account:, subeL~ ~he upper por~:Lon of ~:his fora wL~:h your ~ex payeen~. CUT ALONG THIS LINE I~ RETA/N LONER PORT/ON FOR YOUR RECORDS ~ REV-1607 EX AFP (01-03) #~ ZNHERZTANCE TAX STATEMENT OF ACCOUNT ESTATE OF BRETZ MARLIN H F:ZLE ND. Z1 02-0952 ACM 101 DATE 05-17-Z004 THIS STATEMENT TS PROVI'DED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACM TN THE NAMED ESTATE. SHO#N BELO# TS A SUMMARY OF THE pRINCIPAL TAX DUE, APPLTCATZON OF ALL PAYMENTS, THE CURRENT BALANCE, AND, TF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 04-05-Z004 PRINCIPAL TAX DUE: ......................................................................................................................................................................................................................... PAYMENTS (TAX CREDITS): PAYMENT DATE 1Z-Zq-ZOOZ 04-26-ZO0q RECEIPT NUMBER CD001993 REFUND DISCOUNT C+) INTEREST/PEN PAID C- 117.65 .00 IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDXTIONAL INTEREST. ~F TOTAL DUE 1S LESS THAN 01, NO PAYMENT ~S REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT' (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. 2,353.00 AMOUNT PAID 4,000.00 1,764.65- TOTAL TAX CREDIT 2,353.00 BALANCE OF TAX DUE .00 ZNTEREST AND PEN. .00 TOTAL DUE .00 COYNE & COYNE A PROFESSIONAL CORPORATION ATTORNEYS AT LAW Henry F. Coyne Lisa Marie Coyne Austin F. Grogan Sharon F. Clark 390 I Market Street Camp Hill, Pennsylvania 17011-4227 717-737-0464 Fax: 717-737-5161 February 10, 2005 Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, P A 17013 Re: The Estate of Marlin H. Bretz, Deceased No. 21-02-0932 Dear Sir or Madam: Enclosed please find an original and two copies of the Supplemental Inheritance Tax Return for the above-referenced Estate. Kindly docket the original and return a "clocked-in" copy to this office with the enclosed stamped envelope. Also enclosed is Estate Check No. 115 in the amount of$15.00 for the filing fee and Check No. 116 in the amount of$132.00 for the tax due. Thank you for your assistance. If you have any questions, please contact me. Very truly yours, COYNE & OYNE, P.C. ',c:lf HFC/amd Enclosure Ce: Mrs. E. Carla Bretz, w/enel. ) {",- ", COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT COYNE HENRY F 3901 MARKET STREET CAMP Hill, PA 17011 __n'___ fold ESTATE INFORMATION: SSN: 161-34-4845 FILE NUMBER: 2102-0932 DECEDENT NAME: BRETZ MARLIN HENRY DATE OF PAYMENT: 02/11/2005 POSTMARK DATE: 02/1 0/2005 COUNTY: CUMBERLAND DATE OF DEATH: 09/26/2002 NO. CD 004935 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $132.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK# 116 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS $132.00 GLENDA FARNER STRASBAUGH REGISTER OF WillS 1I.e\/.1f"IEX.~\ W ... ~<.. u"~ w"8 :t:~..J u.... .. " o-V:~'~Q *' OFFICIAL USE ONL V REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 2002 COUNTY CODE YEAR SOCIAL SECURITY NUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT.28OtlO1 KARRISBURG. PA 17128-0601 00932 NUMBER ... Z W o W U W o DECEDENrs NAME (lAST, FIRST, AND MIDDLE INITIAL) BRETZ, MARLIN HENRY 161-34-4845 DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEARl THIS RETURN MUST BE FILED IN DUPUCATE WITH THE 09/26/2002 08/29/1942 REGISTER OF WILLS SOCIAL SECURITY NUMBER (IF APPLICABLE) SURVlVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) BRETZ, E. CARLA 3. Remainder Return (date of death prior 10 12-13-62) 1. Original Retum 2. Supplemental Retum 0 4. Limited Estate 0 4a. Future Intenst Compromise (dale of death after 12-12-62) 0 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach of Will) copy of Trust) 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (dale of death between 12.31-91 and 1-1-135 o 5. Federal Estate Tax Retum Required 8. Total Number of Safe Deposit Boxes o 11.Election to tax under Sec. 9113(A) (Attach Sch 0) .... '"z li!w ",0 OZ u~ 717/737-0464 3901 Market Street . Camp Hill, PA 17011-4227 (1) None (2) 10,407.47 (3) None (4) None (5) None (6) None (7) -0- (8) (9) 2,600.00 (10) 10,407.4 7 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) OFFICIA.L USE'ONL Y z o " :l :> ... ~ 11 w '" 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule 0) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter.Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (,) r..o 10, Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) (11) 2,600.00 7,807 A 7 12, Net Value of Estate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (13) (14) 7,807.4 7 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, 5,203.74 x .00 (15) or transfers under See, 9116(a)(1.2) z 2,604.00 .045 (16) 0 16. Amount of Line 14 taxable at lineal rate x " ;: :> .. 17. Amount of Line 14 taxable at sibling rate x .12 (17) ~ 0 u S 18, Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) 0.00 117.00 117.00 20, 0 . CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Copyright 2000 form software only The Lackner Group. Inc. Form REV.1500 EX (Rev. 6-(0) Decedent's Complete Address: STREET ADDRESS 5177 E. Toodle Road CITY Mechanicsburg -\STATE PA I ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 117.00 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty 15.00 (3) 15.00 (4) (5) 132.00 (SA) (5B) 132.00 TotallnterestlPenalty (0 + E) 4. If Line 2;s greater than line 1 + Line 3, enter the difference. This is theOVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If line 1 + Una 3 is greater than LIne 2, enter the difference. This Is the!TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA. This is theBALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT 1. Did decedent make a transfer and: 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 consjderation? ................. ...... .......,....... .... ....... ...... .... ........ ... .................... ..... ............. ...... 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...... ........... ................... .... ....... ...... .... ............. ............. ............... ............. 0 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS '~ i 1&1 1&1 1&1 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 perjury, I declare Ihat J 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 preparer other than the pe1SOnal representative is based on all information of which preparerhas any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS E. C RETZ DATE , . 5177 E. Toodle Road Mechanicsburg, P A ~!L DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE Lisa Marie Coyne ADDRESS DATE 3901 Market Street Camp Hill, PA 17011-4227 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. 99116 (a) (1.1) (ii)l. The statutedoes not exemota 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. 99116 (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. 99116 1.2) [72 P.S. ~91 1 6 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's sjbJings is 12% [72 P .S. 99116 (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. I I I COMMONWEALTH OF PENNSYlVANJA \ INHERITANCE TAX REiURN ReSIDENT DECEDENT I ESTATE OF BRETZ, MARLIN HENRY *' SCHEDULE B STOCKS & BONDS I \ I I I FILE NUMBER 21 - 2002 - 00932 All property jointly-owned with right of survivorship must be disclosed on Schedule F. -ITEMI~~~-- NUMBER \ DESCRIPTION 1 I 290.930 Shares ofSunoco In~-.~~~~~-~-~- 2 i 54 Shares of MetLife Inc. I I \ , UNIT VALUE \ VALUE AT DATE OF I DEATH 31.371 9,126.00 23.73 1,281.00 10,407.00 TOTAL (Also enter on line 2, Recapitulation) SUN: Historical Prices for SUNOCO INe - Yahoo! Finance Yahoo! Mv Yahoo! Mail ""bos.'Ie.2'-"! FINANCE Welcome, farleydude211l1!1111l1"i' L~' .. [Sian Out, Mv Acccunt1~ Page I of2 Search I the Web i.'~.. '.""'.<0.-,..-,-. ".. Finance Home - .!::f.e.[Q Thursday, February 10, 2005, 11:31AM ET - U.S. Markets close in 4 hours and 29 minutes. ~ - Customize Finance [Show POI Quotes & Info Enter Symbol(s): I e,g, YHOO, ^D)] t. Symbol Lookup I Finance Search lnll'ltld t:~lultj hJ,.j~"", JU~: m. ~!\-HRlTj't.IH; A At l1:llAM ET: 93.44 t' 1.56 (1.~ ~ Free Trades No Inactivitv Fees! Get Free Streamer Historical Prices Get Historical Prices for: L---._ SET DATE RANGE @I Daily o Weekly o Monthly o Dividends Only Start Date: lsep .126 \12002 lEg, Jan 1, 2003 End Date: !Sep .126 i 12002 First I Prey I Next I Last PRICES Date Open High Low Close Volume 31,15 31,42 30,52 @ 533,800 * Close price adjusted for dividends and splits. Adj Close' 26-Sep-02 29,63 First I Prey I Next I Last ~ Download To Soreadsheet GIi Add to Portfolio 'Il<' Set Alert OJ Emaii to a Friend ADVERTISEMENT ~ ~ ~ llili& Iitii GErUP 70 4 FAST AND FREE RAm CII'.lOn!5. http://finance,yahoo.com/q/hp ?s=SUN&a=08&b=26&c=2002&d=08&e=26&f=2002&g=d 2/10/2005 MET: Historical Prices for METLIFE INe - Yahoo! Finance Page 1 of2 yahQ9J ~~Ly~,-hool Mail ~'E.2'_........ N E Welcome, farleYdUde211111P'~ Jt.~"""""<!I> F I NA C [~n Out, My Account] -...- Search I the Web ,,,,, . rS~a~h--1 Finance Home - HelD Thursday, February 10, 2005, 3: 10PM ET - U.S. Markets close in 50 minutes. B.i.lL.Egy - Customize Finance [Show POI Quotes & Info Enter Symbol(s): I e.g. YHOO. ^OJI ..... ^^^^"J. Symbol lookup I Finance Search ~ Free Trades 3_D Fr~e Trades At 2:50PM ET: 39.58 ... 0.66 (1.( I Scottradtl! $1 Online Trade. No Inactlvitv Fees! Historical Prices Get Historical Prices for: I .......J. SET DATE RANGE I!r Daily C Weekly C Monthly C Dividends Only Start Date: ISepllI26_112QO? End Date: ISeplll26 i 12002 Eg. Jan I, . i 2003 ~ First I Prev I Next I Last PRICES Date Adj Close' Open High Low Close Volume 23.50 23.16 23.15 @.991.100 * Close price adjusted for dividends and splits. First I Prev I Next I Last ~l.Pownload To Soreadsheet 26-Sep-02 23.08 bd Add to Portfolio 'I;).' Set Alert 2J .Email to a Friend ADVERTISEMENT http://finance.yahoo.comiqlhp?s=MET &a=08&b=26&c=2002&d=08&e=26&f=2002&g=d 2/10/2005 *' SCHEDULEH FUNERAl.. EXPENSES & ADMINISTRAllVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDeNT DECEDENT -1 ESTATE OF BRETZ, MARLIN HENRY I FILE NUMBER I 21 - 2002 - 00932 Debts of decedent must be reported on Schedule I. -ITEM '-1 --- DESCRIPTION NUMBER ~IFUNERAL EXPENSES: 1 I I I AMOUNT B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions E. CARLA BRETZ Social Security Number(s) I EIN Number of Personal Representative(s): 1,000.00 Street Address 5177 E. Trind1e Road City Mechanicsburg State PA Zip Year(s) Commission paid 2005 Attorney's Fees Coyne & Coyne, P.e. 2. 1,000.00 3. I I I I I 4. I Probate Fees Cumberland County Register of Wills I I 5. I Accountant's Fees I 6. i Tax Return Preparer's Fees I I Other Adminlstrative Costs I Postage i 2 I Filing Fee-- Inheritance Tax Return I I I ---~----- 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 150.00 7. 1 35.00 15.00 Total of Continuation Schedule(s) 400.00 2,600.00 TOTAL (Also enter on line 9, Recapitulation) I . COMMONWEALTH OF PENNSYLVANIA \ INHERITANCE TAX RETURN \ RESIDENT OECEDENT ESTATE OF BRETZ, MARLIN HENRY . SchecUe H Funeral E.qleI aes & AdtIinb1l.-ve CosIsaontinued ~. 31 Waggoner, Frutiger 8. Daub, Accounting--Dave Phillips I 4 I Commissions on Sale of Stock I \ I I I I I \ \ \ I I \ I I FILE NUMBER I 21 - 2002 - 00932 I 200,00 200,00 I I I ---~~~~ Page 2 of Schedule H REV-iS" EX+ (9.00) *' SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BRETZ, MARLIN HENRY NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY -~I~ ~~1TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 I E. Carla Bretz 2 I Robin Mentzer 15435 Wertzville Rd., Enola, PA 17025 3 I Wendy Bucher i 2764 Peters Mountain Rd., Halifax, PA 17032 ! 4 Briao Bretz 7073 Carlisle Pike, Lot 47, Carlisle, PA 17013 I FILE NUMBER 21 - 2002 - 00932 RELATIONSHIP TO DECEDENT Dn Not u.t AMOUNT OR SHARE OF ESTATE Wife 50% of Probate Estate Daughter 1/6 of Probate Estate Daughter 1/6 of Probate Estate I 11/6 of Probate Estate Son I I I I I Enter dollar amounts for distributions shown above on lines 15 through 18. as approPri~te, on Rev 1500 cover she~t II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE I I I I I I I I I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS , l.i, Q\ ,I 1 I I ?Ii if 11 b, -l !=? non::o ;J>ZC::i:'J ::oi:'J:3:Gl t-< t!lH Hni:'JCIl CIlO::oo-'l t-<c::t-<i:'J i:'J::o:t-::o - o-'l Z :>::00 'U 0 "J :t-c::n (flO::8 <TJC::H Zt-< OO(flo-'lt-< -0 >< (J) ,- c:: ' ;:;::;l::>'n ::00 i:'JC:: ::0 >'l :>:: o c:: CIl i:'J o 0 ~~~ Q "'U......H Z :;;:: 0 m r)>:D "" r:D Iii .... :"^',,( 0 ~~(!l 0 --J en "': -< 0-1,"'" Z :;:Rlr>: m .. m:;; "tI ~-1 (-) --J . 'L, ti " i , ~ f "-"':. ..,: f"'o'-'l >',lli. i~ ~ #>,1 , i r"l :i; i , ~ 11 i.~: 3i; ~' , ,I L r> l' t j , I;~ S.",'" '.., ""~~" '". , .. , .. B , , II q _."~ , j , '~ 0, I ~.,h * " BUREAU OF INDIVIDUAL:TNC~S INHERITANCE TAX DIVISION . PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX '-l '~t , DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-18-2005 BRETZ 09-26-2002 21 02-0932 CUMBERLAND 101 LISA MARIE COYNE COYNE II COYNE 3901 MARKET ST CAMP HILL AltOunt R..l tted PA 17011 REY-1547 EX AF 03-05) MARLIN MAKE CHECK PAYABLE AND REMIT PAYMENT REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ 11!V-"Mr:"Yf.m.'l"ft~'U'.!l1.1Mtm.!II!'.!wtAW4M!'t.m.A'II\fIl"tftr.wT~.'la:[W4M!'t.ll'f(.......... DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BRETZ MARLIN H FILE NO. 21 02-0932 ACN 101 DATE 04-1 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN 1. R..1 Estate (Schedule AJ (1) 2. stocks end Bonds (Schedule B) (2) 3. Closely Held Stock/Partnership Interest (Schedule C) (3) 4. Mortgages/Notes Receivable (Schedule DJ (4) 5. CashIBank Deposits/Misc. Personal Property (Schedule E) (5) 6. .Jointly Owned Property (Schedule F) (6) 7. Tr8nsfers (Schedule Gl (7) 8. Total Assets NO. 01 .00 10.407.47 .00 .00 .00 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Ad.. Costs/Hisc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule Il 11. Total Deductions 12. Net V.l.... of T.x Return 13. Charitable/Governnantal Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) 1101 2,600.00 .00 Ill) (12) (13) (14) NOTE: 57,495.61 X 54,895.86 X .00 X .00 X NUHBER CD001993 REFUND CD004935 INTEREST/PEN PAID (-) 123.50 .00 3.67- AHOUNT PAID 4,000.00 1,764.65- 132.00 DATE 12-24-2002 04-26-2004 02-10-2005 ~ TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE NOTE: To insu credit to you subIoit the of this for.. tax pay.ent. 10,4 H : ..... 005 proper ccountl portion h your .47 .47 .00 112,3 .20 lIill 00 = 045 = 12 = 15 = 2,4 .00 .00 .00 .00 .00 1 8 8CR 00 18CR I~ an ass85SDent lias issued previously, lines 14, 15 and/or 16, 17, 18 and 1 reflect ~igures that include the total o~ ~ returns assessed to date. ASSESSMENT OF TAX: IS. Amount of Line 14 at Spousal rate (IS) 16. Anount of Line 14 taxable .t Lineal/Class A rat. (16) 17. Aln.,...,t of Line 14 at Sibling NIt. 1171 18. '-aunt of Line 14 taxable at Coll.teral/Class B rate (18) 19. Princip.l Tax Due C IT. (19)= 2,4 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS TMAN $1, NO PAYMENT IS REIlUIR IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORK FOR INSTRU ONS.) 2,48 1 STATUS REPORT UNDER RULE 6.12 Name of Decedent: MARLIN HENRY BRETZ Date of Death: September 26. 2002 Will No. 21-02-00932 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration ofthe estate is complete: Yes No X 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: FEBRUARY 2006 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No account is: b. the separate Orphans' Court No. (if any) for the personal representative's interest? c. Did the personal representative state an account informally to the parties in Yes No d. Copies of receipts releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Dated: ~ - <jf -rJ ~ U"") CJ ARIE COYNE, ESQU 3 0 arket Street Camp Hill, P A 17011-4227 (717) 737-0464 Counsel for Estate c" c;'. --- CfJ Cumberland County - Register Of Wills One Courthouse Square Carlislel PA 17013 Phone: (717) 240-6345 Date: 8/30/2005 COYNE HENRY I ESQ. 3901 MARKET STREET CAMP HILLI PA 17011 RE: Estate of BRETZ MARLIN HENRY File Number: 2002-00932 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES I NO. 103 SUPREME COURT RULES DOCKET NO. 11 for decedents dying on or after July 11 19921 the personal representative or his counsell within two (2) years of the decedent's deathl shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 9/26/2005 Your prompt attention to this matter will be appreciated. Thank You. SincerelYI ~~~ .",-~",J GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge ~ Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 phone: (717) 240-6345 Date: 7/27/2006 TWIGG CRYSTAL ANN 764 FRANLYN DRIVE DALLAS TOWN , PA 17313 RE: Estate of KEISLING JANET R File Number: 2002-00924 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 9/29/2006 please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, f1 0~' 'nAP )J~, L~"'<J~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/27/2006 BRETZ E. CARLA 5177 E TRINDLE ROAD MECHANICSBURG, PA 17050 RE: Estate of BRETZ MARLIN HENRY File Number: 2002-00932 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 9/26/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, J C"S". Jt!, _ ~ /) /&:~A. l;$I't.ItPjJ~~~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel Cumberland County - Register Of WillE: One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/27/2006 COYNE HENRY F 3901 MARKET STREET CAMP HILL, PA 17011-4227 RE: Estate of BRETZ MARLIN HENRY File Number: 2002-00932 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing lS due by: 9/26/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, .b c,,,~~. ... I . f) {1U/I!~ i:.]~':I'tJt;.,c) . .....' . / ,_.~ '.ll Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Personal Representative(s) (' Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name of Decedent: }/'r/'^ ~"l/ ~ q.Z" - ~n;-{ Date of Death: Estate No.: 2ClC2.- C () ~t 3 z.-- Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether a~~tration of the estate is complete: Yes 0 NOr 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: '~n .:'//) (' T'~.;/; l~ LV~'''~y(~JI /k~ L, h J "l -J1tJ{ 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No 0 b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes 0 No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date:~Z ..::1" ..::1" ~/ I''-L / <VI t'~4 I 7L,/J- Li.,;2 7 ;1-t ,1-12 I t;; .. N x:: a... C{ ~ cr : :::J (~) aoe ~ UG;J 0:- (/) <<:, wz<, -J <C ~f'" U :r: !2. a.. ..._,~ a::O:i o~ U I) '70 J l(,~l-~f Address ~...t~ ~~~-t 7/7- 7 J 7-0 ''---{ c; q , Telephone No. Name I 0- UJ C/) U::> <:::::> = (.......l Capacity: 0 Personal Representative ~ounsel for personal representative \ ~N .~' COYNE & COYNE A PROFESSIONAL CORPORATION ATTORNEYS AT LAW Henry F. Coyne Lisa Marie Coyne 3901 Market Street Camp Hill, Pennsylvania 17011-4227 717-737-0464 Fax: 717-737-5161 August 29,2006 Register of Wills Cumberland County Courthouse Carlisle, PAl 70 13 Re: Estate of Marlin Henry Bretz, Deceased Dear Sir/Madam: We represent the Estate of the Late Marlin Henry Bretz. Pursuant to Orphans' Court rule No. 6.12 of the Pennsylvania Supreme Court Orphans' Court, enclosed is an original Status Report regarding this Estate. Please docket the original and return a "clocked-in" copy to this office with the enclosed envelope. Thank you for your assistance. If you have any questions, please contact me. Very truly yours, COYNE & COYNE, P.C. ~ 'j \ "r \ ,,( ///~ It~ - Lisa Marie Coyne 7 / // --" (--" - LMC/amd " Encl;iure J a... w (/) -.Q = = c:--.J cE ~ Mrs. 5tta Bretz, w/encl. tLOc..) OUr, ::<:: ~;::; a:G0L- UJ~:Z; ~~:""o'". -l"' c.. U Lc" c-; CC"","; 0:5 o ("j ':.0" N - 'Cc: :c 0... Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 9/07/2007 COYNE HENRY F 3901 MARKET STREET CAMP HILL, PA 17011-4227 RE: Estate of BRETZ MARLIN HENRY File Number: 2002-00932 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 9/26/2007 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, ~~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Personal Representative(s) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 9/07/2007 BRETZ E. CARLA 5177 E TRINDLE ROAD MECHANICSBURG, PA 17050 RE: Estate of BRETZ MARLIN HENRY File Number: 2002-00932 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 9/26/2007 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, ~~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel Pa. D.C. Rule 6.12 STATUS REPORT REGISTER OF WILLS OF Cumberland COUNTY, PENNSYL VANIA Name of Decedent: Marlin Henry Bretz Date of Death: September 26, 2002 File Number: 2002-00932 Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: . . . . . . . . . . . . . . . . . . .. IZt Yes D No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. I is YES, state the following: (') 'c-~~O - -D C'l'l -,"n .- , cCc-nt !,"~.) c:-:~ ~.:.:::..:> _>_i (/) PI -() a. Did the personal representative file a final account with the Court? . . . . . . . Q~Y'es ~:2~ -:-J ::::; f',) t2rNo -n b. The separate Orphans' Court No. (if any) for the personal representative's account is: "J ..r:- -.l c. Did the personal representative state an account informally to the parties in interest? ............................... 12) Yes DNo d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date 0(/ 'L 1 / 07 I I IZI Counsel Lisa Marie Coyne, Esq. Name of Person Filing this Form Address 3901 Market Street Camp Hill, PA 17011-4227 (717) 737-0464 Telephone Form RW-IO rev, 10-13.06 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 260601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BRETZ E. CARLA 5177 E TRINDLE ROAD MECHANICSBURG, PA 17050 fold ESTATE INFORMATION: SS-v: ~6~-34-4845 FILE NUMBER: 2102-0932 DECEDENT NAME: BRETZ MARLIN HENRY DATE OF PAYMENT: 12/15/2010 POSTMARK DATE: 12/15/2010 COUNTY: CUMBERLAND DATE OF DEATH: 09/26/2002 TOTAL AMOUNT REMARKS: SEAL CHECK#125 INITIALS: SAP RECEIVED BY: REGISTER OF WILLS i REV-1162 EX111-96) NO. '~C'~,~ 013788 I II~~ I ACN ASSESSMENT II CONTROL NUMBER '~ ,I ~, II '!~ AMOUNT 101 ~ ~ ,5659.00 I' ~ ~ I ~i I 'AID: I, ~ ~ GLENDA EARNER I 5659.00 I ~'' I ~~ I RASBAUGH REGISTER OF WIL~ i ! '! ' .S ~ , ~I s R9r2~ 15056051058 ©C\/ A CAA _-- .-- -- ^\G r ~ ^ ~/ V V t~ luo-uoJ OFFICIAL USE ~ NLY PA Department of Revenue ounty Code Y e di id l T B f I ~r File Number n v ua axes ureau o INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 02, 00932 ENTER DECEDENT INFORMATION BELOW ~, Social Security Number Date of Death Date of Birth __ !, 161-34-4845 ' 09/26/2002 ' 08/29/1942 Decedent's Last Name Suffix Decedent's First Name _, __. ___ MI Bretr 'Marlin I H I _ _ _ _ (If Applicable) Enter Surviving Spouse's Information Below ___ Spouse's Last Name Suffix Spouse's First Name i MI Bretr ' ' E. Carla __ Spouse's Social Security Number _ _ _ __. THIS RETURN MUST BE FILED IN DUPLICATE ~ THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~.... 1. Original Return 2. Supplemental Return w 3. Remai er gtum (date of death prior to 2-13-82) ~._,'_? 4. Limited Estate y.~.: 4a. Future Interest Compromise (date of 5. Federal s to Tax Return Required death after 12-12-82) i `x ~@ 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust _.__~ 8. Total Nu r of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) ~~ 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death C'~ 11. Election tot x under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach ch O) CORRESPONDENT - THt3 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTU\L TAX INFORMAT N HpULD BE DIRECTED TO: Name Daytime Telep ., on _ Number _ _ Lisa Marie Coyne, Esq. (717) 737- . 46 4 .Firm Name (IfApplicable)_ _ REGIST __ C R ~F WILLS USE ONLY 3 ,Coyne & Coyne, P.C. First line of address ~ N _ 3901 Market Street ~ ° ' ~ Second line of address t c ~ ~~ ~ ~ __ __ _ City or Post Office ,,,,..State ZIP Code -~- mm-- . _ ~, ; ~ . _~+... ___ . Gam, r Camp Hill PA 17011-4227 - ~°' N -= ~ ~ `.`a C Correspondent's a-mail address: IISa@coyneandCOyne.com N Under pena8ies of perjury, l dedare that I have examined this return, including accompanying schedules and statements, and to the be t of my knowledge and belief, it is true correct and complete. preparer other than the personal representative is based on all information of which pre ler has any knowledge. F PERSO RES S N DATE a ~oiv RESS E. Carla Bretr, 5177 E. Trindle Ro ,Mechanicsburg, PA 17055 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE I DATE ADDRESS li I PLEASE USE OR161NAL FORM ONLY l j ~~ i Side 1 jl I 15056051058 1505 6051058 Tj .*,7 ry T1 7 ~, J REV 1500 EX 15056052059 Decedent's Name: Marlin H Bretr RECAPITULATION.. ..................._ ..........,._,...._......_ _..,....._....._.....,_.....~~._.........~..... 1. Real estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ', Decedent's ~oc~al Security Number 161-34-4~4~v 4. Mortgages t£ Notes Receivable (Schedule D) ............................. 4. '. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ........ 5. 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... 6. 7. Inter-wos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) ~.~: Separate Billing Requested........ 7. '. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. i 10. Debts of Decedent, Mortgage Liabilities, $ Liens (Schedule I) ................ 10, '. 11. Total Oeductlons (total Lines 9 8~ 10) ................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) ..............:............... 12. '. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ', `~~~ an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ` (a)(1.2) X .0 0 14,647.00 ' 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 14,647.00 ', 16. 17. _.... Amount of Line 14 taxable _.. at sibling rate X .12 ' ' 17. 18. Amount of Line 14 taxable at collateral rate X .15 ' __ __ __ _ 18. 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 59,550.94 59,550.94 30,256.85 _. '~ 29,294.09 L .......... .... . ..... . ... . .~..,.. ~~ 29,294.09 0.00 659.00 9 REV 1500 EX Page 3 Decedent's Complete Address: FII9 ~~mkK, 21 02 00932 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Marlin H Bretr 161-34-4845 STREETADDRESS 5177 E. Trindle Road CITE Mechanicsburg STATE !, PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments _ C. Discount Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty Total InterestfPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 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 VY'ILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPI 1. Did decedent make a transfer and: 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? ...................................................................................................................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND I 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 is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory re filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after Juty 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 adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(x)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefidaries is four and or 72 P.S. §9116(1.2) [72 P.S. §9116(x)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ~OPRIATE BLOCKS Y' s No .E ~T~AS PART OF THE RETURN. orlfor the use of the surviving spouse s~tnylvtng spouse is zero (0) percent ire~nents for disclosure of assets and or',far the use of a natural parent, an (4.5) percent, except as noted in 16(x)(1.3)]. A sibling is defined, under REV-1508 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~CNEp11LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Marlin Henry Bretz ~ 21-02-0932 Indude the proceeds of litigation and the date the proceeds were received by the estate. i All proprarty jointly~ovmed wkh right of survivorship: must ba dbdwsd on Schedule F. i ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. 2. VIOX Litigation Proceeds Regarding Survival Action (15% of total Settlement) EIP CLaim per Viox Litigation Limited Solety to Spouse (15% of total Settlement) I I 51,930.27 7,620.67 .......... TOTAL (Also enter on line 5, Recapitulation) i I', 59,550.94 (If more space is needed, insert additional sheets of the same size) I -793-34b7 ~ INFERITANCE TAX April 30, 2009 Lisa Marie Coyne, fsq. Coyne 8 Come; P.C: 3SU1 Market Street Camp HIU, PA 17011 Dear Ms. Coyne: COMMONWEAL-TH OF PEP(NSYLVANIA DI=PAR'TMi=NT OF REVENUE BUREAU OF IMDiyWUAI.. TAXES .. PQ Box 280601 HARRISBl1RG, PA 17128-0607 Re: Estate of Martin Henry Bretz (rile Number 2102-0932 Court of Common Pleas Cumberland The Department of Revenue has received the Petition fof Approval of S e ' ant Claim to be filed on behalf of the above-referanoed Estate in regard td a wronefut death survival action. It has been forwarded to this Bureau for the Commonwealth's approval of artocation of the proceeds paid to settle the notions. ~ ', Pun;uarrt to the Petition, the 60 year ofd decedent died as a result•dF cam Ilc~tions from the medication Vioxx. Decedent Is swnrtved by his spouse and three children. I Please be advised that, based upon these facts and for inheritance tax pu. es Drily, this Departrrient has no obJecdon to the propos®d allocation of th®r~t proceeds o th rs action, $82,187.31 to•the wrongful death claim and $.14,503.64 to file survival claim. ds of a survival action are an asset included in the decedent's estate and are subbed to i position of Pennsyhran'ra inheritance tax, 42 Pa.C.S.A. §8302; 72 P.S. §9106, 9107, Co fees must be deducted in the saline percentages as the proceeds are ellocatecl. In ~, ' an, 669 A.2d 1059 (t~a_ Cmwlth. 1896). I trust that this letter (s a suffjcient representation of the Department's ~ o on ibis matter. As the Department has no ob)ectlons to the Petition, an att~mey from the D rtrnent of Revenue viii not be attending any heackrg regarding iIr Pease contact me if r the Court has any questions ar requires anything additional from this Bureau. ~-'Shannon !=. Baker ' Trust Valuatlan Spa inheritancr Tax bivi ' Bureau of individual • P1tor~e: 717-783-5824.• Fax: 717-783-3467 - cam: sha~akeroDs I ~. i i 1 ' BY: ANAPOL, SCHWARTZ, WEISS, COHAN, FEL)bMAN & SMALLEY SOL H. WEISS, ESQUIRE GREGORY S. SPIZER, ESQUIRE Identification Nos.15925i82435 1710 Spruce Street PhilAdelphia, PA 19103 (2157 790-4578 Attorneys for Pl COYNE & COYNE LISA COYNE, ESQUIRE Identification No. 3901 Market Street Camp Hill, PA 17011 (717) 737-0464 E. Carla Bretz, Administratrix of the Estate of COURT OF COMMON i Marlin Henry Bretz, Deceased CUMBERLAND COUN' v. ~ pQ - ~9gf. ~tivi l MERCK & CO., INC. PROPOSED .ORDER OF DISTRIBUTION AND NOW, this ,~ie~lay of 'f " , 2009, upon consideration, Petition to Approve Settlement and Distribution of Wrongful Death and Survival , hereby ORDERED~and DECREED as fellows: (1) The allocation of the 40°lo interim payment from the Vioxx Settlemei follows: a. Wrongful Death (85%) b. Survival Action (15%) lrr~ s it is h~ll be as Ii (2} The sum of $142,192.58 represents the 40% interim payment from tl~e Vioxx 'Settlement. The funds shall be distributed as follows: (a) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. For Attorney Fees $ 5'501.63 (b) To: E. Carla Bretz (Widow) i Cl $ 64 1 093 a m For Wrongfiil Death . , For Survival Action $ ,2151.83 (d) To: Wendy Bucher (Daughter) For Wrongful Death Claim $ 3,597.89 For Survival Action $ ,417.27 (e) To: Robin Mentzer {Daughter) For Wrongful Death Claim $ 3,97.89 For Survival Action $ ,4 7.27 (fj To: Brian Bretz (Son) ` For Wrongful Death Claim $1 3,97.89 For Survival Action $ ,417.27 TOTAL: $ 4?~,]9Z.S8 B'1~ THE CaU1tT: J. t+~~v ~~ ~~ ~~ ,~ ~~yt s ~,~ ~'~~ ~. F ~, ~ The funds apportioned to the Survival Action are subject to applicable estate and/o .. •. r inheritance .., .,, tax. ~~ ... _ . , . i _-- ~~ __ !J _ , f ,~ ~ DEC 212009 /~~~ Y• ANAPOL SCHWARTZ, WEISS COHAN FELDMAN & SMALLEY '' B GREGORY S. SPIZER, ESQUIRE ~` AMBER RACINE, ESQUIRE Identification Nos. 82435/208575 ~ - - 1710 Spruce Street ~ I Philadelphia, PA 19103 (215) 790-4574 Attorneys for PI COYNE & COYNE ~~ LISA COYNE, ESQUIRE Identification No. i - ~ 3901 Msrket Street ~I Camp Hill, PA 17011 ~ '~, (717) 737-04b4 ~ !, I E. Carla Bretz, Administratrix of the Estate of COURT (~F COMMON P EJAS Marlin Henry Bretz, Deceased CUMBERLAND COUN I ~,' ivi i TGrr~n v. f~-448(0 ~ MERCK & CO., INC. ~ ' PROPOSED ORDER OF DISTRIBUTION t AND NOW, this,l„Z_~y of J 2009, upon consideration of la~ Petition to Approve Settlement and Distribution of Wrongful Death and Survival Ac 'ox hereby ORDERED and .DECREED as follows: (1) The allocation of the 60% final payrnent from the Vioxx Settlement follows: a. Wrongful Death (85%) b. Survival Action (15%) ~s, it is be as i ~r•^+'~'"'#'""r {. r For Attorney Fees $ ,',690.73 (b) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. For Costs2 $,899.68 (c) To: Common Benefit Expense Funds ! - ~I 1% Assessment $~,4~2.02 (d) To: E. Cazla Bretz (Widow) For Wrongful Death Claim $5 ,31.64 For Survival Action , $1 ,C7~4b.73 (e) To: Wendy Bucher (Aaughter) For Wrongful Death Claim •$1 ,917.22 For Survival Action $3 34.92 (f) To: Robin Mentzer (Daughter) i For Wrongful Death Claim $1 ,9'7.22 For Survival Action $3, 4$.92 (g) To: Brian Bretz (Son) For Wrongful Death Claim $ f 8 97.22 For Survival Action ~ $3, 4.92 (2) The sum of $204,009.23 represents the 60% final payment from the 1Vipxx Settlement. The funds shall be distributed as follows' : ~ ~- (a) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley,l'.C. TOTAL: ~ ~ ~ ~ ~ ~ BY THE COURT: /r/ • J. z The funds apportioned to the Survival Action are subject to applicable estate and/or inheritance tax. ~ Petitioner understands that these costs do not include the costs associated with filing th instant Petition. Further, Petitioner understands that the net recovery to all beneficiaries may b re{iuced slightly as a result of any and sll costs associated with filing the instant Petition. F __ f t oXX C~.~~ N~- BY: ANAPOL, SCHWARTZ, WEISS, COHAN, FELDMAN & SMALLEY GREGORY S. SPIZER, ESQUIRE AMBER RACINE, ESQUIRE Identification Nos. 82435/208575 1710 Spruce Street Philadelphia, PA 19103 (215) 790-4574 Attorneys for PI COYNE & COYNE LISA COYNE, ESQUIRE Identification No. 3901 Market Street Camp Hill, PA 17011 (717) 737-0464 E. Carla Bretz, Administratrix of the Estate of COURT OF COMMON Marlin Henry Bretz, Deceased CUMBERLAND COUN . '~ Orphans Court Division v. .2.ooy-H9~G MERCK & CO., INC. ~A9~6893~- PROPOSED ORDER OF DISTRIBUTION AND NOW, this 2 Y' day of ~.r,T_~' , 2010, upon consideration of Petition to Approve Settlement and Distribution of Wrongful Death and Survival A Extraordinary Injury Program "E_"payment) , it is hereby ORDERED and as follows: (a) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. For Attorney Fees (b) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. For Costs (c) To: Common Benefit Expense Funds 1 % Assessment AUG 2 4 2010 `~ 0 a cGi ~i r.~ .~ :.t' a~ N «t~s (for the $1 ~,2~9.81 8~J $5 _i_~ Y t ~, .tion~rjWld°w~ E-~arlagre~D a C~~m (a~ ~~. For S~iv~al Action F TOTAL: 9,,. $x,10'3.42 ~~ TIC ~~UgT ~ I BY 1• `~ I .~ i I ~~ n ~~,~1:~ t ~~ l..©~'`~ ~~1 ~ ~ J ~~ REV-1511 EX+ (12-89) scN~ou« x COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ec~reTe ne --••-- -• n~c nv~woon i Marlin Henry Bretz 21-02-0932 Debts of decsderd must bs roported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 3,600.00 Name of Personal Representative(s) Carla E. Bretz - Sodas Security Number(s)/EIN Number of Personal Representative(s) Street Address 5177 E. Trindle Road City Mechanicsburg .State P-A rp 17055 Year(s) Commission Paid: 2010 2. attorney Fees 3,000.00 3. Family Exemption: (Ir decedent's address is not the same as daimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 1,000.00 6. Tax Return Preparer's Fees ~. 15% of Total Attorney Fees and Costs for Viox Litigation (Total Atty Fees: $115,554.06) 17,333.11 15% of Total Attorney Fees and Cost for EIP Claim (Total Atty Fees: $16,781.65) 2,517.25 Postage, Overnight mailings, and Certified Mailings 306.49' Mileage and Tolls for Executrix @ $0.55/mile 1,100.00 Long Distance Charges ~! 400.00 Reserves 1,000.00 TOTAL (Also enter on line 9, Recapftulatio ) ~'$ 30,256.85 (h more space is needed, insert additional sheets of the same size) __ _ _ _ _- _ _ __ ___ _ _ - __ _ i _ _ _ _ ,. ..,, w-.- _ ..n ,.,., , ,. REV-1513 EX+ (8.00) IM _ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BRETZ, MARLIN HENRY FILE N M~ER 2 -1002 - 00932 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHI DECEDENT Td AMOUNT OR SHARE OF ESTATE I~ TAXABLE DISTRIBUTIONS (inGude outright spousal distributions) ', 1 E. Carla Bretz Wife 50% of Probate Estate 2 Robin Mentzer Daughter 1/6 of Probate Estate 5435 Wertzville Rd., Enola, PA 17025 'i 3 Wendy Bucher Daughter 1/6 of Probate Estate 2764 Peters Mountain Rd., Halifax, PA 17032 4 Brian Bretz Son 1/6 of Probate Estate 7073 Carlisle Pike, Lot 47, Carlisle, PA 17013 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropria i te, on Rev 1500 c~ er h t II. NON-TAXABLE DISTRIBUTIONS: ', A SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE ', B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ' ~~ ~!,I TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SF~EE COYNE & COYNE A PROFESSIONAL CORPORATION ATTORNEYS AT LAW ,.___.-r Henry F. Coyne 3901 Market Street Lisa Marie Coyne Camp Hill, Pennsylvania Jaime L. High 17011-4227 December 14, 2010 Office of the Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Re: Estate of Marlin Henry Bretz, No. 21-2002-00932 717-737-0464 IFa~C: 717-737-5161 www. ovhieandcovne.com Dear 5ir/Madam: Enclosed please find an original and two (2) copies of the Supplemental Inhe for this Estate. Kindly docket the original and return to this office a "clocked-in" eop; envelope. Also enclosed is check no. 125 in the amount of $659.00 which represents due and check no. 126 in the amount of $15.00 which represents the filing fee for this Thank you for your assistance. If you have any questions, please contact me. Very truly yours, OYNE COYNE, P.C. ~~ isa Marie Coyne LMC/amd Encls. cc: Mrs. E. Carla Bretz, Administratrix Tax Return the enclosed heritance tax ea -:c_c o , ;-~, C'7 G'? C~~~`.7 n-+ s°,-ti GT1 are ~7 ~.~` CJ a ``~ =,~ ~n p °-r? - i, r ~ . ~~ ;°',. ~: ~ ~; F ~; ~. ~` t t ~ ~ ' ~ i h. ~. R' E ~. '±' f ~'~ ~~, i ~ ~ ~ ., `i ~, :~. `{ .~ ~"~ t y (t i ~' y { .!~~ .~;> ~ i r ~ t ~~ s ~; "''' -~ ,. ~ ,k, t , ~ y.~ ~` Y ~' 1. ~~ I ~ 0 ~ { ~ '~ ; ~~ .:,~da ~~a~~~ `.! i~{10~ S,htdl~ ,r `~~ ~ p x~31~ ~, ~;. F }. f e :~ ~'_~ ~~ i :ZS ~a S~ ~3° µ i ') F f ji1 31 u „~(i~U ~: 1 zw ~~~ ~~ , b 4 ` J 15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Depaetrnent of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po sox 2sosol 21 02' 00932 Hamsburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth _. ___ ___ __ 161-34-4845 '... 09/26/2002 :08/29/1942 Decedent's Last Name Suffix Decedent's First Name MI __ _.__ __ . Bretz 'Marlin H __ __ __ _ (If Applicable) Enter Survhring Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Bretz E. Carla __ .......... Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH 1~HE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW ,.,,,,, 1. Original Return ~3 2. Supplemental Return 3. Remaind r Return (date of death 4. Limited Estate .~,_,..° 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received _'~~;~ 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) ' 10. Spousal Poverty Credk (date of death between 12-31-91 and 1-1-95) prior to 11~-1$-¢2) ~? 5. Federal f~state Tax Return Required _,...,.,,__ 8. Total Nurtibek tlf Safe Deposit Boxes s:".~ 11. Election o t¢x under Sec. 9113(A) (Attach ~ch.l0~ CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATIONS OULD BE DIRECTED TO: Name Daytime Telephbnej Number Lisa Marie Coyne, Esq. (717) 737-OJ46 ..Firm Name (If Applicable).. - - -- REGISTE~t 01= WILLS USE ONLY Coyne & Coyne, P.C. First line of address ~ o ;, _.. . _.~ .. _. 3901 Market Street o T} o '''-' Second line of address ~ ~ ~ ~ < =i - ``~~ C.~a ~C7 1 ~ ~ City or Post Office State ZIP Code - .-_ .- .. .- \\ ~~j -.• _~ _ ~.~ __~ _ .....~~ ~~ ;Camp Hill PA .:17011-4227 ~~ ". n ='~ =' _.-: ., fv - __ _ __ _ ~ .-~ .-.- ; _, ~..~ ~ Correspondents e-mail address: lisa@COyneandtAyne.com tV -'~ Under penal~es of perjury, I declare that 1 have examined this return, including accompanying schedules and stetemenffi, and to the st pf'my knowledge and belief, it is true correct and complete. re ' preparer other than the personal representative Is based on all information of which rer has any knowledge. ' F PERSO RES S N ' ' BATE ~~ aoiv RESS E. Carla Bretz, 5177 E. Trindle Ro ,Mechanicsburg, PA 17055 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ' BATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 7 15056051058 1505051058 __ _--- J __ ;_ , J REV-1500 EX Decedent's Name: Marlin H Bretz 15056052059 Decedent's So¢ial Security Number 161-34-0845 w._._......~__._~._._ ... _...__ . __ RECAPITULATION -_ _ _.._ 1. Real estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ............................. 4. 5. Cash, Bank Deposits ~ Miscellaneous Personal Property (Schedule E) ........ 5. ' 59,550 94 6. Jointly Owned Property (Schedule F) ~::.:~ Separate Billing Requested ...... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G} Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... .._,~~..,, 8. ', 59,550.94 .~ ._. 9. . ~,,µ.,.~.._._.. Funeral Expenses 8~ Administrative Costs (Schedule H) ..................... 9. 30,256.85 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. 11. Total Deductions (total Lines 9 8 10} ................................... 11. ' ', 12. Net Value of Estate (Line 8 minus Line 11) ..............:............... 12. ' 29,294.09 ', 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. .. .._..,_~.._ ~..~~_.,.... T ,. ~::.,e , ~ .,,:,,,,~ ~ ~„a , z~ - - - 1a. ' 29.294.09 '. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ~ _ ~~ M.. 15. Amount of Line 14 taxable at the spousal tax rate, or __ _ _, _ transfers under Sec. 9116 (a)(1.2) X .0 0 14,647.00 15. 0.00 16. Amount of Line 14 taxable ' at lineal rate X .0 45 14,647.00 16, 659.00 ~_,, ,..v... 17. Amount of Line 14 taxable at sibling rate X .12 17. ', 18. Amount of Line 14 taxable at collateral rate X .15 18. . 659.00 ..................................... 19. TAX DUE ................... 19.__ __ _ _ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~'~ `-: 15056052059 Side 2 1505~6d52059 REV-1500 EX Page 3 Decedent's Complete Address: Ff1~~Nl~mbgr. . __„ 21 02 'i 00932 __ DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Marlin H Bretz 161-34-4845 STREETADDRESS 5177 E. Trindle Road CITE Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 659.00 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) , 0.00 3. InterestlPenalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Pill in oval on Page 2, 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) 659.00 A. Enter the interest on the lax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 659.00 Make Check Payable to: REGISTER OF WILtS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPI~O~RIATE BLOCKS 1. Did decedent make a transfer and: Y s No a. retain the use or income of the Property transferred :.......................................................................................... b. retain the right to designate who shall use the property transferred or its income : ........................................... c. retain a reversionary interest; or .......................................................................................................................... d. receive the promise for life of either payments, benefits or care? ...................................................................... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FIDE Ifi AS PART OF THE RETURN. For dates of death on ,or after July 1,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to' or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or far the use of thy, su~~vvwing spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requurer~ents for disdosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefidary. 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 pr 1br the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. ', The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefidaries is four and one-Ihalf'!, (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116Qa~(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-1509 EX+ (6-98) ' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scNEau~E ~ CASH, BANK DEPOSITS, & M15C. PERSONAL PROPERTY ESTATE OF FlLE NUMBER Marlin Henry Bretz 21-02-0932 Indude the proceeds of litigation and the date the proceeds were received by the estate. All properly Jointly-ormed with right of survivonhio muat be dbclosad on Schodul. F. __ __ -. - ---. _._ __- ~ _i__. _ i ~•• •~•-•- +row w ..~c..c~, mavn auuiuwai sneers w me same sae) April 30, 2009 -783-34b7 - INHERITANCE TAX GoMMOtvw>=A~~'H of P~NtvsnvgtvlA DEPARTMENT OF REVENUE BUREAU 01= [hltrJMDUAL TAXES .. PO BoX 280601 HARRISBURG, PA 17128-0601 Lisa Marie ~oyna, Esq. Coyne.&-~oyn9;:P.C: 3901 Market Street Camp Hill, PA 17011 Re; Estate of Marlin Henry Bretz Fite Wombat 2102-0932 Court of Common Pleas Cumberland Courtly Dear Ms. Coyne: PAGE 02/02 The Department of Revenue has received the Pstitton for Approval of SettJlarttiep~t Claim to be filed oh behalf of the above-referenced Estate fn r®garcl W a wrongful death $nc1 survival action. It has been forwarded to this Bureau for the Commonwealth's approval of t1~! a~ilooation of the proceeds paid t4 settle the actions. Pursuant to the Petition, the 60 year old decedent died as a result•of cvmpNcxuticbns from the meciicatlon Viaioc. Decedent is survived by his spouse and three children. Please be advised that, based upon these facts and for inheritance tax pues'c-hiy, this Departrrient has no objection to the proposed allocation of the net pn~ceeds o this fiction, $82,187.31 to•the wrongful death claim and $14,303.64 to the survival claim. P'ro4x~ds of a survival action are an asset included in the decedent's estate and are subject to the IrXfposttion of Pennsylvania Inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §9108, 9107. Cosh a flees must be deducted Ni the same percentAges as the proweds are ellocatecl. In . ~„srry~nan, 669 A.2d 1059 (~a_ CrnuAtil. 1l39ti). t trust that this letter (s a auffjcient representation of the Depaftm®nt`s posttipn on this matter. As the Department has no obJectlons #o the Petition, an atttomey from the ~ rtment of Revenue wilt not be attending any hearing regarding lt. Please contact me if yot~ or t#~e Court has any qu~stianS or requires anything $dditionai from thf.S Bureau. . , ereiy, Shannon !`. Baker Trust Valuation Spec'tal~st ~! • inheritance Tax bivisiort Bureau of individual Ta~Kes', ~: PnoriE: 7i7-783-5824 ~ ~'ax: 717-783-3457 - Gay: 51t~Y~„kerl9statl~n3.l~' . . ' BY: ANAPOL, SCHWARTZ, WEISS, COHAN, FELI3MAN & SMALLEl SOL H. W'EISS, ESQUIItE GREGORY S. SPIZER, ESQUIRE Identification Nos. 15925/82435 1710 Spruce Street Philsdelphia, PA 19103 (215) 790-4578 E~ttorneys for Plainitiff COYNE & COYNE LISA COYNE, ESQUIRE Identiffcadon No. 3901 Market Street Camp Hill, PA 17011 (717) 73?-046.4 E. Carla Bretz, Administratrix of the Estate of CUURT OF COMMON ~IEAS Marlin Henry Bretz, Deceased CUMBERLAND COUNh'Y v. ~ (}Q -- 4986 ~ive (~ MERCK & CO., INC. PROPOSED .ORDER OF DISTRIBUTION AND NOW, this ~~ay of 'i" , 2009, upon consideration, oI Plaintiff s Petition to Approve Settlement and Distribution of Wrongful Death and Survival Actions, it is hereby ORDEREDand DECREED as follows: (1) The allocation of the 40% interim payment from the Vioxx Settlement shill be as follows: a. Wrongful Death (85%) h. Survival Action (15%) (2) The sum of $142,192.58 represents the 40% interim payment from the Vioxx 'Settlement. The funds shall be distributed as follows: (a) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. For Attorney Fees $;45;,501.63 (b) To: E. Carla Bretz (Widow) For Wrongful Death Claim $41 „093.64 For Survival Action $'x,2',51.83 (d) To: Wendy Bucher (Daughter) For Wrongful Death Claim $ ~ 3,697.89 For Survival Action $x,417.27 (e) To: Robin Mentzer (Daughter) For Wrongful Death Claim $T,3,6g7.89 For Survival Action $2,417.27 (fl To: Brian Bretz (Son) For Wrongful Death Claim $1'3,697.89 For Survival Action $241'7.27 TOTAL: $1~~#2~192.58 BY' THIr COUlt3': J. ~ ~e~~ ~~~~~ ~ ~ ~~$~`~~~ ~' ~ " ~_ ~. ~. ~ The funds apportioned to the Survival Action are subject to applicable estate and/or il~Gnh~ritanee ,_, .,, tax. r.~ . _.. _ . - .... ~ r. BY: ANAPOL, SCHWARTZ, WEISS, COHAN, FELDMAN & SMALLEY ~ GREGORY S. SPIZER, ESQUIRE ~ DEC 2I 2009 AMBER RACINE, ESQUIRE . identification Nos. 82435/208575 1710 Spruce Street Philadelphia, PA 19103 (215) 790-4574 Attorneys for Plaintiff COYNE & COYNE LI5A COYNE, ESQUIRE Identification No. ; 3901 Market Street Camp Bill, PA 17011 (717) 737-0464 ' E. Carla Bretz, Administratrix of the Estate of COURT CSF COMMON PLDAS Marlin Henry Bretz, Deceased CUMBERLAND COUNTY .. • ~',iv i I 'TGir+r+~ v. • D'Q-448(0 MERCK & CO., INC. ~ ~ 2~ PROPOSED ORDER OF DISTRIBUTION AND NO~V, this,Z,~~y of 2009, upon consideration of Planntiffs Petition to Approve Settlement and Distribution of Wrongful Death and Survival Actions, it is hereby ORDERED and .DECREED as follows: (1) The allocation of the 60% final payment from the Vioxx Settlement shall' be as .follows: . a. Wrongful Death b. Survival Action (85%) (15%) i ~_~ _ _ _ __ (2) The sum of $204,004.23 represents the 60% final payment from the Vioxx Settl ement. The fiords shall be distributed as followsl: ~ (a) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. . ' For Attorney Fees ~64~690.73 (b) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. For Costs2 $'1,899.68'.. (c) To: Common Benefit Expense Funds ,~ - 1%Assessment ~ $~,4~52.02 (d) To: E. Carla Bretz (Widow) For Wrongful Death Claim $56,91.64 For Survival Action , ~ $110,(446.73 (e) To: Wendy Bucher (Daughter) For Wrongful Death Claim •$1 x,9,77.22 For Survival Action $334~~92 { fl To: Robin Mentzer (Daughter) ~ r For Wrongful Death Claim $1$,9'7.22 For Survival Action $3,34.92 (g) To: Brian Bretz (Son) For Wrongful Death Claim $P897;7.22 For Survival Action ' $3,~48•~2 TUTAL: $20~,O~p$.23 ~:t~~ ~`~ ~f ~~~ ~ ~ ~• ~ ~ ~ ~ lb ~~~ ' ~ (, P~1 B V THE COURT: !M ~ ~1! 7. ' The funds apportioned to the Survival Action are subject to applicable estate andlor inheritance tax. a Petitioner understands that these costs do not include the costs associated with. fi ling the jins~,nt Petition. Further, Petitioner understands that the net recovery to all beneficiaries may be ~ec{uced ~~ slightly as a result of any and all costs associated with filing the instant Petition. r ~~yy ~~ii ~~ ~XX l~-~"t . BY: ANAPOL, SCHWARTZ, WEISS, COHAN, FELDMAN & SMALLEY GREGORY S. SPIZER, ESQUIRE AMBER RACINE, ESQUIRE Identification Nos. 82435/208575 1710 Spruce Street Philadelphia, PA 19103 (215) ?90-4574 Attorneys for PNa' COYNE & COYNE LISA COYNE, ESQUIRE Identification No. 3901 Market Street C Camp Hili, PA 17011 (717) 737-0464 AUG 2 4 2010 c~'i .~~ ti ~_~ E. Carla Bretz, Administratrix of the Estate of Marlin Henry Bretz, Deceased v. MERCK & CO., INC. COURT OF COMMON PLjEAS CUMBERLAND COUN'T' Orphans Court Division 2882=68~- PROPOSED ORDER OF DISTRIBUTION AND NOW, this 2 Y' day of _, 201Q, upon consideration of Plair#tiff's Petition to Approve Settlement and Distribution of Wrongful Death and Survival ActijonS (for the Extraordinary Injury Program "EIP Claim" payment) , it is hereby ORDERED and D~E~&.EED as follows: (a) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. For Attorney Fees $16~249.81 (b) To: Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, P.C. - For Costs $23;801 (c) To: Common Benefit Expense Funds 1% Assessment $50$.U~4 I t. (d) To: E. Cazla Bretz (Petitioner/Widow) For Wrongful Death Claim $4,022.80 For Survival Action $5,103.42 TOTAL: $50,$04.4 e°.~y ~~~ 8 fzs~~d ~~ BY THE COURT: ,_ ~- • REV-1511 EX+ (12-99) SCNEp~1LE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINfSTRAT{VE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Marlin Henry Bretr 21-02-0932 lHbts of decedent must bs roported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: t. e. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal RepresentaWe(s) Carla E. Bretr ~, Sodal Security Number(s)IEIN Number of Personal Representative(s) i street Address 5177 E. Trindle Road city Mechanicsburg ,state FrA zip 17055 ', Year(s) Commission Paid: 2010 2. Anomey Fees 3. Family Exemption: {If decedent's address is not fhe same as daimant's, attach explanation) Claimant Street Address ~ City State _ Zip Relatronship of Claimant to Decedent ', 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 15% of Total Attorney Fees and Costs for Viox Litigation (Total Atty Fees.• $115,554.06) 15% of Total Attorney Fees and Cost for EIP Claim (Total Atty Fees: $16,781.65) Postage, Overnight mailings, and Certified Mailings Mileage and Tolls for Executrix ~ $0.55fmile Long Distance Charges Reserves I ~ TOTAL (Also enter on line 9, Recapitulatiorp) $' AMOUNT 3,600.00 3,000.00 1,000.00 17,333.11 2,517.25 306.49 1,100.00 400.00 1,000.00 ~, 30,256.85 (H more space is needed, insert additional sheets of the same size) i! I REV•1513~)C* (8.00) _ ~ _ ' SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE N~JIWBER BRETZ, MARLIN HENRY 21 - 2002 '- 00932 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE OF ESTATE I~ TAXABLE DISTRIBUTIONS (indude outright spousal distributions) 1 E. Carla Bretz Wife 5 % of Probate Estate 2 Robin Mentzer Daughter 1 6 of Probate Estate 5435 Wentzville Rd., Enola, PA 17025 3 Wendy Bucher Daughter 1 6 of Probate Estate 2764 Peters Mountain Rd., Halifax, PA 17032 4 Brian Bretz Son 1 of Probate Estate 7073 Carlisle Pike, Lot 47, Carlisle, PA 17013 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropri ate, on Rev 1500 co~Aer ~h t III NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS i j i I'll TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER ~H4E • COYNE & COYNE A PROFESSIONAL CORPORATION ATTORNEYS AT LAW Henry F. Coyne 3901 Market Street 717-737-0464 Lisa Marie Coyne Camp Hill, Pennsylvania Fax: 717-737-5161 Jaime L. High 1 70 1 1-4227 www.coyheandcoyne.com December 14, 2010 Office of the Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Re: Estate of Marlin Henry Brett Deceased No. 21-2002-00932 Dear Sir/Madam: Enclosed please find an original and two (2) copies of the Supplemental Inheritan a Tax Return for this Estate. Kindly docket the original and return to this office a "clocked-in" copy wit the enclosed envelope. Also enclosed is check no. 125 in the amount of $659.00 which represents the ' eritance tax due and check no. 126 in the amount of $15.00 which represents the filing fee for this matt Thank you for your assistance. If you have any questions, please contact me. Very truly yours, OYNE COYNE, P.C. I, I -I isa Marie Coyne N o ~-. Encls. ~ ~ ~ 1 ~~ G'7 CJ f7"t s`"Yl cc: Mrs. E. Carla Bretz, Administratrix ~ ~ ~ ~`~,~ ~~ O N _r. ~m .~ ~.n p N ~~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: _;....~,~r .. ,_ , REV-1162 EX(11-96) PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. Cp 013788 BRETZ E. CARLA 5177 E TRINDLE ROAD MECHANICSBURG, PA 17050 foW ESTATE INFORMATION: SSN: ~s~-34-4845 FILE NUMBER: 2102-0932 DECEDENT NAME: BRETZ MARLIN HENRY DATE OF PAYMENT: 12/ 15/2010 POSTMARK DATE: 12/15/2010 COUNTY: CUMBERLAND DATE OF DEATH: 09/26/2002 REMARKS: CHECK#125 SEAL TOTAL AMOUNT f INITIALS: SAP RECEIVED BY: REGISTER OF WILLS ACN ~' ASSESSMENT jAMOUNT CONTROL NUMBER GLENDA EARNER STR~SBAUGH REGISTER OF WILLS ~ e ; I ~~ :4"r, VIVV FQ~t~!!~ 10J S.N~id~4 ~o ~~~ w~ ~ t ~~a au ~ n ~ ;-~ ~ r,~'1"1~ ,4 _ pennsyK~ania BUREAU OF INDIVIDUAL TAXES ~~ ~NHEF~~tT~~NCE TAX DEPARTMENT OFRE:VENUE REV-1607 EX: AFP (12'10) INHERITANCE TAX olvlslo" S T A T E M E N T~~' O F A C C O U N T PO BOX 280601 _ HARRISBURG PA 17128-0601 ~.'; ° DATE 01-10-2011 L. . ESTATE OF BRETZ MARLIN H ,_ I DATE OF DEATH 09-26-2002 ; ~ „ FILE NUMBER 21 02-0932 ~~, _ ,, ; . __ ~ , ~ . - COUNTY CUMBERLAND ~ ,, : , f ' ' LISA - ~- MAR I E COYNE ACN 101 COYNE $ COYNE Amount Remitted 3901 MARKET ST __ -- CAMP HIL'~L PA 17011 __ MAKE CHECK PAYABLE AND REh1l:'f PAYME'.NT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS _ ~ __ __ ___ ~~~~~~ ~~~~~ ~~ ~ ~~~~ •~• ~•••• • *** INHERITANCE TAX STATEMENT OF~ACCOUNT ~*~*u~~ ~~ ~ ~~~~N~~~ REV-1607 EX AFP C12-10) ESTATE OF:BRETZ'. MARLIN H FILE NO.: 21 02-0932 ACN: 101 DATE: 01-10-2011. THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMPIAF'Y OF THE'. PRINCI:PAL_ TAX DUE, APPLICATIC)N OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED IIV1"E_RES"f FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 04-11-2005 PRINCIPAL TAX DUE:: 2,470.00 PAYMENTS tTAX CREDITS): PAYMENT RECEIPT DISCOUNT t+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-) 12-24-2002 (~D001993 123.50 ~, 4,000.00 04-2b-2004 REFUND .00 1,764.65- 02-10-2005 CD004935 3.67- 132.00 12-15-2010 CD013788 .00 659.00 TOTAL TAX PAYMENT 3,146.,18 BALANCE OF TAX DUE b7b..18CR INTEREST AND PEN. .00 TOTAL DUE I 67b.18CR * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE Of= l"HIS FORM FOR INSTRUCTIONS. BUREAU OF INDIVIDUAL TAXES ~ ~~ ~f' _ NOTICE OF INHERITANCE TAX INHERITANCE TAX DIVISION J~~~`~` ~~ i~~l~Rf~. ~~ ,, .., ~~', ALLOWANCE OR DISALLOWANCE PO BOX 280601 C, .i.;~ `, , ' .~~OF~; ~',~plt'CTIONS AND HARRISBURG PA 1 7128-0601 `' ~ '1_,..~,j ASSESSMENT OF TAX ~' a', ~ F ~ ~ L_r 4.. ~~~~ G~ rt Q~PH,~4f~'S C~~ 1 T LISA MARIE CO ~;~~; ! , ? r3~ 3901 MARKET ST ~~ t, ~ ~~~ CAMP HILL PA 17011-4227 pennsyLvania ~{~`` DEPARTMENT OF REVENUE r; REV-1547 EX AFP (12-10) DATE 03-28-2011 ESTATE OF BRETZ DATE OF DEATH 09-26-2002 MARLIN H FILE NUMBER 21 02-0932 COUNTY CUMBERLAND ACN 501 APPEAL DATE: 05-27_2011 (See reverse side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0; REGISTER OF WILLS 1 COURTHOUSE SQUARE CUT ALONG THIS LINE CARLISLE PA 17013 y --RETAIN LOWER POR_TION_ FOR YOUR REC_OR REV-1547 EX AFP C12-10~---- - --- - ----- NOTICE OF INHERITANCE TAX APPRAISEMENT - DS ~ ESTATE OF: DISALLOWANCE OF DEDUCTIONS AND ASSESSMENTAOFOWANCE OR ---- BRETZ MARLIN TAX HFILE N0.:21 02-0932 TAX RETURN WAS; ~ ACN: 501 DATE: 03-2$-2011 APPRAISED VALUE OF X ) ACCEPTED AS FILED RETURN BASED ON: LITIGATION RETURN ~ ) CHANGED 1• Real Estate (Schedule q) 2• Stocks and Bonds (Schedule B) C1) 3. Closel '0 0 NOTE: To Y Held Stock/Partnershi C2) ensure proper 4• Mortgages/Notes Receivable [Schedule D) Schedule C) •0 0 credit to your account, C3) • 00 submit the u 5• Cash/Bank Deposits/Misc. Personal Pro ert pper portion (4) .0 0 of this form with your 6• Jointly Owned Property (Schedule F) p y (Schedule E) tax payment. ~5) 59, 550.94 7• Transfers (Schedule G) C6) .00 $• Total Assets ~~) .0 0 APPROVED DEDUCTIONS AND EXEMPTIONS: c8) 9. Funeral Expenses/Adm. 59 550.94 10. Debts/Mort a e Costs/Misc. Expenses (Schedule H) g 9 Liabilities/Liens (Schedule I) C9) ~n _ ~~~ ~~ 11. Total Deductions C10) .0 0 12. Net Value of Tax Return 13. Charitable/Governmental Bequests • X11) 30, 256' 85 14. Net Value of Estate Subject to Tax Non-elected 9113 Trusts (Schedule J) (12) 2 9,2 94.0 9 NOTE: c13) .00 If an assessment was issued previousl [14) reflect fi ures 29 294.09 9 that include the tot l~ fines 14, 15 and/or ASSESSMENT OF TAX: 16, 17, 18 and 19 will 15. Amount of Line 14 at spousal rate A~ returns assessed to date. 16. Amount of Line 14 taxable at C15) Lineal/Class A rate 14, 647.00 x 00 17. Amount of Line 14 at Sibling rate (16) •0 0 ~s~47 0o x 045 = 18• Amount of Line 14 taxable at Collateral/Class B (17) 65 9.0 0 19. Principal Tax Due x 12 = rate ~lg) .00 TAX CREDITS: •00 x 15 = .00 PAYMENT c19)= 659.00 RECEIPT DATE NUMBER DISCOUNT (+) 12 - 15 - 201 0 INTEREST/PEN PgID ~ _ ) AMOUNT PAID CD013788 .00 659.00 * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. TOTAL TAX PAYMENT BALANCE OF TAX DUE 659.00 INTEREST AND PEN. •00 TOTAL DUE •DO .00 IF TOTAL DUE IS REFLECTED AS A "CREDIT" A REFUND. SEE REVERSE SIDE OF THIS FORM FOR) YOU MAY BE DUE INSTRUCTIONS. Pa. O.C. Rule 6.12 STATUS REPORT REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Name of Decedent: MARLIN HENRY BRETZ Date of Death: September 26, 2002 File Number: 21-02-00932 Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete :.................... ®Yes ®No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is YES, state the following: a. Did the personal representative file a final account with the Court? ....... ®Yes ®No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? ............................... ®Yes ®No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date January 10, 2013 id!' ~,. ~_ ~ c -~ ~.. t~; ~ ~,~ . ~ _ ~ .,., Si tore o Person Filing this Fo .. d, ) i '~..J . -, P'+ . .. "' _" Ca acity: ®Personal Representative ®Counsel i.~ ~ ,_, , ~ ~ ~., ~• + Lisa Marie Coyne, Esquire t.,.7 e.,y . t :> ~~' ~ _„~ - Cep Name of Person Filing this Form [.:~ ~° .~s t-` w- °wL ~ ~' - .__t 3901 Market Street c.~ ,~.. eJ ~ W Address C~JW c;? ~~ Camp Hill, PA 17011 ~ ~ `-, U (717) 737-0464 Telephone Form RW-10 rev. 10.13.06 ~U~j