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HomeMy WebLinkAbout06-17-09 (2) 1505607120 --~ REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 0 9 0 0 2 8 8 Po Box.2sosol RESIDENT DECEDENT Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Date of Birth Social Security Number Date of Death 181 58 8220 02 27 2009 07 17 1968 Decedent's Last Name ROZMAN (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW X^ 1. Original Return ^ ^ 4. Limited Estate ^ ^ 6 Decedent Died Testate (Attach Copy of Will) ^ ^ 9. Litigation Proceeds Received ^ Suffix Decedent's First Name MI THOMAS J Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required (date of death after 12-12-82) ~ Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) 1 ~ Spousal Poverty Credit (date of death ^ 11. Election to tax under Sec. 9113(A) between 12-31-gt and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAD y~meFTeleph ne NumberBE DIRECTED TO: Name (717) 761 4540 EDMUND G. MYERS Firm Name (If Applicable) JOHNSON DUFFIE First line of address 301 MARKET STREET Second line of address PO BOX 109 City or Post Office LEMOYNE State ZIP Code PA 17043 REGISTER OF WILLS USE ONLY w ~~ ,~... ~~ c ~ c~ : -Z~ r... ,..~ ~ - r--; __r , ;~ +; - _ DAT ~.rl~l~ `'~ r-, rJ x'77 _ '~'•1 -°r ~" .~ ,-.-a -, , -:. _ -~ ,,_,,._ - - ~ ~. a~ o P~ •r~~ ~_.., ,-; e m dsw.com Correspondent's a-mail address: 9 @~ It Isdtrueecorrlect andecoumpletde.cDeclaration of prepares odther than the persoinalaepresentat ve is based on aldl iriform t on~ of whichhpreparer has any knowledge,belief, ATE / SIGNATURE OF PERSON RESP NSIB E FOR FILING RETURr~ ~ ~ 9 ~ / , ~~, ~ KAREN L. ROZMAN // ! U 9 ADDRESS ~o r.RFFNWAY DRIVE. MECHANICSBURG, PA 17055 SIGNA E OF PRjPARER OTHER THAN REPRESENTATIVE ~~S.y~.ll ~il~An - EDMUND G. MYERS r - ADDRESS 301 MARKET STREET, LEMOYNE, PA 17043 Side 1 1505607120 1505607120 1505607220 REV-1500 EX Decedent's Social Security Number oecedenYs Name: THOMAS J. R O Z M A N 18 1 5 8 8 2 2 0 RECAPITULATION 136,700.00 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 & Notes Receivable (Schedule D) ....................................................... ... 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. .. 5. 28,551.57 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ........... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ........... .. 7, 0 . 0 0 8. Total Gross Assets (total Lines 1-7) ..................................................................... .. g. 1 6 5 , 2 51.5 7 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... .. 9. 38,646.03 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. .. 10. 211,636.95 11. Total Deductions (total Lines 9& 10) .................................................................... .. 11. 2 5 0, 2 8 2 9 8 12• Net Value of Estate (Line 8 minus Line 11) .......................................................... ... 12, - 8 5 , 0 3 1 . 4 1 13. Charitable and Governmental BequestslSec 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. - 8 5 , 0 3 1 . 4 1 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 0 . 0 0 15. 16. Amount of Line 14 taxable 0 0 0 at lineal rate X .045 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 18. 19. Tax Due .............................................................. ...................................................... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505607220 1505607220 0.00 0.00 0.00 0.00 0.00 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-09-00288 DECEDENT'S NAME THOMAS J. ROZMAN STREET ADDRESS 1424 TIMBER CHASE DRIVE CITY MECHANICSBURG STATE PA ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 0.00 3. Interest/Penalty if applicable Total Credits (A + B + C) (2) D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 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. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 0.00 0.00 ~.~~ ~ X _ .:~"~) -k to - i• ;;~„ -T... -- ~ ~' ".' ~ ..(. r` P~ p:~ r }y.t'`:~„sX F 2<'^ ~~ ..~ ~ h `~"[ ~' ~ .~' a K PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................. ^ b. retain the right to designate who shall use the property transferred or its income :.................................... ^ c. retain a reversionary interest; or .................................................................................................................. ^ 0 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? ....................................................................................................................... ^ 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...................................................................................................................... ^x ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemat a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. 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-1502 EX+ (6-98) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 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. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 6-98) COO p~ A. SETTLEMENT STATEMENT U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT HUD-1 OMB No. 2502-0265 1. ®FHA 2. QFmHA 3. ~Conv. Unlns. 6. File Number: 7. Loan Number: 6. Mortgage Insurance Case Number: 4. ^VA 5. ^Conv. Ins. RE09-79 0096875323 441-9133526 C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "(p.o.c.)" were paid outside the closing; they are shown here for informational purposes and are not Included in the totals. D. Name and Address of Borrower(s): Adam J. Weaver Mellisa S. Mellott 7 Wesley Drive, Carlisle, PA 17013 E. Name and Address of Seller(s): Estate of Thomas J. Rozman 1424 Timber Chase Drive, Mechancisburg, PA 17050 F. Name and Address of lender: Wells Fargo Bank, N.A. 111 Continental Drive, Suila 114, Newark, DE 19713 G. Property location: 1424 Timber Chase Drive, Mechancisburg, PA 17050 Hampden Township, Cumberland County 10-15-1283-OOB-U39 Place of Settlement: 1 Irvine Row, Suite B, Carlisle, Pennsylvania 17013 H. Name of Settlement Agent: Orchard Settlement Services, LLC I. Closing Date: Disbursement Date: 5-29-2009 5-29-2009 100y.G"ross~Jlmourif~tDue.Fr'om*Bor~oWer~t~~~'i~~~`~"'~Ft;~ ~~r~t;'.~+d~-~~ ~~~00'~14d°ssd~'mou `(+"'~" w~~'•r~~~~'~'''~' ~'~i~ ~~ r "bueTo~Se11eF. 7 ~rlvrr.,x~, , ,~»; ' 101. Contract sales rice 136 700.00 401. Contract sales rice 136 700.00 103. Settlement cha es to Borrower line 1400 6 747.91 403. 104. 404. 105. 405. 106. Cit /fawn taxes to 406. Cil /town taxes to 107. Count taxes 5-29-2009 to 12-31-2009 171.48 407. Count taxes 5-29-2009 to 12-31-2009 171.48 109. School taxes 5-31-2009 to 6-30-2009 89.51 409. School taxes 5-31-2009 to 6-30-2009 69.51 110. H.O. Assoc. 5-31-2009 to 6-1-2009 -3.55 410. H.O. Assoc. 5-31-2009 to 6-1-2009 3.55 112. 412. 120 Gross Amoun Due From Borrower ... :.. .« y `, nt -'200.Amounts~Pald'B OrSnBeti'a~f'C7f-'Bo'r'r"ower±~'~':~^'F~.- 143 758 16 ~ ! ~ ~ .~` ,..,,~a.,~ 420 Gross Amount Due To Seller W: « •., ,.~ . " xc '. ..ter 4I '~06~Reduc~lonsY'n`Amo~'in~D!1'e"eToaSeher rte., .. 137 p10.25 202, Princi al amount of new loans j 134 208.00 502. Settlement char es to seller Iina 1400 9 964.20 203. Existin loans taken sub ect to 503. Existin loans taken subject to 204. 504. Payoff of first mortgage loan National City Mortgage #0008618704 66,963.00 205. Application Fee Credit 95.00 505. PayoK of second mortgage loan National City Bank ' #5344 34,755.33 206. 506, 208. 508. 209. 504 210. Cit. /town taxes to 510. Cit /town taxes to 211. Count taxes l0 511. Count taxes to 212. Assessments to 512. Assessments to 214. 514. 215. 515. 217. 517. 21 B. 518. 219. 519. s r;,--v, r liifi V~N~•`Y: ~ikz~i t 300!Castl~AtSettlementF.rom~aB°or~vllecrtt~=><Ri,x~..zn! 301. Gross amount due From Borrower line 120 ~y3J~fi~,~r'! 143 758.16 s ,r 60ti sh'~A~$ettl~riie ~r~IF~oni'~eller~C)Y ~.~ " 601. Gross amount due to seller line 420 _11~.~&2~ 137 010.25 303. Cash From To Borrower 1,755.16 603. Cash To From Seller 18 827 72 SELLER'S STATEMENT: The Ihformatlon contained In Blocks E, G, H, and I and on line 401, 406 and 407 is Important tax informationand is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction will beimposed on you if this Item Is required to be reported and the IRS determines that it has not been reported. You are required to provide lheSettlement Agent with your correct taxpayer identification number. If you do not provide the Settlement Agent with your correct taxpayeridentification number, you may be subject to civil or criminal penalties imposed by law. Under penalties of perjury, I certify that the numbershown on this statement Is my correct taxpayer identification number. cc~~o~~l~ 704. Transaction Fae to ERA-NRT Inc. .800: Items Payable''In Gonni:ctlon wlth`-L"oan y ' ''' les 1105. Document re oration to 1106 Notarv f =a to a h 1107 Attorneys fees to includes above items 1108. Title insurance to Orchard Settlement Services, Agent for First American Title _ 1112. Closino Protection Letter to First American Title 1113. Overnight Fee ($12 50 each)/ Wlre Fee ($15 00) to Orchard Settlement Services LLC 1700 -(+evernmPnt Rr+rordine-•ahd Tra ricfa °r`h rare x...a xc '<.~ qtr ~. krt- i x4 Paid From ( Paid From Borrowers Seller's Funds at Funds at Settlement Settlement 939.38 r o rgr.yl 9964.20 CERTIFICATION : I have carefully reviewed the HUD-1 Settlement Statement and to the best o(my knowledge and belief, it is a true andaccurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certiry that I received a copyof the HUD-1 Settlement Statement. Signature of mower " ""~~'` ~'~`"` -% .' Ic~i,,, Signature of Borrower Signature of Seller Signature of Seller The HUD-1 Settlement statement which I 'eve prepared is a true and accurate account of the funds disbursed or to be disbursed by theundersigned as part of the settlement oft Ktransaction. i ature of , ett) nt Agent '-~ Date WARNING: Il is a crime to kno ingly make false statements to the Uhiled States on this or any other similar form. Penalties upon conviction can include a fine and imprisionment. For details see: Title 18 U.S. Gode Section 1001 and Section 1010. Rev-7508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF (FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Cash 3.68 2 Commonwealth of Pennsylvania -final salary check and unused -vacation. 8,496.35 3 PSECU Checking Account. -Date of death balance. 3,861.54 4 United States Treasury -refund - 2008 Form 1040. 890.00 5 Automobile - 2008 G35 Sedan Journey -Sale Price 14,200.00 6 Household Goods -appraised value 1,100.00 TOTAL (Also enter on Line 5, Recapitulation) I 28,551.57 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) COMMONWEALTH OF PENNSYLVANIA OFFICE OF THE BUDGET COMPTROLLER OPERATIONS Karen L. Rozman 19 Greenway Drive Mechanicsburg, PA 17055 ~OOpl~ April 24, 2009 BUREAU OF COMMONWEALTH PAYROLL OPERATIONS P.O. BOX 8006 HARRISBURG, PA 17105-8006 FAX: (717) 772-3104 Dear Ms. Rozman: The enclosed check represents payment to you on behalf of Thomas J. Rozman as the administratrix of his estate. Please note that you as the administratrix will receive a "Form 1099-Misc." in the amount of $9,366.88 at year's end. The form will be in the name of the ESTATE OF THOMAS J. ROZMAN and the TIN#80-6097946 and should be kept along with this letter for tax filing purposes. PAYMENTS (PAY DATE AFTER DATE OF DEATH) PPE DATE PAY DATE TYPE PAY HOURS GROSS DEDUCTION AMOUNT* NET 2/20/09 Sala 75.00 $2,791.50 316/09 Sala 37.50 $1,395.75 Annual 133.35 $4,963.29 4/24/09 Personal 7.50 $279.15 $953.84 $8,475.85 LESS NON-TAXABLE GROSS DEDUCTIONS: AMOUNT _ ~ EXPLANATION OF NON-TAXABLE DEDUCTION I $62.81 I Pre Tax Medical Deceased Employee Estate Payment April 24, 2009 Page 2 *EXPLANATION OF DEDUCTIONS TAKEN FROM PAYMENTS: AMOUNT EXPLANATION OF DEDUCTIONS TAKEN $716.56 Social Securit /Medicare $174.47 Retirement Should you have any questions regarding this letter, please contact Mr. Edmund Brenner, at telephone number (717) 772-5368. /~ , , ~J ~~~w~) -,. Sincerely, U'`' -~ t ,,\ Sharon Wentling, Chief Special Pay Processing Enclosure Rev-1510 EX+ (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST ( EXCLUSION IF APPLICABLE) TAXABLE VALUE 1 PA State Employees Retirement System - 0.00 0.00 decedent's Retirement -Account. (Beneficiary - Decedent's Estate). Decedent was 40 years of age at the time of his death. (DOB: July 17, 1968). Date of death value - $16,076.25. 2 Pension Resources, Inc. -Administrator of 0.00 0.00 Reager 8~ Adler P.C. - 401 K Plan. Beneficiary - Decedent's Estate. Decedent was 40 years of age at the time of his death. (DOB: July 17, 1968). Date of death value - $640.06. TOTAL (Also enter on Line 7, Recapitulation) I 0.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) ~. tR' r~ ~f r Commonwealth of Pennsylvania State Employees' Retirement System 30 North Third Street, Suite 150 Harrisburg, Pennsylvania 17101-1716 www.sers.state.pa. us Telephone:i-800-633-5461 Fax: 717-237-0393 S R S ,~--J, May 27, 2009 KAREN ROZMAN EXECUTRIX THOMAS ROZMAN ESTATE 19 GREENWOOD DR MECHANICSBURG PA 17055 Dear Beneficiary: Member SSN: Beneficiary SSN/EIN: XXX-XX-8220 80-6097946 A check in amount of $16,076.25 will be mailed to you within two weeks. Federal withholding in the amount of $0.00 will be withheld for federal tax purposes. If you have elected to rollover your payment, the taxable portion of $0.00 will be transferred to your qualified plan. This payment representing your designated share of 100.00% in the final settlement of the account of THOMAS J ROZMAN, will be mailed to you within two weeks. If the individual listed above was a member of the Retirement system before January 1, 1982, their contributions prior to that date were taxed as part of their gross income at that time. Therefore, no taxes are being withheld on that portion of their contributions. The difference between the amount of your payment and your share of the deceased member's non-taxable contributions, if any, is taxable for federal income tax purposes. This payment has been reported to the Internal Revenue Service. If a 1099R form is not enclosed with this letter, you will receive one prior to January 31 of next year, with the necessary tax information regarding this payment. Under current law there are no Pennsylvania state or local taxes on any benefits paid from this system. This letter and the 1099R form that you receive should be kept in a safe place, as you will need the information when filing your Federal Income Tax Return. This is the only notice you will receive. Sincerely, Debra G. Murphy, Director Benefit Determination Division ~.,,., ,,.., ,.,^~ ~~^^~ ^un nui um min n~u 11111 VIII IIl11 IIII Illl REV•1151 EX+02.99) gCHEDULE H FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions KAREN L. ROZMAN Social Security Number(s) / EIN Number of Personal Representative(s): Street Address 19 GREENWAY DRIVE City MECHANICSBURG State PA Zip 17055 Year(s) Commission paid 7,107.62 7,500.00 2. Attorney's Fees JOHNSON DUFFIE 4,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 245.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 19,293.41 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 38,646.03 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Charles Stoops -Organist -funeral service. 75.00 2 Debbie White -Cantor for funeral service. 50.00 3 Diocese of Harrisburg -Grave Placque 1,650.00 4 Father T. Rozman -funeral service 100.00 5 Malpezzi Funeral Home -funeral expenses 4,457.62 6 Office of Catholic Cemeteries -interment charges. 775.00 H-A Subtotal 7,107.62 Other Administrative Costs 7 Chuck Bricker, Auctioneer -household goods appraisal 75.00 8 Cumberland Law Journal -advertise letters 75.00 9 Dauphin Tile Company, Inc. -carpeting replaced at 1424 Timber Chase Drive -result 1,159.54 of decedent's death. Balance not covered by -Homeowner's Insurance. 10 .ERA-NRT, Inc.IHooke, Hooke & Eckman -real estate commission -Condominium - 7,794.00 1424 Timber Chase Dr. 11 ERA-NRT, Inc. -Transaction Fee 165.00 12 Hampton Township -sewer charges -1424 Timber Chase Dr. 138.65 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 ITEM NUMBER DESCRIPTION AMOUNT 13 Karen L. Rozman -travel -residence to 1424 Timber Chase Drive - -preparing 1424 168.48 Timber Chase Drive to sell. (288 Miles x .585. 14 M. Essip -payment -sale of Integrity automobile. 50.00 15 Michael Cavanelli -payment for sale of some of the household goods. 50.00 16 Michael Langan, Treasurer - County/Township Real Estate taxes -due at settlement 118.28 -1424 Timber Chase Dr. 17 Michael Langan, Treasurer -Tax Certification -1424 Timber Chase Dr. 5.00 18 Nick Cimino -Contractor -Door and wall repairs -1424 Timber Chase -Drive - 446.00 result of decedent's death. 19 Orchard Settlement Services -Tax Service Fee 100.00 20 Orchard Settlement Services - Wire Fee 25.00 21 PA American Water Co. -water service -1424 Timber Chase Dr. 81.14 22 PNC Bank -Estate check charge. 32.56 23 Postage; Thank You Notes; Home Depot -purchase supplies for -repairs at 1424 80.00 Timber Chase Drive. 24 PPL -Electricity charges -1424 Timber Chase Dr. 29.95 25 Property Management -outstanding charges -1424 Timber Chase Drive 91.57 26 Property Management, Inc. - Re-Sale Certificate 150.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 ITEM NUMBER DESCRIPTION AMOUNT 27 Recorder of Deeds -1% Transfer Tax 28 Register of Wills -file Inventory 8~ Inheritance Tax Return. 29 Seller Credit to Buyer (Settlement Statement) -1424 Timber Chase Dr. 30 The Patriot-News -advertise letters 31 Timber Chase Condo Assoc. -Unpaid Condominium Fees 1,367.00 30.00 6,700.00 141.24 220.00 H-67 Subtotal 19,293.41 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+ (6-98) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Banana Republic -decedent's account balance. 18.87 2 Best Buy -Acct. No. 7021 2600 2044-1200 -balance due. 500.00 3 Capital One -Account No. 5178-0572-2804-2540 -balance due. 2,800.00 4 Comcast Cable -decedent's account. 35.00 5 Hertz Rental -automobile rented by decedent prior to death during -period 70.58 decedent's automobile was being repaired. Balance not covered by insurance. 6 Infiniti Financial Services - 2008 G35 Journey -Account No. 0088-0027-2400-6000 1 - 15,289.32 balance due 7 Lincare, Inc. -medical supplies 241.20 8 National City Bank -Home Equity Line of Credit -Account No. 5344 -1424 Timber 34,755.33 Chase Drive -balance due. 9 National City Mortgage - No. 0008618704 -1424 Timber Chase Drive -balance due. 66,963.00 10 PA American Water -decedent's account. 34.97 11 Pennsylvania Higher Education Assistance Agency, Inc. -Educational Loan Notes 90,155.45 (Guarantor -American Education Services). Date of death balance. 12 Pinnacle Health -decedent's account. 25.00 13 PPL -outstanding electricity charges -decedent's account. 264.89 14 State Farm Insurance -Condominium Insurance. 243.51 15 Timber Chase Condo Assoc. -Condo Fee -decedent's accunt. 110.00 Total of Continuation Schedule See attached page TOTAL (Also enter on Line 10, Recapitulation) 211,636.95 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) ~/ i ~ ~~ . JULY 23, 2008 #BWNDHHG #PRLRGLLEEM0723L6# THOMAS J. ROZMAN 1424 TIMBER CHASE DR MECHANICSBURG PA 17050-9149 DEAR B01=t'i-t~ vvtr,. COO G~V RE: Acct S~ 1467793350 This letter is in regards to the default claim previously paid by this Agency on one or more of your educational loan notes. Your continued refusal to acknowledge the balance due on this claim is resulting in the review of your account for additional action. You MUST remit payment immediately to avoid the possible garnishment of your wages or referral of your account to a collection agency. THE OUTSTANDING BALANCE OF $90,155.45 IS NOW DUE AND PAYABLE TO AES! You must send this amount to the following address and iriclude the above referenced account number to assure proper crediting of payment. AES-DEFAULT, PO Box 8147, Harrisburg, PA 17105-8147 AES has advised the national credit bureaus about the default of your account. This information may be reflected in your credit report. AES reported each defaulted note to national credit bureaus as a "Government Claim". This reporting carries a NEGATIVE rating and may have an adverse effect on future applications for credit. Your continued failure to repay this debt will result in the garnishment of your wa,~es or any Federal.refunds you may~d_r.~,~ Delaying repayment will not relieve you of this obligation, as there is no statute of limitations applicable to this debt. Any questions or comments regarding this matter may be directed to AES-DEFAULT toll free at 1-800-233-0751 for additional information. Office hours are Monday through Thursday 8:00 a.m. to 9:00 p.m., Friday 8:00 a.m. to 5:00 p.m. and Saturday 8:00 a.m. to 12:00 noon. If you are hearing impaired and communicate through a TT device, please call 717-720-2366. Jesse Lawyer ~• - Manager Loan Assets Management LCXH2:PLDSBDLDF3 14677933501467793350 o n - ~- ~ - o o M R `~ American Education Services N °_ 1200 North Seventh Street • Harrisburg, Pennsylvania 17102-1444 Rev-1512 EX+ (6-98) SCHEDULE 1 : DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA continue d INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ROZMAN, THOMAS J. 21-09-00288 VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER 16 Verizon Wireless -decedent's account 129.83 TOTAL (Also enter on Line 10, Recapitulation) I 211,636.95 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1513 EX+ (9.00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX_RET TRN SCHEDULE J BENEFICIARIES ESTATE OF ROZMAN, THOMAS J. NAME AND ADDRESS OF NUMBER PERSON(S) RECEIVING PROPERTYY I. TAXABLE DISTRIBUTIONS dl stributionsr~ antd transfers under Sec. 9116(a)(1.2)] FILE NUMBER 21-09-00288 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($$$) Do Not List Trustees Father One-half 1 HUBERT T. ROZMAN Residue 19 Greenway Drive Mechanicsburg, PA 17055 Mother One-half 2 KAREN L. ROZMAN Residue 19 Greenway Drive Mechanicsburg, PA 17055 I Total Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS v.vv TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COF ErR PA 1500 Schedule J (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. -r ~ ~ N ~~ ~ ~ r.. •~ _-. wk .~ r,r a 1 ~ +~^ '~ ',S lt. 7 ~ ,$ ~ i <,y ~:~ no ~-, •.S Nn v c:- © ~, :,.' ~ Q- ~ ~~ _~ ~ ~~ J ~~~ ~~ iqJ N rr~^t ~~ N N U ^ w x F- LJJ c~ F- ~ .~ `' -' ~ ~ z ~ O ~^ r w T ~" ~ 2 F- u '~ V ~ U w r~ LL ~.. ~' M ~~ Z j M ~ ~ r f ~ -0~ ~~ ~~ ~! ego=w ~ W~ ~ H J _ n ~ W ~ ~ i-i o° ---~ wo Q ~U~~U E~