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HomeMy WebLinkAbout07-06-09 (2).,~,J 1505607121 REV-1500 EX (06-05) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN County Code Year File Number Harrisbur , PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW 2 1 0 8 1 0 2 4 Social Security Number Date of Death Suffix Decedent's First Name J O H N S O N MI J O H N A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILLS Q 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death ^ 4. Limited Estate prior to 12 ^X 6. Decedent Died T t ^ 4a. Future Interest Compromise (date of death after 12-12-82) 13 82) ^ 5. Federal Estate Tax Return Required es ate (Attach Copy of Will) 9. Litigation Proceeds R i ~ 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 1 8. Total Number of Safe Deposit Boxes -' ece ved 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 11. Election to tax under Sec. 9113(A) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL Name t S TAX NF ORMATION HOULD BE DIRECTED 70: D A V I D H S T O N E Daytime Telephone Number Firm Name (If Applicable) E S Q U I R E 7 1 7 7 7 4 7 4 3 S T O N E L A F A V E R S H E K L E T S K First line of address 4 1 4 B R I D G E S T R E E T Second line of address City or Post Office State N E W C U M B E R L A N D p A REGISTER OF WILLS USE ON , L Y a `° -~ ~~7X~ ` r ; ~~~~ ~ /„" ~ ? ~ 1 ~ '~ ~'7(~~j 'D r~' t"> - FILED .~ + t - - ~-~ - ~ N r._ r=r1 w 0 ZIP Code 1 7 0 7 Correspondent's a-mail address: D S T O N E a~ S T O N E L A W -NET .R- ~~t Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF~pERSQN RESPONSIBLE FOR (LING RETURN `~ ~ ~- DATE ADDRESS ~ --~~ ~} ~, 371 SLUNK R T SIGNA RER E PLYMOUTH N REPRESENTATIVE 414 ~'R-I~G~' STRE~T 1505607121, M I--- 4 81? 0 D TE 2y-.~~ NEW CUMBERLAND PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 1 1505607121 J REV-1500 EX 1505607221 Decedent's Name: J O H N A J O H N S O N 5 1 0 2 7 2 8 1. Real estate (Schedule A) . .............. ... 1. 2. Stocks and Bonds (Schedule B) ..... .................... ...... z. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Sched l 6 0 2 1 0, 0 0 u e C) .. , 3 4. Mortgages & Notes Receivable (Schedule D) ......... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E ) ..... 5. 6. Jointly Owned Property (Schedule F 7 Inter Vi R ^ l 2 5 y 6 9. 4 6 . - equested ...... . vos Transfers & Miscellaneous No 6. n-P obate Pr p (Schedule G) ertq ^ Separate Billing Request d e ...... . 7. 8. Total Gross Assets (total Lines 1-7) ... ' . 9. Funeral Expenses & Administrative Costs (Schedule H) 8 5 6 7 9 ~ 4 6 ... s 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 1 9 8 4 1. 8 1 ........10. 11. Total Deductions (total Lines 9 & 10) 1 5 5 7 6. 7 7 ..... .... 11. 12. Net Value of Estate (Line 8 minus Line 11) 3 5 4 1 8 ~ 5 8 .... 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 12 an election to tax has not been made (Sch d 5 0 2 6 0 • 8 8 e ule J) ..................13. 14. Net Value Subject to Tax (Line 12 minus Line 13) 1 6 1 2 8 ~ 2 6 .... 1a. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabl 2. 6 2 3 4 1 3 e at the spousal tax rate or , transfers under Sec. 9118 (a)(1.2) X • 0 16. Amount of Line 14 taxable 0 0 p 15. at lineal rate X• 0 D. Q 0 1 ~ Amount of Line 14 taxable p p Q 16 . at sibling rate X .12 18. Amount of Line 14 taxabl 2 4 3 8 0 5 1 ~ Q 0 0 e . at collateral rate X .15 3 1 6 9 4. 5 7 2 9 2• 5 7 18. 19. Tax Due .... 4 7 5 4. 1 9 ....... ..................... 1s. 5 0 4 6. 7 6 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFU ND OF AN OVERPAYMENT a L 1505607221 Side 2 1505607221 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME 21 O8 1024 JOHN A. JOHNSON STREET - ADDRESS _ _ _ _ _ _ - __ _ -_- 863 Oak Oval - clrv _ _ __ _ Mechanicsburg STATE PA ZIP ' 17055- Tax Payments and Credits: ~ Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 6 500.00 342.10 (1) 5 046.76 3. Interest/Penalty if applicable Total Credits (A + g + C) (2) D. Interest 6 842.10 E. Penalty 4, If Line Z is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.Total Interest/Penalty (D + E) (3) Fill in oval on Page 2, Line 20 to request a refund. 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (4) 1 795.34 A. Enter the interest on the tax due. (5) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) 0.00 Make Check Payable to: REGISTER OF W/LLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred; Yes No .................................................................... ^° X 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? ~~~~~~~~~~~~~~~~"~'~'~"' ^ 0 .................................................... ^ X 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death ^ without receiving adequate consideration? .. .. ............. ^ X 3. Did decedent own an "in trust for" or payable upon death bank account or securit 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?........... _ .............................. u U IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF T HE 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 survivin s o is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. 9 p use 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 ercent [72 P.S. §9116 (a) (1.1) (ii)]. The statute doesdoes no-- t eX?mnt a transfer to a surviving spouse from tax, and the statutory regwrements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. ) p 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)], f•he 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 '2 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. ~he 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)]. Asibling is defined section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. under REV-1503 EX + (6-98) SCHEDUL COMMONWEALTH OF PENNSYLVANIA E INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF JOHN A. JOHNSON FILE NUMBER 21 08 1024 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE ~ 4911.449 shares Janney Montgomery-Alliance Bernstein Global Bd Fd OF DEATH @ $7.110 each 34,920.40 2 900.534 shares Janney Montgomery-Alliance Bernstein High Inc Fd @ $6.580 each 5, 925.51 3 790 shares Janney Montgomery-Nuveen Quality Pfd Inc Fd 3Com @ $3.555 each 2,808.45 4 2741 shares Janney Montgomery-Putnam High Yield Tr @ $6.040 each 16,555.64 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 60 210.00 REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY JOHN A. JOHNSON FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estat~$ 1024 All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER Janney Montgomery-cash account DESCRIPTION VALUE AT DATE 1 OF DEATH 358.19 2 Janney Montgomery-uncashed checks 394.15 3 PNC Bank-Checking Acct #5140032138 Princ. $24,716.92, Int. $.20 24,716.92 4 PNC Bank-Checking Acct #5140032138 -Accrued Interest 0.20 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 25 469.46 REV-1511 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF JOHN A. JOHNSON ITEM NUMBER SCHEDULE H FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS Debts of decedent must be reported on Schedule 1. DESCRIPTION A FUNERAL EXPENSES: St Paul's Church-services rendered Parthemore Funeral Home-funeral expenses FILE NUMBER 21 08 1024 AMOUNT 200.00 10,299.23 B• ADMINISTRATIVE COSTS: ~ Personal Representative's Commissions Name of Personal Representative (s) Cathy CIOUgh Street Address 371 Blunk Street City mouth state MI ~_ zip 48170 Year(s) Commission Paid: 2009 2. Attorney Fees David H. Stone, Esquire 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 Cumberland County Register of Wills and 1 short cent 5 Accountant's Fees 6 Tax Return Preparer's Fees ~ Janney Montgomery-commission on sale of stock 2 Cumberland Law Journal-advertising grant of letters 3 The Patriot News Co.-advertising grant of letters 4 Janney Montgomery-advisor fee 5 PNC Bank-check printing fee 6 Register of Wills-filing Inheritance Tax Return and Inventory 7 Reserve for closing expenses TOTAL (Also enter on line 9. RPranlt~ Marl,,,, (If more space is needed, insert additional sheets of the same size) 4,264.00 4,264.00 204.00 197.35 75.00 141.24 50.00 16.99 30.00 100.00 )I$ 19,_841.81 REV-1512 EX + (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, IN RESIDENT DECEDENTRN MORTGAGE LIABILITIES, & LIENS ESTATE OF JOHN A. JOHNSON FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, in ludmg unr0 mbursed medical ex en ITEM p ses. NUMBER DESCRIPTION VALUE AT DATE 1 Capital Area Health Assoc.-services rendered OF DEATH 221.38 2 Messiah Village-nursing home expenses 15,355.39 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 15 576.77 REV-1513 EX + (g_00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~~ ~ ~+~ c yr JOHN A. JOHNSON NUMBER I. 1. 2 4 5 6 7 II SCHEDULE J BENEFICIARIES NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] CATHY CLOUGH 371 BLUNK STREET PLYMOUTH MI 48170- PHYLLIS STIERSTORFER 7049 QUEENSCOURT LANE MACUNGIE PA 18062- BRADBEHRMAN 1613 GLOUCHESTER PLYMOUTH MI 48170- EDNABEHRMAN 14495 NORTHVILLE ROAD APT #4 PLYMOUTH MI 48170- MARK JOHNSON 528E 11TH STREET PORT CLINTON OH 43452- JAMES JOHNSON 2910 PARK LANE SANDUSKY OH 44870- FILE NUMBER 21 08 102 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Collateral Collateral Collateral Sibling Collateral Collateral AMOUNT OR SHARE OF ESTATE 12,190.22 12,190.22 2,438.05 2,438.05 2,438.04 2,438.04 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. MESSIAH VILLAGE ENDOWMENT FUND 100 MT ALLEN DRIVE MECHANICSBURG,PA 17055 2. ST PAUL'S LUTHERAN CHURCH 530 BRIDGE STREET NEW CUMBERLAND, PA 17070 TOTAL OF PART Q -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 1, 500.00 14, 628.26 ~~~ iiwre space Is needed, insert additional sheets of the same size) 16,128 '~}, ~~ ~s~_;, ~_ ~ wd~ .. ~ ~~ .~. , LAST WILL AND TESTAMENT OF JOHN A. JOHNSON I, JOHN A. JOHNSON of U peer Allen Township, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do hereb make Y publish and declare this as and for my Last Will and Testament, hereby revoking and making void any and all other wills previousl Y made by me. ITEM I: I direct that my Executrix, hereinafter named shall pay all my just debts and funeral expenses as soon as conveniently ma be Y done after my decease. ITE- M jI: I hereby give and bequeath the sum of Cne Thousand Five Hundred Dollars ($1,500.00) unto the MESSIAH VILLAGE ENDOWMENT FUND a t Messiah Village in Cumberland County, Pennsylvania. ITE_ M III: All the rest, residue and remainder of my estate, whether real, personal or mixed, and wheresoever situate, I hereb Y give and bequeath as follows: A. Twenty-five per cent (25%} unto my late wife's niece, PHYLLIS STIERSTORFER, if she survives me. B• Thirty per cent (300) unto ST. PAU~,'S LUTHERAN CH?;:~CH in New Cumberland, Pennsylvania. Page 1 of C. Five per cent (5%) unto my nephew, BRAD BEHRMAN, or if he does not survive me, then unto his issues in equal shires, per stirpes. D. Twenty-five per cent (25%) unto my niece, CATHY CLOUGH, or if she does unto survive me, then unto her issue in equal shares, per stirpes. E. Five per cent (5%} unto my sister, EDNA BEHRMAN, or if she does not survive me, then unto her issue in equal shares, per stirpes. F. Five per cent (5%) unto my nephew, MARK JOHNSON, or if he does not survive me, then unto his issue in equal shares, per stirpes. G. Five per cent (5%) unto my nephew, JAMES JOHNSON, or if he does not survive me, then unto his issue in equal shares, per stirpes. ITEM IV: All federal, state and other death taxes payable because of my death, with respect to the property forming my gross estate for tax purposes, whether or not passing under this will, together with any interest or penalty imposed in connection with such tax, shall be considered a part of tre expense of tn.e administration of my estate and shall be paid from my residuary estate without apportionment or right of reimbursement. Page 2 of 5 r a ITEM V: I hereby nominate, STIERSTORFER Executrix of this my last will. constitute and appoint PHYLLIS Should PHYLLIS STIERSTORFER fail to qualify or cease to act as Executrix, I a ppoint my niece, CATHY CLOUGH, Executrix of this my last will. ITE-- M VI: No fiduciary acting hereunder shall be required to bond or enter security for the faithful performance of her post duties in any jurisdiction. IN WITNESS WHEREOF, I, JOHN A. JOHNSON, have hereunto set my hand and seal this ZO~~ day of 2000. JOH JOHNSON SIGNED, SEALED, PUBLISHED and DECLARED by JOHN A. JOHNSON, the Testator above named, as and for his Last Will and Testament, and in the presence of us, who at his request, in his presence and in the pres ce of eac o her, have subscribed our names as witnesses. 'tnes s ~ Address ' Wi t ne s s - ~~ Z-.~-4 Lit-i2G~ Address Page 3 of 5 COMMONy~7EALTH OF PENNSYLVANIA) COUNTY OF CUMBERLAND ) SS. I, JOHN A. JOHNSON, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified acco to law, do hereby acknowledge that I signed and execute rding d this instru- ment as my Last Will; that I signed it willin 1 g y and that I signed it as my free and voluntary act for the purposes therein contained. JOHN A. J NSON Sworn to or affirmed to and acknowledged before me by JOHN A. JOHNSON, the Testator, this o20~ day of '`~~l 2000 . otary Public NO'I'Af~i~. SEAL QEAALD J. BMiT8K(~r ~I~ ~~I~~I~ll1~OA N'N (fit ~d~iM! COMMONWEALTH OF PENNSYLVANIA} COUNTY OF CUMBERLAND } SS. We , ~ l ,~ ~(X and a~'~t-st- x'17. /~~~w , ---__ the witnesses, whose names are signed to the attached ~r fore going instrument being duly qualified according to law, do depose and say Page 4 o f 5 that we were present and saw Testator sign and execute the instrument as his Last Will; that Testator signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed• t at each of us in the hearing and sight of the Testator signed the will as witnesses; that to the best of our knowledge, the Testator was at the time eighteen years of age or more, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by ~ ~-t~- and ~D/~ ~-,~ yLj ]~//~ witnesses, this -'°~~~ day of ~~- 2000. Notary Public ~~ ~10TARlAL SAL Naw C+umberla~ ~ ~~ Mp Comnlls~lOrl 6cplrea IVby, 9: 200Q P~~9e ~ of ~ •t a ~~~. ~, ~ ~ B ~K ~'" z, ~a.' ~ ~ ~4I ~~~ 4~Yr ~'n a'.~ ¢E,~ f. ~ .~ ~~ ~ yG W80E,~~ ~ {~ CODICIL TO THE LAST WILL AND TESTAMENT OF JOHN A. JOHNSON I, JOHN A. JOHNSON, of Upper Allen Township, Cumberland County, and Commonwealth of Pennsylvania, declare this to be the Soie Codicil to my Last Will and Testament dated December 20, 2000. ITEM I: I hereby revoke Item V of my Last Will and Testament and in its place there shall be a new Item V which shall provide as follows: "Item V. I hereby nominate, constitute and appoint my niece, CATHY CLOUGH, Executrix of this my last will." ITE--- M II_ In all other respects I hereby ratify, confirm ar.d republish my Last Will and Testament dated December 20, 2000, ta~ether with this my sole codicil. IN WITNESS WHEREOF, I have hereunto set my hand ar:d seal this ~ day of 2004. r ~ j~ JOHN A. J ~NSON I i Page 1 of 3 SIGNED, SEATED, .p~LISHED and DECLARED by JOHN A. JOHtJSON Testator above named, as and for a Sole Codicil to his L ~ the ast Will and Testament, and in the presence of us, who at his request, in his presence and in the presence of each other, have subscribed our as witnesses, names Wit / .tr~p Witne l Address t ~ .t 1... 1L ~.ea _t A dress `~ COMMONWEALTH OF PENNSYLVANIA) COUNTY OF CUMBERLAND ) SS. I, JOHN A. JOHNSON, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified acc to law ording do hereby acknowledge that I signed and executed this instru- ment as a Codicil to my Last Will; that I signed it willingly and I signed It as m~ y that y free and voluntary act for the purposes therein contained. JOHN A. JOH SOrI Sworn to or affirmed to and acknowledged before me by JOH~1 A, JOHIv'SOt1, the Testator, this C~~ ---__ day o f ~ ~ "tit 2Gu4. ~- NOT,ggl,~ SE4L ` CARpL L• TAOXELL Nod Notary P u b l i c New Ctand 9~0 ~ C~ ry Public MY Commission Expires Berland Co Page 2 o f 3 Dec. 2~ ~ • A ~ ~ "`r~~ e ~-:~~,~u±-~.:~ it a~ his rr~~e =end ~- _ r~~~~~ xpres;;e,~ • treat e ' a_,h o~ ~al i~~ned tree will as witnes,;e~, • t.h. ± t},. Te~tatoL- wa at th - '~ ' ~ _ - , _~t .;Dian ~ e time eigf;*.ee.. ~ ~r mine an ~' ,~,,~{,~ d under no constraint or ur:d~_l~. i. ~ , '~_~ u~:li~.~_. . r .. ~r-. _ - a~fir:ti_~d _~ =~r:~ s~uk~~cri~e~ t.. k:~_ = ?' ~_ ;?~ r _ -, Ne;v CurrrCerlan.~ ~cr~, ~urn~ r,'arrd l;o. ~ n1y Gornm!~5sran ~`;nlres Dpc, ~ 7.2Q(t5 I I ~ ~ ~ ~~, :~ :7~_ _ ~ t~ ~ STONE LAFAVE.I3 &SHEKLETSKI ATTORNEYS qT Lq~y DAVID H. STONE 414 GRID REET GERgLp J, SHEKLETSKI ELIZABETH B. STONE POST OFFICE BOX E NEW CUMBEBLAND, pA 17070 www. stonelaw net Pennsylvania Department of Revenue Harrisburg District Office Lobby, Strawberry Square Harrisburg, PA 17128-0101 November 4, 2008 Re: Estate of John A. Johnson Date of Death: October 9, 2008 Social Security No. 285-10-2728 Estate No. 21-08-1024 Greetings: OF COUN$gt, CHARLES H. STONE JON F. LAFgyER ~~ TELEPHONE (717) 77q_743J FACSIMILE (717) 77q_3889 Please find enclosed an original Safe Deposit Box Invento estate. ry for the above referenced Thank you for your attention in this matter. Should you have an free to contact me. y questions, please feel Very truly yours, DHS/jam Enclosures cc: Cathy Clough, Executrix STONE LaFAVER &SHEKLETSKI ,- tone, Esquire J ~ REV-485 EX (1-07) 48500041046 SAFE DEPOSIT _. BOX INVENTORY PA Department of Revenue Social Secunty or Death Certificate Number Date of Death L 2 ~. $1 ~ , + , , PEASE SE ORIGINAL FO - . County Code Year U M ONLY 2 ~ $ File Number Decedent's Last Name ~ 1 ~ ' ~ ' ~ f 2 ~ ~ d ~ ~2 ~1 ~ ~ {{ j t ~ j ~~ ~ J O h ~ ~ ~ .~ ~ ? ~_. ~... ~ ~ ..,, ~ First Name jQ '2 -.4_ , ( ~, , ~ .. ~ , - - ~ MI .., ©ADDRESS OF DECEDENT STREET: ~ ~ ~ ' ' ~` ~ J ' O t1 sn ~ ~_-„ ~ ~ '~ ( J I .. . . ~: ~ ~ ~ ~ A_ STATE: ZIP CODE: NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAF CITY. NAME: DaV].C~ H~ . __ Stone E DEPOSIT BOX STREETADDRESS: __-_-.___ _. [----ESC~LIIL'e~ AttOrne~r fOY' Estate ' - - __ _ _ clrY: - -- - - - _ STATE: ZIP-CODE: NAME, ADDRESS AND R LATIONSHIP (fF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENIN a. NAME: G -- -- ----___ -- __ __ _ ___ _ _ RELATIONSHIP: STREETADDRESS: ~ -- ___- -- i ------ _ CITY: ------- _ .---- b. NAME: - - - -- -- -- - STATE: _ - -- -- ---- -- - - - --- ZIP CODE: -_ __-- -- - _. RELATIONSHIP:-- --____ STREETADDRESS. _._ __ -- cITY: --_ __. c. NAME: _- _ -__ _ - -- _ STATE: --- - - - -- -- ZIP CODE: __-- - - - - --- RELATIONSHIP: -- ---- - STREET ADDRESS: -- - -- -- - - - __ - -- _-- ---- -- -- - -- - _ --. _ CITY: _ -- _ -- - __ __ _ -- _ AMEAND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED STATE: ZIP CODE: NAME: PNC - Ba_n_k STREETADDRESS: - - - -- - NAME OF PERSON MAKING CITY LAST ENTRY h a n ; ,. ~. t,. _ ~ STATE: ZIP CODE: ' T...L- - ' DATE OF CONTRACT 70 RENT BOX DATE AND TIME OF LAST ENTRY NUMBER OF BOX 1 TITLE UNOER WHICH 80X IS REGISTERED NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. NAME: John A. Johnson b. NAME: STREETADDRESS: - -. ~ fi3- Qak_ QVa1 STREETADDRESS: CITY: STATE: ZIP CODE: CITY: NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY STATE: - -mod V i A u n i_ ZIF CODE: WAS A WILL IN THE BOX7 ^ YES I~ NO H es, b. Name and address of personal representative, if named )n the will ate of will: NAME: STREETADDRESS: CITY: c. Name and address of attorney, if any STATE: ZIP CODE: NAME: STREETADDRESS: CITY STATE: ZIP CCOE: L 48500041,046 48500041046 REV-485 EX SAFE DEPOSIT BOX INVENTORY Page 2 of 2 ' INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION __ __- --- _ . - ~ - LifE• insurance _policy_ from.- Valley.- Fo>4ge---Life-Lnsurance-.CompsnK ___ _ - policy #PNPAOU2319 - -- - - _ __ - face amount $8,849.00 -- _ _ _ I ERTIFY UN PE A F PERJURY THAT THE A80VE RECORD iS PERSON RECEIVING COPY OF ORRE D C LEE THE BEST OF MY KNOWLEDGE AND BELIEF. ' SAFE DEPOSIT BOX INVENTORY: NA E SIGNATURE ~ii , ' ~Rtp,,{ pR147 NA6fE AND CNECK APPROPRIATE BOX BE~C'N- \ Pc7iNi T17LE f LA TE CNECK APPRC PRL47E BOX `` / 1 J ~ ., .,. - - -- TE: Attach additional 8'/r" x 11" sheet(s) if necessary or use duplicates of this page of form ' P eF.3 i' rf 5 ?t;r - jhy n 11v~L -11.5 ~ ir; ~ fti ~P ~ 1 Ji:"P f .' . ~3~ .. ry "L Ce(5 ~ :: '. if th ml' it ' r ~ - ' ~ a r F al . !'~ fV t .'Frr ,~ y rd ~ ~r ( 3 ~ ~ r )I -~ a 1 r ~ r ~ . e v ~ i,45 r I h ) .. t rI r2S ' . r . . i .. r ~ C Page 1 of 1 Jennifer A. Mearkle From: Pass, Charles [CPass @jmsonline.comj Sent: Tuesday, November 04, 2008 10:00 AM To: Jennifer A. Mearkle Cc: Enders, Lisa Subject: FW: Estate Valuation for John A. Johnson Importance: High Jennifer and David, Attached is the Estate Valuation for John A. Johnson. Pfease call me with any questions. Thanks, CAP 731-4400 At Janney, we build enduring client relationships based upon integrity, experience providing objective advice and superior service that lead our clients to the achievemed trust by goals. nt of their financial Janney Montgomery Scott LLC (Janney) will not accept orders and/or instructions f sale of a security or other product via an a-mail transmission. This electronic Comm or the purchase or only for the person or entity to which it is addressed and may contain confidential privileged material. Any review, re-transmission, dissemination or other unication is intended persons or entities other than the intended recipient is prohibited. No c 'proprietary or waived by any accidental or unintentional transmission. If use of this information by onfidentiality or privilege is you received this electronic communication in error, please contact the sender immediately and delete the material from your com uter. guarantee the confidentiality of the material transmitted and reserves the right to monitor all - communications through its networks. Click here for additional terms an p Janney cannot electronic communication. email d disclosures relating to this ( L'-t/?003 Estate Valuation Date of Death: 10/09/2008 Valuation Date: 10/09/2008 Estate Processin of: John A. Johnson g Date: 11/03/2008 Account: 4553-8188 Report Type; Date of Death Number of Securities: 5 File ID: John Johnson DOD10C908 Shares Security or Par Description Hi h Ask Mean &/or Div g / Ad' & Int Security Low/Bid 7'ments Accruals ~ ~_ value 358.19 CASH (CASH) --~- ----- 2) 4911.449 ALLIANCEBERNSTEIN GLOBAL BD FD (018715102; ANAGX) CL A Mutual Fund (as quoted by NASDAQ) 10/09/2008 7.11000 Mkt 7.110000 3) 900.534 ALLIANCEBERNSTEIN HIGH INCM FD (01859M200; AGDBX) CL B SHS Mutual Fund (as quoted by NASDAQ) 10/09/2008 6.58000 Mkt 6.580000 4) 790 NUVEEN QUALITY PFD INC FD 3 COM (67072W101; JHP) New York Stock Exchange 10/09/2008 3.96000 3.15000 H/L 3.555000 5) 2741 PUTNAM HIGH YIELD TR (746782101; PHIGX) SH BEN INT A Mutual Fund (as quoted by NASDAQ) 10/09/2008 6.04000 Mkt 6.040000 Total Value: Total Accrual: Total: $60,568.19 358.19 34,920.40 5, 925.51 2,808.45 16,555.64 $60,568.19 $0.00 Page 1 'n1s report was produced with Estar_ Pricing Systems, Inc, J eVal, a product of Estate Valaations & anney Montgomery Scott LLC assumes no respor,siGiiir~ accuracy or completeness of the information specific securi Provided the Date -~ for ties, which are valued. rlhi' ~ of Death and t a r~ iaole, ~e do nct warrant or g ~ ~e :^~e deem this infor;r3-i,_~~ b h_ .ten ~. d tJ r-.p>*ituta 1~ al llara .teF? ~ tS 3C~'1r3"y. Tt:1S' ~~ ~' ~n a F' ~~ ~ ~ tax ads; ~ ,,tom :~~t P _., .'Jn31 -~~ Sr:Q~,yd `~ _S end 3ttorr,ey to dis~,~ss eJ*ate cor,sui~ ~l~ j_r~r tea eta ement and 1 any e,~,~1 :r.~rr~rs ~~~ u~,ni~ YI[ IUJ LI`tl ~P~~ LLADING 1"HE WAY October 28, 2008 David H Stone, ESQ 414 Bridge St PO Box E New Cumberland, PA 17070 ~: John A Johnson SSN: 285-10-2728 DOD: 10-09-2008 Dear Mr. Stone: No. 2949 p. ~ In resppnSe to your request for Date of Death IDOD) fiances for the Gusto records show the following; mer noted above, our Checking Account Account # 5140032138 DOD balance: $ 24,X6.92 + 0.20 accnied i~nterest HNSON Established: 03-Q1 _1961 Safe Deposit Boa The decedent maintained safe deposit box 25 Iocated at: Messiah Village Branch 939 Oak Oval Mechanicsburg, p,4 i 7055-8409 (717) - 691-4091 Please note that this office provides date of death balances for d S~n&S)• We do not process any finan~J eposit accounts any of these item l eons or provide statemen ~s~ Cps' Checking and ~ P ease call 1-888-PNC-BANK (1.888-762-2265) or You need assistance with oflgce. ~ by yow local PNC B auk branch Sincerely, National Financial Services CeIrter PNC Bank, N.A. 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