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HomeMy WebLinkAbout04-0036 , Register of Wills of Cumberland, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Harvey D. Fleischer No. (')).r 0 4 -- 6<.0 also known as , Deceased Social Security No 174-01-6817 Nancy A. Johnson Petltloner(s), who Is/are 18 years of age or older, appJy(les) for: (COMPLETE "An OR "B" BELOW:) " o A. Probate and Grant of Letters and aver that Petitioner( s) is Decedent, dated 10/28/1996 and codicil(s) dated N/A Grace B. Fleischer, wife of decedent, named as executrix in will predeceased the decedent Renunciation of Cousin/named alternate executor in will, Robert C. Stacy, renunciation dated December 9,2003 Continued on a Separate paae Stete relevant circumstances, e.g., renunclltlon, death of executor, etc Except as follows, Decedent did not marry, was not divorced and did not h8\18 a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was newr adjudicated Incapacitated: 20'PB..C.S. Section 3155 (b) (5)&(6) it son"tJ. ...in POA.nrrr_pci7 /16/0 ..""LasfWlrronfie Gl B. Grant of Letters of Administration c.t.a. (c.la., d.b.n.c.t.a.: pendente llta, durante absentia; durante mlnorltate) Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence Jeanne F. Atkinson sister 1096 Red MaDle Way. New SmYrna Beach FL Doris Demoss sister-in-law PO Box 14115 So Lake Tahoe CA Helen Merrvman sister-in-law 12633 DaDhane Etlwanda CA Bonnie Robicheau niece-in-Iaw unknown Jav Brandenberaer neDhew-in-law 137 S. Ellsworth Place South Bend IN (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death In Cumberland County, Pennsylvania, with his/her last family or principal residence at 325 Wesley Drive, Bethany Village, Mechanicsburg, PA 17055 (list Itreal, number and municipality) Decedent, then 90 years of age, died November 29 , ~ , at HoIv SPirit HosPital, East Pennsboro. Cumbo Co.. PA (Location) Decedent at death owned property with estimated values u follows: (if domiciled in PAl All personal property ......................................... $ (if not domiciled in PAl Personal property in Pennsylvania .................... $ (If not domiciled in PAl Personal property in County .............................. $ Value of real estate in Pennsylvania ........................................................................................ $ Total.... ............. ................ ....... ............ ................... ........................................ ...... $ 130,000.00 Real Estate situated as follows: N/A 130,000.00 Wherefore, Petitioner(s) respectfully request(s) the probate Df the Last WiD and Codlcll(s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: Typed or printed name and residence Nanc A. Johnson 6424 Pamadeva Rd. Hanover PA 17331 Continuation of Petition for Grant of Letters Harvey D. Fleischer Page 1 Statement of Relevant Circumstances Renunciation of Attorney/named additional alternate executor in will, J. Robert Stauffer, renunciation dated Dec. 3, 2003 Renunciation of Jeanne F. Atkinson, sister of decedent named as residual beneficiary in will, renunciation dated Dec. 9, 2003 Renunciation of Doris DeMoss, sister-in-law of decedent named as residual beneficiary in decedent's will, renunciation dated Dec. 16,2003 Renunciation of Mechanicsburg Presbyterian Church residual beneficiary in decedents will , renunciation dated Dec. 8, 2003 Renunciation of the Salvation Army residual beneficiary in decedent's will, renunciation dated Dec. 15, 2003 Upon information and belief, residual beneficiary New Hope Ministries is corporation not authorized to act as fiduciary in Commonwealth, 20 Pa.C.S. Section 3156(2); but served with renunciation form on Dec. 5,2003 which they have not returned to Attorney Scott Ruth for Nancy A. Johnson Note, sister-in-law Helen Merryman suffers from Alzheimers disease and is incapacitated and residing in a nursing home in California Also note, nephew-in-Iaw Jay Brandenberger was served with a renunciation form on December 5, 2003 which he has not returned to Attorney Scott A. Ruth for Nancy A. Johnson; however, he did call said Attorney on Dec. 9, 2003 and had no objection to the nomination of Nancy A. Johnson as administrator c.t.a. Upon information and belief Bonnie Robicheau, niece-in-Iaw has changed her first and last name and moved and her whereabouts are currently unknown, though it is believed that she resides in California. ,. Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petltloner(s) will well and truly administer the estate according to law. Sworn to and affirmed a~UbSCribed before me this {l,:J. day of vi !:'./ j j:J.. O~ L-v-.. J). 00 ~ '!;/' / ~ 'I' rL-;)/c' MtOm/ J ~MrL.-~~~ ~~j~ C DECREE OF REGISTER Estate of Harvev D. Fleischer Deceased No. also known as Social Security No: 174-01-6817 Date of Death: 11/29/2003 AND NOW, ~ ~ I 3 ,20rN , in consideration of the Petition on the reverse side here~ory proof haVing been presented before me, IT IS DECREED that Letters 0 Testamentary IX) of AdministrationC.t.a. (c.I.a., d.b.n.c.t.; pendente lite; durante absentia; durante minoritate) are hereby granted to Nancy A. Johnson In the above estate and that the Instrument(s), if any, dated October 28, 1996 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters ........................ ............ $ ~ ~t::) . ex.."') ~,L._~~~~+-'~~ agister of Wills Short Certificate(s) ............... $ \ do .00 Renunciation .......................... $ 5'::>,00 Affidavit ( ) ....................... $ Extra Pages ( ).............. $ Codicil .............. ................... $ JCP Fee ................................. $ \0 DU Inventory & Tax Forms............. $ Other........ .............................. $ ~ll~ Attorney Attorney: Scott A. Ruth 1.0. No: 61934 Address: 4 High street Hanover TOTAL ............................$. 312 .00 PA 17331 Telephone: DATE FILED: \-\3-(){ R Of DEATH AWiUlA8lE PfUOft 10 COMPlETION OF CAUSE: ........ g 0 OF OEArH? HomlCd -..... 0 Pendlng In...,igation 0 ....0 No 0 ....... 0 CoWd ROC ~ deletmmed 0 DATE OF INJURY (Mooltl Day. ......1 " RACE . Amencan tndlIR.lYeck, WhiI.. Ilk ......,." White MAAtTAl STATUS - Mamed NtI.,., M..-ried. WIdI')wM, """'--"" Widowed I ower Allen Twp SUAVlVtNG SPOuse 11'....._ '1''''1NoOWl twnel ..... '..-.. Conolite Crematory NAME AND AOORES$Of FACILITY 21d. SChaefferstown, Pa 17088 Uc. M ers Funeral Home Inc. 37 East Main Street Mechanlcsbur Pa. 17055 lICENSE NUMBER DATE SlGNEO 'Moolh. Day. '!\!atl 23b. 23c. _5 CASE REfERRED TO MEOtCAl EXAMINER#COROHER7 .... ~ C-tNN ... I~e : n.,. belwMn I onMI MIl dHth I I NoD PART H: OIhe. ~I condl&ions c:ontfitlubnglO dolh. but not mulling in.... undertyw1Q QlUM gMn in PART I I I , -------r--- : r'L.-I_..,___ TIME OF INJURY INJURY AT WORK? DESCRIBE HON INJURY OCCURRED. ..... 0 NoD ,,1 . ) JO.. ... PlACE OF INJURY - AI home, farm. 11,"" tKlory. office buikjng, etc. 1Sp.:"'1) 2"_ 2.. a. ~. CERTIofIEfl.C~8Cll. 00.., ClfIeI .~:~'::.'::f::==~:;'C:C~ c:::.a:a:::-s:~:~:~::;=:'~~OUocecl dealh al1a compleled Item 23) QS1 " ~ ~ . PRONOUNCING AND CERTIFYING PHYSICIAN jPhvsc:..n bolh ;>Iono",II(;'119 dedth drla Cefl,I..,1tlQ to ca\J~ 01 aeath\ To the bHt 0' "'y kno~.. death OC:CUtred el ~ u.n.. da1a, afld plac.. and dye 10 1M cauM(s' and man"at as slated_ . .UEDICAL EXAMINER/COAONER On the b..I. of ...minallon .ndlor In.....lIg.hon. in my opInion. d..th occutred allhe time, dale. and place. o1nd due to the cause(a) and mannera.st.t"........... ...................... ............ ........... ..... ....... ...............,... ,. ,.. D ~ Rr;:~I~'AR'S SIGNATURE ~NO NUP.t~~R /" ^ I ~'<rJi 1/~.ll)d r(tf't..(A~' ~ t~:)1 ! i~ I t11 o o Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as , Deceased The undersigned,J. Robert Stauffer, ESQuire, Nominated Alternate Executor (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of administration c.t.a. be issued to Nancy A. Johnson Witness c hand this aYOf~~:- (Sig . obert Stauffer Market Square Building, Mechanicsburg (Address) PA 17055 (Signature) (Address) (Signlture) (Addre88) Sworn to or affirmed and subscribed before me this ..J R. 0 day of J--r U n-Jur , ~70 '~ 4 icL/ -f)J. -1);))0 Notary Public My Commission Expires: COMMONWEALTH OF PENNSLVANIA Notarial Seal HelcI M. Nelson, Notary Public ~ 8010, Cumbel1and County My Commission Expires June 27, 2007 Member. PElnI18}<Ivanja Association Of Notaries (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as . Deceased The undersigned, Officer of Mechanicsburg Presbyterian Church, beneficiary under the will of (Relationship) (Capacity) the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration c.I.a. be issued to Nancy A. Johnson Witness hand this f/;:t day of December ~X~ (Signature) Mechanicsburg Presbyterian Church 300 E. Simpson Street, Mechanicsburg (Address) PA 17055 2003 (Signature) (Address) (Signature) (Address) Sworn to or affirmed and subscribed before me this day of , ;,2003. Notary P lic My Commission Expires: Notarial Seal . Vicky Lynn Bogus, Nocary Pud:c Mechanicsburg Boro. ~mbedand :Jb6 My Commission Explfes Feb. 24. - . AssociatiOnotNotari,;s ~. ~p.mber. pennsylVaOla ' (Signature and seal of Notary or other official qualified to administer oalhs_ Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as , Deceased The undersigned,Robert C. Stacy, Nominated Executor and Cousin (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration c.t.a. be issued to Nancy A. Johnson Witness my hand this 2003 Robert C.Stacy 614 Mercer Road, Beaver Falls (Address) PA 15010 .J (Signature) (Address) (Signature) (Address) day of Notary Public My Commission Expires: NOTAHlAL St.:Al Carole L. Bla:r, f\!otnry Public City of Beaver, Ccunty of Beaver My Commission !::xp'res Feb. 16,2004 (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as , Deceased The undersigned, Officer of the Salvation Army, beneficiary under the will (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate a Letters of Administration c.t.a. be issued to Nanc Witness --IIrf-- hand this ilan, Asst. Secreta PA 19123 (Signature) (Address) (Signature) (Address) Sworn to or affirmed a~ subscribed before me this ~~ t. day of ~ ~(JOJ I~J]~ Notary Public --- My Commission Expires: INCA. ..... (Signaled W.... fa .1l......,.. 0"'lCialqUalifled~7 dat~1Ii1t . NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as , Deceased The undersigned, Doris DeMoss, Sister-in-Law and Beneficiary under Will (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration c.t.a. be issued to Nancy A. Johnson Witness my hand this llo.~ day of December 2003 tJrYU~ fj~ ~ (Signature) Doris DeMoss P.O. Box 14115, So Lake Tahoe (Address) CA 96151 (Signature) (Address) , .-.1 (Signature) (Address) Sworn to or affirmed and subscribed before me this-.J 1./t4 day of 1t.--QL-1'l\~t1t1 ~ ~'Y3 (fuu ~ Notary Public ( 1 My Commission Expires: -r Ilf Cf7 I . . . .: ,:: . . . . ~~N COSTE~' . ~ ~ t ii, .-..' '. COMM. .1430543 m ~ =.' ': Notary public.callfornla ~ ~ :'f:, . EL DORADO COUNTY .- ) ~ ~~~". . ~~ C.o~~..~p: :u~ ~~ ~~7.l (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized_ RW-3 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as , Deceased The undersigned,Jeanne Atkinson, Sister and Beneficiary under Will (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration c.t.a. be issued to Nancy A. Johnson Witness my hand this (1'tfL day of December 2003 ~(~ + t1d1:'4~ . (Signature) J nne Atkinson 1069 Red Maple Way, New Smyrna Beach (Address) FL 32168 (Signature) (Address) (Signature) (Address) Sworn to or affirmed and subscribed Cj-I;A. before me this day of ""~ ~oo.3 ~'a.- ~ ta Public LORI A. HITCHNER My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. !\,,\l.V PUt; OFRClAl:NorARYSEAl ~o (.. LORI A HITCHNeR ~ "f~ ~ COMMISSICWNUMBER 7 ~_~ 00055219 ~ o~ MYCOMMISSlONEXPlAES OF FI. c_. SEPT26.20OS RW-3 LAST WILL AND TESTAr-mNT OF HARVEY D. FLEISCHER I, HARVEY D. FLEISCHER, of the Township of Lower Allen, County of Cumberland and State of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can be conveniently done, and in this respect, I direct that all estate, inheritance and succession taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid out of the principal of my general estate to the same effect as if said taxes were expenses of administration, and that all property includable in my taxable estate, whether or not passing under this Will, shall be free and clear thereof. 2. I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, whatsoever and wheresoever the same may be situate, to my wife, GRACE B. FLEISCHER, absolutely and unconditionally. -1- 3. In the event that my wife, GRACE B. FLEISCHER, should predeoease me, or should she die within thirty (30) days from the date of my death, then in either event, I direct the settlement and distribution of my estate to be made in the following manner, to wit: A. I give and bequeath twenty-three (2)%> per cent. of my estate to my sister, JEANNE ATKINSON. B. I give and bequeath twenty-three (2)%) per cent. of my estate to my sister-in-law, DORIS DeMOSS. C. I give and bequeath twenty-three (2)%) per cent. of my estate to my sister-in-law, HELEN MERRYMAN. D. I give and bequeath three (3%) per cent. of my estate to my wife's niece, BONNIE ROBICHEAU. E. I give and bequeath five {5%> per cent. of my estate to my wife's nephew, JAY BRANDENBERGER. F. I give and bequeath five {5%> per oent. of my estate to the MECHANICSBURG PRESBYTERIAN CHURCH. G. I give and bequeath eight (8%> per cent. of my estate to the SALVATION ARMY. H. I give and bequeath five (5%> per oent. of my estate to the NEW HOPE MINISTERIES, of Meohanicsburg, Pennsylvania. -2- I. I give and bequeath five (5%) per cent. of my estate to the BETHESDA MISSION, of Harrisburg, Pennsylvania. LASTLY, I nominate, constitute and appoint my wife, GRACE B. FLEISCHER, Executrix of this my Last Will and Testament, and in the event that my said wife should predecease me, or should she be unable or unwilling to serve in such capacity for any reason, then in such event, I nominate, constitute and appoint my cousin, ROBERT C. STACY, Executor of this my Last Will and Testament, in her place and stead, and in the event that my cousin, ROBERT C. STACY, should predecease me, or should he be unable to serve as such Executor, then in such event, I nominate, constitute and appoint J. ROBERT STAUFFER, Esq., of Mechanicsburg, Pennsylvania, Executor of this my Last Will and Testament, and in all instances, I direct that my said personal representatives be excused from posting bond or other security for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 2x day of October, A. D., 1996. 9~ f) r;f,./~6-7 / . arvey D. Fleischer (SEAL) -)- Signed, sealed, published and deolared by the above named, HARVEY D. FLEISCHER, as and for his Last Will and Testament, in the presence of us, who have subscribed our names hereto as witnesses, at the request of said testator, in his presence and in the presence of each other. ~ d. 71<'<(7 v' -4- 4' ." COMMONWEALTH OF PENNSYLVANIA ) SSe COUNTY OF CUMBERLAND ) I, HARVEY D. FLEISCHER , the testat or whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and volun- tary act and deed, for the purposes therein contained. Sworn and affirmed to and acknowledged before me by- HARVEY D. FLEISCHER , the testator , this ~yT'''' day of Oetopel" ' A. D., 1996. :1~iJ ~ ~~ -" - Harv7 D. Plefs~h;r /'1",:4- f!J &:L . Not y Public Notarial Seal "-', u-,~!r.~ Eakin, Notary PlJb!ic JI "U;,~ij.Boro. Cumberland Counly '~' mIsSion expires Nov. 6, 1997 · AssOaiIOii of NQI~~ COUNTY OF CUMBERLAND ) ) SSe COMMONWEALTH OF PENNSYLVANIA We, the undersigned, J. ROBERT STAUFFER and SUSAN A. HeCOY , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the testat or, HARVEY D. FLEISCHER , sign and exe- cute the instrument as his/iUUI: Last Will and Testament; that the said testat or , HARVEY D. FLEISCHER , executed it as his/~free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the testatOr , signed the Will as witnesses; and that to the best of our knowledge, the testat or was, at the time, eighteen (18) or more years of age, of sound mind, and under no constraint, duress or undue influence. , Sworn and me this October / SUbfr'ibed to befof/ A day of , 1996 . ;11a;.+ ~ ~. -5- RIVERSIDE MEDICAL CLINIC 6405 Day Street Riverside, California 92507 (714) 697-5420 From the desk of _ Iwan S. Ong, M.D. :.. Internal Medicine /2- ~1-2...-03 -.-- / C> w k., ~I PI?! C tf>< Uhn I~ )1~ /'hlLrJ -4.. -s ~ -c....~ :)'II?c...L ~I!"~:S uub ttlCs 7:1 s~ 2. 0-0 I CL.."J cd1t.u~ ~L o~,. ~ (S nul- c'~/}"L ~ 1 . ~~/ ~I ~~ ~ ~~~ .- /r) ~y j "7 a-~ <...e eM-< / ~JJ.{_ it r ~~~ / ~~;i~' re.-u I. ~ r ~~.J.t.~ 3/n~ ~ f'~ /1-.f) !wan S. Ong, M. D. 640S Day St. Fk' ,ide, CA 92507 {9th. ;;591-5420 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as , Deceased The undersigned, Jay Brandenberger, nephew and beneficiary under will (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration c.t.a. be issued to Nancy A. Johnson h ..JAnUtti1 ::J DOt.{ Witness my hand this ~ '-day of ~r ~ . Jay ~ d~~berger 137 South Ellsworth Place, South Bend (Address) IN 46617 (Signature) (Address) (Signature) (Address) /' l Sworn to or affirmed and subscribed before me this q day of ,// I C/aYl~ ' ~OO~ I" /~/fr-f." / ' ,{~;;'J '. (...Vr<.. 5 ~ Notary Publi . V61 <.. 14 L- Ah E l:>15H l5(C. ( My Commission Expires: fL,t 14L( Z~S/.;;l 00'1 (Signature and seal of Nolary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as , Deceased The undersigned,Bonnie Robicheau now known as Julia Youngblood, beneficiary under will of (Relationship) (Capacity) the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration c.I.a. be issued to Nancy A. Johnson Witness hand this day of If ' dt' ) - /1 i'---/~L- /i~~ - . .t:'/" (Signature) Bonnie Robichea nlkla Jy,Jia Youngblood 89187 Sutton Lake Road, Florence (Address) ~_/J~C (Signature) (Address) (Signature) (Address) Sworn to or affirmed and subscribed before me this ~ ~ day of ~:~~) ary Public . -- .. My Commission Expires: ::( f"J.l:V7 ----.,~-...... _OFFICIAL SEAL SUNSHINE JAMISON NOTARY PUBLIC-OREGON .... ..' COMMISSION NO. 365249 MY COMMISSION EXPIRES FEB. 2, 2007 (Signatura and seal of Notary or other official qualified 10 administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the OffICe of Register of Wills are required in some counties to be notarized. RW-3 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No. also known as , Deceased The undersigned. Officer of New Hope Ministries, beneficiary under the will (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration c.t.a. be issued to Nancy A. Johnson 30fu Witness h\1 hand this day of Dece~ 2003 . k ~, (7~ (Signature) New Hope Ministries 15 State Road, Mechanicsburg (Address) PA 17050 (Signature) (Address) (Signature) (Address) Sworn to or affirmed and subscribed 7A~ before me this 2'-' - day of 2Cl~~ . NOTARIAL SEAL . ' .aM J. R\CHAII)SON. JR., NDlary Public IIIsIu~O. York COlinty MyComm Expires ~~._~4 . (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 SCOTT A RUTH ATTY 7176300888 12/22/03 03:41pm P. 006 Register of Wills Cumberland County, Pennsylvania RENUNCIATION Estate of Harvey D. Fleischer No_ also known as , Deceased The undersigned,Officer of Bethesda Mission, beneficiary under the will (Relationship) (Capacity) of the above Decedent. hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration c.t.a. be issued to Nancy A. Johnson q hJ Witness nty hand this /)J.. ~ Bethesda Slon 1500 North 2nd Street, Harrisburg (Address) PA 17102 (Signature) (Address) (Signature) (Address) Swom to or affirmed and subscribed " h~ before me this ......... ~ - day of d Cr6 3 b-~ NOTARIAL SEAL HELEN L. DiEHL Notary Public City of Elliottsburg, Perry County My Commission Expires May 02, ~)J05 (Signature and seal of PI Of~-'-' ...._..__.___h' --, __'0' -NOTE.! Renunciations executed outside the Office of Register of Wills are official qualified to administer oaths_ Show required in some counties to be notarized. date or expiration of Notary's commission.) RW-3 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 JOHNSON NANCY A 6424 PAMADEV A RD HANOVER, PA 17331 -------- fold ESTATE INFORMATION: SSN: 174-01-6817 FILE NUMBER: 2104-0036 DECEDENT NAME: FLEISCHER HARVEY D DA TE OF PAYMENT: 02/27/2004 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 11/29/2003 NO. CD 003608 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $32,000.00 I I I I I I I I TOTAL AMOUNT PAID: $32,000.00 REMARKS: CHECK# 1005 ,.'" SEAL INITIALS: JA RECEIVED BY: (" f L; REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS ;).1:L7fo+ e}.r,=:~S~~N< DATE ~(I $ 3 d;, 000, ()O ""'''''FA A"., L '. . '__ ) Ll.!5 - U'flVl'1. .' .'. ro. . DOllARS. 6l .=..-;:.. ~~ri~;~~ R~637~R- o.f~~ '. ..._ . &l ~-~~~RES~AT~.' ..... . <~1/./. 12 (Z!~~l~~' J...... .... .... H A,.R VC.' ~ Y ADJ~~ NSO N. ". .... f '_-. L ._ ..4. c. _ .----.- ~.-- "'--YJ:cLUa.... '.' . .......... ~.. _..,., , . '. _.... ,) _ _'. j P R~~. ~.' 0 E ~,n" ' . . . "'AN.. H ESQ . ~ . ..../' .~__.__.~"__.__ . ~ ESTATE OF C/O. SCOTT. ARU. T '.' ~f...' .____(_.-.---''--''-.----'---~:--.-- ou. ...... __ __._,_AP . TRUSTEE ~~~:~Rm733t d-kD~-(~J,12 .. t-'__"-"-______'"_",--, FOR ........ '61 tit It ;)1)o'1~IJO01t., . - -0.... ~.. n ~II' ~ ., iLf'V'tqRllftJ~, .' .03 1.3 1..273&': SO . i -tLIA---. . . II' 00 ~00.5 p' '. '. 0: ~ " m See II f; t d do ell In e II t. en h {I /lee See-back "r de t a j 1 s. ftl NO. 1005 60"1273/313 047 '\ v. ;ommpnwealth of Pennsylvania ';ounf9 of Cumberland CERTIFICATION OF NOTICE UNDER RULE 5.6(8) Name of Decedent: Harvev D. Fleischer Date of Death: 11/29/2003 Will No. 2004-00036 Adm. No. To the Register: 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 1/26/2004 Name Jeanne Atkinson Sister of Decedent Doris DeMoss Sister-in-law of Decedent Helen Merryman c/o Dean Merryman Sister-in-law of Decedent Julia Youngblood flk/a Bonnie Robicheau Niece-in-Iaw of Decedent Jay Brandenberger NeDhew-in-law of Decedent Address 1069 Red Maple Way New Smvrna Beach. FL 32168 P.O. Box 14115 So Lake Tahoe CA 96151 12633 Daphane Etiwanda CA 91739 89187 Sutton Lake Road Florence OR 97439 137 South Ellsworth Place South Bend IN 46617 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: none., ~i: o , w.{}Jn (Signature) Scott A. Ruth, Esquire Name: Scott A. Ruth. Esauire Address: 4 Hiah Street Hanover Date: 1/26/2004 o Lf:I '::( a.; cr: ..- PA 17331 N ..- ffi w.... Telephone (717) - 6309333 p Capacity: x Personal Representative Counsel for Personal Representative v- Continuation of Certification of Notice Under Rule 5.6(a) Harvey D. Fleischer Decedent Page 1 11/29/2003 Date of Death Names and addresses Bethesda Mission Address 300 E. Simpson Street Mechanicsburg, PA 17055 701 North Broad Street Philadelphia PA 19123 15 State Road Mechanicsburg, PA 17050 1500 North 2nd Street Harrisburg, PA 17102 Name Mechanicsburg Presbyterian Church Salvation Army New Hope Ministries SCOTT A. RUTH WOtn~ CY1t .Il!aIU 4 HIGH STREET HANOVER, PENNSYLVANIA 17331 TELEPHONE (717) 630-9333 . fAX (717) 630-0888 Jeanne Atkinson 1069 Red Maple Way New Smyrna Beachl FL 32168 Helen Merryman c/o Dean Merryman 12633 Daphane Etiwanda, CA 91739 Mech. Presbyterian Church 300 E. Simpson Street Mechanicsburg, P A 17055 New Hope Ministries 15 State Road Mechanicsburg, PA 17050 He: Estate of Harvey D. Fleischer January 27, 2004 Doris DeMoss P.O. Box 14115 So Lake Tahoe, CA 96151-4115 Julia Youngblood 89187 Sutton Lake Road Florence, OR 97439 Jay Brandenberger 137 S. Ellsworth PI South Bend, IN 46617 Salvation Army - Mechanicsburg Regional Serv. 701 North Broad Street Philadelphia, P A 19123-2491 Bethesda Mission 1500 North 2nd Street Harrisburg, PA 17102 Enclosed please find an Important Notice of Estate Administration required by Orphan Court Rules 5.6 and 5.7. I have previously provided a copy of the will. I also enclose a copy of a Short Certificate - Letters of Administration C.T.A. dated January 13, 2004. SAR/ adr enclosure Sincerely, ~~ Scott A. Ruth REV-l500 EX + (6-00) REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT 'W w .... "'~~ fdo..u :r~g Ulm < COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 I- Z W o W o W o OECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Fleischer Harve D. DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) OFFICIAL USE ONt y FILE NUMBER 21-0436 ""CQtMyC05E -YEAR- - - iiiiER-- SOCIAL SECURITY NUMBER 1 7 4 - 0 1 - 6 8 1 7 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 03. Remainder Retum (ditedde<<hprUto12-13-82) o 5. Federal Estate Tax Return Required 1... 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (AttachSchO) THIS SECTION MUST IE COMPLETED. ALL CORRElIPONDENCE AND CONFIDENTIAl.. TAX INFORMATION SHOULD IE DIRECTED TO: NAME COMPLETE MAILING ADDRESS Scott A. Ruth Attome at Law FIRM NAME (W Appicab~) z o ;::: :3 ::l l- ii: oct o W It:: z o ;::: ;:!: ::l n. :::;: o o >< ;:!: \). 11/29/2003 08/14/1913 (IF APPLICABLE) SURVIVING SPDUSE'S NAME (LAST, FIRST. AND MIDDLE INITIAL) 00 1. Original Return o 4. limited Estate (R] 6. Decedent Died Testate (AttachcopYd'vVil) o 9. litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (date d de5h after 12-12-82) o 7. Decedent Maintained a living Trust (AItach~YdTrust) o 1 Q. Spousal Poverty Credit (dale ri de<<h between 12-31-91 and 1-1-95) .... z w o z o .. .. W It: It: o o 4 High Street TELEPHONE NUMBER 717-630-9333 Hanover 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Noles Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested' 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (tolallines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage liabilities, & liens (Schedule 1) 11. Tolal Deductions (total Lines 9 & 10) 12. Net Value of Estate (Une 8 minus Line 11) (1) (2) (3) (4) (5) 1~~4.77lg cr' .[I, PA 17331 - OFFICIAL USE ONLYj )':~. "" c::: c:;; 0.00 X _(15) 0.00 0.00 X _(16) 0.00 66,778.46 X .12 (17) 8,013.42 156,774.23 X .15 (18) 23,516.13 (19) 31 ,529.55 (6) (7) (9) (10) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to lax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICASLE RATES 15, Amount of Line 141axable atlhe spousal lax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Une 14 taxable at collateral rate 19. Tax Due 20. 0 CHECK HERE IF YOU ARE REQUESTING A REfLJNlJ OF AN OVERPAYMEW ~... K.l 2"",096.37 0\ ( -0 N I,);'" .. :r" - 0.00 l~ (8) 333,961.14 38,751.88 4,868.11 (11) (12) (13) 43,619.99 290,341.15 66,778.46 (14) 223,562.69 o , II r c I te Add ece en s omple ress: STREET ADDRESS 325 Weslev Drive, ADt. 3222 CITV I STATE I ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 31,529.55 32000.00 1.576.48 3. InteresUPenalty ~ applicable D.lnterest E. Penally Total Credits (A + 8 + C) (2) 33,576.48 TotallnteresUPenally (D + E) (3) 4. If Line 2 is 9reater than Line 1 + 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. (SA) 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS t. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;................ .................... .............. ................. .. 0 IRI b. retain the right to designate who shall use the property transferred or its income;.. ................. ................. 0 IRI c. retain a reversionary interest;.or...................... .................... ................. ................. ... 0 IRI d. receive the promise for life of either payments, benefits or care?.. ................. ................... 0 IRI 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideratiDn?......... .................. ................ .................. ......................... 0 IRI 3. Did decedent own an "in trust fo~ or payable upon death bank account orsecurity at his or her death?.............. 0 IRI 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?............ ..................................... ............................................... IRI 0 0.00 2,046.93 0.00 0.00 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 penaIies of perjury, I declare that I have examined this return, incbling accompanyilg schedules and statements, and 10 the best of my knowledge and belief, R is true, correct and compl:J:te. Declaration of prepaer other than the personal representative is based on al information of wIlCh preparer has any knondge. SIGNATUJ<E ERSON RESPONSIBLE F NG RETURN DATE ~, ,&S-: 2m PA ADDRESS PA 17331 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)l. 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 (aJ (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even ~ 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. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers 10 or for the use oflhe decedenfs lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imoosed on the net value of transfers to or for the use of the decedent's siblinas is 12% 172 P.S. S91 16Ia\I1.3\1. A siblino is defined. under Section 9102. as an REV-1503 EX + (6~98) * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Fleischer Harvev D. FILE NUMBER 21 04 All property jointty-owned with right of survivorship must be disclosed on Schedule F. 36 ITEM NUMBER 1. 2. DESCRIPTION PNC Investments, Account No. 32873217 2 East Main Street Mechanicsburg, PA 17055 Scudder Investments, Fund-Account No. 18-893989383 Cadaret Grant & Co. Inc., Gibb Financial Services, Inc. 16 W. Pomfret Street, Carlisle, PA 17013-3216 Merill Lynch, Pierce, Fenner & Smith Inc., Account No. 500 49G04 P.O. Box 1528 Pennington NJ 08534-1528 VALUE AT DATE OF DEATH 100,107.68 12,141.49 3. 12,615.60 . TOTAL (Also enter on line 2, Recapituia!ion) $ 124,864.77 REV.1508 EX + (6-98) .. COMMONWEALTH OF PENNSYlVANlA. INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Fleischer Harvev D ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. FILE NUMBER 21 04 Include the proceeds of litigation and the date the proceeds were received by the estate. All property joIntly-owned with right of survivorship must be disclosed on Schedule F. 36 VALUE AT DATE OF DEATH 293.59 4,783.60 1,137.11 10,676.54 8,423.79 16,695.75 15,952.99 4,681.09 17,398.16 4,354.15 1,631.89 33,137.80 200.00 350.00 8,143.75 8,280.05 DESCRIPTION Misc. cash, uncashed dividend and pension checks PNC Bank, Checking Account no. 50-7007-5422 Bethany Village 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, Ready Access CD, Account No. 31200149738 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, 27 month CD, Account No. 31100226442 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, 12 month CD, Account No. 31400098201 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, 12 month CD, Account No. 31600094239 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, 12 month CD, Account No. 31600093241 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, 18 month CD, Account No. 31000175874 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, 24 month CD, Account No. 31900107106 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, 6 month CD, Account No. 31800196457 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, 6 month CD, Account No. 31300198409 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 PNC Bank, Money Market Account No. 50-0096-2448 Bethany Village, 325 Wesley Drive Mechanicsburg, PA 17055 Lisburn Auction Services Purchase of Household Furnishings Proceeds from sale of 1989 Buick LeSabre VIN # 1G4HP54C2KH450930 Citizens Bank (CD) Ace!. 6140-704987 1 Citizens Drive Riverside, RI 02915-3000 Citizens Bank (CD) Ace!. 6140-734789 1 Citizens Drive Riverside, RI 02915 TOTAL (Also enter on line 5, Recapitulation) $ 209 096.37 Continuation of REV-1500 Inheritance Tax Return Resident Decedent Fleischer, Harvey D. Decedent's Name Page 1 21 04 36 File Number Schedule E - Cash, Bank Deposits, & Mise, Personal Property ITEM NUMBER 17. 18. 19. 20. 21. 22. 23. DESCRIPTION Citizens Bank (CD) Ace!. 6140-719631 1 Citizens Drive Riverside, RI 02915 Citizens Bank (CD) Ace!. 6140-872774 1 Citizens Drive Riverside, RI 02915 Citizens Bank (CD) Ace!. 6140-719658 1 Citizens Drive Riverside, RI 02915 MetLife Policy # 17628 045 A (Policy owner: Grace B. Fleischer deceased; beneficiary P.O. Box 316 was Harvey D. Fleischer) Warwick, RI 02886-0316 Met Life Annuity Account # M8006066 P.O. Box 17700 Denver, CO 80217-0700 New York Life Ins. and Annuity: Annuity Policy # NP 093 965 51 Madison Avenue New York, NY 10010 Personal property (jewelry box, Madonna statues, projector, hand-painted box, misc. jewelry, 1971 Candadian dollar, silver-plated flatward, hand-painted eggs) VALUE AT DATE OF DEATH 18,444.84 12,359.26 10,692.44 1,774.93 24,266.32 4,951.32 467.00 SUBTOTAL SCHEDULE E 72,956.11 209,096.37 GRAND TOTAL SCHEDULE E $ REV-1510 EX + (6-98) * COMMONWEALTH OF PENNSYLVANIA INHERrTANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Fleischer Harvev D FILE NUMBER 21 04 36 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 ITEM tlCLUDE THE I\AUE OF THE TRANSfEREE. THElR RElATlONSHP TO DECEDENT ANO DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEEO FOR REAt ESTATE. VALUE OF ASSET INTEREST VALUE (IF APPlICABlE) 1. MetLife Group Life Claims: Group#0105096 Claim# 1667963 5,000.00 100. 5,000.00 0.00 Transferee:Jeanne Atkinson, sister of decedent Date of Transfer: 3/9/2000 2. MetLife Policy # 21 504 778 A 6,811.96 100. 6,811.96 0.00 P.O. Box 316 Warwick, RI 02886-0316 3. MetLife Policy # 15 703 082 A 1,966.15 100. 1,966.15 0.00 P.O. Box 316 Warwick, RI 02886-0316 4. New York Life Ins. Co. Policy # 17 976 795 2,120.22 100. 2,120.22 0.00 51 Madison Avenue New York, NY 10010 5. Prudential Financial Life Ins. Contract No. 11 361 664 5,429.46 100. 5,429.46 0.00 P.O. Box 7390 Philadelphia, PA 19101 6. Fortis (formerly Liberty Life Ins. Co.) Policy #0040008329 1,993.00 100. 1,993.00 0.00 P.O. Box 19089 Greenville, SC 29602-9089 TOTAL (Also enter on line 7 Recapitulation) $ 0.00 REV-1511 EX + (12-99) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER 21 04 36 Fleischer Harvev D. Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Funeral Home 1,993.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Nancy A. Johnson 16,698.00 Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 6424 Pamadeva Road City Hanover State PA Zip 17331 Year(s) Commission Paid: 2. Attorney Fees Scott A. Ruth, Allorney at Law 16,698.00 3. Family Exemption: (If dececlent's address is not the same as claimant's, attach explanation) Claimant SlreetAddress City Stale Zip Relationship of Claimant to Decedent 4. Probate Fees Lellers Admin cta $235, Short Certs. $54, Renunciations $55, JCP Fee $10 577.00 Inh. Tax Return $15, Inventory $13, Add. fee letters $70, Acct & Adv. $125 5. Accountant's Fees 6. Tax Return Preparer's Fees Michael T. Noel, CPA 1,065.00 Prep. of Income Tax Returns 2001,2002,2003, fiduciary returns(2) 7. Cumberland County Legal Journal 75.00 8. Information Network Associates - find heir 75.00 9. Bob Miller Towing Service 125.00 10. Capital Self Storage, packing supplies 58.82 11. The Sentinel Newspaper 102.11 12. Labor to pack and clean apl. 408.00 13. PNC - estate checks 55.20 14. Notary - transfer car title 10.00 15. Michael T. Noel, CPA - ConsolidationlTransfer of Securities 500.00 16. Death Certificates - Vital Statistics 63.00 17. Mailing/Postage/Mailing supplies- UPS and Postmaster 208.75 18. lillie's Coins & Jewelry - appraisal 40.00 TOTAL (Also enter on line 9, Recapitulation) $ 38 751.88 , REV-15'\.2 EX + (6-98) *' SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA. INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Fleischer Harvev D FILE NUMBER 21 04 36 Include unreimbur.ed medical expen.... ITEM NUMBER DESCRIPTION 1. Bethany Village Retirement Center VALUE AT DATE OF DEATH 1,997.75 2. Statewide Tax Recovery Inc. 26.00 3. Home Instead Senior Care 250.62 4. Select Medical Corporation 840.00 5. Nephrology Associates of Central PA 69.28 6. Holy Spirit Hospital 11.67 7. Alert Pharmacy 26.79 8. MCI 75.91 9. Penn Credit Corp. (2003 Per Capita Tax) 28.50 10. Conner-Rich Associates Internal Medicine 224.69 11. Nephrology Associates of Central P A 20.96 12. Internal Revenue Service - 2003 Estimated Federal Income Tax 271.00 13. Internal Revenue Service - 2001 Federal Income Tax 443.65 14. Internal Revenue Service - 2002 Federal Income Tax 480.00 15. Internal Revenue Service - 2003 Federal Income Tax 69.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 4868.11 Continuation of REV-1500 Inheritance Tax Return Resident Oecedent Fleischer, Harvey D. Decedent's Name Page 2 21 04 36 File Number Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER 16. DESCRIPTION AMOUNT 32.29 Quantum Imaging Therapeutic SUBTOTAL SCHEDULE I GRAND TOTAL SCHEDULE I $ 32.29 4,868.11 REV-1513.EX+tO. COMMONWEALTH OF PENNSYLVANIA INHERrrANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER I=I"ic~h"r H"n,,,v n 71 04 36 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1. TAXABLE DISTRIBUTIONS [include outri~ht s~usal distributions, and transfers under Sec. 9116 (a (1. )J 1. Jeanne Atkinson Sibling 1069 Red Maple Way 23 % New Smyrna Beach, FL 32168 2. Doris DeMoss Collateral P.O. Box 14115 23% So. Lake Tahoe, CA 96151-4115 3. Helen Merryman Collateral c/o Gale Merryman, 12633 Daphane 23 % Etiwanda, CA 91739 4. Bonnie Robicheau now known as Julia Youngblood Collateral 89187 Sullon Lake Road 3% Florence, OR 97439 5. Jay Brandenberger Collateral 137 S. Ellsworth Place 5% South Bend, IN 46617 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. Mechanicsburg Presbyterian Church 300 E. Simpson Street Mechanicsburg, PA 17055 2. Salvation Army - Mechanicsburg Regional Service 701 North Broad Street Philadelphia, PA 19123-2491 3. New Hope Ministries 15 State Road Mechanicsburg, PA 17050 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ flf mOrA !;n~.p ili;. nPArlAt1 ino;prt Mttitinn::.1 <o;hAPtli;. of th"" o;;,::.mp o;;,i7,.,' Continuation of REV-1500 Inheritance Tax Return Resident Decedent Fleischer, Harvey D. Decedent's Name Page 3 21 04 36 File Number Schedule J - Beneficiaries - 28 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 4. Bethesda Mission 1500 North 2nd Street Harrisburg, PA 17102 SUBTOTAL SCHEDULE J.2B LAST WILL AND TESTAMENT OF HARVEY D. FLEISCHER I, HARVEY D. FLEISCHER, or the Township or Lower Allen, County or Cumberland and State or Pennsylvania, being or sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretorore made. 1. I direct the payment or all my just debts and runeral expenses as soon arter my decease as the same can be conveniently done, and in this respect, I direct that all estate, inheritance and succession taxes that may be assessed in consequence or my death, or whatever nature and by whatever jurisdiotion imposed, shall be paid out or the principal or my general estate to the same errect as ir said taxes were expenses or administration, and that all property includable in my taxable estate, whether or not passing under this Will, shall be rree and olear thereor. 2. I give, devise and bequeath all the rest, residue and remainder or my estate, real, personal and mixed, whatsoever and wheresoever the same may be situate, to my wire, GRACE B. FLEISCHER, absolutely and unoonditionally. -1- 3. In the event that my wife, GRACE B. FLEISCHER, should predeoease me, or should she die within thirty (30) days from the date of my death, then in either event, I direot the settlement and distribution of my estate to be made in the following manner, to witl A. I give and bequeath twenty-three (2)%) per oent. of my estate to my sister, JEANNE ATKINSON. B. I give and bequeath twenty-three (23%) per oent. of my estate to my sister-in-law, DORIS DeMOSS. O. I give and bequeath twenty-three (23%) per oent. of my estate to my sister-in-law, HELEN MERRYMAN. D. I give and bequeath three (3%) per oent. of my estate to my wife's nieoe, BONNIE ROBICHEAU. E. I give and bequeath five (5%) per oent. of my estate to my wifel s nephew, JAY BRANDENBERGER. F. I give and bequeath five (5%) per oent. of my estate to the MECHANIOSBURG PRESBYTERIAN CHURCH. G. I give and bequeath eight (8%) per oent. of my estate to the SALVATION ARMY. H. I give and bequeath five (5%) per oent. of my estate to the NEW HOPE MINISTERIES, of Meohaniosburg, Pennsylvania. -2- I. I give and bequeath rive (5%) per oent. or my estate to the BETHESDA MISSION, or Harrisburg, Pennsylvania. LASTLY, I nominate, oonstitute and appoint my wire, GRACE B. FLEISCHER, Exeoutrix or this my Last Will and Testament, and in the event that my said wire should predecease me. or should she be Unable or unwilling to serve in such capaoity for any reason, then in such event, I nominate, oonstitute and appoint my oousin, ROBERT C. STACY, Exeoutor of this my Last Will and Testament, in her place and stead, and in the event that my oousin, ROBERT C. STACY, should predeoease me, or should he be unable to serve as such Executor, then in such event, I nominate, constitute and appoint J. ROBERT STAUFFER, Esq., or Mechanicsburg, Pennsylvania, Executor of this my Last Will and Testament, and in all instances, I direot that my said personal representatives be excused from posting bond or other seourity for the,faithful performanoe of their duties in any jurisdiotion. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ;?.s::? day or October, A. D" 1996. 9~,y) ~;t~'L-/ / arvey D. Fleisoher (SEAL) -3- Signed, sealed, ublished and deolared by the above named, HARVEY D. FLEI CHER, as and for his Last Will and Testament, in the presenoe of us who have subsoribed our names hereto as witnesses, at the req est of said testator, in his presenoe and in the presenoe of ea h other. -4- d COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) I, HARVEY D. FLEISCHER , the teststor whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and volun- tary act and deed, for the purposes therein contained. Sworn and affirmed to and acknowledged HARVEY D. FLEISCHER , the testator day of Octoper' ' A. D., 1996. 57~ 2)~ .KL ". arv~. l' e sch;r /J'?n.: dr. ~ E2L .. Not y Public before me bY.. , thia ~f'~ IIIotariaISeaJ ~.._- ~~NojatyPlU:: MyComrnlsSbi~~~riy AssCi:IidiOnof ' COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) We, the undersigned, J. ROBERT STAUFFER and SUSAN A. McCOY , the witnessea whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the test at or, HARVEY D. FLEISCHER , sign and exe- cute the inatrument as hia/jUD[ Last Will and Testament; that the said testat or HARVEY D. FLEISCHER , executed it as his/~free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the testatOr ,signed the Will as witnesses; and that to the best of our knowledge, the testat or waa, at the time, eighteen (18) or more years of age, of Bound mind, and under no constraint, duress or undue influence. Sworn and me this October " SUb~ibed to befo~ A day of ,1996. ~~+ ~ z:L. NoIariaI Seal Madlyn Kay Eakil. NoIaJy f'tJbIlc Med1anIcSburg l3oro. Q.urbeiIand Courty My CommIsSIon ExpIres Nov. 6. 1997 A"""""""" 01 - PII -'om -s:- Z 3. -,::1 c_:S < O"'a.~< 3 ~O> i'.. III ~I .. o' 0.-0 lQ. 1/1 S:OJ:I: j a cOr,;) _.~ en OJ 0 -t m"'> h !f g~-n" 0"':0 . ~,. C 0 "':!<< ~ t lot . b 8~m9..1 :II >mm ~ G .1- .. 1:-. :::::l Q."'C :3 zen-< ~ n @~ Q)-< ~ ;:u .. 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" '" .' , : ; :.:, ; - tlliaf1Jostea:f6f~iul!$J~~:;;" ~ "~,,,: .AtljqSu,a for ~irteS'eharg';" . , , " 'i' ~ ,^" ID: . ~,,~ "' '" ~ , '" e;L1 .':":',, ::.;; .,,: ." .,,:,,:::"'fl.'+, ....;:.j~.:::,::~:'..::~- :~"\";:h, "; :,L. ;;,:');;~ '''','','' ;'''':", \ , ;':::t:,.;'." :;:;..",,~: \ :::(" t '; ~~! ;; l. ~, ;:;" ' '\';,: ; .f; :: '., ;",;,:;;:';;";':S,';4:d,;:; ...' :d"; , ..'J,':::' " ":,:;'lq; , ","." ,.,_;::;,:;.:: .'::/:; . I', ;:;t,;:: ,,, lU ;. 51 1 . .; . SCUDDER INVESTMENTS .1,,/ .~: :' iLH;: ' ~~" ,;;>: r:/:i .j . ~~;';' ." " ,. -- .,,, '. ,o/~:f::~ '..' i'i::;" . . ,,; '. .,. -; .. : ';. . . .;':;'''; :i;,;" ';\;21'~;~ ~! :!It:: .pr';'" jlticl: % t;.:::':~~. ':: . i~'5fu423 ,\'l~~868 . '~~:!'M;O . 3-i5 ,; $ W'a; :698: ~!::'~. :: ~ ni" 1-. . : ;;',' , ;;i.~ ,. .< :: ; . .::.. :,: " ~L ;, .': ; i.: :' . . : -' '" ' k : : . s;.' , ;.. n' f:;;" ;m: i:::;:':' ., 1;,:;., . ...- '. . , ZSI CNSL IIIIIIIII~I~III~I~IIIIIIIIIIIII .. 4 2 2 0 0 . S~~..!~~~~~.4J.1~~~2...3. Memll I.ynch, Pierce, Fenner & Smith 'ne. Member, Securities Investor Protection Corporation (SIPC) Individual Investor Account ~';:Fft;rr:i~~r;~i'f,~,,;;\\'~ifWf(.~;nfHj~';i.;g+~%!;,~'1J~l'f<HB'i!V,-;,p:;JP':?i'f!~'~;'lj ACCOUNT II TF/A II TpAGE II 500 119GOII 1019 1 STATEMENT PERIOD 11/01/03 TO 11/28/03 CONTACT THE FINANCIAL INVESTOR ADVISORY CENTER AT CRED IT LI NE 1-888-ML-INVEST OFFICE SERVING YOUR ACCOUNT: TYPE PO BOX 1528 PENNINGTON NJ 085311-1528 CASH HARVEY D FLEISCHER AND GRACE FLEISCHER ATBE 3Z5 WESLEY DR APT 31Z9 BETHANY CDURT MECHANICSBURG PA 17055-3511 FOR CUSTdMER SERVICE PLEASE CALL 'TOLL-FREE 1-888-ML-INVEST. - ",..,** ACCOUNT SUMMARY , to ***** OPENING BALANCE CLOSING BALANCE $.00 $.00 INVESTMENTS $0 MONEY ACCOUNTS PRICED PORTFOLIO $12,615.60 $12,615.60 ***** MONEY ACCOUNTS SUMMARY ***** MONEY ACCOUNT OPENING BALANCE CLOSING BALANCE DIVIDEND/INTEREST THIS STMT. YEAR TO DATE MERRILL LYNCH READY ASSETS $12,610.116 $12,615.60 $5.111 $79.67 ***** DAILY ACCOUNT ACTlVHY ***** TRANSACTION DESCR I PTI ON AMOUNT 11 28 Dividend 5 ML READY ASSETS TRUST 0.111000 DIV/INT REINVEST FROM 10-31 THRU 11-26 11 28 CLOSING BALANCE $.00 CHECK YOUR ACCOUNT ANYTIMEI ENROLL IN MERRILL LYNCH ONLINE (SM) AT WWW.MLOL.ML.COM. . .~."""27.L...._.END ...OF . .STATEMENT_ . NOVEMBER. 2003 ~M.rrlll Lynch FOR AN EXPLANA nON OF SYMBOLS, PLEASE SEE REVERSE SIDE PLE.o.SE ADVISE YOUR FINANCIAl ADVISOIlIMMEtlI"'TELY OF ANY DISCREPANCIES ON YOUR STATEMENT OR!F YOU CONTEMPLATe CHANGING YOUR "DDRESS, WHEN MAKING INQUIAIES, PlEASE MENTION YOUR ACCOUNT NUMBER AND ADDRESS All COARESPONDENCE TO THE OFFICE SERVICING YOUFl ACCOUNT. WE URGE YOU TO PRESERVE THIS STATEMENT FDA USE IN PREPARlNl3 INCOME TAX. RETURNS. lelation.hip Overview lank Deposit Accounts ~scrlptlon lterest Checkin~ eI1ific<lte(s) ()f Deposit otalllcposits Account Number Deposit Balance 5,523.01 80,951.'17 86.474.48 fotalBanking Statement )NC Bank Q PNCBA"N<. For the period 11/14/2003 to 12/15/2003 Primary account number: 50-7007-5422 Page 1 of 3 Number of enclosures: 2 HARVEY D FLEISCHER 325 WESLEY DR APT 3129 MECHANICS BURG PA 17055-3574 Q For 24-hollr bcmking, customer service and interest rate information, sign-on to 11' Account link @ by Web on pncbank.colll or call1-888-PNC-BANK Movlno? Please contact us at 1-888~PNC-BANK t2!S:J 'Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 S Visit us at pnchank.com iii TOO termin~l: 1-800-531-1648 Fa! h...~rillg impailed dienl.~ only 50-7007-5422 Totalof9 lave You Ever Run Out of Checks And Forgot To Order Morel . fhis has happened to you, you know what an inconvenience it can be. Well, PNC now has a solution to help make sure this lvon't ;1}llJt'tl to you again. Itls a new FREE service caned Automatic Check Reorder. All you need to do is sign up at your local r~ltIeh, on Account Link(~l at pnchank.com, or simply call1-888-PNC-BANK (1-888~7G2-22G5). Once >'ou sign up, after you place Jur next check order~ ',,"'e lvill begin counting the number of checks you've used and automatically,reonler your next set of leeks before you nm out. Your usual check order fee, ifappticable, wi1l be charged to your account when the order is processed. 's that simple. 'Ve'lI even notif)' you that we're about to place a reorder so you can make any dmnges to your name and address ,fonnafioll or chatlge your check style. So, sign up today for Automatic Check Reorder an,l make your lift" just thall1luch easier. 'remium Plan Ilterest Checking Account Summary :count number: 50.7007-5422 Account Link lI> number: 0174016817 Harvey D Fleischer alance Summary Please see the Activity Detail section for additional information. Beginning balance 5,324.80 Deposits and other additions 2,086A] Checks and other deductions ] ,888.20 Average monthly balance 5,579.84 Ending balance 5,523.01 Charges and fees _00 ransaction Summary Checks paid! withdrawals Check Card pas signed transactions Check Card/Bankcard pas PIN transactions 2 o o Total ATM transactions PNC Bank ATM transactions Other Bank ATM transactions o () o .. \. l \ FORM953R TQtalBanking Statement Annual Percentage Yield Eamed (APYE) 0.15% Number of days in interest period Averagl! collected balance for APYE Interest Earnad this period For the period 11/14/2003 to 12/15/2003 HARVEY 0 FLEISCHER Primary account number: 50-7007-5422 Page 2 013 As of 12/15, a total of $25.10 in interest was earned this year. Q For 24-hour customer service information, sign-on to Account link (fl by Web on pncbank.com or call 1-888-PNC-BANK Account number: 50-7007-5422. continued Interest Summary 32 5,57g..84 .72 Activity Detail Deposits and Other Additions Date Amount Description 12/01 755.69 Direct Deposit - Pension Metlife Pensions 9373931109088 12/03 1,330.00 Direct Deposit - Soc Sec US Treamry 303 174016817A 12/15 .72 Interest Payment There were 3 Deposits and Other Additions totaling $2.086A1. Checks Check number 2468 Amount 26.04 Date paid 11/19 Reference number 028687177 Check number 2469 Amount 515.16 Date paid 11/18 Reference number 026621398 * Gap in check sequence There were 2 checks listed totaling $541.20. There was 1 Online or Electronic Banking Deduction totaling $1.330.00. Online and Electronic Banking Deductions Date Amount Description 12112 1,330.0lJ Direct Paymenl- Reven.l USTreasllry303174016817A Other Deductions Date 12/15 Amount Description 17.00 Direct Pymt Rental Fee Safe Dep Box 833 There was 1 Other Deduction totaling $17.00. Daily Balance Detail Date 11/14 11/18 Balance 5,324.80 4,809.64 Date 11/19 12/01 Balance 4,783.60 5,539.29 Date 12/03 12/12 Balance 6,869.29 5,539,29 Date 12/15 Balance 5,523.rJl -/. ./ " / 1';/, I,}:" ,/ ':~:,/ .,,':.d 0. PNCBAN< Total Banking Statement C For 24-hour customer service information, sign-on to Account link @ L3 - by Web on pncbank.coln or call1-888-PNC-BANK For the period 11/14/2003 to 12/1512003 HARVEY D FLEISCHER Primary account number: 50-7007-5422 Page 3 of 3 A<.'('Ulll1t I1lllnher: 50.7007-5422 - continued Online Bill Payment .Just Got Better - Now It's FREE If you're still paying your hills the old fashioned way - writing checks, huying stamps, rushing to the post-oftice - you're missing out (Ill a quick ,HI(l t'as)' way to save hoth lime atilt money. If you've heen paying a 11I0llthly fee for Onlille Bill Payment Service, f'ither h~' llsing Qllicken'Ji,.\ Online Bill Payment. or t.hrough our Account Ullk(~ site, YOll wrm't pay a fee anYlllore. Online Bill Payment sl.'rviccs arc now free to all PNC personal checking account clIstomers. To gel start.ed ,,,,,ith Account. Link 'Veb Bill Paymetll, jusl sign-on to Aff01l1l1 Link at www.pncbank,('om, and dirk on "Pay a Billu for instructions on how to get slarled, Free "Veh Bill P~lytllt'l1t - jllSt olle more way PNC is meeting the needs of 0\11' customers, Thank you for hanking with llS. Are you taking advantage of all the benefits you get with your PNC Bank Premium Plan@7 As a Premium Plan fllstomer, you can henefit from the most comprehensive set of account servires anll featllres PNC has to offer. YOll CUI link all )'ollr accounts 10 your Premium Plan and receive one combined monthly SI:atemerH; up 1,0 3 free savillgs or mOIley lIl:trkel a('{:ounls plus one additional free checking account; Free Select Style Checks; a free Gold Cherk Canllhat gives you free ATJ\'Ilrallsactions, including no fee ft-om PNC when you lIse another bank's ATM*; Free Travelers Checks for 1, discounl 011 Ir;\\:elt'rs cher:ks for 2; Free Online Banking wilh Ac('ount Link(!~) by ',Veh or QuickeIl(P,;J** Bill Payment; Free SlOp PaymE'nl orders; S;lfe Deposit Box Discoullt; and free and unlimited mHo t.ransfers to your savings or mOlleI' market accourlfs to help you save. l'\'bkc sure you're not missing out on these great features. Stop by your local PNC branch office or call 1-888-PNC-BANK today to sig-n up [or any o[ the accounts and services you don't already have. Thank you for being a most valued cust.olller. :tOlher financial insfilutions and/or ATl\-( operators may charge for using their ATMs. HQllicken is a registered trademark ofJntuit@Jne. Certificates of Deposit InvE"stment number 31200J,197~~~ 3110022(}.1.J2 :J 1 '1000~n~20 J ~J I nOfl09.123~1 31li0009J241 3100017f,874 :11900107101; Harvey 0 Fleischer Description Maturity dale Interest Original or Current rate renewal value value Ready ,Access CD 03/05/2001 0.85 % 1,129.60 1,]3711 27 Month(s) Fixed Rrtt.e 07/15/201l<! ~t~13 % 10,O(}O.OO 10,676.!H 12 1\,10lllh(.s) Fixed R:.1te 08/0G/2Of.H 0.80 % 8,399.71 8,,123.79 12 Month(s) Fixed Rote 08/06/200.1 0:80 % ]6,618.02 16,695.75 12 Mont.h(s) Fixed Rate 08/31/2004 0.85 % 15,913.81 15,952.99 18l\fonlh(s) Fixed Rate 12/19/2004 0.80 % 4,062.79 4,681.09 24 Monl.h(s) Fixed Rate OG/24/2005 0.90 % ]7,323.78 17,398.10 Harvey 0 Fleischer Description Maturity date Interest Original or Current rate renewal value value 61\lonth(s) Fixed R~te 05/09/200] 0.60 % 4,351.58 4,3501.15 G 1\lonth(s) FL",ed R:.lle 05/15/200:j 0.60 % l,tn1.08 l,(i~~ 1.89 Total current value 80,951.47 Investment number 3 I SfJOHlfd57 31300l93,t09 FORM953R . Crnzm~s BANK 1-888"910-4100 (aU Citilen(PhoneBank anytimefo:racCollnt information, current rates '!rid answers to your questions. US002 8R291 HARVEY D FLEISIHER BETHANY TWRS APT 3Z22 325 WESlEY DR MECHANICSBURG PA 17055-3574 CD Statement OaF 1 Beginning January 01, 2003 through December 31, 2003 CD SUMMARY Balance Caleulation Previous Balance Withdrawals Deposits & Additions Interest Paid Current Balance 8,063.12 .00 .00 + 85.65 + 8,148.77 - Maturity Opening/Renewal Date Opening/Renewal Amount Maturity Dote 09/13/03 8,133.55 03/13/04 HARVEY 0 FLEISCHER GRACE B flEISCHER 6 month CD 6140-704987 Previous Balance TRANSACTION DE TA IL 5 Date Amount Description 01/14 10.21 Interest 02/14 10.11 Interest 03/14 9.14 Interest 03/14 .33 Interest 04/15 6.88 Interest 05/15 6.66 Interest 06/13 6.88 Interest 07/15 6.67 Interest 08/15 6.90 Interest 09/11 6.45 Interest 10110 ~,O2 !l1te~e~t 11/13 5.18 Interest 11/11 5.01 Interest r'1l'lIlb~1 FDIC ~ Eq~alHousing LEnd21 Interest Interest Rate Annual Percentage Yield Interest Paid this Year .75% .75% 85.65 8,063.11 o e TotaL Transacttons 85.65 Current Balance 8,148.77 ----.-- ---. ---------"_..---- ------- .: Cn'l1.]2NS HANK. 1.888.910.4100 Call (ftiien~' Phone~ank anytime for accountfilformation. current rates and ~nswers to yQl.lr questions. US002 BR292 HARVEY D FLEISCHER BETHANY TWRS APT 3222 325 WESlEY DR MECHANICSBURG PA 17055-3574 CD Statement o OF 1 Be9inning January 01, 2003 through December 31, 2003 CD SUMMARY Balance Calculation Previous Balance Withdrawals Deposits & Additions Interest Paid Current Balance 8,203.21 .00 .00 + 81. 77 + 8,284.98 = Maturity Opening/Renewal Oate Opening/Renewal Amaunt Maturity Oate 12/13/03 8,284.98 06/12/04 HARVEY 0 FLEISCHER GRACE B FLEISCHER 6 month CD 6140-734789 Previous Balance TRANSACTION DETAilS Date Amount Descrtption 01/14 8.64 Interest 02/14 8.65 Interest 03/14 7.82 Interest 04/14 8.66 Interest 05/14 8.40 Interest 06/13 8.68 Interest 07/14 5.09 Interest 08/14 5.26 Interest 09/12 5.27 Interest 10/14 5.09 Interest 11/14 5.28 Interest 12/12 4.93 Interest HemLer FDIC ti:'J t'luoll-k""ing l~mlel Interest Interest Rnte Annual Percentage Yield Interest Paid this Yea, .75% .75% 81.77 8,203.21 o o Total Transactions 81. 77 Current Balance 8,284.98 Cr:nZI~NS BANK 1-888.910-4100 CaU Citizens' Phone6ank anytime forac.count information, current rates and answers t(;l your questions. US002 8R294 HARVEY D FLEISCHER BETHANY TWRS APT 3222 325 WESLEY DR MECHANICSBURG PA 17055-3574 CD Statement o OF 1 Beginning January 01, 2003 through December 31, 2003 CD SUMMARY Balance Calculation Previous Balance Withdrawals Deposits & Additions Interest Paid Current Balance 18,251.86 .00 .00 t 204.35 t 18,456,21 - Moturity Opening/Renewal Date Opening/Renewal Amo~nt Mat~rjty Date 08/03/03 18.410.02 02/01/04 HARVEY 0 FLEISCHER GRACE B FLEISCHER 6 month CD 6140-719631 TRANSACTION DETAILS Date Amount Description 01/03 23.10 Interest 02/03 21. 64 Interest 03/03 17.40 Interest 04/02 19,29 Interest 05/02 18.68 Interest 06/02 19.33 Interest 07/02 18.72 Interest 08/01 19.37 Interest 08/01 .63 Interest 09/03 11.72 Interest 10/03 11.36 Interest 11/03 11. 74 Interest 12/03 11. 37 Interest ,'.lcr.1lJci f-Die G E4ual HtlUS;;I~ l~lLU~; Interest Interest Rate Annual Percentage Yield Interest Paid this Year .75% .75% 204.35 Previous BaLance 18,251.86 o o Total Transact10ns 204.35 Current Balance 18,456.21 CITIZENS BANK 1"888"910-4100 C.UCitizens'PhoneBank anytime for account infOrmation, c~rrent rates and answel'$ to your ql,lestions. US002 BR291 HARVEY D F lE I SCH E R BETHANY TWRS APT 3222 325 WESLEY DR MECHANICSBURG PA 17055-3574 CD Statement o OF 1 Beginning January 01, 2003 through December 31, 2003 CD SUMMARY Salance Calculation Previous Balance Withdrawals Deposits & Additions Interest Paid Current Balance 12,206.57 .00 .00 + 162.85 + 12,369.42 = Maturity Opening/Renewal Date Opening/Renewal Amount Maturity Date 08/04/03 12.328.16 08/04/04 HARVEY 0 FLEISCHER GRACE B FLEISCHER 12 month CD 6140-872774 TRANSACTION DETAILS Date Amount Description 01/03 15.44 Interest 02/04 15.47 Interest 03/04 13.98 Interest 04/04 15.50 Interest 05/02 15.02 Interest 06/04 15.54 Interest 07/03 15.06 Interest 08/04 15.58 Interest 09/04 10.47 Interest 10/03 10.14 Interest 11/04 10.49 Intelest 12/04 10.16 Interest 1,1~n;hcr ;-liIC~' Eqll~1 Housillg Lcllde;- Interest Interest Rate Annual Percentage Yield Interest Paid this Year 1.0O'k 1.00',(, 162.85 PreviQus Balance 12,206.57 o o Total Transactions 162.85 Current Balance 12,369.42 .,", t~."i"n... ;'I:i?'~~I",'-1 lE'" \' -," "..}" \./llll..f,NS !dLll'1b 1-888-910-4100 Call Citizens' PhoneBank an~me for account information. current rates and answers to your questions. US002 BR294 HARVEY D FLEISCHER BETHANY TWRS A~T .222 325 WESLEY DR MECHANICSBURG PA 17055.3574 CD Statement . OF 1 Beginning January 01, 2003 through December 31,2003 CD SUMMARV Balance Calculation Previous Balance Withdrawals Deposits & Additions Interest Paid Current Balance 10,593.22 .00 .00 + 105.59 + 10,69ij.81 - Maturity Opening/Renewal Date Opening/Renewal Amount Maturity Oate 12/01/03 10,698.81 05/31/04 HARVEY D FLEISCHER GRACE B FLEISCHER fi month CD 6140-719658 Prevlous8a1i1nce TRANSACTION DETAILS Dot. Amount bescrtptton 01(02 11.16 Interest 02(03 11.16 Interest 03(03 10.10 Interest 04(02 11.19 Interest 05/02 10.84 Interest 06/02 11.22 Interest 07/02 6.57 Interest 08/01 6.79 Interest 09/02 6.80 Interest 10/02 6.58 Interest 11/03 6.81 Intere~l 12/01 6.37 Interest H,'r,;b~, fDj( i~ ['iU~,\ hu:;i~~ Lel1ll~1 Interest Interest Rote Annual Percentage Yield Interest Paid this Year .75% .75% 105.59 10,593.22 0 Total Transactions 105.59 e Current BaLance 10,698.81 M LYf~) ~ I e Metropolitan Life Insurance Company . P.O. BOX 316 WARWICK, RI 02886-0316 Notice of Claim Payment ~ I Ageno, Date of Notice 05/19/2004 NAME OF DECEASED GRAr.F FI F I Sr.HFR DATE OF DEATH O~/0917000 SCOTT A RUTH 4 HIGH STREET HANOVER PA 17331 Please See Important Notice on Reverse Side Policy Number Codes Refer to Messages Below. Items Payable Policy Amount One- Year Term Insurance Additional Insurance Dividends With Interest Dividend to Policyholder Terminal Dividend Premium in Advance Interest on Claim This claim has been . approved for the total of the amounts appearing in the boxes below. Items determining these amounts are listed to the left. 17628045 A A 1000.00 Amount Held for Deferred Payment 693.33 41.60 40.00 Check Issued by Customer ServiceCenter Deductions Premium in Arrears Loan Loan Interest TOTAL 1774.93 A. OUR CHECK FOR THE 8ALANCE DUE IS ATTACHED 8ELDW. 1-5876(1093)PrlntedlnU.s.A. Detach stub before cashing JY4518.5CRE(06/01) .~ N~W YORK LIF~ INS. AND ANNUITV 51 MADISON AV~NU~ NEW YORK, NEW YORK 10010 EXPLANATION OF BENEFITS PLEASE DETACH AND SAVE FOR YOUR RECORDS 0776 CHECK NO: 0001091804 MAY 11, 2004 1...111...1,.11...11,..,11..1,11.1.,11,..,11,,11,..,1..1,1..11 SCOTT RUTH - 151 LAW OFFFICES 4 HIGH ST HANOVER PA 17331-2906 POLICY NUMBER: NP093965 CLAIM NUMBER: 840192 INSURED: FLEISCHER HARVE Y D IF YOU HAVE ANY QUESTIONS, CONTACT : THERESE SINDELAR CSC TELEPHONE: (800)695-9873 X8724 STATEMENT OF ACCOUNT 4,951.32 3,261.32 4,951.32 78.34 AMOUNT TOTAL AMOUNT PAYABLE 4,951.32 4,951.32 0.00 AMOUNT OF POLICY TOTAL FEDERAL GAIN YOUR SHARE MISCELLANEOUS INTEREST PAID CHECK PAYABLE TO: ESTATE OF HARVEY D FLEISCHER NANCY A JOHNSON ADMINSTRATDR CTA 6424 PAMADEVA RD HANOVER PA 17331 5,029.66 INTEREST SHOWN IS FROM DATE OF DEATH TO DATE OF PAYMENT AND IS TAXABLE INCOME IN THE YEAR PAID. INTEREST RATECS) : 2004- 3.50X 2003- 3.50X. A CHECK FOR THE AMOUNT PAYABLE HAS BEEN SENT TO SCOTT RUTH, ATTORNEY, FOR DELIVERY TO THE ESTATE. 4,951. 32 WITHHELD MetLife. Statement of Value of Annuity Contract 1. Name and address of Insurance Company Metropolitan Life Insurance Company, One Madison Avenue, New York, NY 10010 2. Name of Annuitant 3. Date of Annuitant's Death 4. Annuitant's Social Sec. No. Harvey Fleischer 11/29/2003 17401 6817 5, Contract Number 6. Type of Annuity 7. Date of Issue M8006066 Nonaualified 12/09/1988 8. Owner's Name 9. Assignee's Name 10. Date Assigned (Attach copy of Application) (Attach copy of assignment) Haryey Fleischer N/A N/A 11. Name(s) of Beneficiary(ies) Nancy Johnson, Administrator CTA for the Estate of Harvey Fleischer 12. Description of Contract Nonaualified Tax Deferred Annuity 13. Value of annuity contract on date of death of Annuitant $24,696.62. This represents the death benefit as follows: Accumulation Value on Date of Death $24,266.32 Cost Basis/Return of Payments $10,856.08 Interest $13,840.54 Total Payout $24,696.62 14. How payable: One Sum =:l See Remarks 1 5. Remarks The undersianed hereby certifies that this statement sets forth true and correct information. 16. Date of Certification Signature Title August 20, 2004 ~A ifrj ~ A_ Ji Claim Aooroyer I 'i7( rtJlr Da~: May 20, 2000 LIBERTY LIFE INSURANCE COMPANY P .0. BOX 19089 GREENVILLE, SC 29602-9089 MYERS FUNERAL HOME 37 EAST MAIN STREET MECHANICSBURG, PA 17055 (864) 609-8111 (717) 076-6034 Annual Report Death Benefit Projection Insured Name: Policy Number: Issue Date: FLEISCHER, HARVEY DUANE 0040008329 OS/20/1995 Death Beuefit at Issue: $ 1 , 4 1 2 .00 Death Benefit on OS/20/199:9 + Guaranteed Growth: + Nou-Guaranteed Paid-Up Additions: $1,676.00 $48.00 $32.00 ----------- ----------- Death Beuefit on OS/20/20QO $1,756.00 Guaranteed Death Benefit *Projected Total Death Beuefit CASH DEATH BENEFIT 05-20-2005 (ten years from issue date) $1,996.00 $2,221.00 The terms of the policy dictate the death benefit. I paid an initial premium to start my individualized Purple Shield Plan. Additional premiums are scheduled as follows or until death, whichever occurs first. No further premium is due. Your policy is paid-up *Beginning with the first policy amliversary, the Company may declare excess interest which will be used to purchase additional death benefits. The Projected Total Death Benefit is not guaranteed and is based on a current declared rate of 04.00%. The Projected Total Death Benefit will grow compounded at the actual declared rate or will be equal to the Guaranteed Death Benefit, if higher. There is no guarantee that excess interest will be declared to purchase additional death benefits. RE!gister of Wills York County, Pennsylvania INVENTORY Estate of Harvey D. Fleischer , Deceased No. 21 2004 36 Date of Death 11/29/2003 Social Security No. 174-01-6817 also known as Personal Representative(s) of the abOllO Estate, deceased, wrify that the ~ems appearing in the following inventory include all of the personal assets wherewr situate and all of the real estate in the Commonweafth of Pennsytvania of said Decedent, that the valuation placed opposite each item of said in..ntory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. IlWe wrify that the statements mede in this in-wry are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. e.s. Section 4904 relating to unsworn falsification to authorities. Personal Representative: Name of Attorney: Scott A. Ruth, Esquire I.D. No.: 61934 Address: 4 High Street Hanover PA 17331 Telephone: 717-630-9333 Description PNC Investments, Account No. 32873217 Value 100,107.68 Scudder Investments, Fund-Account No. 18-893989383 12,141.49 Merill Lynch, Pierce, Fenner & Smith Inc., Acc!. No. 500 49G04 12,615.60 Miscellaneous cash, dividend & pension checks 293.59 PNC Bank, Checking Account No. 50-7007-5422 4,783.60 \/,) "-, '-~VjUI1l8 1:3,"') '. 1,137.11 PNC Bank, Ready Access CD, Account No. 31200149738 [S: Zd 9Z rill 170. Total (Attach Add~ional Sheets W necessary) "'88 333,961.14 :::',., ._' ,c-' "_0 .. ~:- NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election e personal representative, include the value of each item. but such figures should not be extended into the total of the Inventory. RW-4 v- Continuation of Inventory Harvey D. Fleischer 21 2004 36 PaQe 1 Description of Inventory Description PNC Bank, 27 month CD, Account No. 31100226442 Value 10,676.54 PNC Bank, 12 month CD, Account No. 31400098201 8,423.79 PNC Bank, 12 month CD, Account No. 31600094239 16,695.75 PNC Bank, 12 month CD, Account No. 31600093241 15,952.99 PNC Bank, 18 month CD, Account No. 31000175874 4,681.09 PNC Bank, 24 month CD, Account No. 31900107106 17,398.16 PNC Bank, 6 month CD, Account No. 31800196457 4,354.15 PNC Bank, 6 month CD, Account No. 31300198409 1,631.89 PNC Bank, Money Market Account No. 50-0096-2448 33,137.80 Household furnishings & personal property 667.00 1989 Buick LeSabre Vin. No. 1G4HP54C2KH450930 350.00 Citizens Bank CD Account No. 6140-704987 8,143.75 Citizens Bank CD Account No. 6140-734789 8,280.05 Citizens Bank CD Account No. 6140-719631 18,444.84 Subtotal $ 148,837.80 Continuation of Inventory Harvey D. Fleischer 21 2004 36 PaQe 2 Description of Inventory Description Citizens Bank CD Account No. 6140-872774 Value 12,359.26 Citizens Bank CD Account No. 6140-719658 10,692.44 MetLife Policy #17628 045A(Policy Owner: Grace B. Fleischer, deceased; beneficiary was Harvey D. Fleischer) 1,774.93 MetLife Annuity Account No. M8006066 24,266.32 New York Life Ins. and Annuity: Annuity Policy #NP 093 965 4,951.32 Subtotal $ 54,044.27 333,961.14 Grand Total $ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU C1' IND~~ri~lPfliSfprF .Oc INHF.RITANCE TAX D~lU~,) V . 1'-'_ I PO ltox 280601 m:,,::!c'rr:q, \:/1\ 1 ~ HARRISBURG, PA 171a8~': L , . "",-" NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX 200~ DEe 29 A~i 9: 09 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 12-20-2004 FLEISCHER 11-29-2003 21 04-0036 CUMBERLAND 101 CLERK OF ORPHAN'S COURT 1"IItIW.R< ".j,f:t I~~ f"")' SCOT \..MfVi:lJ.'lTfH'A TV_I" it\ 4 HIGH ST HANOVER PA 17331 '* REY-15~7 EX AFP (09-0~1 HARVEY D Allount Rellitted (1) (2) (3) (4) (5) (6) (7) .00 124,864.77 .00 .00 209,096.37 .00 .00 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV: is'4-j-ix--AFP--foY:03Y-NOYici--OF-YtiHiififlifCE-YAX-jfPPRjfisii'-iNT~--ALi-owliicE-cfR------------- ---- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF FLEISCHER HARVEY D FILE NO. 21 04-0036 ACN 101 DATE 12-20-2004 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( x) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax 38,751.88 4.868.11 (11) (12) (13) (14) (9) (10) NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. (8) 333,961.14 43.619 99 290,341.15 66,778.46 223,562.69 NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS. .00 X 00 = .00 .00 X 045 = .00 66,778.46 X 12 = 8,013.42 156,784.23 X 15 = 23,517.63 (19)= 31,531.05 . .n......... . I+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 02-27-2004 CD003608 1,576.55 32,000.00 TOTAL TAX CREDIT 33,576.55 BALANCE OF TAX DUE 2,045.50CR INTEREST AND PEN. .00 TOTAL DUE 2,045.50CR . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) ~~ q.... REV-1470 EX "-88) INHERITANCE TAX EXPLANATION OF CHANGES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG PA 17128-0601 DECEDENTS NAME FILE NUMBER REVIEWED BY ACN 2104-0036 101 Harvey D. Fleischer Sheila Megonnell ITEM SCHEDULE NO. EXPLANATION OF CHANGES The value of the estate has been adjusted as the result of the correction of an error in arithmetic. ROW Page 1 BUREAU OF INDIVIDUAL TAX~$ INHERITANCE TAX DIVISION PO BOX Z80601 HARRISBURG PA 111Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT '* REV-ln7 EX AFP 112-04) l.-< ; 'J DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 02-28-2005 FLEISCHER 11-29-2003 21 04-0036 CUMBERLAND 101 HARVEY D SCOTT A RUtH"ATTY 4 HIGH ST HANOVER PA 17331 Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this fOri! with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ~~:r&~~.!5r.i~~..rGl~6!'...........:rA~r'~elr~l5r.sfl~A~.o~.ltl:60~....j(..................... ESTATE OF FLEISCHER HARVEY D FILE NO.21 04-0036 ACN 101 DATE 02-28-2005 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 12-13-2004 PRINCIPAL TAX DUE:. 31,531. 05 PAYMENTS (TAX CREDITS): ~ PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 02-27-2004 CD003608 1,576.55 32,000.00 02-09-2005 REFUND .00 2,045.50- TOTAL TAX CREDIT 31,531.05 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 If SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT 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 Cumberland County - Register Of Wills One Courthouse Square Carlisler PA 17013 Phone: (717) 240-6345 Date: 10/11/2005 JOHNSON NANCY A 6424 PAMADEVA RD HANOVERr PA 17331 RE: Estate of FLEISCHER HARVEY D File Number: 2004-00036 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULESr NO. 103 SUPREME COURT RULES DOCKET NO. 1r for decedents dying on or after July 1r 1992r the personal representative or his counselr within two (2) years of the decedent's deathr shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 11/29/2005 Your prompt attention to this matter will be appreciated. Thank You. SincerelYr ~~~ c/ GLENDA FARNER ST~~SBAUGH REGISTER OF WILLS cc: File Counsel Judge G Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 10/11/2005 RUTH SCOTT A 4 HIGH ST HANOVER, PA 17331 RE: Estate of FLEISCHER HARVEY D File Number: 2004-00036 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 11/29/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~~~ GLENDA FAP~~ER STP~.SBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge ~~ Cyt~ h \\\-;;1\0 FIRST AND FINAL ACCOUNT OF Nancy A. Johnson, Administratrix, c.t.a. For ESTATE OF Harvey D. Fleischer, Deceased Date of Death: Date of First Advertisement of Grant of Letters of Administration Date of Administratrix c.t.a. Appointment Accounting for the ~iod: _ (,J('/\~e.rIAJ"~ Lw )JJrIHd ,,-Jlf~f\f.e f\1Ili1'k (J 'J..,I~ ,'J-ool.{ ~t/ltl~ t\~....erh(t AM h " ~) n I Jrotf File Number J November 29, 2003 March 2, 2004 January , 2004 November 29, 2003 to November 23, 2005 21-04-36 Purpose of Account: Nancy A. Johnson, Administratrix c.t.a., offers this account to acquaint interested parties with the transactions that have occurred during her administration. The account also indicates the proposed distribution of the estate. It is important that the account be carefully examined. Requests for additional information or questions or objections can be discussed with: Scott A. Ruth, Esquire 4 High Street Hanover, PA 17331 717-630-9333 ,--) ..--J ,. f"J L.1.) -~) \ \ , -' '..l . l:-) r',i .- - .. co ~1- SUMMARY OF ACCOUNT Page Proposed Distribution to Beneficiaries 10 Principal Receipts 3 Less Disbursements Administration Cost Debts and Payables Federal and State Taxes 5 6 6 Balance before Distributions Distribution to Beneficiaries Principal Balance on Hand 7 For Information: Investments Made Changes in Investment Holdings Income Receipts Less Disbursements Balance Before Distributions Distributions to Beneficiaries 9 Income Balance on Hand Combined Balance on Hand 9 2 Value as of 11/21/2005 $284,534.76 $38,275.88 $4,891.61 $32,000.00 Fiduciary Acquisition Value $284,534.76 352,060.41 352,060.41 75,167.49 276,892.92 0.00 276,892.92 7,641.84 0.00 7,641.84 0.00 7,641.84 284,534.76 RECEIPTS OF PRINCIPAL Assets Listed in Inventory (Valued as of Date of Death) Accounts and Securities Titles as Pay-in-Deatb MetLife Annuity Acct# M8006066 New York Life Annuity #NP 093 965 Cash and Cash Equivalents Citizens Bank CD 6140-719658 Citizens Bank CD Acct #6140-704987 Citizens Bank CD Acct #6140-719631 Citizens Bank CD Acct #6140-734789 Citizens Bank CD Acct #6140-872774 MetLife Policy#17628 045 A PNC Bank Acct # 31600093241 PNC Bank CD Acct # 31100226442 PNC Bank CD Acct # 31400099201 PNC Bank CD Acet # 31600094239 PNC Bank CD Acct # 31900107106 PNC Bank CD Acct #31000175874 PNC Bank CD Acet #31200149738 PNC Bank CD Acet #31300198409 PNC Bank CD Acct #31800196457 PNC Bank Checking Acct #50-7007-5422 PNC Bank Money Market Acct #50-0096-2448 Cash and Undeposited Checks Cash & undeposited checks Stocks Bonds and Mutual Funds Merill Lynch Pierce Fenner & Smith Inc. PNC Investments Acct# 32873217 Scudder Investments Fund Tangible Personal Property Proceeds from Sale of Personal Property Proceeds from Sale of Vehicle TOTAL INVENTORY 3 $ 24,266.32 5,029.66 $ 10,692.44 8,143.75 18,444.84 8,280.05 12,359.26 1,774.93 15,952.99 10,676.54 8,423.79 16,695.75 17,398.16 4,681.09 1,137.11 1,631.89 4,354.15 4,783.60 33,137.80 12,553.43 100,107.68 12,141.49 200.00 350.00 Fiduciary Acquisition Value 29,295.98 178,568.14 293.59 124,802.60 550.00 $ 333,510.31 OS/26/2004 12/23/2004 04/21/2005 10/27/2005 05/17/2004 05/17/2004 05/17/2004 05/17/2004 RECEIPTS OF PRINCIPAL (Continued) FORWARD Receipts Subsequent to ltrventory (Valued When Received) Met Life - dividend Met Life - dividend Inheritance Tax Refund - prepayment discount IRS - Income tax refund Prudential Life Ins. # I 1 361 664 New York Life Life Policy #17 976 795 MetLife Policy #21 504 778A MetLife Policy #15703 082A TOTAL RECEIPTS OF PRINCIPAL 4 $51.60 51.52 2,045.50 12.00 5,491.15 2,120.22 6,811.96 1,966.15 Fiduciary Acquisition Value $333,510.3 ] 2,160.62 16,389.48 $352,060.41 DISBURSEMENTS OF PRINCIPAL Administration Cost 01/13/2004 Register of Wills 01/13/2004 INA -locate heir 01/29/2004 Capital Self Storage - boxes 02/05/2004 PNC Bank 02/13/2004 Cumberland County Legal Journal 02/27/2004 UPS - express mail 04/14/2004 Notary - transfer car title 04/14/2004 The Sentinel 04/14/2004 Register of WiIls- short certs. 04/16/2004 Vital Statistics - death certs for G. Fleischer OS/26/2004 T. & G. Druck - Labor at Estate OS/26/2004 B. Nash - Labor at Estate 06/l 0/2004 Check printing fee - PNC 06/l6/2004 Register of Wills - short certs. 08/05/2004 PostNet 08/05/2004 Little's Coins & Jewelry Appraisal 08/l8/2004 Michael T. Noel, CPA,prepare 2001-2003 tax returns 09/22/2004 Register of Wills- filing fees 01/11/2005 Scott A. Ruth, Esq., attorney fees 1/2 01/11/2005 Nancy A. Johnson, Admin. - commission 1/2 02/09/2005 Michael T. Noel, CPA 02/09/2005 P ADept. of Revenue 11/08/2005 Michael T. Noel, CPA 11/17/2005 Michael T. Noel, CPA 11/21/2005 Register of Wills - filing, adv., dist. schedule 1/10/2006 Nancy A. Johnson, Admin. - commission 1/2 1/10/2006 Scott A. Ruth, Esq. attorney fees 1/2 Debts and Payables 02/1 0/2004 Bethany Village 02/13/2004 Statewide Tax Recovery Inc. 02/20/2004 Alert Pharmacy 02/20/2004 Select Medical Corp 02/20/2004 Holy Spirit Hospital 02/20/2004 MCI 02/20/2004 Home Instead Senior Care 02/20/2004 Nephrology Assoc. of Central PA 04/14/2004 Internal Revenue Service 04/14/2004 Penn Credit Corp. 04/14/2004 Conner-Rich Assoc. Internal Medicine 05/11/2004 Nephrology Assoc. of Central PA 07/09/2004 IRS - 2001 taxes 07/09/2004 IRS - 2003 Taxes 5 $312.00 75.00 183.82 27.60 75.00 42.66 10.00 102.11 27.00 63.00 204.00 204.00 27.60 15.00 166.09 40.00 450.00 10 1.00 8,349.00 8,349.00 575.00 594.00 390.00 855.00 340.00 8,349.00 8,349.00 1,997.75 26.00 26.79 840.00 11.67 75.91 250.62 69.28 271.00 28.50 224.69 20.96 432.00 69.00 $38,275.88 DISBURSEMENTS OF PRINCIPAL (Continued) FORWARD 07/09/2004 IRS - 2002 taxes 08/02/2004 Quantum Imaging Therapeutic 08/24/2004 United States Treasury(income tax interest) 10/25/2004 Statewide Tax Recovery, Inc. Federal and State Taxes 02/13/2004 Register of Wills, Agent TOTAL DISBURSEMENTS OF PRINCIPAL 480.00 32.29 11.65 23.50 32,000.00 6 $43,100.05 4,891.61 32,000.00 $75,167.49 PRINCIPAL BALANCE ON HAND Cash and Cash Equivalents PNC Bank Estate Acct #50-0441-4721 PRINCIPAL BALANCE ON HAND 7 Current Value $276,892.92 $276,892.92 Fiduciary Acquisition Value $276,892.92 $276,892.92 Cash and Cash Equivalents PNC Bank Estate Acct #50-0441-4721 INCOME BALANCE ON HAND INCOME BALANCE ON HAND 8 7,641.84 7,641.84 $ 7,641.1,84 RECEIPTS OF INCOME Fiduciary Investment Interest Income Value 07/15/2005 Citizens Bank CDs Interest 11/29/2003 to 7/1/2005 $892.36 09/30/2004 Interest - Mutual Service Corp. 8/18/2004 to 9/30/2004 51.05 12/31/2004 Interest - Mutual Service Corp. 10/1/2004 to 12/31/2004 318.11 03/31/2005 Interest - Mutual Service Corp. 1/1/2005 to 3/31/2005 357.95 05/31/2005 Interest - Mutual Service Corp. 4/1/2005 to 5/31/2005 489.79 06/30/2005 Interest - Mutual Service Corp. 6/1/2005 to 6/30/2005 219.90 09/30/2005 Interest - Mutual Service Corp. 7/1/2005 to 9/30/2005 778.04 11/13/2005 Interest - Mutual Service Corp. 368.68 2,583.52 05/17/2004 Met Life Annuity Acct Interest 11/29/2003 to 5/15/2004 430.30 01/29/2004 PNC Interest - Money Market & CDs 11/29/2003 to 143.03 1/29/2004 07/18/2005 PNC Investments - Interest 11/29/2003 to 7/15/2004 2,752.75 08/05/2005 PNC Investments - Interest 7/15/2005 to 8/1/2005 74.60 10/27/2005 PNC Investments - Interest 8/1/2005 to 10/15/2005 107.20 2,934.55 08/05/2005 Scudder Investments Interest 11/29/2003 to 8/1/2005 658.08 658.08 $7,641.84 TOTAL RECEIPTS OF INCOME $7,641.84 9 PROPOSED DISTRmUTION TO BENEFICIARIES Fiduciary Current Acquisition Value Value TO: Atkinson, Jeanne - Per Article 3 (A) PNC Bank Estate Acct #50-0441-4721 $1,757.62 $1,757.62 PNC Bank Estate Acct #50-0441-4721 63,685.37 63,685.37 65,443.00 65,443.00 TO: Bethesda Mission - Per Article 3 (1) PNC Bank Estate Acct #50-0441-4721 382.09 382.09 PNC Bank Estate Acct #50-0441-4721 13,844.65 13,844.65 14,226.74 14,226.74 TO: Brandenberger, Jay - Per Article 3 (E) PNC Bank Estate Acct #50-0441-472] 13,844.65 13,844.65 PNC Bank Estate Acct #50-0441-4721 382.09 382.09 14,226.74 14,226.74 TO: DeMoss, Doris - Per Article 3 (B) PNC Bank Estate Acct #50-044]-4721 63,685.37 63,685.37 PNC Bank Estate Acct #50-044]-4721 1,757.62 1,757.62 65,443.00 65,443.00 TO: Mechanicsburg Presbyterian Church - Per Article 3 (F) PNC Bank Estate Acct #50-0441-4721 382.09 382.09 PNC Bank Estate Acct #50-0441-4721 13,844.65 13,844.65 14,226.74 14,226.74 TO: Merryman, Estate of Helen L. - Per Article 3 (C) PNC Bank Estate Acct #50-0441-472] 63,685.37 63,685.37 PNC Bank Estate Acct #50-0441-472] 1,757.62 1,757.62 65,443.00 65,443.00 TO: New Hope Ministries - Per Article 3 (H) PNC Bank Estate Acct #50-0441-4721 13,844.65 13,844.65 PNC Bank Estate Acct #50-044] -4721 382.09 382.09 14,226.74 14,226.74 TO: Salvation Army - Per Article 3 (G) PNC Bank Estate Acct #50-0441-4721 611.35 611.35 PNC Bank Estate Acct #50-0441-4721 22,151.43 22,151.43 22,762.78 22,762.78 TO: Youngblood, Julia aka Bonnie Rochicheau - Per Article 3 (0) PNC Bank Estate Acct #50-0441-4721 229.26 229.26 PNC Bank Estate Acct #50-0441-4721 8,306.79 8,306.79 8,536.04 8,536.04 TOTAL $284,534.76 $284,534.76 10 NANCY A JOHNSON, Administratrix c.t.a. under the Estate of HARVEY D. FLEISCHER, deceased, hereby declares under oath that she has fully and faithfully discharged the duties of her office; that the 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 her knowledge, there are no claims now outstanding against the Estate; and that all taxes presently due from the estate have been paid. /'. / /" /! //.lA),'jJ " I' LV/' L/~ \_~/ . / /"t: . NANCY A/JOHNSO u Administratrix c.t.a. I I '? /(} ~)l /// Subscribed and sworn to by NANCY A JOHNSON before me this ~N.J- day of Nove r, 2005. .~__ ,__,_~,,,,,,,"____......,~...n ,..,-..","<_ ~ N():t~,~iz] S_I,~;.l~. , ::;. t,,',;(' ~ I Amth, Druck Ruth, j\'O'~'!J ! .'L..~ 1 L !-IuTI0ver Bow. York Cm'nlY N ! ." . ~ '" ,., l ~ 1:, "')<, -'1' ;(, l\.iv C(JITHnl:.~slon Exp~re:, .JulY iJ, _'I..,J ~ ".. .__.1 PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16,1929), P. L.1784 STATE OF PENNSYL VANIA : ss. COUNTY OF CUMBERLAND : Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, VIZ: MARCH 5, 12, 19,2004 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Fleischer, Harvey D., dec'd. Late of Mechanicsburg. Administratrix c. La.: Nancy A. Johnson. Attomey: Scott A. Ruth, Esquire, 4 High Street, Hanover. PA 17331. SWORN TO AND SUBSCRIBED before me this 19 day of MARCH 2004 IAL SEAL LOIS E. SNYDER, Notary Public Carlisle Boro, Cumberland County My Commission Expires March 5, 2005 PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland. Rich Canazaro, Internet Director of THE SENTINEL , of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regula~ly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following dates, viz Copy of Notice of Publication The Sentinel March 02,09,16, 2004 !. EXECUTOR'S NOTICE Estate of HARVEY D. FLEISCHER, late of Mechanicsburg, Cumberland County, Pennsylvania, deceased. Letters Administration. c.I.a. on said Estate having been granted to the undersigned, all persons indebted there- to are requested to make immediate payment, and those having claims or demands against the same will present them without delay for settle- ment to the undersigned counsel for the Estate. Nancy A. Johnson Administrator c.I.a. Affiant further deposes that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true March 18, 2004 Scott A. Ruth, Esquire 4 High Street Hanover, PA 17331 Attorney for Estate Sworn to day of subscribed before m this March , 20 4. ) My commission expires: : I,v iARIAL SEAL I DAWN f,1. SHUGHART. Not2ry Public Carlisle. Cumberland Co: My Commission Expire" Nov. 28, 200C I hereby certify that wrlM'" Fletioa of the filing of this AccOunt. and at the date. time and plaCe when the seme win be preeentGd ~ the Court for confirmation and of the lBIt _ to tie written objectionS to said ~, hell been given to every unpaid ctaim8f'lt and 10 every other person known to the accountant ., h8Y8 or cteim an interest in the estate as credItOr. ben8ficiary. heir or next of kin. ~.U\? \ \\?-1 \OS h.,feby Cf:lrtify mat wrttten notlcl of the filing of this Stat$ment of Proposed 0tstrtbutI0n. and of the date. time d.nd place when the same wtI be ~ to the COIJ1't for conftll~ and cllt1e IIIIldBv to file written objectiOnS to Mid ~ne.lt 01 Proposed Distribution. has been gMIn to wary unpeid claimant and to f.Nef'J other person Ilncwn to the accoul'llllnt to have or claim an Intere8t in the __ .. CRCMor. \j,Jneticiai'V. heir or next of kin. ;:, .:Gt:Jy (;1 ,.aid Statement was included with the notice. ~-[l~ t\\J3(~S \\:\ ~ -:n .J".. ~ ~ ~ -;;3- ~ ,s;: :J ~ ,.. '" F -.J c \' -:r ~ <:J c: .~ ~ FT .:tJ <7 <:>00 ~ ", ., ....j ---T- ,....... ~ -.",. -;- ~, ~1 -.:f) <2> ::::> , ;::,- ~ c:::,....- ~ ~ ~ <:5"-. iF ':> .:::>, ~ .:::> ~ 'C::::. ........ - '^0 -f-- 0 ? ~, 0 .., v .~ ~ \) " ~ ~. "'" 3 ~ ~ ~ Co ""< ~ ..2 ~ :s v:::J --.., :L <:; ~. b (;::::) + .() ""'-J -:r c::. c:: -. ....> -.......l .-..- ~ ...:::::t- ?: ~. \ ~. ~ \J"--. e; -4 -' ~ r :>- 0- ....- -- \N \) <. ? .", q" ~ -, -~ 0- -;-., ~, '""" <:. ~ ~ ~. ;:> .:), '"::- ~ "'2: .7 S ~ '- -2 ~ ....J - .::t> v.:J ~ ~ """-.J ~ ~ -- G .:s- --r--:. ~ (;\ ::s '~ ~ ......... <:-. ~ :::r- ~ ~ ~ r- ~ :::> c:. -, ~ ~ d- -) "- "1-. :.::t:,. I hereby certify that written ROtice of the filing of this AcoOunt. and 01 the date. time and pIaee when the same will be prel8l"48d \0 \he Court for confirmation and of the ... _ \0 fie written objectionS to said ~. hM been given to every unpaid c\aifTl8nt and \0 evetY other per90n known to the accountant to heYe Of oteim an interest in the estate 85 credttOr. ben8ficle.ry. heir or nmet of kin, nf\. ; Mereby c-ertity that writterl not\cll of the 1I1lng of this StalJZment of Proposed ()IstributIOn. and of the date. time and place when the 88J1l8 wi! be preeen\8d to the Court tor COfdk...eIon and 01 the IMt ~ to fi4e 'Mitten objectionS to Mid be _It 01 Proposed Distribution. has been tjNetl to fNery unpeid claimant and to ~ other person known to the aocountent to ~java cr ~m an lntere8t In the __ .. oredIOr. !'nneticlti.;'i, heir Of next of kin, . ;::0;;''1 ,;t ,~td Statement was included with the notice, ~JJ C~~ \\\?,r"r- ~C\? G \ \\?1 \OS ~ ~ ? ~ ....j 0 \ -:r - ---- ~ ~ :t; --.J d- -'\- ........ ~t ~, , :;r' '.:+> iF ~, '::> ~ ~ -t- ~ ~ 0 '') CL) \ ~ ~' 0 ~ 3- ""< v:J --... c". -.....J -::::r -.......; ~' 0 \ ~ "" $; r ~ <:. -~ ~. ~ ~ ....j ....AJ '-'J I So s-.,""\ ;Ii~ (/!.t...!. .7 , Q.-c 0 I J ~~" 1= ~ .1 - Q. 't1 f i~~ 9- If 1-0 ~ ...a Oc: 1= ;lga ID.~~ ..oa- .'ii t.-\ \\j 7\ V' ~ ~ ~ ~ ~-., F \J 3.J ~ Q c:: 0 \.><> ~. ..., -, ~ \"":> -- -y G ::::r c:'::>-' 3) '~ ~ ~ .:::::>, -:::r::- ;::..- C:> ?" ~ ~. .......... c. 0 ?;. ~ 3 ~ 2f> -2 ~ .~ .., ~ ~ <;-. + c <:) b () c: P --> .;::::t- ..:::> " ..4- .;., ~ ::>" C:>- --- Cb \) <:;;"" 5, ? ~ ~, ......, ~ ~ c. J '"=' \.r. > -z: ....... 7" S ~ "--- <:' ~ ~ --- ..::t:> ~ ~ y C G ~. ~ ~ ~ :s ~ ~ ...... <--, ~ ~ ~ ~ (' ~ ...... ~ ~ <::. ~ ~ -r -) 1"\ 4-- ..:.b 1 , I' ST ATUS REPORT UNDER RULE 6.12 Name of Decedent: Harvev D. Fleischer Date of Death: 11/29/2003 Will No. 21-04-36 Admin. No. Pursuant to Rule 6. 12 of the Supreme Court Orphans I Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: I . State whether administration of the estate IS complete: Yes __ No x: 2 . If the answer is No, state when the personal representative reasonably believes that the administration will be complete: accountina is filed contemPOraneouslv & adiudication oendina 1/10/06 3 . If the answer to No. 1 is Yes, state the following: a. account with the Court? Did the personal representative file a final Yes No b . The separate Orphans I Court No. (if any) for the personal representative' s account is: c . Did the personal representative state an account informally to the parties in interest ? Yes No d . Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to th;~epO~ fl .!2. Date: 11/23/2005 Q1rdV\ V~~ Signature Scott A. Ruth. Attornev at Law Name (Please type or print) 4 High Street Hanover PA 17331 Address ( 717 ) 630- 9333 Tel. No . 1""';'"-;- Capacity : Personal Representative x Counsel for personal representative ( '~) V~ ~ --.J 15056041125 REV -1500 EX (06-05) PA Department of Revenue. Bureau of Individual T axes INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death County Code Year 2 1 0 4 File Number 003 6 Date of Birth 174016817 11292 0 0 3 08141913 F LEI S C HER HARVEY MI D Decedenfs Last Name Suffix Decedent's First Name (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW D 1 . Original Return o 4. Limited Estate (Z] 6. Decedent Died Testate (Attach Copy of Will) o 9. Litigation Proceeds Received 00 2. Supplemental Return o 4a. Future Interest Compromise (date of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach Copy of Trust) o 10. Spousal Poverty Credit (date of death D 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL T AX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number D o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 4 H I G H S T R E E T 7 1 7 6 3 0 ~~3 3 3 C:',:.~;:~ -... .., ~ ~:~ w"", ;, -) rw.~.', [-RiciISTeR ~ ~I~LS U~ONL y' t ' I .. !:'; d, l ' I' I I I I S COT TAR U THE S QUI R E Firm Name (If Applicable) First line of address Second line of address J -1 (.,.) City or Post Office State ZIP Code i - -.J DATE FILED I, ; I HANOVER P A 1 7 3 3 1 Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN~.T~.~ . ~ PERSON RESPONSIBL!.F;OR FilING RETUR~ DATE~/ ' )( ~7 '1ft'/(/'''Y' a ~>A.m.8;7>1/ ) 7 )Cf/JLt), /,j7 ~ftJ.6 ADDRESS.. ... (>'1 624 PAMADEVA DRIVE HANOVER FA 17331 SIGNAT~~F P~~ARll: ~AN REPRESENTATIVE DATA r; I '3, j.ct:(, ADDRES~ r , 4 HIGH STREET HANOVER FA 17331 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041125 15056041125 ---I REV-1500 EX Page 3 Decedent's Complete Address: File Number 0036 DECEDENT'S NAME HARVEY D. FLEISCHER STREET ADDRESS 325 WESLEY DRIVE, APT. 3222 CITY I STATE I ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 372.26 Total Credits ( A... B ... C) (2) 0.00 3. I nterest/Penalty if applicable D. Interest E. Penalty 42.05 5. If Line 1 ... Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 42.05 0.00 414.31 Total Interest/Penalty ( D ... E) (3) 4. If Line 2 is greater than Line 1 ... Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 8. Enter the total of Line S ... SA. This is the BALANCE DUE. (SA) (58) A. Enter the interest on the tax due. 414.31 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;... . . . 0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . " 0 00 b. retain the right to designate who shall use the property transferred or its income; . . . 0 .. ., . . . .0. . . . . . . 0 . . . 0 . 0 . . .. D 00 c. retain a reversionary interest; or.... 0.0.....0....00......................................... 0... 0.0...0. 0.....0............... D 00 d. receive the promise for life of either payments, benefits or care?........ 0.............0..... 0..... 0" 0...............0 0 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration.? 0 . . . . . . . . . 0 . . . . . 0 . o. . . . . 0 .. . . . . 0 . . . . . . . . .... . . 0.... . . . .. . . . .0. . . . . . . . . . . . . . 0 . .. . . . .. 0 lRl 3. Did decedent own an -in trust for- or payable upon death bank account or security at his or her death? ..0...... 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?. ...........................0...0.. ...................................... 0.............. ..... D [g] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.So 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefICiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (O) percent [72 P .S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) (72 P.S. 99116(a)(1)l. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: Discount: 0.00 Interest Table [~--~y .. ~--- Days Delinquent ear th- t- - d IS Ime peno .. .. Before 1981 1982 1983 1984 11985 11986 ~ 11187 -. ...... - .- I 1988 through 1991 _____ l~992- - --- 1993 throilgh 1994 n ~_j995 through 1998 11999 ~----~-"-_._~---------,.- 2000 1-2001 - 2002 2003 ~-'---'----_.~~ --------- 2004 2005 ____~__,_c 2006 Balance Due this year Interest th is period ~- -l -l I - I . I l I-~-I - .. -I - . - i= --f= .... ....~ --- 1- ---=-1- ..1 I ~_~ -____ I I + I 32 _~__ 365 365.. 96 I ---1- ~~~:~:II- -t------ 372,26. I _'--:2.~61 -I-~------+--- 1-- I -~ . .... r .. --=-1.. I I .._-. -- ~I _ 1.63 14.9 ~ ~~ --------1 --- ! -~ 42.~ r-- TOTALS L--.....~...__-_.__ 8q~__ Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996:__ Penalty: REV-1503 EX + (6-9B) - COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF HARVEY D. FLEISCHER FilE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. 2. DESCRIPTION MetLife Policyholder Trust, Investor ID 80654204069 c/o Mellon Investor Services 480 Washington Blvd.) Jersey City, NJ 07310 MetLife Policyholder Trust, Investor ID 806196205158 c/o Mellon Investor Services 480 Washington Blvd.,Jersey City, NJ 07310 VALUE AT DATE OF DEATH 3,460.80 ITEM NUMBER 1. 865.20 TOTAL (Also enter on line 2, Recapitulation) $ 4.326.00 REV-1511 EX + (12-99) '* , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF HARVEY D. FLEISCHER SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Nancy A. Johson 216.30 Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 6424 Pamadeva Drive City Hanover State P A Zip 17331 Year(s) Commission Paid: 2. Attorney Fees Scott A. Ruth, Attorney at Law 216.30 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 Supplementallnh. Tax Return, Supp. Inventory, Release 48.00 5. Accountant's Fees Michael T. Noel, CPA 390.00 prepare fiduciary return 6. Tax Return Preparer's Fees 7. United States Postal Service-postage, cert. of mailing 27.63 TOT AL (Also enter on line 9, Recapitulation) $ 898.23 REV"5'3EX*(* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF HARVEY D. FLEISCHER SCHEDULE J BENEFICIARIES FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Jeanne Atkinson Sibling 1069 Red Maple Way 23% New Smyrna Beach, FL 32168 2. Doris DeMoss Collateral P.O. Box 14115 230/0 So. Lake Tahoe, CA 96151-4115 3. Helen Merryman Estate, cIa Gale Merryman Collateral 12240 Mannix Road 230/0 San Diego, CA 92129 l ~ 4. Bonnie Robicheau now known as Julia Youngblood Collateral 89187 Sutton Lake Road 3010 Florence, OR 97439 5. Jay Brandenberger Collateral 1035 Notre Dame Avenue 5010 South Bend, IN 46617 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. Mechanicsburg Presbyterian Church 300 E. Simpson Street Mechanicsburg, PA 17055 2. Salvation Army-Mechanicsburg Regional Service 701 North Broad Street Philadelphia, PA 19123-2491 3. New Hope Ministries 15 State Road Mechanicsburg, PA 17050 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If mnrA ~n;:ar.A i~ nAAnAn iMArt ;:annitinn;:al ~hAAt~ nf thA ~;:amA ~i7A\ Continuation of REV-1500 Inheritance Tax Return Resident Decedent HARVEY D. FLEISCHER Decedent's Name Page 1 File Number Schedule J - Beneficiaries - 28 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 4. Bethesda Mission 1500 North 2nd Street Harrisburg, PA 17102 SUBTOTALSCHEDULE~2B REV-1500 Continuation Sheet 21-04-0036 Estate of Harvey D. Fleischer Any penalty should be waived because initially the estate overpaid estimated inheritance tax; decedent was a poor record keeper; administratrix filed a formal change of address within three months of opening the estate but some of the mail was not forwarded; the newly acquired asset was managed by Mellon Investor Services which managed some of decedents assets but, upon information and belief, had changed name from and/ or merged with another bank; administratrix made formal claims to MetLife on other policies and annuities which administratrix knew about but MetLife did not inform her of this recent stock until December, 2005; some of the stock was in the name of the decedent's wife who predeceased him. I MetLlfe Policyholder Trust Statement HARVEY D FLEISCHER Account Market Value . Stock Price as of Total Market 11/07/2003 Value $30.900 $3,460.80 RETAIN FOR YOUR RECORDS Investor 10 I 8065 4204 0269 2003 Dividend Summary Record Date Total Trust DMdend per Current Interests Trust Interest Distribution 11/07/2003 112.??oo $0.23 $25.76 Payable Date Tax Withheld Net Distribution Prior Year Distribution 12/15/2003 $0.00 $25.76 $23.52 The aggregate amount paid to all Trust Beneficiaries In this distribution Is $84,005,793.40 Trust Beneficiarv Information You may purchase or sell shares of Metlife. Inc. common stock through the Trust. free of any commissions or other fees. under the MetLife Purchase and Sale Program. as amended. A copy of the brochure describing the program is available on the Internet at www.metlife.com by selecting Investor Relations and then the Shareholder Services Information page. or by calling the number listed below. You are permitted to transfer your Trust Interests only in the circumstances described in the brochure. You may also instruct that all (but not less than at!) of your shares of MetLife. Inc. common stock held by the Trust be withdrawn from the Trust. Information regarding your withdrawal rights may be found in the Purchase and Sale. Brochure or by calling the number listed below. An annual shareholders' meeting to elect members of the Board of Directors of MetLife. Inc. and for transaction of other business is expected to be held on April 27. 2004. The deadline for submitting shareholder proposals for consideration at this meeting was November 28. 2003. A copy of MetLife, Inc.'s annual report and proxy statement will be available free of charge on or before March 31. 2004. along with other Metlife. Inc. ar)d Policyholder Trust filings under federal securities laws. (i) on the Internet at www.metlife.com on the Investor Relations portion of the website. (ii) by writing to Metlife, Inc. at the address listed below or (iii) by calling the number listed below. These and other securities filings by Metlife and the Policyholder Trust are also available on the Internet at www.sec.gov. For Inquiries about your account, the status of your Trust Interests, or discrepancies on this statement, contact Information Is listed below: Internet: www.mellonlnvestor.com/lsd E-mail: Metlife@melloninvestor.com Phone: 1-800-649-3593 0066565 General Mall: MetUfe. Inc. cfo Mellon Investor Services P:O. Box 4412 South Hackensack. NJ 0760&2012 MetLife Please Note: Important 2003 Tax Information ~~~~W6~i~YSTRIBUTIONS u.s. TAX INFORMATION FOR 2003 RECIPIENT'S IDENTIFICATION NUMBER TOTAL ORDINARY DIVIDENDS 174-01-6817 L1A $25.76 PAYER'S NAME MELLON INVESTOR SERVICES AS CUSTODIAN OF THE METLlFE POLICYHOLDER TRUST QUALIFIED DIVIDENDS I BOX 18 . $25.76 OMB NO. 1545-0110 COpy B FOR RECIPIENT FEDERAL INCOME TAX WITHHELD t~~x 4 $0.00_ J PAYER'S FEDERAL IDENTIFiCATION NUMBER 51-6516987 SECURITY DESCRIPTI TRUST INTERESTS ~. . - ....... REPORTED BY MELLON INVESTOR SERVICES 85 CHALLENGER ROAD RIDGERELD PARK NJ 07660 IMPORTANT 2003 TAX INFORMATION This Is Important tax Information and Is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction may be imposed on you If this Income Is taxable and the IRS determines that It has not been reported. I Box 1A.- Shows ordinary dividends that are taxable. Include this amount on line 9a of Form 1040 ~ or 1040A. Also, report it on Schedule B (Form 1040) or Schedule 1 (Form 1040A), if required. The , amount shown may be a distribution from an employee stock ownership plan (ESOP). Report it as I a dividend on your income tax return. but treat it as a plan distribution, not as Investment income for any other purpose. Box 1 B.- Shows the portion of the amount in box 1 a that may be eligible for the new 15% or 5% capi- tal gains rates. See the Form 1040/1 040A instructions for how to determine this amount. Report the eligible amount on line 9b, Form 1040 or 1040A. HARVEY D FLEISCHER BETHANY VILLAGE 325 WESLEY DR APT 3129 MECHANICSBURG PA 17055-3515 FOR INFORMATION REGARDING THE ABOVE, CALL 1-800-649-3593 Box 4.-.Shows backup withholding. For example, a payer must backup wit~hold on certain payments at the applicable rate If you did not give your taxpayer identification number to the payee. See form W-9, Request for Taxpayer Identification Number and Certification, for information on backup withholding. Include this amount on your Income tax return as tax withheld. Nominees. If this form Includes amounts belonging to another person, you are considered a nominee recipient You must file Form 1099-DIV with the IRS for each of the other owners to show their share of the Im;ome and you must furnish a Form 1099-DIV to each. A husband or wife is not required to file a nominee return t~ show amounts owned by the other. See the 2003 General Instructions for Forms 1099, 109B, 5498, and W-2G. *Please Deposit the Enclosed Check Immediately* ,-, \ L r RETAIN FOR YOUR RECORDS I Investor 10 I 8061 9620 5158 I Metllts Policyholder Trust Statement iRACE B FLEISCHER $30.900 $865.20 2003 Dividend Summary Record Date T atal Trust Dividend per Current Interests Trust Interest Distribution 11/07/2003 28.0000 $0.23 $6.44 Payable Date T ax Withheld Net Distribution Prior Year Distribution 12/15/2003 $0.00 $6.44 $5.88 Account Market Value Stock Price as of 11/07/2003 Total Market Value he aggregate amount paid to all 'rust Beneficiaries In this distribution ; $84,005,793.40 'rust Beneficiarv Information 'ou may purchase or sell shares of Metlife. Inc. common stock through the 'rust. free of any commissions or other fees. under the Metlife Purchase and iale Program. as amended. A copy of the brochure describing the program is vailable on the Internet at www.metlife.com by selecting Investor Relations nd then the Shareholder Services Information page. or by calling the number sted below. You are permitted to transfer your Trust Interests only in the ircumstances described in the brochure. You may also instruct that all (but lot less than all) of your shares of MetLife. Inc. common stock held by the 'rust be withdrawn from the Trust. Information regarding your withdrawal ights may be found in the Purchase and Sale Brochure or by calling the lumber listed below. An annual shareholders' meeting to elect members of the Board of Directors of MetLife. Inc. and for transaction of other business is expected to be held on April 27. 2004. The deadline for submitting shareholder proposals for consideration at this meeting was November 28. 2003.. A copy (J)f MetLi'e. Inc.'s annual report and proxy statement will be available free of charge on or before March 31, 2004. along with other MetLife. Inc. and Policyholder Trust filings under federal securities laws. (i) on the Internet at www.metlife.com on tha Invastor Relations portion of tha 'Website. (ij) by writing to Matlife. Inc. at the address listed below or (iii)'by calling the number listed below. These and other securities filings by MetUfe and the Policyholder Trust are also available on the Internet at www.sec.gov. =or inquiries about your aooount, the status of your Trust Interests, or discrepancies on this statement, contact information is listed below: Internet: www.melloninvestor.eom/isd E-mail: Metllfe@mellonlnvestor.com Phone: 1-800-649-3593 General Mall: MetLlfe. Inc. 0/0 Mellon Investor Services P.O. Box 4412 South Hackensack. NJ 07606-2012 ~76330 Yhy did I receive this check? 'au are receiving the enclosed check because you are a Beneficiary of the MetLife Policyholder Trust. Your Trust '1terests (shares) receive dividends paid on MetLife, Inc. common stock. The Trust was established in connection vith the conversion of Metropolitan Life Insurance Company from a mutual company to a company with ihareholders. Owners of an eligible policy at the time of the conversion were entitled to receive shares of JletLife, Inc. common stock. , you have never updated your social security number, you may do so at your convenience. 'ou may update your social security number on your account by calling 1-800-649-3593. You will need your lvestor ID located in the upper right hand corner above. The automated system will instruct you on how to )roperly update your account. The automated system is available 24 hours a day, 7 days a week. rhe original account holder Is deceased. How do I transfer the account? n order to transfer the account, please provide us with the following information to the address listed above: I) A letter of instruction detailing the transfer you would like to complete; 2) The name, address and taxpayer 10. :social security number) of the person or persons to whom the shares will be transferred; 3) A completed stock )Ower form, signed by the legal representative and guaranteed with a medallion stamp* and, 4) A certified copy )f the death certificate. You may also need an original Inheritance Tax Waiver if required by your State. ''The medallion stamp may be provided by a commercial bank, trust company, securities broker/dealer, credit Inion or savings association participating in the medaflion stamp program. 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FLEISCHERJ of the Township of Lower Allen, County of Cumberland and State of Pennsylvania, being of sound and disposing mind, m~mory and understanding, do make, publish and deolare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me B.t any time heretofor'e made. 1. I direct the payment of all my just debts and funeral expenses as soon a.fter my decea.se as the BRme oan be oonveniently done~ and in this respeot, I direct that all estate, inheritanoe and suooession taxes that ma.y be assessed i.n consequence of my death, of wha.te"'{er nature and by whateve~ jiurisdiotion imposed, shall be paid out of the prinoipal of my g€,neral estate to the same effeot as if said taxes were expenses of administration, and that all property inoludable in my taxable esta.te, whether or not passing under this Will, shall be free and olear thereof. 2. I give, devise and bequeath all the re,st, residue and remainder of my estate, real, personal and mixed; whatsoever and wheresoever the same may be situate, to my wife, GRACE B. FLEISOHER, absolutelJ" and unoonditionallYe -1- 3. In the event that my wife, GRACE B. FLE:rSCHER, should. predeoease me, or should she die within thirty (30) days from the date or my death, then in either event, I direct the settlement and distribution or my estate to be made in the :rollowing manner, to wit: A. I give and bequeath twenty-three (~~3%) per oent. o.:r my estate to my sister, JEANNE ATKINSON. B. I give and bequeath twenty-three (;~3%) per cent. of my estate to my sister-in-law, DORIS DeMOSS. a. I gi va andbequea th twenty-thl'ee (;~3%) per oent.. of my estate to my sister-in-law, HELEN MERRYMAN. D. I give and bequeath three (3%) per cent. of my estate to my wife's niece, BONNIE ROBICHEAU. E. I give and bequeath five (5%) per cent. of my estate to my wit'e' s nephew, ~rAY BRANDENBERGER. F. I give and bequeath five (5%) per oent. or my estate to the l1ECHANICSBURG :PRESBYTERIAN CHURCH. G. I give and bequeath eight (8%) per oent. of my estate to the SALVATION ARMY. H. I give and bequeath five (5%) per oent. of my estate to the NEW HOPE MINIS'rERIES, of Mechaniosbu.rg, Pennsylva.nia. "2- I. I give and bequeath five (5%) per cent. of my estate to the BETHESDA MISSION, of Harrisburg, Pennsylvania. LASTLY, I nominate, oonstitute and appoint my wife, GRACE B. FLEISOHER, Executrix of' this my Last Will and Testa.ment, and in the event that my said wife should predecease me; or should she be unable or unwilling to serve in suoh oapaoity for B.ny reason, then in such event, I nomina.te, 'oonsititute and appoint my oousin, ROBERT C. STACY, Exeoutor of this my Last Will and Testamen'h, in her plaoe a.nd stead, and in the event that my oousin, ROBERT C. STACY, should predeoease DIe, or should he be unable to serve as such Executor, then in suoh event, I nominate, constitute and appoint J. ROBERT STAUFFER, Esq.; of Mechaniosburg, Pennsylvania, Exeoutor of this my Last Will and Testament; and in all instances; I direct that my said personal representatives be exoused from posting bond or other security for the,faithful performance of their duties in a.ny ju.risdiction. IN WITNESS "'IHEREOF J I have hereunto se1j my hand and seal this 2A day of October; A. D.; 1996. . / fJ ~., 'L- v; . , b-1_ . J~ .... A~ .r~ ~~.~ ;I arvey D. FIala ohar (SEAL) "'3- narned, Signed, sealed, in the and deolared by the above and for his Last Will and Testament, who have subscribed our names hereto as witnesses, at the req est o~ said testator, in his presenoe and in the presenoe or ea P.i'/,.r/ /~ ~.~ . vr-" .~ / / , . V d. '7;1~7 -4- COMMONWEALTH OF PENNSYLVANIA ) SSe COUNTY OF CUMBERLAND ) I, HARVEY D. FLEISCHER , the testat or whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and volun- tary act and deed, for the purposes therein contained. Sworn and affirmed to and acknowledged before me by- . HARVEY D. FLEISCHER , the testator ,this tA.Y-{~ day of Octo1le~ ,A. D., 1996. ~~~ /' a.rv~. p .~ se ar /Y!~:' '1rr ~ D.L; . Not ~y Public SSe ~Kay~,~PIJjJc_.J~''''' My Com~Boro. Cumbeifand County . n Exrims Nov. 6, 1997 , ~aAsSocIa1fOn of ~~..a COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF CUMBERLAND ) We, the undersigned, J. ROBERT STAUFFER and SUSAN A. HoCOY , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the testat or, HARVEY D. FLEISCHER , sign and exe- cute the instrument as his/iurx Last Will and Testament; that the said testat or HARVEY D. FLEISCHER , executed it as his/~free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the testat~7 signed the Will as witnesses; and that to the best of our knowledge, the test at or was, at the time, eighteen (18) or more yearaof age, of sound mind, and under no constraint, duress or undue influence. Sworn and me this Ootobel~ ~ /~ /./' sub~ribed to befop~/ ,1,1'- day of , ..1996.. A~~ f:i; . Notarial Seal Marftyn Kay Eakin, Notal}' Public Med1anlcSburg 80m, CUmberland County . My CornrnlsSlon Expires Nov. 6, 1997 ,Perins anla~ofNo'. Register of Wills Cumberland County, Pennsylvania SUPPLEMENTAL INVENTORY Estate of , Deceased No. 21 2004 0036 Date of Death 11/29/2003 Social Security No. 174-01-6817 also known as Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inWHltory 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 the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative: Name of Attorney: Scott A. Ruth 1.0. No.: 61934 Address: 4 High Street Hanover Telephone: 717-630-9333 Nancy A. Johnson, Administrator c.t.a. "7'''' . ./' -7 /! Dal~ (1'?1~J' ~(l;;2'~f(~~ PA 17331 Description MetUfe Policyholder Trust, Investor ID 80654204069 Value 3,460.80 MetUfe Policyholder Trust, Investor 10 806196205158 865;20 t C", 1) --:,.:.'# 0-' co Total (Attach Additional Sheets if necessary) 4,326.00 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representatiw, include the value of each item, but such figures should not be extended into the total of the Inwntory. RW-4 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 JOHNSON NANCY A 6424 PAMADEV A RD HANOVER, PA 17331 ___n_n fold ESTATE INFORMATION: SSN: 174-01-6817 FILE NUMBER: 2104-0036 DECEDENT NAME: FLEISCHER HARVEY 0 DATE OF PAYMENT: 04/06/2006 POSTMARK DATE: 04/06/2006 COUNTY: CUMBERLAND DATE OF DEATH: 11/29/2003 NO. CD 006533 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $414.31 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK# 1053 SEAL INITIALS: MG RECEIVED BY: REGISTER OF WILLS $414.31 GLENDA FARNER STRASBAUGH REGISTER OF WILLS Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 11/09/2006 RUTH SCOTT ALLEN ESQUIRE 4 HIGH STREET HANOVER, PA 17331 RE: Estate of FLEISCHER HARVEY D File Number: 2004-00036 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on t~e below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of wills a Status Report of completed or uncompleted administration. This filing 1S due by: 11/29/2006 please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Personal Representative(s) Cumberland County - Register Of WillE, One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 11/09/2006 JOHNSON NANCY A 6424 PAMADEVA RD HANOVER, PA 17331 RE: Estate of FLEISCHER HARVEY D file Number: 2004-00036 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COUET RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing lS due by: 11/29/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, Glenda Farner St Clerk of the Orphans' Court cc: File rnnnspl Register of Wills of Cumberland County SUPPLEMENTAL STATUS REPORT UNDER RULE 6.12 Name of Decedent: Harvey D. Fleischer Date of Death: 11/29/2003 Estate No.: 2004-00036 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: I. State whether administration of the estate is complete: Yes 0 No Ql: 2. If the answer is No, state when the personal representative reasonably believes that the administration will be-complete: three months 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No 0 b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes 0 No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. ~ c-..::> [}me: r-"- Signature (~",: Scott A. Ruth, Esq. Name 4 Hiqh Street, Hanover. PA 17]31 Address 717-630-9333 Telephone No. Capacity: 0 Personal Representative rn Counsel for personal representative \ ~ , ,..- ,'~'. -.... COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE ~OTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE 'OF'DEDUCTIONS AND ASSESSMENT OF TAX '* BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 'Inll Or', -I {,'I:'" 10: 47 L"j I I i...t . REV-15~7 EX AFP (06-05) DATE 09-24-2007 ESTATE OF FLEISCHER HARVEY D DATE OF DEATH 11-29-2003 FILE NUMBER 21 04-0036 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 11-23-2007 ( See reverse side under Ohjections) A.ount Re.ittedl I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE .... RETAIN LOWER PORTION FOR YOUR RECORDS +- ------------------------------------------------------------------------------------------- REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF FLEISCHER HARVEY D FILE NO. 21 04-0036 ACN 101 DATE 09-24-2007 SCOTT A RUTH 4 HIGH ST HANOVER CLr=p!-( or"~ ,. r;f,"':,--](' " , 1'1" \~) ......1 ATTY PA 17331 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Stock/Partnership Interest (Schedule C) (3) 4. Mortgages/Notes Receivable (Schedule D) (~) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 6. JointlY Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. Total Assets NO. 01 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate SUbject to Tax .00 4.326.00 .00 .00 .00 .00 .00 (8) NOTE: To insure proper credit to your account, submit the Upper portion of this form with your tax payment. 4,326.00 (9) (10) 898.23 NOTE: .00 (11) (12) (13) (14) 898 ?~ 3,427.77 788.39 226,202.07 If an assess.ent was issued preViously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due (15) (16) (17) (18) .00 .00 67,566.85 158,635.22 X 00 X 045 = X 12 = X 15 = A M DATE 02-27-2004 02-09-2005 04-06-2006 (19)= .00 .00 8,108.03 23,795.28 31,903.31 C NUMBER CD003608 REFUND CD006533 +) INTEREST/PEN PAID (_) 1,595.17 .00 22.26- AMOUNT PAID 32,000.00 2,045.50- 414.31 * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. TOTAL TAX CREDIT 31,941.72 BALANCE OF TAX DUE 38.41CR INTEREST AND PEN. .00 TOTAL DUE 38.41CR ( IF TOTAL DUE IS LESS THAN .1, NO PAYMENT IS REQUIRED. r1 . IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DU~ A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 10/31/2007 RUTH SCOTT ALLEN ESQUIRE 4 HIGH STREET HANOVER, PA 17331 ...;--.,.1 <~-~ } "",1-'':: I j .-':"-~ --~.-'- RE: Estate of FLEISCHER HARVEY D File Number: 2004-00036 co I'n.'.) ( , ..AJ Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 11/29/2007 please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, tJ ~ . 2; ~,/'.'. . .'1'" r... . ,'_';:/ /~l..~~ Glenda Farner Strasbau~ Clerk of the Orphans' Court cc: File Personal Representative(s) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 10/31/2007 JOHNSON NANCY A 6424 PAMADEVA RD HANOVER, PA 17331 o ~ :TJ , ""\"J , , <:J , , "..';",-' RE: Estate of FLEISCHER HARVEY D File Number: 2004-00036 ( ->.J Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of wills a Status Report of completed or uncompleted administration. This filing 1S due by: 11/29/2007 please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, ,~~u~ ...,....."'/ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel STATUS REPORT UNDER RULE 6.12 Name of Decedent: Harvev D. Fleischer Date of Death: 11/29/2003 Will No. 2004-00036 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: I . State whether administration of the estate is complete: Yes No X 2 . If the answer is No, state when the personal representative reasonably believes that the administration will be complete: on or about January. 2008 3. If the answer to No. 1 is Yes, state the following: a. account with the Court? Did the personal representative file a final Yes No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: 11/20/2007 Signature Scott A. Ruth. ESQuire Name (Please type or print) 4 High Street Hanover PA 17331 Address ( 717 ) - 6309333 Tel. No. Capacity: Personal Representative W ,to"f) . Id,'r'"" .:-~li\ilv J. 'j' . ,. .'., 'uQ i \.JJ7Hdo ~~,/"'\ '.1,U-'II"") ..,v Jk.n Iv X Counsel for personal representative LO :f: Wd I Z AON LaOl ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX OIVISION PO BOX 280601 HARRIS8URG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE prr.('nr"-n 0(.F'I"r ,.- ,['\ '!.H':UC) ,X-:V:: []"NHERITANCE TAX ! \~TATEHENT OF ACCOUNT '1',,- _....! '* REV-1607 EX AFP (03-05) 2001 DEe, 0 PM I: 29 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-13-2007 FLEISCHER 11-29-2003 21 04-0036 CUMBERLAND 101 HARVEY o SCOTT A RUTH 4 HIGH ST HANOVER CLERK OF ORPHAN'S COURT r.f 'MRPI 6i,lr) ('{, R'^ ATTYv ,.".u, 'c. '.,u., l"l Amount Remitted PA 17331 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS +- --------------------------------------------------------------------------- REV-1607 EX AFP (03-05) *** INHERITANCE TAX STATEMENT OF ACCOUNT *** ESTATE OF FLEISCHER HARVEY o FILE NO. 21 04-0036 ACN 101 DATE 11-13-2007 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 09-17-2007 PRINCIPAL TAX DUE: 31,903.31 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 02-27-2004 CD003608 1,595.17 32,000.00 02-09-2005 REFUND .00 2,045.50- 04-06-2006 CD006533 22.26- 414.31 10-29-2007 REFUND .00 38.41- TOTAL TAX CREDIT 31,903.31 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 II IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) ~ ~~.w~Z- STATUS REPORT UNDER RULE b.12 Name of Decedent: Harvev D. Fleischer Date of Death: 11 /29/2003 Will No. 21-04-36 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1 . State whether administration of the estate is complete: Yes _~ No 2 . If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes ~_ No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes ~_ No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: 6/26/2008 Signature Scott A. Ruth,. Attorne~at Law Name (Please type or print ) 4 High Street Hanover _ PA ..17331 Address 4u V,, r'•~ i '. ~ '. i j`,, ~-~, .~:_; 01) _ ~ , ,,V~ ~ ~ 7r~ rYrl YJ~, 4~,^4 ( 717) 630- 9333 Tel. No. Capacity: Personal Representative __X- Counsel for personal representative