The URL can be used to link to this page

Home My WebLink About02-0490 P~Jl~Ig~Mf1?JttR~f.TE and GRANT OF LETTERS Estate of John George Mihal~ No. _.. also known as To: Register of Wills for the Deceased. County of ClIDlhE,rJ and in Social Security No. 341-12-3100 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of a~ or older an the executrix in the last will of the above decedent, dated -11 DecEmber 1998 and codicil(s) dated n/a the named ,19_ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumberland County, Pennsylvania, with h is last family or principal ~ence at 5340 Oxford Circle, Apt. 38, MfeChanic.sburg. PA dlll)JJ, aUhw"';e I (list street, number and un~ipality) Decendent, then 79 years of age, died 2 April 2002 , 19 at Ho.cy Spirlt Hospital, Camp Hill, PA Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows; (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: none ~oo,ooo.oo $ $ $ WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters testamentary (testamentary; administration c.I.a.; administration d.b.n.c.t.a.) theron. v u " " :gZ "' "'v " -00 i::"'= ~'.c -" ~'- "~ " 0 ;;; " ~ Vi j~~ 2 ~ Oft ia E. Miha a 3601 March Drive Camp Hill, PA 17011 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA l ss COUNTY OF Cumberland j The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well an trulyadministe t1)e estate according to law. 2. affirmed and 17th Register If '" ,... " ., - " Ol ~ /7-00-/ --- Estate of No. 21-20u2-490 ~... <f~ M~h*A .=-k~ John George Miha1ka p . Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW May 20th ~ .~__~Oil}jn C()rt:,iUt;fUliun \ 1'1':'!,i.'1" "~Ii the reverse side hereof, satisfactory proof having been presented before me, lT IS DECREED that the instrument(s) dated~ December 1998 described therein be admitted to probate and filed of record as the last will of John G. Mihalka, aka John Georqe Mihalka and Letters Testamentarv are hereby granted to Julia E. Mihalka MARY C. IHfiS ~ FEES Probate, Letters, Etc. ......... $ 305.00 Short Certificates( 6) . . . . .' .. $ 18.00 Renunciation ............... $ ~-Pages (3) $ 9.00 JCP TOTAL _ $ 5.00 Filed .. Mi'lY. 2P.1;!)', 20.0.2. . . . . .$. ,3,:n .0.0.. . Samuel L. Andes ATTORNEY (Sup. C:. l.D. :"10.) 525 N. 12th Street Lanoyne, PA 17043 ADDRESS 17225 717 761-5361 PHONE c'; ,--) Mailed letters to attorney on May 20th, 2002 ",.;"',, I!q ","" This is to cerrif~' rnar the in/~)nnation lH:'re giVl'!l is cOITn..d\, Lopil'd frurn an original certiflcatl' of death duly hied w'ith 111e as Loc~ll 'ReEisLrar.'The original certificate will ~he fonv:ndcd Ie; rhe >itatl' \fiu] Records Office for permanent f'1ling. ,c' , WARNING: II is illegal to duplicate this copy by photostat or photograph. No. ,",;;"(~(1;fotj;!;^ //#, ~(~\ /i~! Itt<~\;'-:" I~~:. '-.:: IY~ i~=' -. '=:::: I~ tJ",';"l. :J:;..~ ',* ~..~.. ,; *,1 \,"'- '.' ':>", \\.~', '~"'l ,'. '1",. ~...v" ""<:.!MENl ~\ ~"""" ~~I!!./ V~ ,2, VL Fcc t~H Lhis ct'rtillc:uc, $2.()() I.oul Rl'gis(rar ArK ,[ b I ~(jO'2. [);ue P 8203814 H,O, ;<JR&. 2i~7 COMMONWEALTH OF PENNSYLVANIA. DePARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH TYPE,PA'NI '" PlRM'o'N(NI Ill,O,CI\INK' 79 UNDE'F\'YEAR ..."""'" D.oro ,.. SlAl~F'll""lolll~R SOC'AlSl:CUlllTYNUl.lIl~1l ,341 - 12 N.......EOF O~CEDENTlf"" ....,.,.., L....' Jahrr'George Mihalka AGE 11." B",,,,,,,.) ~iiPlAcEIC"V"'4 31Al.aof",..jo,C"''''.1 , COlJNfYOFDEA1H '" CUmber land a. '. 5340 Oxford Circle trnen 38 .. 17dCl......__inTrLJI:>T 1l.11;:>n r.tAIlIlAlSTA,JU$__ _.......iN.~. wi~ ,il/hite SUFMvINGSI'OUS€ I"-.~_- OECEDE...rsUS1J.t.I.OCCUPoQlClI\l I~-:"~~~'::;zt::r nIL chief naval supp~y:~ II . DECEOENrSMAllINGA!lOAESS($lr...CoIyfbw>__,l'o>COdoI ~ '- 41 .OI~., .. z . @ M Q ~ ~ z ,~ CWnberland lTot.O :.:..~.::::... IolOTHEIl'S NN.lEiF..I._, M_SulI\IImOJ Julia Kish - ___1lI...[]: " -ORI.IANT.SMAlUNQADlIAESS'SIr....~_,lipCodolI ...3601 March Drive Hill PA 17011 PlACEOf'OlSf'OSlT1ON.-...oI~Ity,C,"""-"'"Y lOC~-~.SI....lipC<ld. 0_- ril 8 2002 lICENSE NUMBE'1l zZb011667 L zfc'~. Sheridan National Cern. Zf..~ort Sheridan, Ill. NNolEANOADlIAESSOl'FAClL'fY 8 Market Plaza Way lPezzi Funeral Hans lICENSE NUloI8ER _.Do>-t;_1 G{l d ~ I uC/k-Q(ucL Om uu ~.!}i. f.)~ DtJETO(OIlASAC OUENCEOftIl.. CJ_ OUETOlOfIAS,O,COOSEOUENCEOf) .~--_._- - -- nIo. Z:Jc. ~CA.SeIlEFEIlIll::O'OMEOICAlEltA"'NERlCOAOtoIER7 :'_'rI1 _0 ."" K. .AflPra........ .....RTN: ou...roigrl_cao-..~lo_lI>.!>uI :__n """1MUIIing"1lloI~""'gr...n""","1 :--- i I~e()w. tcu..ltvu... [, \1-(- ! 0Uf: lOlOfI ASACONS{Qu{Ni:;e O/-i-~--- '---~_---1--- , : , . WERE AUlOPSYFfflOWGS ,....Il_A8l.EPRIOAlO COIolPl.IITIOHOFCAUSE 0l'0EATH7 MANNEIlOf'DUfH ~.. -- !<J [J [J OA.n:OF1NJURY IM"""'_Da.__) T'WEOF 'NJUIlY INJURY AlWOAK1 DEliCRIIlE H(MI'NJuIlYOCC~O -.- [J [J [] f'UlCEOFINJUIlY_....__'......_,'8CtOIy,a_ .... ""~..c.'s.p..;;.'.1 - ..... 0 NoD _D ~ Z... ... CUl'flFlt:"'C~.,.on;.onotl "CUlTII'Y_ PKnJc.."t(PnY"CoM'C*Wy<>QCOOUMoI<k;lIh""'.o .'''''''''' ""'''''oM'''.'?,OOOUn<o&<l ~""'" .""CCO"".,,,,,,,,.. ~J' IO..._.I"'1........~.....Ih""......._......u"...(.I.....m..,n.'.....,... P-...."'n_"",, _D ~[J ~- Could""'Wdo'.'m'n.... n ""/" JL:.'R~1ZL LGL~ LOCMlONtSIr_.~,_1 K. .'AOHOUNClHQANDClIlTIfYINQPHYSICl.....4~...l>OI/, ",on"'''"''''9'''''.Itl.'odce"d.,flI,j'''c"."", ol "e.."" lo....._a''''f~....~.......IhOC<:....'...81__.d...."''''pl.<........d_'O''...c.u...(.I.''''m...n.'..".'04 .IIlEDIC,O,l U:AUINERlCORONEIl On Ill. bui. "l..amin.llon .ndlor In....llg.lion.;n my opi,,;o". dUIll oee"...d .1 Ih. 11m.. d.I.,.nd piau. ,nd d".lo ,h. C''''.l') .nd m.nn..a.II>1'" ". Ou l "\iVY' tel I~ b Pc, I7lll. . ~ \. -"$ /;: ~ i ~J 1/ WILL OF JOHN G. MIHALKA 21-2002-490 I, JOHN G. MIHALKA, of Lower Allen Township, Cumberland County, Pennsylvania, I I I ~ I}.. ~ " declare this to be my last will and revoke any will previously made by me. ITEM I. I direct that all my just debts and funeral expenses, including my gravemarker and all expenses of my last illness, and any and all taxes and assessments imposed by any governmental body as a result of my death, whether on property passing under this will or otherwise, shall be paid from my residuary estate as soon as practicable ~ ~ ~ after my decease as a part of the expense of the administration of my estate. ITEM II. I give, devise, and bequeath all of my possessions and estate of every nature and wherever situate as follows: A. Twenty-eight (28%) percent thereof to my daughter, JULIA E. MIHALKA, provided she survive my death by sixty (60) days and, if she does not so survive my death, to such of her issue, per stirpes, as survive my death by sixty (60) days and, if she leaves no such issue, then to the persons taking under sub-paragraphs Band C of this Item II of this my last will. B. Twenty-four (24%) percent thereof to my son, MICHAEL D. MIHALKA, provided he survive my death by sixty (60) days and, if he does not so survive my death, to such of his issue, per stirpes, as survive my death by sixty (60) days and, if he leaves no such issue, then to the persons taking under sub-paragraphs A and C of this Item II of this my last will. C. Twenty-four (24%) percent thereof to my son, KENNETH MIHALKA, provided he survive my death by sixty (60) days and, if he does not so survive my death, to such of his issue, per stirpes, as survive my death Page 1 of 4 It by sixty (60) days and, if he leaves no such issue, then to the persons taking under sub-paragraphs A and B of this Item II of this my last will. D. Twenty-four (24%) percent thereof to such of my grandchildren, including any adopted grandchildren, who survive my death by sixty (60) days. ITEM III. I appoint my daughter, JULIA E. MIHALKA, executrix of this my last will. Should my said daughter predecease me or otherwise fail to qualify or cease to serve as I\) '" ~ executrix of this my last will, I appoint my son, KENNETH MIHALKA, executor of this my last will. Should my said son predecease me or otherwise fail to qualify or cease to serve ~ .'- as executor of this my last will, I appoint my son, MICHAEL MIHALKA, executor of this my " last will. ~ ) ITEM IV. In addition to the other powers and authorities granted to my personal representative by Pennsylvania Law and by the other terms and provisions of this will, I hereby give to my personal representative the following powers and authorities effective without court approval and until actual distribution of all property: to compromise any claim or controversy; to make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as my personal representative may determine and at valuations finally to be fixed by them; to invest in all forms of property, including any stock or other ecurities in any corporate fiduciary or its successor without restriction to investments authorized for Pennsylvania fiduciaries, as my personal representative deems proper, without regard to any principle of risk or diversification; to retain any or all assets of my estate, real or personal, without regard to any principle of risk or diversification; to sell at public or private sale, to exchange, or to lease for any period of time, any real or personal property and to give options for sales, exchanges, or leases, for such prices and upon such terms or conditions as my personal representative deems proper; and to allocate receipts Page 2 of 4 I' I and expenses to principal or income or partly to each as my personal representatives deem proper in their sole discretion. ITEM V. I direct that my personal representatives and fiduciaries shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand this day of /1 !) L-<:. ,1998. ~.:~ C:::-,.~?~, OHN G. MIHALKA The preceding instrument, consisting of this and TWO other typewritten pages, each identified by the signature of the testator was on the date thereof signed, published, and declared by JOHN G. MIHALKA, the testator therein named, as and for his last will, in the presence of us, who at his request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. ~~~^D,) Sa I L. Andes ~.~-R~lAA Amy Ros 11 Page 3 of 4 I' COMMONWEALTH OF PENNSYLVANIA ) ( 55.: ) COUNTY OF CUMBERLAND The undersigned, being the testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, does hereby acknowledge that I signed and executed the foregoing instrument as my last will, that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~?,/~~~ HN G. MIHALKA Sworn or affirmed to and acknowledged before me by the testator named above this /1 '" day of tJc'"c",n,"/ur ,1998. -------..-. - ./ ~~ L:;]'Vl<?~LJ2 __ _ _;J\\J\CSEAL publIC \ II NotaryPublic \ - ~~ENFEI.O. :~ CO~ \ \ LiNN Ee 6Oro'~r811/llll\l.H~ \~l1l\SS\O" ..::--------- \.!1.--~ COMMONWEALTH OF PENNSYLVANIA ) ( 55.: COUNTY OF CUMBERLAND ) WE, SAMUEL L. ANDES and AMY ROSELLI, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the testator sign and execute the instrument as his last will; that he signed it willingly and that he 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 testator was at that time 18 or more years of age, of sound mind, and under no constraint or undue influence. Sworn or affirmed to and acknowledged before me this IlK, day of J}e<op!x''€, 1998. &~ - . ~-.Q/~ Samu L. Andes o.){)r\) .\ \.-f(l \J2&ru ).A.~ Amy Rosel4l\ -~ ~\... VU'O\\C / r'1~ /17 -~""\.. "o~1'l6 coU\\'Ij,~ ~'4AA ~U' ~ ~~\'p. ~ \1 ~ Notar/Public ".------ ~~~~IO.I))'t\-~\). \.'{~~.- ~~o\\ ~ \.~01~\SS \lI'jCO Page 4 of 4 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: John G. Mihalka Date of Death: 2 April 2002 Will No. To the Register: Admin. No. 21-02-490 I certify i:hat notice of beneficial interest required by Rule 5.6(a) of the Orphans Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on 26 June 2002 Julie E. Mihalka Michael D. Mihalka Kenneth Mihalka 3601 March Drive CMR 409 Box 570 5907 North Mattox j Camp Hill, PA 1701 1 APO AE 09053 Kansas City, MO 64151 Wolf Mihalka Nicole Mihalka Nicolas Mihalka CMR 409 Box 570 7104 Franklin Avenue, #18 1917 Fairfield Road APO AE 09053 Los Angeles, CA 90046 Lindehurst, IL 60046 Shayne Mihalka Kristen Mihalka Matthew Mihalka 5907 North Mattox 3015 Charolette Street 5907 North Mattox Kansas City, MO 64151 Newbury Park, CA 91320 Kansas City, MO 64151 Notice has now been given to all persons entitled thereto under Rule 5.61a) except: None Date: 26 June 2002 -~"v~-~`-d Signature ' Name: Samuel L. Andes Address: 525 N. 12t~ Street ~- Lemoyne, PA 17043 Telephone #761-5361 Counsel for Personal Representative ".. , SAMUEL L. ANDES ATTORNEY AT LAW ~25 NORTH TWELFrH STREET P. O. BOX 168 LEMOYNE, PENNSYLVANIA 17043 Register of Wills Office Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 28 June 2002 RE: Estate of John G. Mihalka Ladies: TELEPHONE (717) 761-l5361 FAX (717) 761-1435 Enclosed is a check payable to the Register of Wills for $9,000.00 which I wish to deposit against the inheritance tax due in the above estate. If you have questions or need anything further, please contact my office. Otherwise, please process this check as that deposit. amh / Enclosure Sincerely, c & t Andes -< SAMUEL L. ANDES ATTORNEY AT LAW 525 NORTH TWELFTH STREET P. O. BOX 168 LEMOYNE, PENNSYLVANIA 17043 Register of Wills Office Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 -.J \. fr~'i';$-:-~:-~'L:-:. fj"2, 1",111",111."",11.,11",11."11,,,1,1,,11,1,/',1.1.,1,1,,1 Y.-J '-- I C> 'f'-J -J::: ~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1712B-0601 AEV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SAMUEL L ANDES ESQUIRE 525 N 12TH STREET LEMOYNE, PA 17043 _H_nn fold EST A TE INFORMATION: SSN: 341-12-3100 FILE NUMBER: 2102-0490 DECEDENT NAME: MIHALKA JOHN G DATE OF PAYMENT: 07/01/2002 POSTMARK DATE: 06/28/2002 COUNTY: CUMBERLAND DATE OF DEATH: 04/02/2002 NO. CD 001358 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $9,000.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: SAMUEL L ANDES ESQUIRE CHECK# 004152 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS $9,000.00 MARY C. LEWIS REGISTER OF WILLS 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 ANDES SAMUEL l ESQUIRE 525 NORTH 12TH STREET lEMOYNE, PA 17043 --- fold ESTATE INFORMATION: SSN, 341-12-3100 FILE NUMBER: 2102-0490 DECEDENT NAME: MIHAlKA JOHN G DATE OF PAYMENT: 03/13/2003 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 04/02/2002 NO. CD 002282 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $7,004.94 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: MEMBERS 1 ST BANK CHECK# 00006409 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS $7,004.94 DONNA M. OTTO DEPUTY REGISTER OF WillS A' , . llfV.l5lll,lEX~) 17-G5- / REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT / .~;:-::;!c~ ;82 ONL.Y '* COMMONWEALTH OF j PENNSYLVANIA . :ll DEPARTMENT OF REVENUE DEPT. 280601 r HARRISBURG, PA 17128-0601 I!! ",:$~ lilltg :z:o..J offm .. .. fILE NUMBER 2 1 _0 2 o 4 9 0 CC\INTY CODE YEAR ---- """''" ... Z w Q w o W Q DECEDE~IrS NAME (LAST, FIRST, AND MIDDLE INITIAL) MihCllka, John G. DATE OF JEATH IMM-1JD.YEAR) DATE OF BIRTH (MM-DD.YEAR) 04/02/2002 07/01/1922 (IF APPUGABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) None SOCIAL SECURITY NUMBER 341 - 12 3100 THIS RETURN MUST BE FILED IN DUPUCA IE WITH REGISTER OF WILLS SOCIAL SECURITY NUMBER [iJ 1. Or ginal Relurn o 4 Un.1aIl Eslale o 6. Decedent Died Testate (Al!adlCWfolWil) o 9. Liti~ation Proceeds Received o 2. Supplemental Relum o 4a. Future Interest Compromise (da!9ofdealhalw12.12-82j o 7. Decedent Maintained a Uving Truat (NladI ~ ofTlUS\\ o 10. Spousal Poverty Credit (dlIleof:lta1hbelween12.J1-91 and H.95) o 3. Remainder Return (dale ofdeJ1h prior 10 12-1U2) o 5. Federal Estate Tax Return Required 8. Telal Number 01 Sale Deposit Bexes o 11. Election 10 lax under Sec. 91131A) 1_" I- Z W C ~ .. V> W ~ " () NAME COMPLETE MAILING ADDRESS Samuel L. Andes FIRMNAME~r_) 525 North 12th Street Lemoyne, FA 17043 TELEPHO~E NUMBER (717) 761-5361 11} (2) 223,655.94 (3) (4) (5) 64,192.70 OFFICIAL USE ONLY z o ~ ::l !:: Q,. 0( o w It: 1. Real Estate (Schedule A) 2. Stod<s and Bonds (Schedule B) 3. Close".' HeI<I Corpc<ation, Partnership" SoIe-Proprielorshi 4. Mortgages & Notes Receivable (Sdledule 0) 5. Cash, Ilank Deposits & Miscellaneous Personal property (SchedllleE) 6. JoinUy ONned Property (Schedule F) o &~perate Billing Requestad 7. Inter-VIVos Transfers & Miscellaneous NorJ..Probate Property (Sched.e G Of L) B. Total ~"oss Assets (tolal Lines 1-7) 9. Funera, Expenses & Admmistralive Costs (Schedule H) 10, Debts <I Decedenl, Mortgage Liabirues, & Liens {Schedule I) \1. Total Deductlons (total Unes 9 & 10) 12. Net Value of Estate (line 8 minus Una 11) 13. Chama!lle and Governmental Bequests/Sec 9113 Trusts for which an elect:ior to tax has not been made (:ichedule J) (11) 26,064.50 (12) 365,665.33 (13) (14) 365,655.33 (6) 71,188.81 (7) 32,692.38 , ~ (B) 391,729.83 (9) 23,478.31 (10) 2,586.19 14. NetV.lue Subjeello Tax (Une 12 minus Line 13) SE~ INSTRUCTIONS ON REVERSE SIDE FOR APPUCABLE RATES z o ~ I'" ::l 0- ::IE o o ~ 15. Amount of Line 14 taxable al the spousal tax rate, or lransfers under Sec. 9116 (aXI.2) x.O_ (15) x .01f.i.. (16) $16,454.94 x .12 (17) x .15 lIB) 119) 16,454.94 16. Amount of Une 14 taxable at lineal rate $365,665.33 17_ Amount of Une 14 taxable at sibling rate 18. Amount of Une 14 taxable at collateral rate 19. Tax DUf~ 20U , .,.", ~""'''c,l'> >'BE SllD""4Iri~A!:J;"'UEll1l0<iS~~~lllE~""'Et""t"'''ATH<'<' . ~> .,,,,lji..,d;i;L,,,,-,.,,n""""""""_d"___ _~:l'::~~" "d""'_ .,__~". ~.)I'oiII,,~".__ ..,"._,~~_.:;:M"'7;.__ d.__ ,_ ..__ .__^,,",...'.><.. ,,~;;90._~.,.~"~_. "~!.~.. "....^.-,.. HECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYM~NT .. " \ '''-~. '. r Decedent's Complete Address: STREET ADDRESS 5340 Oxford Circle, Apt. 38 CITY Mechanicsburg I STATE I ZIP 17055 PA Tax Payments and Credits: 1. Tax Due (P"ge 1 Line 19) 2. Credits/Payments A Spoosal Poverty Credit B. Prior Payments C. Discount (1) $16,454.94 $9,000.00 (1 July 2002) $450.00 Total Credi1s (A + B + C) (2) $9,450.00 3. InterestlPenalty if applicable D. Interest E. Penalty TotallnteresVPenalty ( 0 + E ) (3) 4. If Line 2 is grealer than Line 1 + line 3, enler the difference. This is the OVERPAYMENT. Check box on Page 1 Une 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) $7,004.94 A. Enter Ihe interest on the tax due. 6. Enter the totai of Line 5 + 5A. This is the 6ALANCE DUE. (5A) (56) $7,004.94 Make Check Payable to: REGISTER OF WILLS, AGENT ;&~~~11~1~~~~'r>-m~..,<_,,- ~ . .tY~~jJr<<~iJ ~~~~~JEi}~;~~U:flFJiBR PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Ves No a. retain the use or income ofthe properly transferred;.......................................................................................... 0 ~ b. retain the right to designate who shell use the properly transferred or its income;............................................ 0 ~ c. retain a reversionary interest; or.......................................................................................................................... 0 I2SI d. receive the promise fur life of either payments, benefits or care? ...................................................................... 0 iXl 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate cOl1sideralion?............................................................................................................. 0 I8J 3. Did decedent own an 'in trust tor" or payable upen death bank accoont or security al his or her death?.............. 0 01 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designa\ion? ........................................................................................................................ 0 iKl 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 penallitls of perjury, I dedare that 1 have examined this ralurn, including accomparlying schedulu and stalflmenls, and to the best of my knowledge and belief, il is we, calfee! and complele. Oel::laralion of pmparer other than the personal represeJ1lativ& is based on all informalion of which prepwer has any knowledge. SIGNATURE OF PERSON SP.ONSfLE mu~URN Julie E. Mihalka DATE 7 .? I/, c3 ADDRESS 3601 March Drive, Camp Hill, PA 17011 SIGNATURE OF HA Samuel L. Andes X ADDRESS 525 North 12th Street, Lanoyne, PA 17043 DATE ;~y ~1X0;,:::/J;#;~1~'f1j~s:~r;-:2--_:.f.~-.:._;/:{(;;'~::;\~-;~:;;.;;k;:.t:;.:;;~fX:.<H-'ill~?~Sf~~r~~!~~::~Jl~~m~~~~~~~,~ifX.~'W~~~_~1!~:-X{:J:~:~-iI-: .;--:.8t~~::~,i't,b~i-,;;:~1;;;:-:'.!, 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 survivin9 speuse is 3% [72 P.S. '19116 (a) (1.1) (ill. For dates of death on or after Janua/)' 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving s",,"se is 0% {n P.S. '19116 (a) (1.1) Iii)]. The statute does nol exemol a lransler to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even IT the surviVing spouse is the only beneficiary, For dates of death on or after July I, 2000: The tax rate imposed on the net value of transfers from a deceased cl1ild twenty-one years of age or younger at death to or lor the use of a natural parant. an adoptive parenl, or a stepparent of the child is 0% /72 P.S. 'I9116(a)(1.2)]. The tax rate imposed on the nel value 01 transfers 10 or lor the use of me decedenfs lineal beneficiaries is 4.5%, except as noted in 72 PS. '19118(1.2) [72 PS. 'i9116(a)(1}j. The tax rate impesed on the net vatue of transfers to or for the use of the decedent's siblings is 12% {72 P.S. 'I9116(3)(1.3)J. A sibiin9 is defined, under Section 9102. as an individual who has at ieast one parent in common with the decedent. whether by blood or adoption. ~1SlSD.~{I.m\ '* SCHEDULE B STOCKS & BONOS COMMONWEALTH Of PENNSYL"~N" INHERIT ~NCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21-02-0490 ESTATE OF John G. Mihalka All property jolntly-owned with rlght.I survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. 460 shares of Waypoint Bank stock (at $16.425 per share) $7.555.50 2. 500 shares of Consumers Financial Corporation (at $0.08 per share) $40.00 3. 1,000 shares of Hilite Industries, Inc. (at $14.25 per share) $14,250.00 4. 1,000 shares of Harsco Corp. (at $38.475 per share) $38,475.00 5. 603 shares of Draxis Health Inc. (at $2.815 per share) $1,697.45 6. 17 shares of Supervalu Inc. (at $25.77 per share) $438.09 7. 500 shares of C.R. Bard $29,572.50 8. 600 shares of Penn National Gaming, Inc. $20,868.00 9. 36 shares of Prudential Financial Corp. (at $31.20 per share) $1.123.20 10. 119 shares of Met Life, Inc. (at $31.26 per share) $3,719.94 11. 22,583.4250 shares in Dreyfus Growth and Income Fund F $105,916.26 (NOTE: See letter from stock appraiser attached) TOTAL (Also enter on line 2, Recapitulation) $ 223,655.94 (If more space IS needed. insert additional sheets of the same size) ... Frank R. Baker 146 Springhouse Lane Spring Grove, PA 17362 Phone: 717/225-5450 Fax: 717/225-0494 e-mail: frankr.baker@suscom.net July 15, 2002 Samuel LAndes Attorney At Law 525 North Twelfth Street P.O. Box 168 Lemoyne, PA 17043 Here is the information you requested concerning the values of the stocks owned by John G. Mihalka as of April 2, 2002. Equities Hi2h Low A vera2e Shares Value Waypoint Bank WYPT 16.65 16.20 16.425 460 7,555.50 Consumers Financial Corp. CFIN 0.08 500 40.00 *Hilite Industries, Inc. HLRD 14.25 1,000 14,250.00 Harsco Corp. HSC 38.95 38.00 38.475 1,000 38,475.00 .Draxis Health Inc. DRAX 2.93 2.70 2.815 603 1,697.45 Supervalu, Inc. SVU 25.92 25.62 25.77 17 438.09 C.R. Bard BCR 59.44 58.85 59.145 500 29,572.50 Penn National Gaming, Inc. PENN 35.30 34.26 34.78 600 20,868.00 Total: 112,896.54 .Tender offer for all shares, offered 14.25 on July 26,1999 .Deprenyl Research Ltd. changed it's name to Draxis Health Inc. If you have any questions, please call me at 717-225-2540 Sincerely, -WaJu~~ Frank R. Baker Frank R. Baker 146 Springhouse Lane Spring Grove, P A 17362 Phone: 717/225-5450 Fax: 717/225-0494 e-mail: frankr.baker@suscom.net December 13,2002 Samuel L Andes Attorney At Law 525 North Twelfth Street P.O. Box 168 Lemoyne, PA 17043 Here is the information you requested concerning the values of the stocks owned by John G. Mihalka as of April 2, 2002. Eauities Hie:h Low A verae:e Shares Value Prudential Financial Corp. PRU 31.40 30.99 31.20 36 1,123.20 MetLife, Inc. MET 31.55 30.% 31.26 119 3,719.94 ClosiDl! Price Dreyfus Growth & Income nJa nJa 4.69 22,583.4250 105,916.26 FundF FRMUX Total: 110,759.40 If you have any questions, please call me at 717-225-5450 Sincerely, -'l~. 0~ Frank. R. Baker COMMO~WEALTH Of PENNSYLVANIA iNHERiTANCE TAX RETURN RESIDENT OECEOENT ~,1SOO8\'I"~;: ESTATE OF '* SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER John G. Mihalka 21-02-0490 Include the pro<eeds ollitigalioo and the dale ttle pro<eeds were received by ttle estate. AU property jointly-owned wi1h the right of survivorship must be discloSed on Schedule F. ITEM NUMBER 1. 2. 3. 4. 5. 6. VALUE AT DATE OF DEATH DESCRIPTION Checking account No. 5140106846 with PNC Bank (see letter attached) $10,821.76 Annuity Fund No. N3 092 580 with New York Life Insurance and Annuity Corporation (see letter attached) $18,326.43 Investment account with Quick & Reilly (Account #219-00079-10PB168, see statement attached) $840.00 Certificate of Deposit No. 15846-44 with Members First Federal Credit Union (see statement attached) Certificate of Deposit No. 15486-49 with Members First Federal Credit Union (see statement attached) $14,640.68 $17,563.83 Miscellaneous items of personal property, clothing, and the like $2,000.00 TOTAl (Also enler on line 5, Recapitulation) $ 64,192.70 Ilf more space is needed, insert additional Sheels of the same sIZe) ]UL~25~2002 09:26 PNCBRNK elF DEPARTMENT 412 705 0057 P.01/01 Q PNCBAN< July 24, 2002 Samuel 1. Andes 525 North 12'" Street P.O Box 168 Lemoyne, PA 17043 RE: Estate of John G. Miha1k:a, deceased SSN: 341-12-3100 000: 41212002 Dear Mr. Andes: In response to your request for Date of Death balances for the customer noted above, our records show the following: Checking Account Account #5140106846 Established 07/01/1974 JOHN G MIHALKA DOD balance: $10,82 [.76 (non-interest bearing) Please note that this office only provides date of delith balances for deposit accounts (IRAs, CDs, Checking and Savings accounts). We do not process any financ:ial traosamons or provide statements. If you need assistance with any of these items, please call1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, ~uJ.RJh Rachelle Wel1s 1-800-762-1775 P7-PFSC-04-F 500 first Ave. Pituburgh PA IS219 Member FDIC TDTRL P. 01 .1302395 NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION . fA DELAWARE CORPORATION) PO BOX 6916 CLEVELAND OH 44101.6916 1.800-695-9873 M'WW,MwyorkJif..oom November 9, 2001 Agent JAMES D DAY (711) 232-2555 11 1..,11I,..11I....1,1..1,1..1..1,1..1,,1.1,11..1,1..1,1..1..1.1 JOHN G MIHAlKA 5340 OXFORD CIR MECHANICSBURG PA 11055.4426 Policy: N3 092 580 Annuitant: John G Mihalka 'UM" Dear Policyowner: The following informalion pertains 10 an additional annuity deposit of $3,000.00 received on November 9, 1987. The currenl cash value of this deposit is $6,749.26. It is guaranteed to earn an effective annual yield of 4.20% from November 9,2001 through November 8,2002. If you have made any olher additional deposits 10 this policy, a separate stalement will be mailed to you on the anniversary date of each deposil. Each statement will display the guaranteed interesl rate that is applicable 10 that deposit. As of November 9, 2001, the lotal cash value of your annuity policy, including all other deposits, is $18,326.43. If you have any questions regarding your annuity policy, please call your agent or one of our customer service representatives aI1.800-695-9873. Thank you for making New York Life The CompaNY You Keepall. Sincerely, Gb~ Service Center Vice President I I" I ~ Gl 0 "<0 ~ Wo "'... :Jo.oi l/)".... .~t-.._ lii"':l;'" !:t,(:ll~ ~~('l~ ~ g"'Ill 8-~~ ~ ...i!'...._ ~ ~F a J~ ~ ] - - . ~ .$! forth ~ :::: u c: ~ ~ ~"~H .;. >z ~""t~ uu' i '" irliJi ~ g '" ~ ~>;:l..J~ is ! II) III 0 .... ~ .... '- .. ~~if ::s &: .!t-i~ 0 < 0 ~@~~ s'~ " ll~ "'Z z'" -~a.!'l sJ ~ l2'''' ::li - ~~ ClOlll~ f~ " z~ .i'j 1'" 6(f)~W ~ iJ .... - ~Ill ::li 1/1. .1 ~ "e- o ~"".5 . . !~ "'GlU" ~ fisIJ . 38 c J~i" . ,JJ... 'ii2 I . . ;tJ!i c c eEB a . B~I~ .. a t= 1 .. 8 88 0 .!!tIII'5.E ~ c " 0 ~HI ~ lit 5151 ~ ~ 0 ,gllh of mm .... .. .. ~h.. '" =' li siLl) ~ =' ... ~ c N .sl_ " ;; ~ =i11 II .... " fO) .... ..15e II ! l;jlj ~ ... 8 88 8 ~Ir c CIoI 0 ~~ ~ &Jii.!l c ~ f c ... .El~j! " ~ ~.ri ..r liEf.! " 8 .. u. ~E c CIoI .w. ~ " ~ ... 3!jj< I U) f151: I !i :.1 .. 0 N .... '" ::J r<- =' 0 0 it! ~ =' .. ~ ~ ~ '" c( .. N " r 0 .. 0: ~ :;r ... !ul .. ~ W m III '" .... m c( c ::li % .... 0 J! ... :::J :Ii z '" I 0 CIoI :::J 0 ~ ~ Z c ~ Z 0 ;; Ii: 0 l:J ~ ., Q. :. tl :::J z 5;;( ~ :J: t;; ~ 0 0 ~.... - z i2 lNnooov ,vnOIA ION I ~ z ~ o o o c October 1, 2001 - December 31, 2001 ~ Quick & Reilly 1000 MARKET ST. SUITE 118 PHILADELPHIA, PA 19103 TEL: (215)568-6770 (800)523-1412 (NATIONWIDE) PAG~20F 2 ACCOUNT NUM8ER 2~079-10 P8 168 A FleetBoston Financial Company JOHN G MIHALKA ~ FSI'S NET CAPITAL AT 8-31-01 WAS $753 MIWON, EXCEEDING REQUIREMENTS BY $710 MIWON. FSI'S BALANCE SHEET MAY BE OSTAINED BY ACCESSING WWW.USCUEARING.OOM, OR BY CALUNG FSI'S TOLL-FREE NUMBER AT 1-87Hl20-4088. AT 10-31-01, FSI'S NET CAPITAL WAS $743 MIWON, EXCEEDING REQUIREMENTS BY $705 MIWON. ...J C ~ Q .... POJ.HFOLlO 5UI'.1I.IARY _IOV ...."'" _0 UltMOInN'l UT......UAL. ,. Of lOTAL DUCI'''ID'' C~IP nPE 0......... ..... ...... M.UlVIWII: .- ,_- I'OIlIFIIUO EQUITII!I IO'TIONI GUDBAL CROSSING LTC GX C 1,000 $0.84 $840 $1,270 -34% 100.000% T_ Equltl.. $140 100.0Cl0% TOTN.. PRIC!D .....,MAJO SMO > Q Z 010 OUSUS ZIP 2 02 200 01/02/02:07:23 10 025855 0013450 173 MemberslST FEDERAL CREDIT UNION INSURANCE DEPARTMENT 5000 Louise Drive P. O. Box 40 Mechanicsburg, PA 17055 1-800.283-2328 or (717) 697.1161 July 2, 2002 Samuel L. Andes 525 N. Twelfth Street PO Box 168 Lemoyne, PA 17043 RE: Estate of John G. Mihalka SSIN 341-12-3100 Dear Mr. Andes, Enclosed is the information requested in your letter of June 24, 2002 regarding the accounts held with Members 1st by John Mihalka. Please do not hesitate to contact me at 795-5131 should you have any questions or require additional information. fj;;y Denise A. Anders Insurance Products Supervisor Enclosure MemberslSl FEDERAL CREDIT UNION INSURANCE DEPARTMENT 5000 Louise Drive P. O. Box 40 Mechanicsburg, PA 17055 1-800-283-2328 or (717) 697-1161 REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846-00 03/04/1974 $1,885.02 $.09 $1,885.11 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 02120/1976 LIFE SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 -04 02101/2001" $4,000.00 $.19 $4,000.19 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 02101/2001 CHECKING ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846-11 01/14/1983 $2,068.33 $.00 $2,068.33 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 01/14/1983 INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 -05 10/01/1985 $76,288.06 $5.16 $76,293.22 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 10/01/1985 Page 1 JOHN G. MIHALKA SSIN 341-12-3100 IRA SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Beneficiaries 15846 -10 01/04/1982 $13,967.00 $.80 $13.967.80 Michael 0 Mihaika. Kenneth M Mihalka. Julia E Mihalka - equal shares CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15846 -44 1 YR 05/19/1995 $14,638.62 $2.06 $14,640.68 05/17/2003 None CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15846-45 1 YR 05/19/1995 $14,638.62 $2.06 $14,640.68 05/17/2002 Michael 0 Mihalka 05/19/1995 15846 -46 1 YR 15846 -47 1 YR 05/19/1995 05/19/1995 $14,638.62 $14,638.62 $2.06 $2.06 $14,640.68 $14,640.68 05/17/2002 05/1712003 Kenneth M Mihalka Julia E Mihalka 05/19/1995 05/19/1995 CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15486 -48 26 WK 06111/1996 $17.562.78 $1.05 $17.563.83 12/03/2002 Julia E Mihalka 06/11/1996 Page 2 15846 -49 26 WK 06/11/1996 $17.562.78 $1.05 $17,563.83 12/03/2002 None JOHN G. MIHALKA SSIN 341-12-3100 CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15486 -50 26 WK 06/11/1996 $17,562.78 $1.05 $17,563.83 06104/2002 Kenneth M Mihalka 06111/1996 15846 -51 26 WK 06/11/1996 $17,562.78 $1.05 $17,563.83 06104/2002 Michael D Mihalka 06/11/1996 ..Life Savings Account, 15486-04, opened w~h transfer of funds from 15486-00 DIT UNION D ise A. Anders Insurance Products Supervisor July 2, 2002 Estate of: JOHN G. MIHALKA Date of Death: 04102/2002 Social Security Number: 341-12-3100 1lFII.1S:SEX~IWllI . COMMONWEALTIi Of PENNSYLVANIA INHERITANCE TAl( RETURN RESIDENT DECEDENT ESTATE OF John G. Mihalka SCHEDULE F JOINTL Y.OWNED PROPERTY K an asset was made joint within one yoar 01 the decedent's date 01 death, ft mutt be reported on Schedule G. SURVIVING JOINT TENANT(S} NAME A. Julie E. Mlhalka B. Michael D. Mihalka c. Kenneth Mihalka JOINTLY-QWNEO PROPERTY: AOORESS 3601 March Drive, Camp Hill, PA 17011 CMR 409 Box 570 APO AE 09053 5907 North Mattox, Kansas City. MO 64151 FILE NUMBER 21-02-0490 RELATIONSHIP TO DECED! Daughter Son Son LETTER DATE DESCRIPTION OF PRCFERTY %OF DATE OF DEAl ITEM FOR JOINT ...DE Include n<lTie of financial instiluOOo and bank account number or 5imilcr identl1)lfng nurnbef, AIta::h DATEOFQEATf{ DECO'S VALI.'EOF NUMB€R TENANT JOlNT deed for iOintly-hekl rea estate. VALUE OF A.SSET INTEREST DECEDENT'S ME 1. A. 2/97 Savings Account No. 1802134578 with Waypoint $3,634.70 50% $1,B17.35 Bank (see statement attached) 2. A,B,C 2/20/ Regular savings account No. 15846-00 with Members $1,885.11 25% $471.28 1976 First Federal Credit Union (see statement attached) 3. A,B,C 2/1/ Life savings account No. 15846-04 with Members $4,000.19 25% $1,000.05 2001 First Federal Credit Union (see statement attached) 25% $517.08 4. A,B,C 1/14/ Checking Account No. 15846-11 with Members First $2,068.33 1983 Federal Credit Union (see statement attached) 5. A,B,C 1011/ Investment savings account No. 15846-05 with $76,293.22 25% $19,073.30 1985 Members First Federal Credit Union (see statement attached) $7,320.34 $14,640.68 50% 6. B 5/19/ Certificate of Deposit No. 15846-45 with Members 1995 First Federal Credit Union (see statement attached) $17,563.83 50% $8,781.91 7. B 6/11/ Certificate of Deposit No. 15846-51 with Members 1996 First Federal Credit Union (see statement attached) $14,646.68 50% $7,323.34 8. C 5/19/ Certificate of Deposit No. 15846-46 with Members 1995 First Federal Credit Union (see statement attached) 9. C 6/11/ Certificate of Deposit No. 15846-50 with Members $17,563.83 50% $8,781.91 1996 First Federal Credit Union (see statement attached) TOTAL (Also enter on line 6, Recapitulation) $ continued on next shee (If more SDaCe is needed, insert additional sheets of the same size) RE'IMDEX.(I.a1) *' SCHEDULE F JOINTL Y.OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERJTANCE TAlI RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER John G. Mihalka 21-02-0490 Wan asset was made joint within one year.I the de<:edent.s date.I death, n II1tIlII be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDI A. B. c. JOINTLY -OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %0' DATE OF DEAl ITEM FOR JOINT MADE Include name of financial institution and ba'lk account number or similar idenllfylng numbet. AIla:h OA TE OF DEATH DECO'S VAlUE OF NlMlER TENANT JOINT _1orj<jnJly"'~reaI_. VAlUE OF ASSET INTEREST DECEDENT'S ME 1. A. Continued: 10. A 5/19/ Certificate of Deposit No. 15846-47 with Members $14,640.68 50% $7,320.34 1995 First Federal Credit Union (see statement attached) 11. A 6/11/ Certificate of Deposit No. 15486-48 with Members $17,563.83 50% $8,781.91 1996 First Federal Credit Union (see statement attached) TOTAL (Also enter 011 line 6, Recapitulation) $ 71,188.81 (If more space is needed. insert additional sheels of the same size) VI Way Rqi!lt LOOK FOR U5. WE'LL GET YOU THERE. 6/26/02 SAMUEL LANDES 525 N TWELFTH ST PO BOX 168 LEMOYNE PA 17043 The information which you requested on the account(s) of JOHN MIHALKA (Social Security Number 341123100 ) is/are as follows: Account Number Class of Account Date Opened Principal Balance Accrued Interest Balance at Date of Death Account Ownership JOINT Name of Joint JULIA E Owner, if any MllIALKA Date Ownership 020497 Was Established 1802134578 SAVINGS 020497 3634.33 .37 3634.70 Account Number Class of Account Date Opened Principal Balance Accrued Interest Balance at Date of Death Account Ownership Name of Joint Owner, if any Date Ownership Was Established Additional Information Requested W-9 PENDING Sincerely, .--:;-) / h~:-"" -<-11~t:- . Ginger Rock Operations Associate II P.O. Box 1711, HARRISBURG, PENNSYLVANIA 17105-1711 Toll Free 1-866-WAYPOINT (1-866-929-7646) . www.waypointbank.com MembersIST FEDERAL CREDIT UNION INSURANCE DEPARTMENT 5000 Louise Drive P. O. Box 40 Mechanicsburg, PA 17055 1-800-283-2328 or (717) 697-1161 July 2, 2002 Samuel L. Andes 525 N. Twelfth Street PO Box 168 Lemoyne, PA 17043 RE: Estate of John G. Mihalka SSIN 341-12-3100 Dear Mr. Andes. Enclosed is the information requested in your letter of June 24, 2002 regarding the accounts held with Members 1st by John Mihalka. Please do not hesitate to contact me at 795-5131 should you have any questions or require additional information. M tr~IY youfJ-Y'/ ,Li~@<' -z:t:5T Denise A. Anders Insurance Products Supervisor Enclosure MemberslSl FEDERAL CREDIT UNION INSURANCE DEPARTMENT 5000 Louise Drive P. O. Box 40 Mechanicsburg, PA 17055 1-800-283-2328 or (717) 697-1161 REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 -00 03104/1974 $1,885.02 $.09 $1,885.11 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 02120/1 976 LIFE SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner 15846 -04 02101/2001*' $4,000.00 $.19 $4,000.19 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 02101/2001 Date Joint Ownership Created CHECKING ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued I nterest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 -11 01/14/1983 $2,068.33 $.00 $2,068.33 Michael D Mihalka. Kenneth M Mihalka, Julia E Mihalka 01/14/1983 INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 -05 10/01/1985 $76,288.06 $5.16 $76,293.22 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 10/01/1985 Page 1 JOHN G. MIHALKA SSIN 341-12-3100 IRA SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Beneficiaries 15846 -10 01/04/1982 $13,967.00 $.80 $13,967.80 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka - equal shares CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15846 -44 1 YR 05/19/1995 $14,638.62 $2.06 $14,640.68 05/17/2003 None CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15846 -45 1 VR 05/19/1995 $14,638.62 $2.06 $14,640.68 05/17/2002 Michael D Mihalka 05/19/1995 15846-461 VR 15846-471 VR 05119/1995 05/19/1995 $14,638.62 $14,638.62 $2.06 $2.06 $14,640.68 $14,640.68 05/1712002 05/17/2003 Kenneth M Mihalka Julia E Mihalka 05/19/1995 05/19/1995 CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15486-4826WK 06111/1996 $17.562.78 $1.05 $17,563.83 12/03/2002 Julia E Mihalka 06/11/1996 Page 2 15846 -49 26 WK 06/11/1996 $17,562.78 $1.05 $17,563.83 12/03/2002 None JOHN G. MIHALKA SSIN 341-12-3100 CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15486 -50 26 WK 0611111996 $17,562.78 $1.05 $17,563.83 06/04/2002 Kenneth M Mihalka 06/11/1996 15846 -51 26 WK 06/11/1996 $17,562.78 $1.05 $17,563.83 06/04/2002 Michael 0 Mihalka 06/11/1996 --Life Savings Account, 15486-04, opened with transfer of funds from 15486-00 MilBERS 1 ST FED ~e A. Anders Insurance Products Supervisor DIT UNION July 2, 2002 Estate of: JOHN G. MIHALKA Date of Death: 04102/2002 Social Security Number: 341-12-3100 "Re'H51OEX-(j,911 '* SCHEDULE G INTER.vIVOS TRANSFERS & MISC, NON.PROBATE PROPERTY COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER John G. Mihalka 21-02-0490 Tho; schellule must be oompletad and filed if Ihe answer to any of questions 1thmugh 4 on the ",""".>slde of the REV.15OC COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM lHCllJOE T.'lE tWlE OF THE TRANSfEREE, THElRRaJ,llONSHWTOOECEOEtH Io.HO THE ~re 0" rPAASFER DATE OF DEATH OECO'S EXCLUSI~~ TAXABLE W AT1'ACHACOPYQFlHEDEfDFQRREAlESTATE NUMBER VALUE OF ASSET INTEREST ,IF"""lICABlE 1. Individual retirement account No. 15846-10 with Members $13,967.80 100% N/A $13,967.80 First Federal Credit Union(see statement attached) 2. Savings Account held in name of Decedent as trustee for his children, being Account No. 1916680 with Great Lakes $4,127.35 100% N/A $4,127.35 Federal Credit Union NOTE: These funds were held in a revocabie "Totten" trust as demonstrated by the Declaration of Trust attached hereto. 3. Certificate of Deposit No. 1916680 with Great Lakes Federal Credit Union which the Decedent held, as trustee, $14,597.23 100% N/A $14,597.23 in trust, for his three children NOTE: These funds were held in a revocable "Totten" trust as demonstrated by the Declaration of Trust attached hereto. TOTAL (Also enter on line 7, Recapitulation) $ $32,692.38 (W more space is needed, insert additional sheets of the same size) MemberslST FEDERAL CREDIT UNION INSURANCE DEPARTMENT 5000 Louise Drive P. O. Box 40 Mechanicsburg, PA 17055 1-800-283-2328 or (717) 697-1161 July 2, 2002 Samuel L. Andes 525 N. Twelfth Street PO Box 168 Lemoyne, PA 17043 RE: Estate of John G. Mihalka SSIN 341-12-3100 Dear Mr. Andes, Enclosed is the information requested in your letter of June 24, 2002 regarding the accounts held with Members 1 sl by John Mihalka. Please do not hesitate to contact me at 795-5131 should you have any questions or require additional information. n;y Denise A. Anders Insurance Products Supervisor Enclosure MemberslST FEDERAL CREDIT UNION INSURANCE DEPARTMENT 5000 Louise Drive P. O. Box 40 Mechanicsburg, PA 17055 1-800-283-2328 or (717) 697-1161 REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 -00 03/04/1974 $1,885.02 $.09 $1 ,885.11 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 02/20/1976 LIFE SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 -04 02/01/2001** $4,000.00 $.19 $4,000.19 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 02/01/2001 CHECKING ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 -11 01/14/1983 $2,068.33 $.00 $2,068.33 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 01/14/1983 INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Created 15846 --os 1 0/01/1985 $76,288.06 $5.16 $76,293.22 Michael D Mihalka, Kenneth M Mihalka, Julia E Mihalka 10/01/1985 Page 1 JOHN G. MIHALKA SSIN 341-12-3100 IRA SAVINGS ACCOUNT: Account Number/Suffix Date Account Opened Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Beneficiaries 15846 -10 01/04/1982 $13.967.00 $.80 $13.967.80 Michael D Mihalka. Kenneth M Mihalka. Julia E Mihalka - equal shares CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15846 -44 1 YR 05119/1995 $14.638.62 $2.06 $14,640.68 05/1712003 None CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15846 -45 1 YR 05/19/1995 $14.638.62 $2.06 $14,640.68 05/17/2002 Michaei D Mihalka 05/19/1995 15846 -46 1 YR 15846 -47 1 YR 05/19/1995 05/19/1995 $14,638.62 $14.638.62 $2.06 $2.06 $14.640.68 $14,640.68 05/17/2002 05/17/2003 Kenneth M Mihaika Julia E Mihalka 05119/1995 05/19/1995 CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Totai Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15486 -48 26 WK 06111/1996 $17.562.78 $1.05 $17.563.83 12/03/2002 Julia E Mihalka 06/11/1996 Page 2 15846 -49 26 WK 06/11/1996 $17.562.78 $1.05 $17,563.83 12/03/2002 None JOHN G. MIHALKA SSIN 341-12-3100 CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Certificate Purchased Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Maturity Date Name of Joint Owner Date Joint Ownership Created 15486 -50 26 WK 06/11/1996 $17,562.78 $1.05 $17,563.83 06104/2002 Kenneth M Mihalka 06/11/1996 15846 -51 26 WK 06/11/1996 $17,562.78 $1.05 $17,563.83 06/04/2002 Michael D Mihalka 06111/1996 "Ufe Savings Account, 15486-04, opened with transfer of funds from 15486-00 D ise A. Anders Insurance Products Supervisor July 2, 2002 Estate of: JOHN G. MIHALKA Date of Death: 04102/2002 Socia' Security Number: 341-12-3100 June 28, 2002 Samuel L. Andes Attorney at Law 525 N. Twelfth St. P. O. Box Lernoyne, PA 17043 RE: Estate of John G. Miha1ka Date of Death: 2 Apri12002 Dear Mr. Andes: In response to your letter dated June 24, 2002, shown below is the status of the accounts held by John G. Mihalka on Apri12, 2002. Beneficiaries of the trust were Julie Mihalka, Kenneth Mihalka, and Michael Mihalka to be distributed in equal portions. Account # 1916680 Account Type Savings Open Date 4/5/63 Ownership John G. Mihalka, Trustee* John G. Mihalka, Trustee* Account Value $4127.35 1916680 Certificate of Deposit $14,597.23 If you have any questions, 1 can be reached at 1-847-574-1146 or 1-888-833-2185, extension 1146. Very truly yours, l/ . It" . { ! / i~, { , Il A0 Dawn E. Denman Compliance Technician ded _ 2525 Green Say Road _ (847) 578-7000 - (800) 982-7850 - WWw.glcu.org North Chicago. IL 60064 _ Dawn E. Denman Compliance Technician Ph. 847/574-1146 Fax 847/574-1144 November 18,2002 Samuel L. Andes Attorney at Law 525 North Twelfth St. P. O. Box 168 Lemoyne, P A 17043 RE: Account Number 1916680 John G. Mihalka, deceased Dear Mr. Andes: In reply to your letter dated November 14, 2002, I have enclosed a copy of the trust agreement for Mr. Mihalka's account. The account was held in John G. Mihalka's name as a totten trust for Julie Mihalka, Kenneth Mihalka and Michael Mihalka with funds divided equally upon his death. If you have any questions, I can be reached at 1-847- 574-1146 or 1-888-833-2185, extension 1146. Very truly yours, ilJl!t~-::J Dawn E. Derunan Compliance Technician Enclosure cc: Julie Mihalka 3601 March Dr. Camp Hill, PA 17011 2525 G _ reen Bay Road . (847) 578-7000 . (800) 982-7850 - WWw.glcu.org North Chicago, IL 60064 _ . ~ , , By this Oeclaretion of Trust dated ,:r .4 AJ 1'1 19 QO and known as Trust No. 19 I f..~ Y() the undersigned hereby declere that tho shares in the Great Lakes Credit Union issued in the name of the undersigned, as trustee under this trust, including all additions hereafter made or accumulations resulting therefrom is held in trust by the undersigned in accordance with the terms hereof for the following beneficiary (or beneficiaries, as tenants in common), who shall have an interest in all sums in said account in the proportion set opposite each beneficiary's name: B~ary'a ~!"o lh Proportlonato Interost . Birth Oato Relati.onshlP to :- ~/l~~~1 1~;1 ~11~\1' ~i~~~r The terms and conditions under which the undersigned h~d said share Iccount Ire as follows: 1. All ..mlngs thereon shall be added to the shares in said account and become and remain 8 part of this trust, subject to the terms hereof, unless the undersigned, IS trUltM, .h.1I direct that same be paid to anyone or more of the undersigned for his own personal account and use. 2. Upon compliance with, and Subject to, the bylaws of the Credit Union, the undersigned, liS trustee, shall have the right to vote, to sign IInd execute proxies with rt.pect to the shares comprising said account (if allowad by applicable lawl, to make payments upon, withdraw, pledge. and otherwise deal with said account and the .hlre. thereof IS fully as though owned absolutely by the undersigned. However, upon any such withdrawal from said account by the undersigned. 8$ trustee, the trust hereby declared shall be revoked as to the amount of the share account so withdrawn and the undersigned shall retain the proceeds of such withdrawal for hislher own personal account and use. Except as prOvided with regard to distribution upon the death of the undersigned, to the designated beneficiaries who are living and so designated .. of the date of death of the undersigned, the beneficiaries shall have no right in, or access to, the principal or earnings in this account. 3. The undersigned has the right at any time to change the beneficiary or beneficiaries or their respective proportionate interests or in IIny manner to amend this trust, but It is understood that no such change or amendment shall be effective as to the Credit Union unless and until written notice thereof in such form as the Credit Union ahall designate I, delivered to the Credit Union. 4. The death of any beneficiary before the death of the undersigned shall operate as a revocation of the interest of that beneficiary in this trust and the interest of luch decelled beneficiary shall vest in the undersigned individually. The death of all the beneficiaries of this trust before the death of the undersigned shall operate as a complete ravoc.tlon of this trust. 5. Upon the death of the undersigned the surviving beneficiaries shall become entitled to their proportionate interest in all sums in said account as provided by this Agreement or any .mendment thereof as herein authorized. "any beneficiary Is a minor at the time of payment, the Credit Union may deliver the share to which any such minor beneficiary Is entitled to such minor beneficiary or to the guardian of auch minor beneficiary or to the person or persons standing in loco parentis to such minor beneficiary. 6. The Credit Union shall not be liable for the validity or existence of any trust hereby created or for any payment or other consideration made or given by the Credit Union to the undelSigned, as trustee Or otherwise, in connection with said account. The payment or delivery to the undersigned, as trustee or otherwise, or, in the event of the death of the undersigned, to the parties entitled hereto in their respective interests or any receipt or aQuittance signed by any such parties for any such payment or delivery shall be a valid and sufficient release and discharge of the Credit Union. 7. The Credit Union or any person dealing with the undersigned, as trustee, shall not be required to see to the application of any moneys paid or to question the propriety of anv act of the undersigned as trustee hereunder. 8. It Is expressly understood and agreed that the terms used herein and rights of the undersigned, as trustee or otherwise, and of the beneficiaries hereunder shallet all times be construed and determined in accordance with the laws of the Stete of Illinois and the by-laws of the Great Lakes Credit Union. , ". "._."1:;:"'~.i:: OO~, DECLARATION OF TRUST - Revocable Individual This application approved by (check one) C Board Date: 01- /9- 66 ;< ~o...~~'~-. Trustee (Seal) SHARE ACCOUNT TRUST AGREEMENT - INDIVIDUAL TRUST ACCOUNT NO. J q I to!o 9. 0 . TRUSTEE'S NAM~.JO~ ~ t;. WI I /-1 J4c U< 14. The undersigned, as Trustee under the provisions of the declaration of trust appearing on the reverse side hereof, hereby applies for membership and the Issuance of shares in the Great Lakes Credit Union in accordance with and subject to all provisions of its bytaws nevi or hereafter in force. The undersigned agrees to subscribe for at least one share and that said share account. including all additions hereafter made or accumulations thereon shall be held in the undersigned's name 8S trustee, under the provisions of said declaration of trust, and that the share and any document issued to evidence said account shall be issued to the undersigned's name as trustee. All sums in said account may be paid or delivered in whole or in part to, or other rights relating thereto may be exercised by the undersigned without regard to any notice to the contrary. Payment or delivery to, or a receipt signed by, the undersigned shall be valid and sufficient release and discharge of the Credlt Union for the payment or delivery made. If no written notice of revocation or termination of said trust shall have been given to the Credit Union. then upon death of the undersigned all sums in such account, or other rights relating thereto, may, at the option of the Credit Union, be paid or delivered. in whole or in part, pursuant to the provisions of the declaration of trust. Payment or delivery to, or a receipt or acquittance Signed by. those entjtled thereto under the provisions of the declaration of trust ::~E~e veli~;d :U;iCi:n~:le:::;:harge of the Credn Union for the pay@ OFde~. ?h. '.d/~ as Trustee Addre.. C;,"'3 L( (') {)X FoP:>::' C (f2 c LIE Telephone No. City 1Vlt::' t'" fJ A AJ I (' S.f,Uf?tZ,.. State Pt4 Zip Code 170<<; Social Security No ,31./:1- 1;;L- ,oz./oo ~DeteofBirth O~/nl/,;z.;;L CERTIFICATION: Under penalties of perjury, I certify 111 th.t the number shown on this form is my correct taxpayer identification number and (21 that I am not subject to backup withholding either because I have not been notified that I am subject to backUP withholding as a result of . failure to report all interest or dividends, or the lnternal Revenue Serv;ee has. notified me that , ~m no longer subject to backup withholding. Signat c;-. /;vJ'~.z..... InstrUction: If you have been notified that you are subject to backUp withholding due to failure to report all i erest and dividends and you have not been advised bv the Intem.t Revenue Service that backup withholding has terminated, you must strike out the language in number -2- above. SHARES ARE NOT TRANSFERABLE EXCEPT AS AUTHORIZED BY THE GREAT lAKES CREDIT UNION, REV-1511 EX+ (12-99) ,,~,:1t..tK .~~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF John G. Mihalka FILE NUMBER 21-02-0490 Debts of decedent must be reported on Schedule L ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION AMOUNT I. Malpezzi Funeral Home, Mechanicsburg, PA (funeral services) Kristan Funeral Home, Mundelein, IL (burial services) $6,209.35 $1,611.09 , B. ADMINISTRATIVE COSTS: I. Personal Representative's Commissions Name of Personal Representative(s) N/A Social Security Number(sVEIN Number of Personal Aepresentatille(s} Street Address City__ n .... ~__ Slate __ Zip Year(s) Commission Pajl:t 2. Attorney Fees Samuel L. Andes $15,000.00 3. Family Exemption: (If decedent's address is nol the same as claimant's, attach explanalion) Claimant N/A Street P.ddress Cily ~----- -.--- --- Slale _n_ ..._ Zip Relationship of Claimanl to Decedenl 4. Probate Fees Register of Wills $352.00 5. Accountant's fees 6. Tax Relurn Preparer's Fees 7. The Sentinel (advertising) $80.87 Cumberland Law Journal (advertising) $75.00 Frank R. Baker (stock appraiser) $150.00 -- TOTAL (Also enter on line 9, Recapitulalion) $23,478.31 (If more space is needed, insert additional sheets of the same size) . . -~. .. . . Malpezzi Funeral Home 8 Market P1aza Way Mechanicsburg, PA 17055 (717)697-4696 May 20, 2002 Julia E. Mihalka 3601 March Drive CampHill, PA l70ll The Funeral Service for John George MihaLka We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. TIfE FOLWWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING TIfE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Other I'leporatioo of Body. . . 2. FACILITIES AND SERVICES Funeral Ceremony. . . . . . 3. AUTOMOTIVE EQUIPMENT Hearse (Casket Coach) . . . Lead car/Clergy . . . . . . . Transportation to Dulle, Airport . . FUNERAL HOME SERVICE CHARGES SELECTED MERCHANDISE: Solid Oak Casket. . . . . Wood Bottom Air Tray. . . . Regi.Uer. Memorial Cards, Ac1m. . THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THATYOUHAVESELECTED . . . . . . . . . . . . . . $3945.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. TIfE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. C. SPECIAL CHARGES Foward remains . . . . CASH ADVANCES Newspaper Notice, . I.ocal . Airfare. . . . . ClergylMas' Offering. . . OrgaoOs~ . . . . . . CertiiieJ Copie~ of lhe Dcaih C~rtificai.e . TOTAL CASH ADVANCES AND SPECIAL CHARGES . CONTRACT PRICE . . . . . . . . . . . . HISTORY 05120/2002 Cumb. Co. V A Allowance. TOTAL AMOUNT DUE . $125.00 $425.00 $285.00 $115.00 $125.00 $1075.00 $2690.00 $135.00 $45.00 $1745.00 $75.60 $318.75 $100.00 $75.00 $50.00 $2364.35 $6309.35 ~HOO.oo .. f~ :ii'! . \ I . lifo.. {.Y-, ~ OK(OI A. CHARGE FOR SERVICES SELECTED B. CHARGE FOR MERCHANlDSE SELECTED 1. Professional ServIces Professional Servl~s of Funeral Oireclor and Ef11balmfng Other Preparalion of Body 2. Faclllt.... and Equipment & Stoff Use of Facilities & Staff for Ylewt~sllation Usa of Facilities ~ ~taff for.Funeral Ceremony Use of Facilities & Staff for Memorial Se<vioe - ". - - - - .. - - - - Use of Equipment & Staff for Gravaside Use of Equipment & Staff for Churclt SefVice 3. Transportation Transfer of Remains to Funeral Home Hearse limOUSine Sedan --_._--- S~celUtill!y V~hicle 4. other Servlc;ea/FaclllUaalEqulpmant TOTAL OF SERVICES SELECTED (A) . _ . . TOTAL OF MERCHANDISE SELECTED (8) , Kristan Funeral Home P.C. 219 W. Maple Ave. Mundelein. IL 60060- PHONE: (847)566-8020 DECEASED John G. Mihalka DATE OF DEATH April 02, 2002 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED NO. 02-037 DATE OF STATEMENT April 02,2002 Chatrles are only for fhose neros that are you selected or that .ff> required. If we are required by law or by a cemetery or crematory /0 use any items, we wm explain reasons ;n writing below. C. SPECIAL CHARGES forwan:llng remains to Forwarding of Remains to: Receiving remains from Receiving of Remains From: Immed!a~buria! Direct aemaUon -- -.." TOTAL OF SPECIAL CHARGES (Cl _ D. CASH ADVANCES Certified Copies of Death Certificate 1 @$ 0.00 each DISCLOSURES " )'01/ saIected II' hNleral w1lic:tt rwqtMu ~ sudl a, a ti.Q! WIth l'fwwing, )OtI may he.... to De)' !bf emQlWmmg. You do not haw kJ( ~g )IOU dkJ nof appl'OVe " }lOll SIltected arrsnpmefJ such as a Oifffi cro!mation Of JtT1Il't$d'Iare t>.Jllaf. (f W!t ch~ f ~. _IW.I explain wtlybelow. RttaIDflb'embahnIhg essket (or other receptacle) . NsrneINo. Maleriel Color Outer Burial Container 975.00 NamalNo. MontioelQ Burial Vault Material Act<nowIedgement canis Ragister book Memory FoIders/Pra,.... Cenls CremaUoo Urn Clothing Cruclllll- s If 4My n, csmtJt<<y OF a1Im.tfDry teQUhments _ve rwqwed thf1 oo.ueof ,ny fflfm.tJl8d, U-/WNor ~ Is~bekwt. Burial Vault Clergy 100.00 ACKNOWlEDGEMENT AND AGREEMENT I lwe) .utl'loiUe ItIi$ tunlDl homIlO PIfftNm 3lINce5,. furnish QOOds. ina.Ir~ c:hafges 8f)tCifi.o'Q(t tNs~. I (we) ~ t !We) ~ a General flrioe list, . Catllet Prle. UIt and an Outflf 8 ComalrlerPl1cltUIIl TERMS; . $1 Musldan Beacon News Newspaper NoUoes Herald News~Sun 111.00 82.50 96.90 FlJI pil)lmenl is due no -..lha't May 02. 2002 If any payment IS not paid \IIr'tlerl Olie,8l"l ~.. LAI~ U1ARU 0.00 """""""" (AHIIUAL PERCENTAGE RAn; 0.00 Cemetary Vautt Setting Fee 175.00 TOTAL OF CASH ADVANCES (0) $ 565.40 We charge you for our services in lll>laining (specify casn . advanoe items:) on the unpaid balance .... be due. I lWII} have IUc:l (or been read) ~~~~~'.:s'\r'~~~to ...".. ON hLl". SocIal Seeunty No. ........ 3601 Marsh Or. "" Cemp Hill ZJp 17011 Co-Slgned Co-SignoO ACe""" SUMMARY Total Funeral Home Cherges (A+B+C) SBles Tax, i' applicable Total Cssh Advances (D) COMPLETE TOTAL PAYMENT RECEIVED FROM s.. PA T_ (7'7)783-7831 s s s s 975.00 70.69 565.40 1611.09 51 975.00 I BALANCE DUE .~ .:i.:-;~ . .....~ t-'. . _ -~-~~ -,,~:; 5 5 5 ... . I . R(V.1511EJl.!1,~7j . 'ISh '..& COM~.10iNr'F..l,l TH OF ?ENNSYlVAt,,::\ INHfRlTt.NC~ TAX RETur{:~ RES1DPlT DECEDENT ESTATE OF John G. Mihalka SCHEDULE I DEBTS OF DECEDENT, MORTGAGEJIABILlTIES, & LIENS I FILE NUMBER 21-02-0490 Include un reimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 2. UGI - decedent's gas utility bills $101.32 $170.00 $971.83 , Verizon - decedent's telephone bills 3. Oxford Manor Apartments - final rent, apartment cleanout, and related expenses to landlord 8. SpaceMart Storage Center - moving and storage of decedent's tangible personal property $60.00 $25.00 $103.04 $100.00 $1,055.00 4. AT&T - decedent's long distance telephone bill 5. Comeast - decedent's eable bill 6. State Farm - final payment on renter's insurance 7. William Beck - fee to prepare tax return TOTAL (Also enter on 1:i1€ 10, Recap'\J1aton) (if more spaCE ::; needed. insert addltiona! sheets of (he samE: size) S 2,586.19 ... . . ... REV-1513 EX+ (9-00) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF John G. Mihalka NUMBER 1 1. 1. 2. 3. 4. 5. 6. 7. 8. 9. RELATIONSHIP TO DECEDENT NAME AND ADDRESS OF PERSON(SI RECEIVING PROPERTY 00 Not UstTrustee{s) TAXABLE DISTRIBUTIONS [include outright spousal distributions, and trans1ers under Sec. 91161a) (1.2)) Julie E. Mihalka, 3601 March Drive, Camp Hill, PA 17011 Wolf Mihalka, CMR 409 Box 570, APO AE 09053 Shayne Mihalka, 5907 North Mattox, Kansas City, MO 84151 Michael D. Mihalka, CMR 409 Box 570, APO AE 09053 Nicole Mihalka, 7104 Frankling AVe. #18, Los Angeles,CA 90046 Kristen Mihalka, 3015 Charlotte Street, Newbury Park, CA 91320 Kenneth Mihalka, 5907 North Mattox, Kansas City, MO 84151 Nicolas Mihalka, 1917 Fairfield Road, Lindenhurst, IL 60046 Matthew Mihalka, 5907 North Mattox, Kansas City, MO 84151 L FILE NUMBER 21-02-0490 AMOUNT OR SHARE OF ESTATE daughter 28% grandson 4% granddaughter 4% son 24% granddaughter 4% I granddaughter 4% son 24% grandson 4% grandson 4% ENTER OOLLARAMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18. AS APPROPRIATE, ON REV.15oo COVER SHEET 11 NON. TAXABLE OISTRIBUTIONS, A. SPOUSAL DiSTRIBUTIONS UNOER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE ,. None B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TtOTAL OF PART 11- ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF AEY.1500 COYER SHEET S 0.00 /If more space is needed, insert additional sheets of the same size) /1-6.::;-= / \- BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z8D60l HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT} ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX SAMUEL LANDES 525 N 12TH ST LEMOYNE '03 CdATE " 'Jt::"loSTATE OF DATE OF DEATH F~kE NUMBER I\PR 28 P 3 ci\:illNTY ACN 04-21-2003 MIHALKA 04-02-2002 21 02-0490 CUMBERLAND 101 '* REV-1547EXAFPtDI-D3l JOHN G ;11 PA 17043 (;is'ft' CtnnbE:, :', FA Amount Rellitted 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'4TExuAf'i..-coFo:3rNii'ficniF-YNHERiTANcE-TAin-PPRA-iSEi.rENT~--ALi.-OWAircrifR-----------_m_- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MIHALKA JOHN G FILE NO. 21 02-0490 ACN 101 DATE 04-21-2003 TAX RETURN WAS: 1 X) ACCEPTED AS FILED ) CHANGED 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 CJ 4. Mortgages/Notes Receivable (Schedule OJ 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule f) 7. Transfers (Schedule GJ 8. Total Assets (1) (2) (3) (4) IS) (6) (7) .00 223,655.94 .00 .00 64,192.70 71.188.81 32,692.38 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens {Schedule Il 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 (9) (10) 23,478.31 2.586.19 Ill) (12) (13) (14) NOTE: To insure proper credit to your account} submit the upper portion of this form with your tax payment. 391,729.83 76 .064 ~o 365,665.33 .00 365,665.33 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: IS. 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 = .00 365,665.33 X 045 = 16,454.94 .00 X 12 = .00 .00 X 15 = .00 (19)= 16,454.94 . I" AMOUNT PAID DATE NUMBER INTEREST/PEN PAID 1-) 06-28-2002 CDOO1358 473.68 9,000.00 03-13-2003 CD002282 23.68- 7,004.94 BALANCE OF UNPAID INTEREST/PENALTY AS OF 03-14-2003 TOTAL TAX CREDIT 16,454.94 BALANCE OF TAX DUE .00 INTEREST AND PEN. 43.27 TOTAL DUE 43.27 . IF PAID AFTER DATE INDICATED} see REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. I IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) BUREAU OF INOIVIOUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG~ PA 17128-0601 SAMUEL LANDES 525 N 12TH ST LEMOYNE COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLDWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX R!-jcn'~)c;~.: DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN '03 MAY -8 mo :41 (;,211. PA 17~~b8' ." ~* REV.1541EXAFPIDl_DSl 04-21-2003 MIHALKA 04-02-2002 21 02-0490 CUMBERLAND 101 JOHN G Amount Remitted L.f3.d MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ 525 NORTH TWELFTH STREET P. O. BOX 168 LEMOYNE, PENNSYLVANIA 17043 i)-\' 0) tff () SAMUEL L. ANDES ATTORNEY AT LAW .-!:-.-, h". Register of Wills Cumberland County Court House Carlisle, PA 17013 i70i3+33S2 02 1,,,III,,,III,,,,,,II,,II,,,II,,,II,j,I,,,,I,II,I,,I,I,,,,II,1 nn_u_ fold COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: ANDES SAMUEL L ESQUIRE 525 N 12TH STREET LEMOYNE, PA 17043 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ESTATE INFORMATION: SSN: 341-12-3100 FILE NUMBER: 2102-0490 DECEDENT NAME: MIHALKA JOHN G DATE OF PAYMENT: 05/08/2003 POSTMARK DATE: 05/07/2003 COUNTY: CUMBERLAND DATE OF DEATH: 04/02/2002 ACN ASSESSMENT CONTROL NUMBER 101 TOTAL AMOUNT PAID: REMARKS: JULIA E MIHALKA C/O SAMUEL L ANDES ESQUIRE CHECK# 811 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS REV-1162 EX(' 1-96) NO. CD 002544 AMOUNT $43.27 $43.27 DONNA M. OTTO DEPUTY REGISTER OF WILLS Name of Decedent: Date of Death: Will No.: STATUS REPORT UNDER RULE 6.12 Admin. No.: Zooz - 0o o Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: State whether adm_~Ktistration of the estate is complete: Yes [~ No '~1~ 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: ao Did the personal representative file a final account with the Court? Yes _ No b. The separate Orphans' Court No. (ifauy) for the personal representative's account is: c. Did the personal representative state au account/_u.formally to the parties in interest? Yes I--] No I'"] Co 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 thi~~ Signature Name Address Telephone No. Capacity: [--] Personal Representative [~1 Counsel for personal representative /"7-0.":::-'1 '\ - - BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT hac" .~ f~l2 ~__;' ,~' DATE ESTATE OF DATE OF DEATH FILE NUMBER All :17 COUNTY ACN 05-19-2003 MIHALKA 04-02-2002 21 02-0490 CUMBERLAND 101 SAMUEL LANDES 525 N 12TH ST LEMOYNE '03 JUN-2 Amount Remitted PA 17t.'U'f ClImbb F~.'--\ MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 *' REV-IU1EXAFP (0I-05l JOHN G 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 ~ REY:ir.1WEx-AFP--coFo:3r-----iiio.-xNHERITANcrTAx-sTAYEME-NT-O-"-Ac-ciiiiNT-....ii--------------------- ESTATE OF MIHALKA JOHN G FILE NO.21 02-0490 ACN 101 DATE 05-19-2003 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED 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: 04-21-2003 PAYMENTS (TAX CREDITS): PRINCIPAL TAX DUE:, 16,454.94 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 06-28-2002 CDOO1358 473.68 9,000.00 03-13-2003 CD002282 23.68- 7,004.94 05-07-2003 COO02544 43.27- 43.27 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. I IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. J 16,454,94 .00 .00 .00 Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 3/03/2005 ANDES SAMUEL L 525 N 12TH ST LEMOYNE, PA 17043 RE: Estate of MIHALKA JOHN G File Number: 2002-00490 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS. COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 4/02/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~A-=::::~ REGISTER OF WILLS cc: File Personal Representative(s) Judge J Register of Wills of Cumberland County Date of Death: STATUS REPORT UNDER RULE 6.12 3 D~tJ' C;;, Ml ko. (~o. (.t p~\ \ L l 2-007- '1a:/L- fJo'1QO Name of Decedent: Estate 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 g No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: ,.4 A 3. If the answer to No. I is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes 0 No ~ b. The separate Orphans' Court No. (if any) for the personal representative's account is: ~/A . c. Did the personal representative state an account informally to the parties in interest? Yes ~ No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date:~ ~_...... '-''''''~1 a~~~~9 Si e vor 5 4r'^"^- €L- L A-rJoes Name 525 /V. (2.:~ ).Jyz.ed- Le 'IIC () ., tvC PA- /7 I) '0 , Address ~(7 7b(:5 36( Telephone No. Capacity: 0 Personal Representative J&1 Counsel for personal representative ~