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03-0557
Estate of, also known as Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Marie Jo. Vander Gheynst No._,~/- ~,~ - ~'5' , Deceased Geo_99Lgg_B. Vander Ghey_nst and Carl J. Va~st Petitioner(s), who is/are 18 yeats of age or older, apply(les) for: (COMPLETE "A" OR "B" BELOW:) Social Security No. 143-20-2837 A. Probate and Grant of Letters and aver that Petitioners are the executors named in the Last Will of the Decedent, dated. September 28, 1978 and codicil(s) dated None ~Vander Ghe nst Decedent's souse and named Executor in ara rah 4 of Decedent's Will rec--"~eceased Decedent State reJevanl cJrcumslances, e.g., renunciation, dealh of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: NO EXCEPTIONS B. Grant of Letters of Administration (d.b.n.c.ta.: pendenle lite; duranle absentia; duranle minorilale) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Relationship Residence (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland Messiah Village, 100 Mt. Allen Drive, Mechanicsburq, PA 17055 (Upper Allen Township) (li$1 streetr number and municipality) Decedent, then 80 years of age, died June 26 ,2003, at Messiah Village, Upper Allen Township (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property ....................................................................................... $ (If not domiciled in PA) Personal property in Pennsylvania ................................................................ $ (If not domiciled in PA) Persona property n County ............................................................................... $ Value of real estate in Pennsylvania Real Estate situated as follows: None County, Pennsylvania, with her last family or principal residence at 240~000.00 N~ .............................................................................................................. $ o.oo ......................................................................................................... $. 240,000.00 Wherefore, Petitioners respectfully request the probate of the last Will presented with this Petition and the grant of letters in the appropriate form to the undersigned: Signature yped or printed name and residence George B. Vander Gheynst 3 South Cross Road, LaGrangeville, NY 12540 Carl J. Vander Gheynst 2616 Mill Road, Box 28, Grantham, PA 17027 Form RW. 1 Page 1 of 2 (Dauphin County) -Rev, 9/92 Oath of Personal Representative Commonwealth of Pennsylvania County of '(~o-~-~_~c,~A The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Pt¢ition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative( of the Decedent, Petitioner(s) will well and truly administer the estate according to I~ Sworn to and affirmed and subscribed v/' before me this o~,dZ) day of No. .~l- Estate of ~(~ ~ _ ~n ~, ~Y.x"~t~ o~_ C~¥t~_~,,~c.. Deceased Social Security No: ~r.'~-,--~O -,~ "] Date of Death: AND NOW, (~,,J~. ~ ,20 0..¢, , in consideration of the reverse side hereon, s~isfac(t)ory proof having been presented before me, IT IS DECREED that Letters [] Testamentary [] of Administration d b n.c.l.; pendente lile; durante absenlia; durante minorilate are hereby granted to,_~.0-u2.~_ '~ ~7'~ ~ o, ~ in the above estate and that the ins{~ument(s) dated described in the Petition be admitted to probate and filed of record as the last Will of Dec Petition on the adent. FEES Letters ........................... Short Certificate(s) .......... Renunciation .................. $ Affidavit ( ) ................. $ Extra Pages ( ) ............ $ Codicil ..........................$ JCP Fee ........................ $ Inventory ....................... $. Other ............................$ $ /5', co /E. 42¢ Attorney: Lawrence B. Abrams TOTAL ................ Form RW-1 Page 2 of 2 (Dauphin Courtly) . Rev 9/92 I.D. No: 18028 Address: Rhoads & Sinon LLP, PO Box 1146 I South Market Square, Harrisbur.q, PA 17108-1146 Telephone: 717-233-5731 his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent fiiing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 9267472 ~EM # SHOULD READ AS FOLLOWS: Local Registrar JU~ 2., 8 2003 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH 80 ~,,. "~CEO~N,'S USUAL ~U~ ~ (~ve ~ ~k ~e ~ ~ KIND ~ ~51NES~IN~STRy ~-.. 100 ~. I~. Date I u.o~R,,~,n I UNO~R,D~ F' DA~'EOF.,.T. , .~m.~-,", 2 2837 ' J~e 26 2003 ~o ,.I , I : /~_s_-. I___ _. '::. [~,,*,: ,o,.,.: - ' I : I : L ~o~ r. ' / e~-JZ'~ ........ F. .. I~- ~ I~. ~ n~.~ ~s~ W~ Acu ,~.. s,.,. P~nsylvania 100 ~. ~n ~ive .Es,~ ~ ~ ,,~.~ ~.~,~. ~r ~len ". ~icsb~9, PA 17055 Hans Vander~eyns t Carl VanderGh~ynst · SIGN/G'URE OF FUNERAL S VICE LICE -- ~R ACTING AS SUCH LICENSE NUMBER ~ ....,. ~ ~-~-'F----~ ., 012755-L er~ Har , . ~,,~- .-~ ~-~.,~/--~ ~...¢. . : . I,~Y - ~r ~, 1903 ~t S~ CH. On the bllil of exllminlllon and/o~ investigation, in my opinion, dealh occurred al the me da · manner Il $tat~ ............. , , and place and due to the cause(l) and ~ flEGIST~R'S~ATURE AND~BER / / IINJURY AT WORK? JD£SCRmE H(~N INJURY OCCURRED. ~.,E] NoEl -, · /-' / z., ~ ~,~.,~ LAST WILL AND TESTAMENT I, MARIE JOHANNA VANDER GHEYNST, of the Borough of Mechanicsburg, County of Cumberland and State of Pennsylvania, being of sound~mind, memory and understanding, do make, pub- lish and declare this to be my Last Will and Testament, here- by revoking and making void all former Wills and Codicils heretofore made by me. I order and direct that all my just debts and funeral expenses be paid by my Executor, hereinafter named, as soon as conveniently may be done after my decease. I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal, and mixed, whatso- ever and wheresoever situate, unto my beloved husband, PAUL BRYS VANDER G~EYNST, absolutely and in fee simple, if he sur- vives me. If my husband fails to survive me, then and in that event, I give, devise and bequeath all of my estate, real, personal and~ mixed, whatsoever and wheresoever situate, to my sons, GEORGE B. VANDER GHEYNST and CARL J. VANDER GHEYNST, equally, share and share alike. Should both of my sons pre- decease me without leaving issue to survive then,and in that event, I dispose of my estate as follows: ne One-quarter (%) thereof I give and. bequeath to my daughter-in-law, SUZA~.~NE VANDER GHEY%;ST, Page 1. provided she survives me; One-quarter (%) thereof I give and bequeath to my daughter-in-law, SUELLEN VANDER GHEYNST, provided she survives me; Ce One-quarter (¼) thereof I gi~ and bequeath to SAI}~T LUKE'S EPISCOPALIILN CHURCH, of Mechanics- burg, Pennsylvania; One-quarter (~) thereof I give and bequeath to HOLY SPIRIT HOSPITAL, of Camp Hill, Pennsyl- vania. Should any daughter-in-law fail to survive me, the share she would have received is to be divided equally among the shares of the foregoing beneficiaries who do survive me. I hereby nominate, constitute and appoint my said husband, PAUL BRYS VAt, DER GHEYNST, Executor of this, my Last Will and Testament. Should my husband fail to survive me or cease to act as Executor, then, in that event, I appoint my sons, GEORGE B. VANDER GHEYNST and CARL J. VANDER GHEYNST, as Co-Executors of this, my Last Will and Testament. I here- by relieve my Executor or Executors from the necessity of posting bond in conjunction with his or their duties as such in any jurisdiction in which he or they may be called, upon to act insofar as I am able by law to do. IN WITNESS WHEREOF, I, MARIE JOH~qNA VANDER GHEYNST, Page 2. the Testatrix, have hereunto set my hand and seal to this, my Last Will and Testament, this ?~-~ day of ~e~~.~- A. D. 1978. M~rie Johanna Vander Gh~nst The preceding instrument, consisting of this and two (2) other typewritten pages, each id. entified by the sig- nature of the Testatrix, was on the date thereof, signed, sealed, published and declared by MARIE JOHANNA VANDER GHEYNST, the Testatrix therein named, as and for her Last Will and Testament, in the presence of us, who, at her request and in her presence, and in the presence of each other, have sub- scribed our names as witnesses thereto. ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) : CO~;TY OF CUMBERLanD ) SS. I, MARIE JOHANNA VkNDER GHEYNST, whose name is signed to the attached or foregoing instrument, hav- ing been duly qualified according to law, do hereby acknowledge that I signed and executed and instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the pur- poses therein expressed. ~rie Johanna Vander Gh~nst' Sworn to or affirmed before me this ~i ~_n day of ~T/.~i~ , 1978. AFFIDAVIT COMMON~EALTH OF PENNSYLVANIA ) : SS. COUNTY OF CUMBERLAND ) We, -_.~ , *... ~ . ~. ~_ j and names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and exe- cute the instrument as her Last Will and Testament; that MARIE JOHANNA VANDER GHEYNST signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us, in the hear- ing and sight of the Testatrix, signed the Will as wit- nesses, and that to the best of our knowledge, the Tes- tatrix was at that time eighteen (18) or more years of age, of sound mind~ and under no constraint or undue in- flurnce. Sworn to or affirmed to and. subscribed before me by . ~ ~..1~ ~ ~), ~ ~- and © , ........ , ~{'~ day of ~_~,~..~ witnesses, this , A. D. 1978. Witness Wi tness: ~otary Public LAST WILL ~D TESTAMENT OF MARIE JOHANNA V~DER GHEYNS'~ JOSEPH P. ALEXA, Attorney-at-Law, 16 South Market Street, ~e chanicsburg, Pennsylvania, 17055 Name of Decedent: Date of Death: Will No. To the Register: CERTIFICATE OF NOTICE UNDER RULE 5.6(a) Marie Johanna Vander Gheynst June 26, 2003 Adm. No. 2003-00557 I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on July q, 2003. Name Address George B. Vander Gheynst Carl J. Vander Gheynst 3 South Cross Road LaGrangeville, NY 12540 2616 Mill Road, Box 28 Grantham, PA 17027 Notice has now been given to all persons entitled thereto u~er Rule 5.6(a_~cept NO EXCEPTIONS / \ ( / ~"~. Date: July q, 2003 Signature: ~~ (~~~~~ Name: KI 'Lawrence B. A r~a~s, Esquire Address: Rhoads & Sinon LLP One South Market Square, 12th Floor P. O. Box 1146 Harrisburg, PA 17108-1146 Telephone: (717) 233-5731 Capacity: Personal Representative X Counsel for Personal Representative 479035.1 ROBERT H. LONG, SHERILL T. MOYER JAN P. PADEN RICHARD B. WOOD LAWRENCE B. ABRAMS III J. BRUCE WALTER JOHN P. MANBECK FRANK J. LEBER PAUL A. LUNDEEN JACK F. HURLEY, JR. DAVIDB,DOWLING DAVIDF.O'LEARY DAVID O.TWADDELL CHARLES J. FERRY STANLEY A. SMITH JENS H. DAMGAARDz DRAKE D. NICHOLAS THOMAS A. FRENCHe DEAN H. DUSINBERRE DONNA M.J. CLARK CHARLES E. GUTSHALL PAUL F. WESSELL SHAWN D. LOCHINGER ]AMES H. CAWLEY DEAN F. PIERMATTEI KENNETH L. JOEL~' DEBRA M, KRIETE TODD J. SHILL DAVID M. BARASCH THOMAS 3. NEHILLA ROBERT J. TRIBECK TIMOTHY J. NIEMAN LOR1.1, McELROY KEVIN M. GOLD CARL D. LUNDBLAD JAMES E. ELL[SON RICHARD E. ARTELL PAUL 3. BRUDERt JR.'e JOANNE BOOK CHRISTINE MICHAEL W. WINFIELDa STEPHANIE E. DIVITTORE KATHLEEN D. BRUDER4's JO[IN M. COLES HEATHER Z. KELLY JAMES J. JARECIG" JENNIFER ZIMMERMAN ALSO ADMITTED TO THE DISTRICT OF COLUMBIA BAR ALSO ADMITTED TO THE FLORIDA BAR ALSO ADMITTED TO THE MARYLAND BAR ALSO ADMITTED TO THE NEW JERSEY BAR ALSO ADMITTED TO THE NEW YORK BAR NATIONAL BOARD OF TRIAL ADVOCACY CERTIFIED ~HOAD8 & ~INON LLP ATTORNEYS AT LAW TWELFTH FLOOR ONE SOUTH MARKET SQUARE P.O. BOX 1146 HARRISBURG, PA 17108-1146 TELEPHONE (717) 233-5731 FAX: (717) 232-1459 E M A I L: ydurham@rhoads-sinon.com W E B S I T E: www.rhoads-sinon.com September 26, 2003 OF COUNSEL HENRY W. RHOADS RETIRED JOHN C. DOWLING PAUL H. RHOADS 1907-1984 FRANK A. SINON 1910-2003 JOHN M, MUSSELMAN 1919-1980 CLYLE R. HENDERSHOT 1922-1980 DIRECT DIAL NO. (717) 231-6677 FILE NO. 8596/01 Re: Register of Wills County of Cumberland Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 Dear Sir/Madam: Estate of Marie Johanna Vander Gheynst File No.: 0557 of 2003 ~-~ :' Enclosed is a check in the amount of $13,000 representing payment on account of Pennsylvania Inheritance Tax for the Estate of Made Johanna Vander Gheynst, file number 0557 of 2003. We are making payment within three months of Mrs. Vander Gheynst's death (June 26, 2003) in order to qualify for the 5% discount for early payment. Kindly time-stamp the enclosed copy of this letter and return it to the bearer of this letter. Enclosures cc: Carl Vander Gheynst George Vander Gheynst Very truly yours, RHOADS &SINON LLP By: yy/o/me R. Durham LL~al Assistant 488926.1 YORK: AFFILIATED OFFICE: LANCASTER: STE. 203, 1700 S. DIXIE HWY, BOCA RATON, FL 33432 TELEPHONE (717) 843-'1718, FAX (717) 232-1459 TELEPHONE (561) 395-5595, FAX (561) 395-9497 TELEPHONE (717) 397-4431, FAX (717) 232-1459 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 0O3059 ABRAMS LAWRENCE B ESQUIRE RHOADS & SINON P O BOX 1146 HARRISBURG, PA 17108-1146 ........ fold ESTATE INFORMATION: SSN: 143-20-2837 FILE NUMBER: 21 03-0557 DECEDENT NAME: VANDER GHEYNST MARIE JOE DATE OF PAYMENT: 09/26/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 06/26/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $ 13,000.00 ~NA TOTAL AMOUNT PAID: 3,000.00 REMARKS: C/O LAWRENCE B ABRAMS,ESQ. SEAL CHECK//1 O7 INITIALS: JA RECEIVED BY' DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS November 4, 2003 SINCE 1888 3211 North Front Street EO. Box 5300 Harrisburg, PA 17110-0300 717-238-8187 Fax: 717-234-9478 Office of Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Other Offices Colonial Park Mechanicsburg 717-652-7020 717-691-5577 Millersburg Shippensburg 717-692-5810 717-530-7515 Re: Estate of Eugene T. Spelman No. 21-02-0557 Ladies and Gentlemen: Herewith is the above-named Estate's check in the amount of $147.57, as per the October 21 Appraisement and Assessment of the PA Department of Revenue. A pre-posted envelope is enclosed for your returning a receipt. Thank you. Very truly yours, CKERSHAM, KNAUSS & ERB, P.C. Jered L. Hock JLH/amm Enclosures ... cc: David V. Spelman 291882-1 James E Carl Edward E. Knauss, IV* Jered L. Hock Steven IZ Miner Clark DeVere Milton Bernstein Bruce J. Warshawsky Francis J. Lafferty, IV David H. Martineau Andrew W. Norfleet Andrew C. Spears Young-Suh Koo * Board Certified in civil trial law and advocacy by the National Board of Trial Advocacy 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 SINCE 1888 Office of Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Name of Decedent: Date of Death: Will No. To the Register: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Admin. No. 2003-00577 I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on 3.~./~_812003 : Name Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except SignOre Name Address Teleph°ne (~7/7 ~r~'~L -760 ,,~ Capacity: ~ Personal Representative /~ ~¢,~"q..jC Counsel for personal representative ROBERT H. LONG, `iR.2 SHERILL T. MOYER ]AN P. PADEN RICHARD B. WOOD LAWRENCE B. ABRAMS IIIz 3. BRUCE WALTER 3OHN P. MANBECK FRANK `l. LEBER PAUL A. LUNDEEN .)ACK F. HURLEY, .1R. DAVID B. DOWLING DAVID F. O'LEARY DAVID O. TWADDELL CHARLES `l. FERRY STANLEY A. SMITH `lENS H. DAMGAARD2 DRAKE D. NICHOLAS THOMAS A. FRENCHG DEAN H. DUSINBERRE DONNA M.3. CLARK CHARLES E. GUTSHALL PAUL F. WESSELL SHAWN D. LOCHINGER .lAMES H. CAWLEY DEAN F. PIERMATTEI KENNETH L. -lOLL~ DEBRA M. KRIETE TODD .l. SHILL DAVID M. BARASCH THOMAS .1. NEH[LLA ROBERT .1. TRIBECK TIMOTHY .1. NIEMAN LORI .1. McELROY KEVIN M. GOLD CARL D. LUNDBLAD .lAMES E. ELLISON RICHARD E. ARTELL PAUL `l. BRUDER `iR.4 .1OANNE BOOK CHRISTINE MICHAEL W. WINFIELD* STEPHANIE E. DIV[TTORE KATHLEEN D. BRUDER~'s 3OHN M. COLES HEATHER Z. KELLY `lAMES .1..IARECKI .I~NIF1ER 71MMB~,4AN ALSOADMITTED TOTHEDISTRICT OF COLUMBIA BAR ALSOADMITI'ED TOTHEFLORIDA BAR ALSOADMITTED TOTHEMARYLAND BAR ALSO ADMITTED TO THE NEW JERSEY BAR ALSO ADMITTED TO THE NEW YORK BAR NATIONAL BOARD OF TRIAL ADVOCACY CERTIFIED ATTORNEYS AT LAW TWELFTH FLOOR ONE SOUTH MARKET SQUARE P.O. BOX 1146 HARRISBURG, PA 17108-1146 TELEPHONE (717) 233-5731 FAX: (717) 232-1459 E M A ! L: ydurham@rhoads-sinon.com W E B S ! T E: www.rhoads-sinon.com December 2, 2003 OF COUNSEL HENRY W. RHOADS RETIRED .IOHN C. DOWLING PAUL H. RHOADS 1907-1984 FRANKA, SINON 1910-2003 .IOHN M. MUSSELMAN 1919-1980 CLYLE R. HENDERSHOT 1922-1980 DIRECT DIAL NO. (717) 231-6677 FILE NO. 8596/01 Re: Estate of Marie Johanna Vander Gheynst Cumberland County File No. 00557 of 2003 Register of Wills Cumberland County 1 Courthouse Square Carlisle, PA 17013 Dear Sir or Madam: Enclosed are the following in connection with the above-captioned Estate:.. 2. 3. 4. 5. Pennsylvania Inheritance Tax Return, in duplicate, showing tax due. Check in the sum of $539.99 in payment of the balance of tax due. Inventory. Check in the sum of $34.00 in payment of your filing fees for the Return and Inventory. A copy of this letter, with the first page of Return attached, which we ask that you time stamp and return to our messenger. Enclosures cc: George B. Vander Gheynst Carl J. Vander Gheynst Very truly yours, RHOADS 84 SINON LLP Yv/6n~he R. Durham L ~a'l Assistant 497169.1 YORK: AFFILIATED OFFICE: LANCASTER: STE. 203, 1700 S. DIXIE HWY, BOCA RATON, FL 33432 TELEPHONE (717) 843-1718, FAX (717) 232-1459 TELEPHONE (561) 395-5595, FAX (561) 395-9497 TELEPHONE (717) 397-4431. FAX (717) 232-1459 REV-1500 EX (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG. PA 17128-0601 REV-1 500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER COUNTY CODE OFFICIAL USE ONLY YEAR NUMBER DECEDENTS NAME (LAST. FIRST. AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~ ~ander Gheynst Marie Johanna Z 143-20-2837 LU DATE OF DEATH (MM-DO-YEAR) I DATE OF BIRTH (MM-DD-YEAR) t't THIS RETURN MUST BE FILED IN DUPUCATE WITH THE t~l 06/26/2003 I 09/05/1922 REGISTER OF Wll L$ Lu (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST. AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~ I X l 1. Original Return I I 2. SupplementelReturn ~ 3. Remainder Return (date of death prior to 12-13-8 ,,~, ~.(.3 I I 4. Limited Estate Il 4a. Future Interest Compromise (dats of death after 12-12-82) I I 5. Federal Estate Tax Return Required ~:O_o._. ~ r-~ 0 ,--, 0. Decedent Died Testate (Attach copy of Will) I I 7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes {J nm ~ [~ 9. Lifigafion Proceeds Received ~-~ lO'SpousalP°vertyCredit ida'sof~lea"'~wae, li-3'-,la.d,-,-95, ["~ 11. Election to tex under Sec. Bl13(A)iAma~,,: NAME Lawrence B. Abrams, Esquire FIRM NAME (If Applicable) Rhoads & Sinon LLP TELEPHONE NUMBER 717-233-5731 COMPL~E MAILING ADDRESS One S. Market Square, Harrisbur9, PA 17108 P. O. Box 1146 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation. Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash. Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 0. Jointly Owned Property (Schedule F) (6) ~ Saparate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Asaeta (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities. & Liens (Schedule I) (10) 11. Total Deductione (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11 ) 13. 0.00 215,374.02 __ 0.00 0.00 31,296.19 0.00 87,660.78 (8) 12,549.91 5,687.64 Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) OFFICIAL USE ONLY 334,330.99 (11) 18,237.55 (12) 316,093.44 (13) 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 316,093.44 SEE INSTRUCTioNS ON REVERSE SIDE FOR APPUCABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate. or transfers under Sac. 9110 (a)(1.2) 0.00 x .0 0.00(15) 0.00 10. Amount of Line 14 taxable at lineal rate 316,093.44 x.O45 (10) 14,224.20 17. Amount of Line 14 taxable at sibling rate 0.0 0 x. 12 (17) 0.0 0 18. Amount of Line 14 taxable at collateral rate. 0. 00 x. 15 (18) 0.0 0 19. Tax Due (19) 14,224.20 20. ~ [I,]"- I {IK'I -' I=1 '-'&.~. ,--'~1111- i-'~ il iJ ';---'q.,,.lJ ~',.,'~ I I k.'~ leg'!l_ ~' a e _BI L'q I III] ~'~_lg Elll'.41 ..... :i './_*'l~'4 r,vj i =1L,,i i l- _ - HASPXXNUMBER Decedent's Complete Address: ISTRE~ ADDRESS 100 Mt. Allen Drive Cumberland County Mechanicsburg I~ATE J ZIP PA 17055- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Interest/Penalty if applicable D. Interest E. Penalty 0.00 13,000.00 684.21 0.00 0.00 (1) Total Credits (A + B + C) (2) Total Interest/Penalty (D + E) (3) 14,224.20 13,684.21 0.00 0.00 539.99 4. If Line 2 is greater than Line I + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 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). 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 539.99 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: 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; ......... F~ ~-] c. retain a reversionary interest; or ................................ ~ [~ d. receive the promise for life of either payments, benefits or care7 ................. [~] ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration7 ............................ [] J-~ 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 designation7 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. [ decJare 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. Deciarafion of preparer other than the personal representative is based on all information of which preparer has any knowledge. ~IGN~,TURE OF PREPA.~.,~f~TH~,J~_I-IAN REPRESENTATIVE ' DATE c/o Rhoads & Sinon LLP, P.O. Box 1146, Harrisburg, PA 17108 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.§ 9910 (a) (1.1) (i)]. For dates of death on or after January 1, 1995. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. § 9116 (a) (1.1) (ii)] The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. § 911 §(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. § 9115( 1.2 ) [ 72 P.S. § 9115(a)( 1 )]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (72 P.S. § 9115(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. HASPXXNUMBER REV-I'503 EX * (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER Marie Johanna Vander Gheynst 21 2003 0557 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1,107.03 Shares Aim Equity Funds, Charter Fund B CUSIP: 001413806 Inc., 300 Par BNY Capital Trust IV Def Int TR PFD SECS SR-E, 6.875%, Dec. 1, 2028 CUSIP: 09656G201 300 Par Detroit Edison Company Quarterly Income Debt Sec., 7.625%, Mar. 31, 2026 CUSIP: 250847712 5,000 Par Equitec Finl Corp Escrow Sub Deb, 12%, Dec. 15, 1993 WORTHLESS CUSIP: 2945889B6 12,000 Par Household Fin Corp Int NT BE dated 3/29/2001, mat. 3/15/2011, 7.05% CUSIP: 44181EAC2 Interest accrued to 06/26/2003 10,000 Par Integrated Res Inc Sbdb 8.625 97 Mat. 4/15/1997 WORTHLESS CUSIP: 458124~%E4 1,182.308 Shares Investment Co America CL B CUSIP: 461308207 Total from continuation pages TOTAL (Also enter on line 2, Recapitulation) VALUE AT DATE OF DEATH 11,302.78 7,731.00 7,729.97 0.00 12,487.81 212.10 0.00 30,160.68 145,749.68 iS 215,374.02 HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) Schedule B (Page 2) Estate of: Marie Johanna Vander Gheynst Item No. Description 757.247 Shares Jundt Emerging Growth Fund, CL B CUSIP: 481711208 3,344 Shares Lord Abbett Affiliated Fund, Inc. CUSIP: 544001100 10 3.037 Shares Lord Abbett Tax-Free Income TR PA Ser CL A CUSIP: 543912208 11 1,322.589 Shares Merrill Lynch Large Cap Ser FD Value B CUSIP: 59021R770 12 1,125.798 Shares Merrill Lynch Fundamental Growth CL B CUSIP: 589958206 13 8.082 Shares MFS Charter Income Trust CUSIP: 552727109 Dividend accrued on 06/26/2003 14 1,459.9904 Shares Salomon Bros Emerging Market Income Fund II CUSIP: 794910109 Dividend accrued on 06/26/2003 15 2,692.9143 Shares Salomon Bros 2008 Worldwide Fund CUSIP: 79548R103 Dividend accrued on 06/26/2003 16 600 Par Wells Fargo Capital IV GTD Cap Sec, 7.00%, Sep. 2, 2031 CUSIP: 94976Y207 Value at Date of Death 8,034.39 39,425.76 16.31 14,548.48 14,466.50 71.57 0.36 22,520.35 602.25 29,595.13 196.58 16,272.00 Total (Carry forward to main schedule) 145,749.68 REV-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Marie Johanna Vander Gheynst 21 2003 0557 Include the )roceeda of litigation and the date the proceeda were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule ITEM NUMBER 2 6 10 iAmerican Express Travelers DESCRIPTION Cheques 20,000 Par First USA Bank Wilmington DEL Certificate of Deposit dated 8/2/2000, mat. 8/2/2005, 7.05% CUSIP: 3374343J1 Interest accrued to 06/26/2003 Medco Health, medical insurance reimbursements PNC Checking Acct. #50-7008-6287 Interest accrued to 06/26/2003 PNC Money Market Acct. #50-3011-9945 Principal Life Insurance Company, Settlement Death Benefit Award United States Treasury, refund, decedent's final 1040 The Hartford, insurance refund Highmark Blue Shield, reimbursement for unused medical insurance premium Pharmerica, refund TOTAL (Also enter on line 5, Recapitulation) VALUE AT DATE OF DEATH 240.00 21,385.26 564.00 1,392.21 4,243.83 0.16 935.96 1,285.74 800.00 21.00 415.67 12.36 $ 31,296.19 HASPXXNUMBER (If more apace is needed, insert additional aheets of the same size) REV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Marie Johanna Vander Gheynst 21 2003 0557 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. DESCRIPTION OF PROPERTY 96 OF ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DATE OF DEATH DECD'S EXCLUSION DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY DF THE TAXABLE VALUE NUMREF DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (~F APPLICABLE) 1. Principal Financial Group Annuity #0035196. Beneficiaries: Decedent' s two sons, George Vander Gheynst and Carl Vander Gheynst, in equal shares. 87,660.78 100.000 0.00 87,660.78 TOTAL (Also enter on line 7, Recapitulation) $ 87,660.78 (If more space is needed, insert additional sheets of same size.) HASPXXNUMBER REV-~5~ 1 EX + (1-97) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Marie Johanna Vander ~neynsc 21 2003 0557 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION FUNERALEXPENSES: George Vander Gheynst Reimbursement for the following expenses: Flowers, 63.60; Cemetery fees 185.00; Minister 200.00; Organist 75.0O Total from continuation pages ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) / EIN Number of Personal Representative(s) Street Address City State__ Zip Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address city Relationship of Claimant to Decedent Proba~ Fees Accountant's Fees ~x Return Preparer's Fees Cumberland Law Journal Advertising Grant of Letters Testamentary George Vander Gheynst Reimbursement for the payment of an Oath fee to the Register of Wills of Dauphin County Total from continuation pages State __ Zip TOTAL (Also enter on line 9. Recapitulation) $ AMOUNT 523.60 2,701.00 8,500.00 307.00 75.00 15.00 428.31 12,549.91 HASPXXNUMBER (If more space is needed, insert additional sheets of same size) Schedule H part 1 (Page 2) Estate of: Marie Johanna Vander Gheynst Item No. Description Amount Myers-Harner Funeral Home, Inc. Funeral and burial expenses 2,701.00 Total (Carry forward to main schedule) 2,701.00 Schedule H part 2 (Page 2) Estate of: Marie Johanna Vander Gheynst Item No. Description Amount 3 4 Merrill Lynch Annual account fee Patriot News Co. Advertising Grant of Letters Testamentary PNC Bank, account fee Rhoads & Sinon LLP Reserve for out-of-pocket expenses 125.00 147.31 6.00 150.00 Total (Carry forward to main schedule) 428.31 REV-1512 EX + (1-97) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Marie Johanna Vander Gheynst 21 2003 0557 Include unreimbursed medical expenses. ITEM NUMBEF 1. Merrill Lynch margin account 2 Messiah Village Balance due 3 Pharmerica Balance due DESCRIPTION TOTAL (Also enter on line 10, Recapitulation) AMOUNT 2,097.42 3,222.00 368.22 $ 5,687.64 HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) RE~/-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES Marie Johanna Vander Gheynst NUMBER L II. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal di~dbutions, and transfe~ under Se. 9116 (a) (1.2)] Carl J. Vander Gheynst 2616 Mill Road, Box 28 Grantham, PA 17027 One-half annuity, $43,830.39 One-half residue, $107,446.34 George B. Vander Gheynst 3 South Cross Road LaGrangeville, NY 12540 One-half annuity, $43,830.39 One-half residue, FlU NUMBER 21 2003 0557 $107,446.34 ~on RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) AMOUNT OR SHARE OF ESTATE 151,276.73 ~on 151,276.73 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHFFT NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ HASPXXNUMBER (If more space is needed, insert additional sheets of the same size) I, MARIE JOHk~NA VANDER G}{F~YNST, of the Borough of Mechanicsburg, County of Cumberland and State of Pennsylvania, being of sound mind, memory and understanding, do make, pub- lish and declare this to be my Last Will and Testament, here- by revoking and making void all former 1'fills and Codicils heretofore made by me. I order and dire~ that all my just debts and funeral expenses be paid by my Executor, hereinafter named, as soon as conveniently may be done after my 2. I give, devise and bequeath all the rest, residue~ and remainder of my estate, real, personal, and mixed, wh~so- ever and wheresoever situate, ~.un. to my beloved husband, PAU~ 9~YS VA~TDER G~EY~;ST, absoI]2tely and i~.fee simp1%, if he sur- vives me. If my husband fails to survive mm, then and in that event, I give, devise and bequeath all of my estate, real, personal an~. mixed, whatsoever and wheresoever situate, to my sons, G~.ORGE B. V~NDER G~EYNST and CARL J. VANDER GHEYNST, ' equally, share and share alike. Should both of my sons pre- decease me without leaving issue to survive then, and in that event, I dispose of my estate as follows: A. One-quarter (%) thereof I give and bequeath to my daughter-in-law, SUZA~FNE VANDER GHEY~TST, 9rovided she survives me; One-quarter (%) thereof I give and bequeath to my daughter-in-law, SUELLEN VA}IDER GHEY~.IST, provided she survives me; Ce One-quarter (%) thereof I give and bequeath ~o SAI}~T LUKE'S EPISCOPALIkN CHURCH., of ~echanics- burg, Pennsylvania ~ One-quarter (%) thereof I qiv~ and bequeath to HOLY SPIRIT HOSPITAL, of Camp Hill, Pennsyl- rani a. Shou/d any dauqhter-in-l~ £a~1 to survive t, the shar~ she would have received i. to be d~vid~l~d: equally amo~9 the ~haree of the forego:Lng benef:Lciarias~who do survive m~. 4® I hereby nominate, constitute and appoint[my said husband, PA~ B~S ~I~R ~~, Exe~ of ~is~. ~ Las~ or ~all tO a~ al E~~, ~e~ ~n that e~nt, I appo~n~ ~ son~ ~O~ B. V~a ~ST ~d ~ j. V~D~R G~IST, a~ Co~~o~ of ~s, ~ ~s~ ~'~11 ~d Test~nt. I here- b~ relieve my Executor oF Executors fro~ the necessity of posting bond in conJunc~ion with his or their duties as such in any Jurisdiction tn which he or they may be called upon to ac~ insofar u I ~m ~ble by law to do. IN WITNESS I~I~EOI~, Z, MARIE JOH~A V~/.;DER GHEY~ST, the Testatrix, have hereunto set my hand and seal to this, my Last ~,'~ill and Testar~nt, this A. D. 1978. ~.lar~e Johanna Van~er Gheyns~-- The preceding instrument, consisting o5 this and two (2) other typewritten pages, each identified by the sig- nature of the Testatrix, was on the date thereof, signed, Sealed, publfshed and declared by MARIE JOHANI~A VANDE~ G~Y~ST; the Testatrix therein n~d, .as ~a~d for her La~ Testament, in the presenc~ of us, who, a~ her request and her presence, and in the presenc~ of each other, have sub- scribed our names as wi~nessee thereto. ACKNOWLEDGMENT C0MMON~.~ALTH OF PENNSYLVANIA : SS. COUnty OF CUMBERLA~{D ) I, MARIE JOHANNA V~N~ER GHEYNST, whose name is signed to the attac~..ed or for~going instrument, hav- ing been duly .aualified according to law, do hereby acknowledge that I signed and executed and instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the pur- poses therein expressed. ' -~ Sworn to or affirmed before me this $'~ ~ day of ~m~ , 1978. Marie Johanna Vander Ghe~n~ COMMON[',~ALTH OF PE~NSYLVANIA ) : SS. COUNTY OF CUMBERLAND ) ~ -, whose names are signed to the attached or foregoing instrmumnt, being duly qualified ?.ccording to law, do depose and say that we were present and saw the Testatrix' sign and exe- cute the instrument as her Last Will and Testament; that 'MARIE JOHANNA VANDER G~ST sig~ed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that ,ach of us, in the hear- ing and sight of the Testatr~, signed ~he Wi1! as wit- nesses, and that to the best of our knowledge, the Tes- tatrix was at that time eightse~ (18) or more year~, of age, of sound mind and under no constraint or und~ in- flurnce. Sworn to or affirmed to and subscribed Before , wi e,,e,, thi, day of ~4~.~.,..~ , a. D. ~97S. Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of also known as Marie Johanna Vander Gheynst No. 00557 of 2003 Date of Death June 26, 2003 , Deceased Social Security No. 143-20-2837 We, Georqe B. Vander Gheynst and Carl J. Vander Gheynst Personal Representatives of the above Estate, deceased, vedfy that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. We verify that the statements made in this Inventory are true and correct. We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unswom falsification to authorities. Name of Attorney: Lawrence B. Abrams, Esquire I.D. No.: 18028 Address: Rhoads & Sinon LLP, P.O. Box 1146 Harrisburg, PA 17108-1146 Telephone: (717) 233-5731 Personal Representatives: ~eor~'B. Vander Gheynst- uan a. vanoer Gheynst Description Value See attachment $246,670.21 (Attach Additional Sheets if necessary) Total: $246,670.21 u NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. Form RW-7 (Dauphin County - Rev. 9/92) 496130.1 Estate of Marie Johanna Vander Gheynst Estate Inventory Valued as of Date of Death Face Value 20,000 No. of Shares 1,107.03 1,182.308 757.247 3,344 3.037 1,322.589 1,125.798 8.082 1,459.9904 2,692.9143 Cash & Cash Equivalents First USA Bank Wilmington DEL Certificate of Deposit dated 8/2/2000, mat. 8/2/2005, 7.05% Interest at Date of Death PNC Checking Acct. #50-7008-6287 Interest at Date of Death PNC Money Market Acct. #50-3011-9945 Total Cash & Cash Equivalents Stocks Aim Equity Funds, Inc., Charter Fund B Investment Co America CL B Jundt Emerging Growth Fund, CL B Lord Abbett Affiliated Fund, Inc. Lord Abbett Tax-Free Income TR PA Ser CL A Merrill Lynch Large Cap Ser FD Value B Merrill Lynch Fundamental Growth CL B MFS Charter Income Trust Dividend at Date of Death Salomon Bros Emerging Market Income Fund II Dividend at Date of Death Salomon Bros 2008 Worldwide Fund Dividend at Date of Death Total Stocks 21,385.26 564.00 4,243.83 0.16 935.96 11,302.78 30,160.68 8,034.39 39,425.76 16.31 14,548.48 14,466.50 71.57 0.36 22,520.35 602.25 29,595.13 196.58 27,129.21 170,941.14 Page 1 (1) Estate Inventory Par Value 3OO 3OO 5,000 12,000 10,000 6OO Bonds, Debentures & T-Bills BNY Capital Trust IV Def Int TR PFD SECS SR-E, 6.875%, Dec. 1, 2028 Detroit Edison Company Quarterly Income Debt Sec., 7.625%, Mar. 31, 2026 Equitec Finl Corp Escrow Sub Deb, 12%, Dec. 15, 1993 WORTHLESS Household Fin Corp Int NT BE dated 3/29/2001, mat. 3/15/2011, 7.05% Interest at Date of Death Integrated Res Inc Sbdb 8.625 97 Mat. 4/15/1997 WORTHLESS Wells Fargo Capital IV GTD Cap Sec, 7.00%, Sep. 2, 2031 Total Bonds, Debentures & T-Bills 7,731.00 7,729.97 0.00 12,487.81 212.10 0.00 16,272.00 44,432.88 Miscellaneous American Express Travelers Cheques Medco Health, medical insurance reimbursements Principal Life Insurance Company, Settlement Death Benefit Award United States Treasury, refund, decedent's final 1040 The Hartford, insurance refund Highmark Blue Shield, reimbursement for unused medical insurance premium 240.00 1,392.21 1,285.74 800.00 21.00 415.67 Page 2 (2) Estate Inventory Miscellaneous Pharmerica, refund Total Miscellaneous Total Inventory 12.36 4,166.98 246,670.21 Page 3 (3) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD REV-1162 EX(11-96) 003308 ABRAMS LAWRENCE B ESQUIRE ONE S MARKET SQUARE PO BOX 1146 HARRISBURG, PA 17108 ........ fold ESTATE INFORMATION: SSN: 143-20-2837 FILE NUMBER: 2103-0557 DECEDENT NAME: VANDER GHEYNST MARIE JOE DATE OF PAYMENT: 12/04/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUM BERLAN D DATE OF DEATH: 06/26/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT A 101 $539.99 ~NA TOTAL AMOUNT PAID: $539.99 REMARKS: CARLJ VANDERGHEYNST C/O LAWRENCE B ABRAMS ESQUIRE SEAL CHECK//109 INITIALS: SK RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS MARIE JGHANNA VANDER GHEYNST Deceased IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 00557 of 2003 APPROVAL OF ACCOUNT ]~_~LEASE AND INDEMNIFICATION WHEREAS, MARIE JOHANNA VANDER GHEYNST (the "Decedent") died testate on June 26, 2003, leaving a Will which was duly probated by the Register of Wills of Cumberland County, Pennsylvania on July 8, 2003; and WHEREAS, the Decedent's Will appoints Decedent's sons, George B. Vander Gheynst and Carl J. Vander Gheynst as Executors of Decedent's estate (the "Executors"); and WHEREAS, Letters Testamentary were duly granted to said named Executors on July 8, 2003; and WHEREAS, the Executors and the beneficiaries desire that the Estate be concluded without the expense and formality of a court accounting; and WHEREAS, the Executors are willing to consent to such a conclusion of the Estate upon receipt of a proper release and indemnification, which it is the purpose of this Agreement to provide; and WHEREAS, the undersigned are the direct pames im:~nterest under Decedent's Will. NOW, THEREFORE, the undersigned, for themselves, representatives and assigns: ,,~ their heirs, personal (1) State that they have examined the First and Final Account of the administration of Decedent's Estate, which is attached hereto as Exhibit "A", and approve the transactions and distributions set forth or proposed therein as though they had been confirmed absolutely by the Court having jurisdiction over the Estate. (2) Waive the filing and auditing of the Account by any Court and agree that having jurisdiction over the Estate may confirm the Account and any Proposed any Court Distribution. (3) Acknowledge receipt from the Executors of the assets shown as being distributed or distributable to them in such Account. (4) Do hereby absolutely and irrevocably release, remise, quitclaim and forever discharge the said Executors, their heirs and personal representatives, of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever relating to the Estate of the said Decedent. (5) Do hereby absolutely and irrevocably release the Executors from filing any Account, Petition for distribution or other document with the Court of Common Pleas of Cumberland County, Pennsylvania, or in any other jurisdiction in connection with the Estate of the Decedent. (6) Do hereby agree to indemnify the Executors and hold them harmless to the extent of the Estate assets received by the undersigned from and against any and all claims, loss, liability or damage (including legal fees and costs) which the Executors may suffer or to which they may be subjected by reason of the administration of the Estate or the distribution of the assets of the -2- estate without having formal approval of the Court of Common Pleas, Orphans' Court Division, of Cumberland County, Pennsylvania, or any other court. This instrument shall be legally binding on the undersigned and their personal representatives, heirs and assigns. IN WITNESS WI-IEREOF, the undersigned have executed this Agreement on the ,~f.'t~ day of ~/~ ~ ,2004. Wimess Carl J. Vander Gheynst ,(SEAL) -3- estate without having formal approval of the Court of Common Pleas, Orphans' Court Division, of Cumberland County, Pennsylvania, or any other court. This instrument shall be legally binding on the undersigned and their personal representatives, heirs and assigns. IN WITNESS WHEREOF, the undersigned have executed this Agreement on the ~ day of /~/7~_o~1 ,2004. Wimess ess George B. Vander Gheynst ~Carl J. Vander Gheyn-st / ' (SEAL) (SEAL) & STATE OF NEW YORK COUNTY OF · SS: On this, the /~ [~ day of ~-~6~ ,2004, before me, a Notary Public, in and for the State of New York, the undersigned officer, personally appeared GEORGE B. VANDER GHEYNST, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within Agreement and acknowledged that he executed the same for the purposes therein contained· IN WITNESS WHEREOF, I hereunto set my hand and official seal. ~ ~_c~., ~ (~,__-o~~o~ (SEAL) Notary Public My Commission Expires: (SEAL) 8UgAN U. REG. NO. GUAUFIED IN DUTCHE88COUN1Y . COMMONWEALTH OF PENNSYLVANIA · · SS: COUNTY OF ~ · On this, the , ~""~¢f day of /~~.~. ,2004, before me, a Notary Public, in and for the Commonwealth of Pennsylvania, thet~fXlersiglaed officer, personally appeared CARL J. VANDER GHEYNST, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within Agreement and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. /~ Publi~ . ~_~.~ (SEAL) tdVly Commission Expires: (SEAL) C~OMMONWEALTH OF PENNSYLVANIA Notarml Seai ~Y..vonn_e R. Durham, Notary Public city otHarrisburg, Dauphin County J My Commission ExPires Aug. 20, 2005 Member, Pennsylvania ;~ssocJatJon of Notaries EXHIBIT A IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 0557 of 2003 FIRST AND FINAL ACCOUNTING OF George B. Vander Gheynst and Carl J. Vander Gheynst, Executors For ESTATE OF MARIE JOHANNA VANDER GHEYNST Date of Death: Date of Appointment: Accounting for the Period: June 26, 2003 July 8, 2003 June 26, 2003 to April 15, 2004 Purpose of Account: George B. Vander Gheynst and Carl J. Vander Gheynst, Executors, offer this account to acquaint interested parties with the transactions that have occurred. The account also indicates the proposed distribution of the Estate assets. It is important that the account be carefully examined. Requests for additional information, or questions, or objections, can be discussed with: Lawrence B. Abrams, Esquire Rhoads & Sinon LLP One South Market Square, 12tn Floor P.O. Box 1146 Harrisburg, PA 17108-1146 (717) 233-5731 514172.1 Estate of Marie Jo'hanna' Vander Gheynst Summfiry of;Account Principal Receipts Net Gain on Sales or Other Dispositions Less Disbursements: Debts of Decedent Funeral Expenses Administrative Expenses Federal & State Taxes Fees & Commissions Balance Before Distributions Less Distributions to Beneficiaries Principal Balance On Hand For Information: Investments Made Unpaid Expenses Unrealized Gains and Losses Income Receipts Net Gain on Sales or Other Dispositions Less Disbursements: Administrative Expenses Balance Before Distributions Less Distributions to Beneficiaries Income Balance on Hand For Information: Investments Made Unpaid Expenses Unrealized Gains and Losses Combined Balance on Hand Page 2 5 11 15 16 23 23 23 27 28 29 31 32 36 36 6,694.81 3,224.60 759.52 13,539.99 3,750.00 92.54 247,405.21 67.04 247,472.25 27,968.92 219,503.33 218,703.33 800.00 4,088.70 (0.03) 4,088.67 92.54 3,996.13 3,996.13 0.00 800.00 Page 1 (1) Estate of Marie Johanna'Vander Gheynst Receipts of Principal FACE 20,000 Cash and Cash Equivalents First USA Bank Wilmington DEL Certificate of Deposit dated 8/2/2000, mat. 8/2/2005, 7.05% Interest to Date of Death PNC Checking Acct. #50-7008-6287 Interest to Date of Death PNC Money Market Acct. %50-3011-9945 Inventory Value 06/2612003 21,385.26 564.00 4,243.83 0.16 935.96 No. of Shares 1,107.03 1,182.308 757.247 3,344 3.037 1,322.589 1,125.798 Total Cash and Cash Equivalents Stocks Aim Equity Funds, Inc., Charter Fund B Investment Co America CL B Jundt Emerging Growth Fund, CL B Lord Abbett Affiliated Fund, Inc. Lord Abbett Tax-Free Income TR PA Ser CL A Merrill Lynch Large Cap Ser FD Value B Merrill Lynch Fundamental Growth CL B MFS Charter Income Trust Dividend at Date of Death Inventory Value 06~26~2003 11,302.78 30,160.68 8,034.39 39,425.76 16.31 14,548.48 14,466.50 70.84 ** 0.35 27,129.21 ** MFS Charter Income Trust value adjusted by (.74). Page1 (2) Receipts of P'rincip~al (Continued) f No. of Shares 1,459.9904 2,692.9143 Stocks Salomon Bros Emerging Market Income Fund II Dividend at Date of Death Salomon Bros 2008 Worldwide Fund Dividend at Date of Death Inventory Value 06/2612003 22,520.35 602.25 29,595.13 196.58 Total Stocks 170,940.40 Par Value 3OO 3OO 12,000 6OO Bonds, Debentures & T-Bills BNY Capital Trust IV Def Int TR ?FD SECS SR-E, 6.875%, Dec. 1, 2028 Detroit Edison Company Quarterly Income Debt Sec., 7.625%, Mar. 31, 2026 Household Fin Corp Int NT BE dated 3/29/2001, mat. 3/15/2011, 7.05% Interest to Date of Death Wells Fargo Capital IV GTD Cap Sec, 7.00%, Sep. 2, 2031 Total Bonds, Debentures & T-Bills Inventory Value 06~26~2003 7,731.00 7,729.97 12,487.81 212.10 16,272.00 44,432.88 240 Miscellaneous American Express Travelers Cheques Inventory Value 06126/2003 240.00 Page 2 (3) · ° Receipts of P~incip&l (Continued) ' Miscellaneous 1,392.21 Medco Health, medical insurance reimbursements 1,285.74 Principal Life Insurance Company, Settlement Death Benefit Award 800 United States Treasury, refund receivable, decedent's final 1040 21 The Hartford, insurance refund 415.67 Highmark Blue Shield, reimbursement for unused medical insurance premium 12.36 ?harmerica, refund Total Miscellaneous Total INVENTORY RECEIPTS SUBSEQUENT TO INVENTORY 735.74 07/28/2003 Principal Financial annuity checks mailed after death, later reimbursed to company Total RECEIPTS SUBSEQUENT TO INVENTORY Total Receipts of Principal Inventory Value 06~26~2003 1,392.21 1,285.74 800.00 21.00 415.67 12.36 $ 4,166.98 $ 246,669.47 735.74 735.74 $ 247,406.21 Page 3 (4) Estate of Marie Joharma' Vander Gheynst ' Gains and Losses on Sales or Other Dispositions of Principal Net Gain 07/03/2003 Sale 275 Shares Salomon Bros Emerging Market Income Fund II Inventoried at $ Net Proceeds 4,240.24 4,064.21 $ 07/03/2003 Sale 370 Shares Salomon Bros Fund Inventoried at Net Proceeds 2008 Worldwide $ 4,066.20 3,950.99 07/28/2003 Sale Principal Financial annuity checks mailed after death, later reimbursed to company Net Proceeds $ Carried at 7~5.74 735.74 07~30~2003 Sale 850 Shares Lord Abbett Affiliated Fund, Inc. Net Proceeds $ Inventoried at 10,220.15 10,021.50 $ 198.65 08/07/2003 Collection American Express Travelers Cheques Net Proceeds $ Carried at 240.00 240.00 08/27/2003 Sale The Hartford, insurance refund Net Proceeds $ Carried at 21.00 21.00 Net Loss 176.03 115.21 Page 1 (5) 09/1812003 09/25/2003 09/25/2003 09/25/2003 10/14/2003 10/16/2003 11/26/2003 'Gain3 and Losses on Sales or Other Dispositions of Principal (Continue~l) Net Gain Collection Highmark Blue Shield, reimbursement for unused medical insurance premium Net Proceeds $ Carried at 415.67 415.67 Collection Medco Health, medical insurance reimbursements Net Proceeds $ Carried at 1,392.21 1,392.21 Collection PNC Checking Acct. #50-7008-6287 Net Proceeds Carried at 4,973.73 4,973.73 Collection PNC Money Market Acct. #50-3011-9945 Net Proceeds $ Carried at 935.96 935.96 Collection Principal Life Insurance Company, Settlement Death Benefit Award Net Proceeds $ Carried at 1,285.74 1,285.74 Collection Pharmerica, refund Net Proceeds Carried at 12.36 12.36 Capital Gain Distribution Lord Abbett Affiliated Fund, Inc. Net Proceeds $ Inventoried at 4.49 0.00 4.49 Net Loss Page 2 (6) 12/17/2003 12/17/2003 'Gains and Losses on Sales or Otl~er Dispositions of Principal (Continue'd) Net Gain Net Loss Capital Gain Distribution Investment Co America CL B Net Proceeds $ 249.03 Inventoried at 0.00 $ 249.03 Sale 270 Shares Salomon Bros Fund Inventoried at Net Proceeds 2O08 Worldwide $ 2,967.23 2,873.34 $ 93.89 $ 385.13 Total Gains and Losses Net Gain $ 452.17 $ 67.04 Page 3 (7) Estate of Marie Johanna'Vander Gheynst Disbursements of Principal Date Paid Amount Paid 06/27/2003 07/29/2003 07~29~2003 08/19/2003 11/05/2003 07~29~2003 08/13/2003 Claims presented, allowed, paid, credited and appearing in the Summary Statement Merrill Lynch margin balance Messiah Village Balance due Check Number 102 Pharmerica Balance due Check Number 101 Principal Financial Group Return of annuity checks issued after death Check Number 105 Messiah Village Transportation charges Check Number 108 Total Claims presented, allowed, paid, credited and appearing in the Summary Statement Funeral Expenses Myers-Harner Funeral Home, Inc. Funeral and burial expenses Check Number 103 George Vander Gheynst Reimbursement for the following expenses: Flowers, 63.60; Cemetery fees 185.00; Minister 200.00; Organist 75.00 $ 2,240.74 3,222.00 368.22 735.74 128.11 $ 6,694.81 2,701.00 523.60 Page 1 (8) Disbursements df Prin'cipal (Continued) Date Paid 07/07/2003 08/05/2003 08/05/2003 08/13/2003 09/05/2003 12/02/2003 09/26/2003 12/03/2003 Funeral Expenses Check Number 104 Total Funeral Expenses Administration Expenses ?NC Bank, account fee Merrill Lynch Annual account fee PNC Bank, account fee George Vander Gheynst Reimbursement for the payment of an Oath fee to the Register of Wills of Dauphin County Check Number 104 PNC Bank, account fee Rhoads & Sinon LLP Reimbursement for out-of-pocket expenses per 11/26/2003 statement Total Administration Expenses Federal and State Taxes Register of Wills, Agent Payment on account of PA Inheritance Tax Check Number 107 Register of Wills, Agent Balance due, PA Inheritance Tax Amount Paid $ 3,224.60 $ 2.00 125.00 2.00 15.00 2.00 613.52 $ 759.52 $ 13,000.00 539.99 Page 2 (9) Disbursements o'f Principal (Continued) Date Paid 12/02/2003 Federal and State Taxes Check Number 109 Total Federal and State Taxes Fees and Commissions Rhoads & Sinon LLP Payment on account of attorneys' fees Total Fees and Commissions Total Disbursements of Principal Amount Paid $ 13,539.99 $ 3,750.00 $ 3,750.00 $ 27,968.92 Page 3 (10) Estate of Marie Jr>hanna' Vander Gheynst Distributions of Principal to Beneficiaries Distribution Value Carl J. Vander Gheynst 01/06/2004 553.03 Shares Aim Equity Funds, Inc., Charter Fund B 01/06/2004 150 Par BNY Capital Trust IV Def Int TR PFD SECS SR-E, 6.875%, Dec. 1, 2028 01/06/2004 150 Par Detroit Edison Company Quarterly Income Debt Sec., 7.625%, Mar. 31, 2026 01/06/2004 2,500 Par Equitec Finl Corp Escrow Sub - Deb, 12%, Dec. 15, 1993 WORTHLESS 01/06/2004 Cash 01/06/2004 10,000 Par First USA Bank Wilmington DEL Certificate of Deposit dated 8/2/2000, mat. 8/2/2005, 7.05% 01/06/2004 6,000 Par Household Fin Corp Int NT BE dated 3/29/2001, mat. 3/15/2011, 7.05% 01/06/2004 595.6315 Shares Investment Co America CL B 01/06/2004 5,000 Par Integrated Res Inc Sbdb 8.625 97 Mat. 4/15/1997 WORTHLESS 01/06/2004 378.247 Shares Jundt Emerging Growth Fund, CL B 5,646.44 3,865.50 3,864.98 0.00 1,601.69 10,692.63 6,243.91 15,204.86 0.00 4,013.20 Page I (11) Distributions of Principal to l eneficiaries (Continued) Distribution Value Carl J. Vander Gheynst 01/06/2004 1,247 Shares Lord Abbett Affiliated Fund, Inc. 14,702.13 01/06/2004 1.037 Shares Lord Abbett Tax-Free Income TR PA Ser CL A 5.57 01/06/2004 661.589 Shares Merrill Lynch Large Cap Ser FD Value B 7,277.48 01/06/2004 563 Shares Merrill Lynch Fundamental Growth CL B 7,234.55 01/06/2004 0.798 Shares Merrill Lynch Fundamental Growth CL B 10.25 01/06/2004 4 Shares MFS Charter Income Trust 35.42 01/06/2004 612.30605 Shares Salomon Bros Emerging Market Income Fund II 9,441.18 01/06/2004 1,035.4334 Shares Salomon Bros 2008 Worldwide Fund 11,379.14 01/06/2004 300 Par Wells Fargo Capital IV GTD Cap Sec, 7.00%, Sep. 2, 2031 George B. Vander Gheynst 01/06/2004 554 Shares Aim Equity Funds, Inc., Charter Fund B 8,136.00 5,656.34 09,354.93 Page 2 (12) Distributions of Princip'al to l eneficiaries (Continued) Distribution Value George B. Vander Gheynst 01/06/2004 150 Par BNY Capital Trust IV Def Int TR PFD SECS SR-E, 6.875%, Dec. 1, 2028 01/06/2004 150 Par Detroit Edison Company Quarterly Income Debt Sec., 7.625%, Mar. 31, 2026 01/06/2004 2,500 Par Equitec Finl Corp Escrow Sub Deb, 12%, Dec. 15, 1993 WORTHLESS 01/06/2004 Cash 01/06/2004 10,000 Par First USA Bank Wilmington DEL Certificate of Deposit dated 8/2/2000, mat. 8/2/2005, 7.05% 01 ~06~2004 6,000 Par Household Fin Corp Int NT BE dated 3/29/2001, mat. 3/15/2011, 7.05% 01/06/2004 595.6315 Shares Investment Co America CL B 01/06/2004 5,000 Par Integrated Res Inc Sbdb 8.625 97 Mat. 4/15/1997 WORTHLESS 01/06/2004 379 Shares Jundt Emerging Growth Fund, CL B 01/06/2004 1,247 Shares Lord A2obett Affiliated Fund, Inc. 3,865.50 3,864.99 0.00 1,601.69 10,692.63 6,243.90 15,204.85 0.00 4,021.19 14,702.13 Page 3 (13) Distributions of Princip'al to t}eneficiaries (Continued) George B. Vander Gheynst 01/06/2004 2 Shares Lord Abbett Tax-Free Income TR PA Ser CL A 01/06/2004 661 Shares Merrill Lynch Large Cap Ser FD Value B 01/06/2004 562 Shares Merrill Lynch Fundamental Growth CL B 01/06/2004 4 Shares MFS Charter Income Trust 01/06/2004 612.30605 Shares Salomon Bros Emerging Market Income Fund II 01/06/2004 1,035.4334 Shares Salomon Bros 2008 Worldwide Fund 01/06/2004 300 Par Wells Fargo Capital IV GTD Cap Sec, 7.00%, Sep. 2, 2031 Total Distributions of Principal 10.74 7,271.00 7,221.70 35.42 9,441.18 11,379.14 8,136.00 Distribution Value $ 109,348.40 $ 218,703.33 Page 4 (14) Estate of Marie Johanmt'Vander Gheynst Principal Balance On Hand Valued as of April 20, 2004 Inventory Value Miscellaneous 8OO United States Treasury, refund receivable, decedent's final 1040 800.00 Total Miscellaneous $ 800.00 $ 800.00 Total Balance on Hand Page 1 (15) Estate of Marie Johanna'Vander Gheynst Information Schedules - Principal New Investments Investment Co America CL B 12/17/2003 8.955 Salomon Bros Emerging Market Income Fund II 06/30/2003 39.6217 Shs. Shs. Salomon Bros 2008 Worldwide Fund 06/30/2003 17.9525 Shs. Total New Investments Purchased via Reinvestment Purchased Reinvestment of dividend, all of which was accrued income Purchased Reinvestment of dividend, all of which was accrued income Inventory Value $ 249.03 $ 602.25 $ 196.58 $ 1,047.86 Exchanges and Stock Distributions Aim Equity Funds, Inc., Charter Fund B 06/26/2003 1,107.03 Shs. 01/06/2004 (554) Shs. 553.03 Shs. 01/06/2004 (553.03) Shs. Received Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst Inventory Value $ 11,302.78 (5,656.34) $ 5,646.44 (5,646.44) American Express Travelers Cheques 06/26/2003 08/07/2003 Received Collected 240.00 (240.00) Principal Financial annuity checks mailed after death, later reimbursed to company 07/28/2003 07/28/2003 Received Sold 735.74 (735.74) Page 1 (16) Information Scheduies - P 'incipal (Continued) Exchanges and Stock Distributions BNY Capital Trust IV Def Int TR PFD SECS SR-E, 6.875%, Dec. 1, 2028 06/26/2003 300 Par 01/06/2004 (150) Par 150 Par 01/06/2004 (150) Par Received Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst Inventory Value 7,731.00 (3,865.50) $ 3,865.50 (3,865.50) Detroit Edison Company Quarterly Income Debt Sec., 7.625%, Mar. 31, 2026 06/26/2003 300 Par 01/06/2004 (150) Par 150 Par 01/06/2004 (150) Par R~ceived Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst $ 7,729.97 (3,864.99) $ 3,864.98 (3,864.98) Equitec Finl Corp Escrow Sub Deb, 12%, Dec. 15, 1993 WORTHLESS 06/26/2003 5,000 01/06/2004 (2, 500) Par Par 01/06/2004 2,500 Par (2,500) Par Received Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst $ 0.00 0.00 0.00 0.00 First USA Bank Wilmington DEL Certificate of Deposit dated 8/2/2000, mat. 8/2/2005, 7.05% 06/26/2003 20,000 01/06/2004 (10,000) Par Par Par 10,000 Received Distribution To George B. Vander Gheynst On Hand 21,385.26 (10,692.63) $ 10,692.63 Page 2 (17) ' " Information Schedules - l~rincipal (Continued) ' ' Exchanges and Stock Distributions First USA Bank Wilmington DEL Certificate of Deposit dated 8/2/2000, mat. 8/2/2005, 7.05% (Continued) 01/06/2004 (10,000) Par Distribution To Carl J. Vander Gheynst Inventory Value $ (10,692.63) Household Fin Corp Int NT BE dated 3/29/2001, mat. 3/15/2011, 7.05% 06/26/2003 12,000 Par 01/06/2004 (6,000) Par 6,000 Par 01/06/2004 (6,000) Par Received Distribution To George B. Vander Gheynst OD Hand Distribution To Carl J. Vander Gheynst $ 12,487.81 (6,243.90) $ 6,243.91 (6,243.91) Integrated Res Inc Sbdb 8.625 97 Mat. 4/15/1997 WORTHLESS 06/26/2003 10,000 01/06/2004 (5,000) Par Par 01/06/2004 5,000 Par (5,000) Par Received Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst $ 0.00 0.00 0.00 0.00 Investment Co America CL B 06/26/2003 12/17/2003 Ol/O6/2oo4 1,182.308 Shs. 8.955 Shs. 1,191.263 Shs. (595.6315) Shs. 595.6315 Shs. (595.6315) Shs. 01/06/2004 Received Cap gain reinvestment On Hand Distribution To Carl J. Vander Gheynst On Hand Distribution To George B. Vander Gheynst $ 30,160.68 249.03 $ 30,409.71 (15,204.86) $ 15,204.85 (15,204.85) Page 3 (18) ' ' Information Scheduies- l~rincipal (Continued) Exchanges and Stock Distributions Jundt Emerging Growth Fund, CL B 06/26/2003 757.247 Shs. 01/06/2004 (379) Shs. 378.247 Shs. 01/06/2004 (378.247) Shs. Received Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst Inventory Value $ 8,034.39 (4,021.19) $ 4,013.20 (4,013.20) Lord kbbett Tax-Free Income TR PA Ser CL A 06/26/2003 3.037 Shs. 3.037 Shs. 01/06/2004 (2) Shs. 1.037 Shs. 01/06/2004 (1.037) Shs. Received $ 16.31 On Hand $ 16.31 Distribution (10.74) To George B. Vander Gheynst On Hand $ 5.57 Distribution (5.57) To Carl J. Vander Gheynst Lord Abbett Affiliated Fund, Inc. 06/26/2003 3,344 07/30/2003 (850 11/26/2003 01/06/2004 Shs. Shs. 2,494 Shs. 2,494 Shs. (1,247 Shs. 1,247 Shs. (1,247 Shs. 01/06/2004 Received Sold On Hand Cap. gain dist. On Hand Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst $ 39,425.76 (10,021.50) $ 29,404.26 0.00 $ 29,4O4.26 (14,702.13) $ 14,702.13 (14,702.13) Medco Health, medical insurance reimbursements 06/26/2003 09/25/2003 Received Collected 1,392.21 (1,392.21) Page 4 (19) Information Schedules - Principal (Continued) Exchanges and Stock Distributions Merrill Lynch Large Cap Ser FD Value B 06/26/2003 1,322.589 Shs. 01/06/2004 (661) Shs. 661.589 Shs. 01/06/2004 (661.589) Shs. Received Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst Inventory Value $ 14,548.48 (7,271.00) $ 7,277.48 (7,277.48) Merrill Lynch Fundamental Growth CL B 06/26/2003 1,125.798 Shs. 01/06/2004 (562) Shs. 01/06/2004 563.798 Shs. (563) Shs. .798 Shs. (.798) Shs. Shs. 01/06/2004 Received Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst $ 14,466.50 (7,221 30) $ 7,244.80 (7,234.55) $ 10.25 (10.25) $ 70.84 $ 70.84 (35.42) $ 35.42 (35.42) MFS Charter Income Trust 06/26/2003 8 8 01/06/2004 (4) Shs. Shs. 4 Shs. (4) Shs. 01/06/2004 Received On Hand Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst Principal Life Insurance Company, Settlement Death Benefit Award 06/26/2003 10/14/2003 Received Collected 1,285.74 (1,285.74) Page 5 (20) Information Scheduies- Pi'incipal (Continued) Exchanges and Stock Distributions United States Treasury, refund receivable, decedent's final 1040 06/26/2003 The Hartford, 06/26/2003 08/27/2003 insurance refund Highmark Blue Shield, reimbursement for unused medical insurance premium 06/26/2003 09/18/2003 Pharmerica, 06/26/2003 10/16/2003 refund Salomon Bros Emerging Market Income Fund II 06/26/2003 1,459.9904 06/30/2003 39.6217 Shs. Shs. 1,499.6121 Shs. 07/03/2003 (275) Shs. 1,224.6121 Shs. 1,224.6121 Shs. 01/06/2004 (612.30605) Shs. 612.30605 Shs. 01/06/2004 (612.30605) Shs. Received On Hand Received Sold Received Collected Received Collected Received Purchased Reinvestment of dividend, all of which was accrued income On Hand Sold On Hand On Hand Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst Inventory Value $ 800.00 $ 800.00 21.00 (21.00) 415.67 (415.67) 12.36 (12.36) $ 22,520.35 602.25 $ 23,122.60 (4,240.24) $ 18,882.36 $ 18,882.36 (9,441.18) $ 9,441.18 (9,441.18) Page 6 (21) Information Scheduies- P~'incipal (Continued) Exchanges and Stock Distributions Salomon Bros 2008 Worldwide Fund 06/26/2003 2,692.9143 Shs. 06/30/2003 17.9525 Shs. 2,710.8668 Shs. 07/03/2003 (370) Shs. 2,340.8668 Shs. 2,340.8668 Shs. 12/17/2003 (270) Shs. 2,070.8668 Shs. 2,070.8668 Shs. 01/06/2004 (1,035.4334) Shs. 1,035.4334 Shs. 01/06/2004 (1,035.4334) Shs. Inventory Value Received $ 29,595.13 Purchased 196.58 Reinvestment of dividend, all of which was accrued income On Hand $ 29,791.71 Sold (4,066.20) On Hand $ 25,725.51 On Hand $ 25,725.51 Sold (2,967.23) On Hand $ 22,758.28 OR Hand $ 22,758.28 Distribution (11,379.14) To George B. Vander Gheynst On Hand $ 11,379.14 Distribution (11,379.14) To Carl J. Vander Gheynst Wells Fargo Capital IV GTD Cap Sec, 7.00%, Sep. 2, 2031 06/26/2003 600 Par 01/06/2004 (300) Par 300 Par 01/06/2004 (300) Par Received $ 16,272.00 Distribution (8,136.00) To George B. Vander Gheynst On Hand $ 8,136.00 Distribution (8,136.00) To Carl J. Vander Gheynst Page 7 (22) Estate of Marie Jbhann'a. Vander Gheynst Receipts of Income Income Collected BNY Capital Trust IV Def Int TR PFD SECS SR-E, 6.875%, Dec. 1, 2028 09/02/2003 Interest on 300 Par 12/01/2003 Interest on 300 Par Detroit Edison Company Quarterly Income Debt Sec., 7.625%, Mar. 31, 2026 06/30/2003 Interest on 300 Par 09/30/2003 Interest on 300 Par 12/31/2003 Interest on 300 Par Merrill Lynch Money Market Acct. #872-55857 08/29/2003 Interest 09/26/2003 Interest 09/29/2003 Interest 10/31/2003 Interest 11/28/2003 Interest 12/31/2003 Interest First USA Bank Wilmington DEL Certificate of Deposit dated 8~2~2000, mat. 8/2/2005, 7.05% 08/04/2003 Interest on 20,000 Par Less accrued portion 128.91 128.91 142.97 142.97 142.97 2.25 2.26 0.33 1.88 1.56 1.15 699.21 (564.00) 257.82 428.91 9.43 135.21 Page 1 (23) Receipts of Income (Continued) Household Fin Corp Int NT BE dated 3/29/2001, mat. 3/15/2011, 7.05% 09/15/2003 Interest on 12,000 Par Less accrued portion Investment Co America CL B 09/08/2003 Dividend on 1,182.308 Shares 12/17/2003 Dividend on 1,185.88 Shares Lord Abbeff Affiliated Fund, Inc. 08/22/2003 Dividend on 2,494 11/28/2003 Dividend on 2,494 12/22/2003 Dividend on 2,494 Shares Shares Shares Lord Abbett Tax-Free Income TR PA Ser CL A 07/08/2003 08/07/2003 09/04/2003 10/03/2003 11/04/2003 12/04/2003 Dividend on 3 Dividend on 3 Dividend on 3 Dividend on 3 Dividend on 3 Dividend on 3 037 048 052 064 075 086 Shares Shares Shares Shares Shares Shares MFS Cha~er Income Trust 06/30/2003 Dividend on 8 Shares 07/31/2003 08/29/2003 09/30/2003 Less accrued portion Dividend on 8.041 Shares Dividend on 8.082 Shares Dividend on 8.1241 Shares 378.00 (212.10) 93.99 93.09 124.70 124.70 62.35 0.06 0.03 0.06 0.06 0.06 0.06 0.35 (0.35) 0.35 0.36 0.37 165.90 187.08 311.75 0.33 Page 2 (24) Receipts of II, come (Continued) ' MFS Cha~er Income Trust 10/31/2003 Dividend on 11/28/2003 Dividend on 12/31/2003 Dividend on 8.1662 Shares 8.2093 Shares 8.2522 Shares Merrill Lynch Money Market 07/28/2003 Interest 07/30/2003 Interest PNC Checking Acct. #50-7008-6287 07/17/2003 Interest 08/18/2003 09/17/2003 09/24/2003 Less accrued portion Interest Interest Interest Salomon Bros Emerging Market Income Fund II 06/30/2003 Dividend on 1,459.9904 Shares 09/29/2003 12/26/2003 Less accrued portion Dividend on 1,224.6121 Shares Dividend on 1,257.1604 Shares Salomon Bros 2008 Worldwide Fund 06/30/2003 Dividend on 2,692.9143 Shares 07/25/2003 08/29/2003 09/29/2003 Less accrued portion Dividend on 2,340.8668 Shares Dividend on 2,340.8668 Shares Dividend on 2,357.1877 Shares 0.38 0.38 0.38 0.95 0.73 0.59 (0.16) 0.61 0.40 0.08 602.25 (602.25) 505.15 518.58 196.58 (196.58) 170.88 170.88 172.07 2.22 1.68 1.52 1,023.73 Page 3 (25) Receipts of Incom'e (Continued) ' Salomon Bros 2008 Worldwide Fund 11/03/2003 Dividend on 2,372.802 Shares 12/01/2003 Dividend on 2,388.7074 Shares 12/29/2003 Dividend on 2,134.618 Shares Wells Fargo Capital IV GTD Cap Sec, 7.00%, Sep. 2, 2031 09/02/2003 Interest on 600 Par 12/01/2003 Interest on 600 Par Total Income Received 173.21 175.54 175.54 262.50 262.50 $ 1,038.12 525.00 4,088.70 Page 4 (26) 09/25/2003 01/06/2004 Estate of Marie Johanna'Vander Gheynst Gains and Losses on Sales or Other Dispositions of Income Net Gain Collection PNC Checking Acct. %50-7008-6287 Net Proceeds $ 1.52 Carried at 1.52 Sale 0.0429 Shares MFS Charter Income Trust Inventoried at $ 0.37 Net Proceeds 0.34 Total Gains and Losses Net Loss $ 0.00 Net Loss $ 0.03 $ 0.03 $ o.o3 Page 1 (27) Estate of Marie Jol~anna'Vander Gheynst Disbursements of Income Date Paid 06/30/2003 07/31/2003 Administration Expenses Merrill Lynch Margin interest Merrill Lynch Margin interest Total Administration Expenses Total Disbursements of Income Amount Paid $ 88.24 4.30 $ 92.54 $ 92.54 Page 1 (28) Estate of Marie Jol'Janna Vander Gheynst Distributions of Income to Beneficiaries Distribution Value Carl J. Vander Gheynst 01/06/2004 Cash 01/06/2004 3.4595 Shares Investment Co America CL B 01/06/2004 0.06 Shares Lord Abbett Tax-Free Income TR PA Ser CL A 01/06~004 0.2522 Shares MFS Charter Income Trust 01/06/2004 31.69395 Shares Salomon Bros Emerging Market Income Fund II 01/06/2004 0.269 Shares Salomon Bros Emerging Market Income Fund II 01/06/2004 39.5666 Shares Salomon Bros 2008 Worldwide Fund 01/06/2004 0.4182 Shares Salomon Bros 2008 Worldwide Fund George B. Vander Gheynst 01/06/2004 Cash 01/06/2004 3.4595 Shares Investment Co America CL B 01/06/2004 31.69395 Shares Salomon Bros Emerging Market Income Fund II 01/06/2004 39.5666 Shares Salomon Bros 2008 Worldwide Fund 957.78 93.54 0.33 2.20 509.7O 4.33 431.34 4.56 957.77 93.54 509.7O 431.34 2,003.78 1,992.35 Page 1 (29) Distributions of Income to Beneficiaries (Continued) Distribution Value Total Distributions of Income $ 3,996.13 Page 2 (30) Estate of Marie Johanna Vander Gheynst Income Balance On Hand Valued as of April 20, 2004 Inventory Value Total Balance on Hand 0.00 Page 1 (31) Estate of Marie JohannaJVander Gheynst Information Schedules - Income New Investments Investment Co America CL B 09/08/2003 3.572 12/17/2003 3.347 Shs. Shs. Lord Abbett Tax-Free Income TR PA Ser CL A 07/08/2003 08/07/2003 09/04/2003 10/03/2003 11/04/2003 12/04/2003 011 Shs 004 Shs 012 Shs 011 Shs 011 Shs 011 Shs MFS Charter Income Trust 06/30/2003 .041 Shs. 07/31/2003 .041 Shs. 08/29/2003 .0421 Shs. 09/30/2003 .0421 Shs. 10/31/2003 .0431 Shs. 11/28/2003 .0429 Shs. 12/31/2003 .0429 Shs. Salomon Bros Emerging Market Income Fund II 09/29/2003 32.5483 12/26/2003 31.1086 Shs. Shs. Salomon Bros 2008 Worldwide Fund 09/02/2003 16.3209 Shs. 09/29/2003 15.6143 Shs. 11/03/2003 15.9054 Shs. 12/01/2003 15.9106 Shs. 12/29/2003 15.8002 Shs. Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased Reinvestment of dividend Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased Reinvestment of dividend Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Purchased via Reinvestment Inventory Value $ 93.99 93.09 $ 0.06 0.03 0.06 0.06 0.06 0.06 $ 0.35 0.35 0.36 0.37 0.38 0.38 0.38 $ 505.15 518.58 $ 170.88 172.07 173.21 175.54 175.54 Page 1 (32) Information Schedules - Income (Continued) New Investments Total New Investments Inventory Value $ 2,080.95 Exchanges and Stock Distributions Investment Co America CL B 09/08/2003 3.572 Shs. 12/17/2003 3.347 Shs. 01/06/2004 6.919 Shs. (3.4595) Shs. 3.4595 Shs. (3.4595) Shs. 01/06/2004 Lord Abbett Tax-Free Income TR PA Ser CL A 07/08/2003 08/07/2003 09/04/2003 10/03/2003 11/04/2003 12/04/2003 01/06/2004 011 Shs 004 Shs 012 Shs 011 Shs 011 Shs 011 Shs 06 Shs (06) Shs MFS Charter Income Trust 06/30/2003 .041 Shs. 07/31/2003 .041 Shs. 08/29/2003 .0421 Shs. 09/30/2003 .0421 Shs. 10/31/2003 .0431 Shs. 11/28/2003 .0429 Shs. 12/31/2003 .0429 Shs. Income Reinvestment Income Reinvestment On Hand Distribution To George B. Vander Gheynst On Hand D~stribution To Carl J. Vander Gheynst Income Reinvestment Income Reinvestment Income Reinvestment Income Reinvestment Income Reinvestment Income Reinvestment On Hand Distribution To Carl J. Vander Gheynst Purchased Reinvestment of dividend Income Reinvestment Income Reinvestment Income Reinvestment Income Reinvestment Income Reinvestment Income Reinvestment Inventory Value $ 93.99 93.09 $ 187.08 (93.54) $ 93.54 (93.54) $ 0.06 0.03 0.06 0.06 0.06 0.06 $ 0.33 (0.33) $ 0.35 0.35 0.36 0.37 0.38 0.38 0.38 Page 2 (33) Information Schedules - Income (Continued) Exchanges and Stock Distributions MFS Charter Income Trust (Continued) .2951 Shs. 01/06/2004 (.2522) Shs. .0429 Shs. 01/06/2004 (.0429) Shs. Salomon Bros Emerging Market Income Fund II 09/29/2003 32.5483 Shs. 12/26/2003 31.1086 Shs. 63.6569 Shs. 01/06/2004 (31.69395) Shs. 31.96295 Shs. 01/06/2004 (31.69395) Shs. .269 Shs. 01/06/2004 (.269) Shs. On Hand Distribution To Carl J. Vander Gheynst On Hand Sold Income Reinvestment Income Reinvestment O~ Hand Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst Inventory Value $ 2.57 (2.20) $ 0.37 (0.37) $ 505.15 518.58 $ 1,023.73 (509.70) $ 514.03 (509.70) $ 4.33 (4.33) Salomon Bros 2008 Worldwide Fund 09/02/2003 16.3209 Shs. 09/29/2003 15.6143 Shs. 11/03/2003 15.9054 Shs. 12/01/2003 15.9106 Shs. 12/29/2003 15.8002 Shs. 79.5514 Shs. 01/06/2004 (39.5666) Shs. 39.9848 Shs. 01/06/2004 (39.5666) Shs. .4182 Shs. Purchased Reinvestment of dividend Income Reinvestment Income Reinvestment Income Reinvestment Income Reinvestment On Hand Distribution To George B. Vander Gheynst On Hand Distribution To Carl J. Vander Gheynst On Hand $ 170.88 172.07 173.21 175.54 175.54 867.24 (431.34) 435.90 (431.34) 4.56 Page 3 (34) Information Schedules - Income (Continued) Exchanges and Stock Distributions Salomon Bros 2008 Worldwide Fund (Continued) 01/06/2004 (.4182) Shs. Distribution To Carl J. Vander Gheynst Inventory Value (4.56) Page 4 (35) AFFIDAVIT George B. Vander Gheynst and Carl J. Vander Gheynst, Executors under the Will of MARIE JOHANNA VANDER GHEYNST, Deceased, hereby declare under oath that said Executors have fully and faithfully discharged the duties of their office; that the foregoing First and Final Account is true and correct, and fully discloses all significant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; that, to their knowledge, there are no claims now outstanding against the Estate; that all taxes presently due from the Estate have been paid. -~org~B~ Vander ~heynst, 'Fx~ecutor Carl J. Vander Gheynst, Executor Sworn to and subscribed before me this ~[ day of ~tc~ , 2004. NOTARY PUBLIC MY COMMISSION EXPIRES: ( SEAL ) AFFIDAVIT George B. Vander Gheynst and Carl J. Vander Gheynst, Executors under the Will of MARIE JOHANNA VANDER GHEYNST, Deceased, hereby declare under oath that said Executors have fully and faithfully discharged the duties of their office; that the foregoing First and Final Account is true and correct, and fully discloses all significant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; that, to their knowledge, there are no claims now outstanding against the Estate; that all taxes presently due from the Estate have been paid. George B. Vander Gheynst, Executor Carl J. Vander Gh~nst, Executor Sworn to and subscribed before me this ~ day of ~, 7~ , 2004. N C MY COMMISSION EXPIRES: ( SEAL ) ,,,~.~O~WEALTH OF PENNSYLVANIA Notarial Seal Yvonne R. Durham, Notary Public City of Harrisb_urg, Dauphin County My Core__mission Expires Aug. 20, 2005 ~embel', Pe~ns?vani~ ;\ssociation of Notades ESTATE OF MARIE JOHANNA VANDER GHEYNST Addendum to First and Final Account Proposed Final Distribution of Balance per Account Balance on hand, per Account TO: TO: Proposed Distribution: GEORGE B. VANDER GHEYNST One-half IRS refund, upon receipt CARL J. VANDER GHEYNST One-half IRS refund, upon receipt $400.00 400.00 800.00 800.00 Balance Due on Account of Attorneys' Fees Balance due Rhoads & Sinon LLP on account of attorneys' fees and reimbursement for out-of-pocket expenses per attached statement $4,742.29 514359.1 BUREAU OF /NDIVIDUAL TAXES TNHERTTANCE TAX DTVTSTON DEPT. Z80601 HARRISBURG, PA 171Z8-060! CONNONWEALTH OF PENNSYLVANIA DEPARTNENT OF REVENUE NOT/CE OF ZNHER/TANCE TAX APPRAISEHENT, ALLO#ANCE OR DISALLO#ANCE OF DEDUCTIONS AND ASSESSNENT OF TAX LAWRENCE B ABRAMS ESQ RHOADS & SZNON PO BOX 1146 HBG PA 17108 DATE 02-02-2004 ESTATE OF VANDERGHEYNST DATE OF DEATH 06-26-2005 FILE NUHDER 21 03-0557 COUNTY CUHBERLAND ACN 101 I Aaoun~ Ramified REV-ZGd? EX AFP CO~.-OS) HARIE J HAKE CHECK PAYABLE AND RENZT PAYHENT TO: REGISTER OF WILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17015 CUT ALONG THZS LZNE ~ RETAIN LOWER PORTZON FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSENENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTZONS AND ASSESSNENT OF TAX ESTATE OF VANDERGHEYNST HARZE J FILE NO. 21 05-0557 ACN 101 DATE 02-02-2004 TAX RETURN #AS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAZSED VALUE OF RETURN BASED ON: ORTGZNAL RETURN 1. Roe1 Es~e~a (Schedule A) (1) 2. S~ocks and Bonds (Schedule B) (2) :5. Closely Held S~ock/Par:knership Tn~eres~ (Schedule C) (:5) r~. Nor~cgagas/Nogcas Receivable (Schedule D) $. Cash/Bank Daposigcs/Nisc. Personal Propar~y (Schedule E) (S) 6. Jointly Owned Propar~y (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. To,al Assa~cs APPROVED DEDUCTIONS AND EXENPTZONS: 9. Funeral Expanses/Ada. Cos~:s/Niso. Expanses (Schedule H) (9) 10. Dab~s/Nor~gaga Liabili:klas/Lians (Schedule 1) (10) 11. To~al DeducJ:ions 12. Ne~ Value of Tax Re~urn Z151374.02 .00 31~296.19 .00 .00 NOTE: To insure proper cradi~ ~o your account, subai~ ~ha upper por~ion .00 of ~his fora wi~h your ~ax payment. 12,549.91 5,687.64 (~1) 18.~37.55 (1~) $16,093.4~ 1:5. NOTE: ASSESSNENT OF TAX: 15. Aaoun~ of Line lq a~ Spousal ra~e 16. Aaoun~ of Line lq ~axabla a~ Lineal/Class A ra~a 17. Aaoun~ of Line lq e~ Sibling rata 18. Aaoun~ of Line 1~ ~axabla a~ Collateral/Class B rata 19. Principal Tax Due TAX CREDITS: PAYfl~NT K~CEZPT DISCOUNT (+J DATE NUNDER INTEREST/PEN PAID (-) 09-26-200:5 CD00:5059 684.21 12-04-200:5 CD003:508 .00 reflect figures that include the total of ALL returns assessed to date. (15), .00 X O0 = .00 (16) 316,093.44 X 045= 14,224.20 (17) .00 x 12 = .00 (18) .00 x 15 = .00 (19)= 14,224.20 ANOUNT PAID 1:5,000.00 5:59.99 TOTAL TAX CREDIT · ALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE Chari*abla/Govarnaan~al Bequas*s; Non-alec~ad 911:5 TrusSes (Schedule J) (1:5) . O0 Na~: Value of Es~aJ:a Sub.~ec~ ~o Tax (1~) :516,09:5.44 Zf an assessment ~as lssued previously, lines 1~, 15 and/or 16, 17, 18 and 19 ~ill 14,224.Z0 .00 .00 .o0 ( IF TOTAL DUE IS LESS THAN $1, NO PAYNENT IS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A "CRED/T" (CR), YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORN FOR INSTRUCTIONS.)*~P-~ ~ ZF PAID AFTER DATE INDICATED, SEE REVERSE fOR CALCULATZON OF ADDIT/ONAL INTEREST. 87~660.78 (8) :534,330.99 RESERVATION: PURPOSE OF NOTICE: PAYMENT: REFUND (CR): OBJECTIONS: ADMIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December II, 198Z -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collataral) beneficiaries of the decedent after the expiration of any estate for life ar for years, the Commoneealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the laaful Class D ¢collatsral) rate on any such futura interest. To fulfill the requirements of Section ZlqO of the Inheritance and Estate Tax Act, Act Z3 of 2000. [7Z P.S. Section 91q0). Detach the top portion of this Notice and submit with your payment to the Register of Nills printed on the reverse side. --Make check or money order payable to: REGISTER OF NILES, AGENT A refund of a tax credit, which was not requested on the Tax Return, may ba requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" [REV-l$15). Applications ara available at the Office of the Register of Mills, any of the 25 Revenue District Offices, or by calling the special Iq-hour ansearing service for forms ordering: 1-800-56Z-Z050~ services for taxpayers with special hearing and / or speaking needs: l-BOO-qqT-50ZO (TT only). Any party in interest not satisfied with the appraisement, a11oaancs, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object aithin sixty [603 days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. ZDIOZ1) Harrisburg) PA 171ZB-10Z1) OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in mriting to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Reviea Unit) Dept. Z80601) Harrisburg) PA 17128-0601 Phone [717) 787-6S05. See page S of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. If any tax due is paid within three (5) calendar months after the dscadent's death) a five percent [SZ) discount of the tax paid is allowed. The 1SI tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the and of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (l) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of six [6Z) percent per annum calculated at a daily rate of .00016q. All taxes which became delinquent on and after January 1, 198Z will bear interest at a rate ehich will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 19DA through ZOO5 ara: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Data Factor leDz ZOZ . O00Sq8 1987 97. . O00Zfi7 1999 7X . 00019Z 1985 167. .000458 1968-1991 117. · 000501 ZOO0 DX .000Z19 1984 117. .000501 199Z 97. .000247 ZOOX 97. .000Z47 1985 15Z .000556 1995-1994 72 .000192 ZOOZ 67. .000164 1986 lOX .000Z74 1995-1998 92 .000247 ZOO5 52 .0001S7 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELIN~IUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen ilS) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must ba calculated. Name of Decedent: Date of Death: STATUS REPORT UNDER RULE 6.12 Marie Johanna VanderGheynst June 26, 2003 Will No. Admin. No. 00557-2003 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 of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: Yes o If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? No X b. The separate Orphans' Court No. (if any) for the personal representative's account is: 518071.1 parties in interest? Yes Did the personal representative state an account informally to the X No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cler/k-of the Orphans' Court and may be attached to this report. _ Date: Signature '" Lawrence B. Abrams, Esquire Name (Please type or print) Rhoads & Sinon LLP P. O. Box 1146 Harrisburg, PA 17108-1146 Address 717-233-5731 Tel. No. Capacity:~ X Personal Representative __Counsel for personal representative RHOADS & SINON LLP Yvonne R. Durham ph (7] 7) 23] -6677 Ix (7] 7) 232-] 459 yd u rham@rhoads-sinon.com FILE'JO 859610] July 12, 2006 Re: Estate of Marie Johanna Vander Ghevnst PA File No.: 21-03-0557 ) , Ms. Glenda Farner-Strasbaugh Cumberland County Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 (:Y'~ Dear Ms. Farner-Strasbaugh: Enclosed are the following in connection with the above-captioned Estate: 1. Supplemental Pennsylvania Inheritance Tax Return, in duplicate, showing tax due in the amount of$174.83. 2. A check in the amount of$174.83 in payment of tax. 3. A check in the amount of$15.00 for filing the Supplemental Inheritance Tax Return. 4. A copy of this letter along with the first page of the tax return. Please date stamp these pages and return them to the undersigned in the enclosed envelope. Very truly yours, Enclosures RHOADS & SINON LLP By: ~ .;1L:(" ./ /cc-.. /(' kt&/./ ,/~ I Y vop.ne R. Durham Par,ilegal ../" 615342. ] Rhoads &: Sinoll LLP 0 .1,tlOfIlCYS at Law 0 Twelfth Floor 0 Onc South \Iarket Square 0 PO I)()"\ 114h ILtrrisburg. PA 17108-] 146 o/,h (717) 233-5731 oj.\ (717) 232-1459. www.rhoads-sinoll.col11 OOMMONVVE,4L TH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVICUAL TAXES DEPT 280'301 HAR8!SBURG, F'L, 1 ~128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT VANDER GHEYNST CARL J 2616 MILL ROAD BOX 28 GRANTHAM, PA 17027 un j,.:;ld ESTATE INFORMATION: SSN: 143-20-2837 FILE NUMBER: 2103-0557 DECEDENT NAME: VANDER_GHEYNST MARIE JOt- DA TE OF PAYMENT: 07/17/2006 POSTMARK DATE: 07/14/2006 COUNTY: CUMBERLAND DA TE OF DEATH: 06/26/2003 NO. CD 006981 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $174.83 I I NNA I I I I I I A TOTAL AMOUNT PAID: $174.83 REMARKS: V ANDERGHEYNST CARL CHECI<# 2493 SEAL INITIALS: AJW RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS 0:'>' \t) ("")" ;..J. j ~. 21 9: r,.J .~ Z 1':"'..1 () (5\ 0;:'. "":.t u.. ;": ~~f % i.:",) - (~_l - .cr C\ Z -'~ ~ ~ -, ,,/ '~ ~, / .~ , / ~ ~ ~ ~, .... ~ ~ - .- <<S 5 U) U) (G - o 1n l- .- u.. rJl ~ ~ 'M ';3: Ll-I .c 0 Q) 01 (fl ;j >-l ;j to Q) 0 .0 ...,.c r- Ul(fl+' co to .M \.4 M \.4 01 ;j Q) c') +,Q)0\.41 ~~U~~ \.4 \>< \>< t1 0 Q) +' ..., tf) r- ~~~ .-l \.4 ;j ;j Q) to 0 0 ~ ><t I:t-< U U 0 p... to<Q<Q.c <Q~~+'Q). ~ to to \.4 Q)~~:I~ ~ \.4 \.4 0 (fl l? Q) Q) U -M .~~Q)~ Ul ;j ;j o~ utO ~ U U ,..,.1: :n ~~ ~5\ <C7~. o~~ ~~i <> I- REV-1500 EX (6-00) OFFICIAL USE ONLY COMMONWEAL TH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ~L OOUNTY CODE ~L 0557 ___ YEAR NUMBER I- Z W C W U w C DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) Vander Ghe nst Marie Johanna DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 6/26/2003 9/5/1922 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 143-20-2837 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER W I- lo::~lI) uD::lo:: wa..u :z:OO uD::...J a..lll a.. <( D 1. Original Return D 4. Limited Estate D 6. Decedent Died Testate (Attach copy of Will) D 9. Litigation Proceeds Received [i] 2. Supplemental Return D 3. Remainder Return (date of death prior to 12-13-82) D 4a. Future Interest Compromise (date of death after 12-12-82) D 5. Federal Estate Tax Return Required D 7. Decedent Maintained a Living Trust (Attach copy ofTrust) _ 8. Total Number of Safe Deposit Boxes D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS .... Z W C z o "- en w D:: D:: o U Lawrence B. Abrams, Es FIRM NAME (If Applicable) Rhoads & Sinon LLP TELEPHONE NUMBER ire P. O. Box 1146 Harrisburg, PA 17108 717-233-5731 :1 1. Real Estate (Schedule A) (1) 0.00 " OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) Z 6. Jointly Owned Property (Schedule F) (6) 0 D Separate Billing Requested i= <( Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) ...J 7. ::> (Schedule G or L) l- ii: 8. Total Gross Assets (total Lines 1-7) <( U W 9. Funeral Expenses & Administrative Costs (Schedule H) (9) c::: 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 0.00 0.00 3,900.00 0.00 ~ >',- ..., ~:~-.) 0.00 (8) 3,900.00 15.00 0.00 (11) 15.00 (13) 3,885.00 0.00 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) (12) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax 0.00 Z rate, or transfers under Sec. 9116 (a)(1.2) 0 i= 16. Amount of Line 14 taxable at lineal rate 3,885.00 <( I- ::l 0.00 a.. 17. Amount of Line 14 taxable at sibling rate :;; 0 0.00 U 18. Amou nt of Line 14 taxable at collateral rate >< <( Tax Due I- 19. (14) 3,885.00 x .0 ~(15) x ,0 ~(16) x .12 (17) x .15 (18) (19) 0.00 174.83 0.00 0.00 174.83 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < 3W4645 1000 Decedent's Complete Address: S1REET ADDRESS Messiah Villaae,100 Mt. Allen Dr Cumberland CI1Y I STATE I ZIP Mechanicsbura PA 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) 174.83 0.00 0.00 0.00 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty 0.00 0.00 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. Check box on Page 1 Line 20 to request a refund (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 174.83 A. Enter the interest on the tax due. (5A) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Pa able to: REGISTER OF WILLS, AGENT (58) 174.83 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes D D D D 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D [iJ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 No [Jg [Jg D Ul og og Harrisburg, PA 17108-1146 DATE & Sinon LLP, PO Box 1146 Harrisburg, PA 17108-1146 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. 99916 (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)] The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 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. 9 9116(1.2} [72 P.S. 99116(a}(1 }]. The tax rate imposed on the net value oftransfers to or for the use of the decedent's siblings is 12% (72 P.S. 9 9116(a}(l.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. 3W4646 1.000 REV.150e EX + (e-ge) COMMONWEALTH OF PENNSYL V AN IA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Marie Johanna Vander Gheynst 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. FILE NUMBER 21. 03 0557 ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Commonwealth of PA, Treasury Department, Bureau of Unclaimed Property Check dated 5/24/06 for funds due decedent from GE Capital Assurance EREQUEST THAT INTEREST BE ABATED 3,900.00 3W46AD 1000 TOTAL (Also enter on line 5, Recaoitulationl $ (If more space is needed, insert additional sheets of the same size) 3,900.00 REV-1511 EX + (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Marie Johanna Vander Gheynst SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Debts of decedent must be reported on Schedule I. FILE NUMBER 2103 0557 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. None B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) - - Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Filing fee, supplemental inheritance tax return 15.00 TOTAL (Also enter on line 9. Recapitulation) $ 15.00 3W46AG 1000 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mar1e Johanna Vander Ghevnst NUMBER I 1 NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Carl J. Vander Gheynst 2616 Mill Road, Box 28 Grantham, PA 17027 50% of Residue: 1,942.50 2 George B. Vander Gheynst 3 South Cross Road LaGrangeville, NY 12540 50% of Residue: 1,942.50 FILE NUMBER 21 03 0557 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE Son Son 1,942.50 1,942.50 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 3W46A11.000 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If more space IS needed. Insert additional sheets of the same size) $ 0.00 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 NO. CD 007333 VANDER GHEYNST CARL J 2616 MILL ROAD BOX 28 GRANTHAM, PA 17027 ACN ASSESSMENT CONTROL NUMBER AMOUNT -------- told 101 I $1.71 ESTATE INFORMATION: SSN: 143-20-2837 I FILE NUMBER: 2103-0557 I DECEDENT NAME: VANDER_GHEYNST MARIE JOt- IA NNA I DATE OF PAYMENT: 10/23/2006 I POSTMARK DATE: 10/23/2006 I COUNTY: CUMBERLAND I DATE OF DEATH: 06/26/2003 I I TOTAL AMOUNT PAID: $1.71 REMARKS: SUELLEN M VANDERGHEYNST CHECK# 2574 SEAL INITIALS: CM RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS \&I :5 ~~ Z Bl- oC UI ..I II. > ::>> )C..I 0 ~~ ~!~ z> \&I CII \&I ZUl W -= i UlG: ~ 0 CI) A. IL l:; \&I ~ ILO :5 ~: :!Z ! B i -UI ..I oC ~~ ~ ~ I :i~ ~~t:! 1& i!~ _ CI)\&I E HCII o ~II. U 11.0 II. oC ~ f ,... 11\ o I 10 o .... ..., Cl. ~ ~ t-4 01: < :IE: ...0- 0111 01: N.g I- IU en ...0 . ~ z .... oS' ...0 >- tfl .... = 1 Q o~OU"lZ N... o ::c Cl U"I < .... ~ NCDNCl.... ~ 101:1101: I: .... 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UI a: < D. 1 II :lI to k tiii ~ 71,\~'S.~ RHOADS Ji'1I""'l & SINON LLP Yvonne R. Durham Phone (717) 231-6677 Fax (717) 232-1459 ydurham@rhoads-sinon.com FILE NO: 8596/1 October 19,2006 Re: Estate of Marie J. Vanderszhevnst File No.: 0557 of 2003 Ms. Glenda Famer-Strasbaugh Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, P A 17013 Dear Ms. Famer-Strasbaugh: Enclosed is a check in the amount of $1.71 representing payment of the balance of Pennsylvania Inheritance Tax due for the above captioned Estate in accordance with the enclosed Notice. Kindly time-stamp the enclosed copy of this letter and return it to the bearer of this letter. Very truly yours, RHOADS & SINON LLP Enclosures r~ () So .-.,~::o ',.' '-'J -1::c C) j'~ ::u-l .> f'o",,) c:::::) c:::;) c:::l"\ o \) -f N W ::.:0 In <..""'") ,::::) ::0 CJ 23 o -'1 " ~ (3- "'1::,1 , :x:- :x: ~ +- U1 626633.1 Rhoads &: Sinon LLP · Attorneys at Law · Twelfth Floor · One South Market Square. P.O. Box 1146 Harrisburg, PA 17108-1146 · ph (717) 233-5731 · Ix (717) 232-1459 · www.rhoads-sinon.com BUREAU OF INDIVIDUAL TAXES'~('r INHERITANCE TAX DIVISION . . PO lOX 2110601 HARRISBURG PA 111211-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE ,",' INHERITANCE TAX ;~TATEMENT OF ACCOUNT .. REV-1601 EX AFP (03-05) Z005 r.JOv 27 Pr; 3: 32 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-13-2006 VANDERGHEYNST 06-26-2003 21 03-0557 CUMBERLAND 101 AlIOWIt R_Itted MARIE J CLERK OF ~:::~~c: :I:::Ii~~~~,:~!,~ZY}iTpA PO BOX 1146 HARRISBURG PA 17108 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To Insure proper credit to your eccount, subIIlt the upper portion of this fOrll with your tex P8YlMInt. CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ... --------------------------------------------------------------------------- REV-1607 EX AFP (03-05) ... INHERITANCE TAX STATEMENT OF ACCOUNT ... ESTATE OF VANDERGHEYNST MARIE J FILE NO. 21 03-0557 ACN 101 DATE 11-13-2006 THIS STATEMENT IS PROVmED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAttED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIeuRE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 01-26-2004 PRINCIPAL TAX DUE: 14,224.20 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 09-26-2003 CD003059 684.21 13,000.00 12-04-2003 CD003308 .00 539.99 10-23-2006 CD007333 .00 1. 71 . TOTAL TAX CREDIT 14,225.91 BALANCE OF TAX DUE 1.71CR INTEREST AND PEN. .00 . IF PAm AFTER THIS DATE, SEE REVERSE TOTAL DUE 1.71CR SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $I, NO PAYltENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRl, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. l