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Home My WebLink About03-01-101505607121 REV-1500 Ex (~-os> OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number POBOx26osot INHERITANCE TAX RETURN 2 1 0 9 0 5 8 7 Hanislwrg, PA 17128.01301 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2 0 4 7 0 6 4 6 6 0 6 0 6 2 0 0 9 1 0 1 0 1 9 8 9 Decedent's Last Name Suffix Decedent's First Name MI Q u i g l e y J o n a t h a n R (N Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL INAPPROPRIATE OVALS BELOW ® 1. Original Retum ^ 4. Limited Estate ^ 8. Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^ 2. Supplemental Return ^ ^ 4a. Future Interest Compromise (date of ^ death after 12-12-82) ^ 7. Decedent Maintained a Living Trust (Attach Copy of Trusq ^ 10. Spousal Poverty Credit (date of death ^ between 12-31-91 and 1-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number T h e r e s a L S h a d e W i x 7 1 7 6 5 2 8 4 5 5 Firm Name (If Applicable) W i x W e n g e r & W e i d n e r First line of address 4 7 0 5 D u k e S t r e e t Second line of address City or Post Office H a r r i s b u r g State ZIP Code P A 1 7 1 0 9 S Correspondent's e-mail address: tl8vv2000t~aOl.com Under penalties of perjury, I declare that I harre examined this rehrm, including accompanying schedules and stalemeMs, and to the best of my knowledge and belief, it is bue, correct and complete. Ded~ratpn of preperer odler than the personal representatlve a based on all infomla8on of which preparer has any knowledge. TORE OF P S SIBLE ES~ SIG U E OF PRE AR OTHE ADD//RJJESS ~~ CC_ ^ vL ~ W 1~.1~~ S~~ is b ~cr~u . ~ ~ ~ ~ ~ R USE ORIGINAUFORM ONLY 1505607121 Side 1 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required 8. Total Number of Safe DeposR Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) REGIS OF WILLS ~ ONLY _ y a ~ ~r.? >- a `-`- - ' i c. ~ r.. y rz-~ ~ ~ _' ' O ~ ~ ~ -, ~i .._ ATE FILE'S `" t- N" Z~ t7 1505607121 v V J 1505607221 REV-1500 EX Decedents Name: Jonathan R• Q u i g l e y Decedent's Social Security Number 2 0 4 7 0 6 4 6 6 RECAPITULATION 1. ..................................... Real estate (Schedule A) ... 1 ~ • 2. Stocks and Bonds (Schedule B) ............................... ... 2• 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 4. Mortgages & Notes Receivable (Schedule D) ..................... ... 4. 3 2 5 1 2 1. 2 3 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) .... ... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6. 2 2 7 , 1 5 7. Inter-Vivos Transfers 8 Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested .... ... 7. 8. Total Gross Assets (total Lines 1-7) ....................... ... 8. 3 2 5 3 4 8. 3 8 9. Funeral Expenses & Administrative Costs (Schedule H) ............. ... 9. 1 2 9 6 0 • 1 5 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule 1) ......... ... 10. 1 t. Total Daductiorrs (total Lines 9& 10) ........................ ... 11. 1 2 9 6 0. 1 5 12. Net Value of Estate (Line 8 minus Line 11) ...................... ... 12. 3 1 2 3 8 8 . 2 3 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............... ... 13. 3 1 2 3 8 8 2 3 14. Net Valus Subject to Tax (Line 12 minus Line 13) ........... ..... .. 14. . TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 (a)(1.2)X.0 _ 15. . 16. Amount of Line 14 taxable 3 1 2 3 8 8 2 3 0. 0 0 at lineal rate x .D _ . 16. 17. Amount of Line 14 taxable 0 0 0 0 . 0 0 at sibling rate X .12 17. 18. Amount of Line 14 taxable 0 0 0 ~ ' ~ ~ at collateral rate X .15 ' 18. 19. Tax Due ................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505607221 1505607221 0. 0 0 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 O9 o5s7 DECEDENTS NAME Jonathan R. Quigley STREET ADDRESS - 11 Charles Way CITY STATE ZIP Mechanicsbur PA 17055 Tax Payments and Credits: ~ • lax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit (1) 0.00 B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 0.00 4. If Une 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) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. (5) 0.00 (5A) B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT ~ "_ ~G:d~{rg ario-.:- .~ .~'°. m~ ~ "~?'~ ..`:~*'"~IE$ir"~+e tt'~$~s"~§r~ ,,~~t¢,r~ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................... ^ c. retain a reversionary interest; or ................................................................................................ ^ d. receive the promise for I'rfe of either payments, benefits or care? ....................................................... ^ 2. If death occurred after December 12,1962, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ X^ 3. Did decedent own an 'in trust for' or payable upon death bank acceunt or security at his or her death? ......... ^ X^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a benefidary designation? .................................................................................................. ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. y ; u b g°':1ix ~3. v £ wC" -.-fit s° ~ k t.' a nra - ` , z ... ...~. .r... ew ..*x~ a a.~=,i7°*?S. xr.~r '-a ~}r. a _ ..:.. . ..... ... .. vr~ th eaa:- fir! 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 throe (3) percent (72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disdosure 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-0ne years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lined beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent (72 P.S. §9116(a)(1.3)]. Asibling 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-1508 EX + (g-98) r scHF,~v~E E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERRANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILI Jonathan R. Quii7ley 21 09 0587 Indude the of litlgation and the date the proceeds were received by the estate. AN properly ohrtlyownsd wNh right of furvlvonhip mlat be dkcbfed on ScMduN F. ITEM VALUE AT DATE NUMBER DESCRIPTION _ OF DEATH PNC Bank, 2 East Main St., Mechanicsburg, PA 17055 Checking Account #1025565264 (See Schedule E, Exhibit 1) Settlement from a Wrongful Death/Survival Action instituted after the death of the decedent. The Department of Revenue has issued a letter agreeing to the allocation between wrongful death and survival action as approved by the Cumberland County Court of Common Pleas on October 9, 2009. following documents have been attached to this Exhibit regarding the settlement proceeds: 1. Petition for Approval of the Settlement Proceeds 2. Court Order dated 10/9/2009 and executed by the Honorable Kevin J. Hess regarding the payment of the settlement proceeds 3. Correspondence dated 9/22/2009 from Shannon E. Baker of the Pennsylvania Department of Revenue, Bureau of Individual Taxes, regarding the Department's position on the aforementioned Petition. The Department as per the t~rrespondent had no objection to the Petition and approved the proposed allocation of the gross proceeds. The correspondence from the Department of Revenue further indicates that the decedent was 19 years old and died as a result of a motor vehicle accident and the sole heir to decedent's estate is his parents. Therefore, any proceeds paid to settle the survival action would pass to decedent's parents and would be subject a zero percent inheritance tax rate. (See Schedule E, Exhibit 2) 121.23 325, 000.00 TOTAL (Also enter on line 5, Recapitulation) ~ S (If more space is needed, insert additional sheets of the same size) ~~ 1W~1!li~lid6Y November 10, 2009 Theresa LShade-Wix F.sq 4705 Duke St Haaisbw.g, PA .17109 RE: Name; Jo~aathan Ryan Quigley SSN: 204-70-6466 DOD: 06'-06-2009 hear Ma. Wix: In response tD your request for Date of Death (DOD) ~ for the automec tested above, om records showtbe'follawigg: ~~g AOEOgat Accantrt # 1023565264 Established: 06-17-2008 )ONATHAN RYAN QUIGI.EY' JUDTTH R QUIGT.EX DOD balance: $12T.23 won interest bearing Aeco~nt A;cconat #5004753504 Fslabliahed: 07-11-2005 JONATHAN RYAN QUIGLEY JUDTTH IC QUIGLEX DOD balance: $454.28 + 0.01 accrued interest Plaa~e mte thu this offxx provides Abe of death balmcaa for deposit accounts (IltAa, CDs. (~eckiag and Savings}. We do swt pneceo ~ 1laaecla! ~ or preside tf ycu need sce with sny of those items, please calm 1-888-PNC-BANK (1-888-762-2265) or sboP by Your bcsl PNC Bank branch of$ce. Sincerely, Natia®al Fiaanr~ial Services Center PNC Ban1S N.A. Member FDIC Page 1 of ] Schedule E, Exhibit 1 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA IN RE: NO. ~ - (o5gY ~lv i lTerM ESTATE OF JONATHAN RYAN QUIGLEY, Deceased Petitioner, Judith K. Quigley, Administratrix of the Estate of Jonathan Ryan Quigley, deceased, by and through her counsel, Richard H. Wix, Esquire, of Wix, Wenger & Weidner, respectfully petitions this Honorable Court for an order of Court approving a compromise settlement of claims asserted under the Pennsylvania Wrongful Death and Survival Act and in support thereof avers as follows: 1. Petitioner Judith K. Quigley ("Petitioner") is an adult individual residing at 11 Charles Circle, Mechanicsburg, Pennsylvania 17055 and is the Administratrix of the Estate of Jonathan Ryan Quigley, deceased, late of Mechanicsburg, Cumberland County, Pennsylvania ("Decedent"). Petitioner is the mother of the Decedent and was appointed to serve as Administratrix of the Estate of Decedent by the Register of Wills of Cumberland County on June 23, 2009, to File Number 2009-00587. Schedule E, Exhibit 2 rw.auu l x Incident Number: H05-1855889 Commonwealth of Pennsylvania PAGE 1 Crash Involves: POIIC@ C'r1Sh R@pOft REPORTABLE CRABH G DUl ~ Fatality Q Hit and Run Q Commercial Vehicle Q State Police Vehicle t~ Local Pollee Vehicle Q NIA Q Work Zone Q ATV Q Snowmobile Q Commonwealth Vehicle Q Local Gov Vehicle gency Name Case Cosed Patrd Zone Investigation Date c PA STATE POLICE -NEWPORT NO a. m . 42 06/06/2009 Dispatch Time Areival Tuna tnvestlpator Badge Number 06:10 hrs 06:35 hrs. DUDDY, DAVID J 10Y84 ~ pproval Date Reviewer Reviewer Badge Number 0 Date of Crash ime of Crash Day of the Week Crash Desclption 08106!2009 06:10 hrs. SATURDAY HIT FIXED OBJECT County Munbipality PERRY CARROLLTWP 3 Weather Conditons Relatlon to Roadway o NO ADVERSE CONDITIONS ROADSIDE r ~ Illumination Road Surtax Conditions v DAYLIGHT WET # of Units # of People # of Injured # Killed EMS Agency Medical Facility 001 003 001 002 SHERMANS DALE EMS HERSHEY MEDICAL CENTER SUiool Bus Related School Zone Related PennDOT Nolifiad Type of Intersection Spedal Location NO NO NO MIDBLOCK NOT APPLICABLE Wbr1c Zone Work Zone Type YVhere in Work Zone o NO Y Speed Limit Workers Present Officer Present Work Zone Characteristla 3 Road Cosed Work an Shoulder Lane Cbsure Intemettent or Flogger ^ ^ with Detour ^ or Median ^ Moving Work ^ Control ~ Other v Route Signing Route Number Seg ment Number ravel Lanes S ed Limit pe Orientatbn ~ A LOCAL ROAD OR STREET T303 02 35 MPH WEST .~ House Number Street Name SL End m0 a 90 FOX HOLLOW.. ROAD Route Signing Route Number Segment Number ravel Lanes Speed Limit Orientation o+ Used in Intersection d >' Crashes Street Name St. Ending u c ~ d .- Route Number Or Mile Post enths r Segment Marker Ramp Use Onty Feet A E m a ~ a n Street Name trees ndinp Or Miles Tenths E J ~ v r Route Number Or Mile Post Tenths Or Segment Marker Ramp Use Only m ~ A The above entry is the ~ ~ ~ Street Name Street Ending distance from the Crash O J Scene to Landmark 1 of o: Degrees Minuks Seconds Decimal Degrees Minutes Seconds Decimal Latitude: 40 18 L , ~ 00 , 281 ongitude: ~ ~~ Og ~ 41 204 o ~ Traffic Control Device Traffic Contrd Funcfiorrinp ~ NOT APPLICABLE NO CONTROLS m o Lane Cbaed FULLY Lane Clostue Direction EAST AND WEST Traffic Detoured EsOmated Time Closed J YES 3-6 HRS Environmental I Roadway Potential Factors (E/R) Factor 1 NONE Factor 2 Factor 3 g First Harmful Event in the Crash Most Harmful Event in the Crash w Unit Number D01 Harmful Event HIT TREE OR SHRUBBERY Unit Number 001 armful Event HIT TREE OR SHRUBBERY e I DRIVER ACTION nR Number Prime Factor Driver Action 001 ~ UNKNOWN ~ W Prime Factor EnviromentavROadway Prime Factor Vehicle Failure Prime Factor pedestrian Action Road Surtax Type Spedel Jurisdiction BLACKTOP NO SPECIAL JURISDICTION PrfMed At: PA State Pollu -Newport 07121/200910:02 AM Page 1 Forn #: HOS-195li999 Exhibit "A" AA-500 TX Incident Number: H05-1855889 Commonwealth of Pennsylvania PAGE 2 Crash Involves: Police Crash Report REPORTABLE CRASH 0 OUI Q FataBty ~ Hh and Run ~ Commercial Vehlela Q State Pollee Vehicle Q Local Polce Vehicle Q WA 0 Work Zone ~ ATV ~ Snowmobile Q Commonwealth Vehicle ~ Local Gov Vehicle Unit Number ype Unit Commercal Vehide 001 Motor Vehieta In Transport No First Name MI Last Name Suffer DOB Tebphone Number GREGORY A BRETZ 10H0/1989 (717) 697-5819 Sveet Address City State Zip Cotle 1222 GROSS DRIVE MECHANICSBURG PA 17D50 Gander License Number' License State Class pirotion Dale OwnedOriver c MALE 28720774 PA C 10I11I2009 PRIVATE VEHICLE NOT OWNEDILEASED BY DRIVER ,_, Driver Presence Physical Condition Primary Vehide Code Violation person Charged ~ DRIVER OPERATED VEHICLE APPARENTLY NORMAL 3309(1) YES c kohoUDrugs Suspected MI Test Type Alcohol Teat Results NO BLOOD PERCENT VALUE.00 m DriverACtion UNKNOWN s m o Pedestrian Action P d i Si l i ~ e estr an gna s Pedestr an Cbthing Pedestian Location a z O 1st Harmful Evanl Left or Right Side Moal Harmful UOllty Poh Number HIT TREE OR SHRUBBERY LEFT NO 2nd Harmful Event Lett or Right Side Most Harmful UOlity Pole Number HIT TREE OR SHRUBBERY LEFT YES 3rd Harmful Event Lett or Right Side Most Harmful UDlity Pole Number 4th Harmful Event Left or Right Side Most Harmful UGI'dy Pole Number Owner First Name Owner MI Owner Last Name or Business Name uffix LEE E BRETZ II SveetAddress City State Zip Code 1222 GROSS DRIVE MECHANICSBURG PA 17050 Vehide Type Spedal Usage Government Equipment Number SMALL TRUCK NOT APPLICABLE Model Year Vehide Make Vehide Model Vehide Color VIN 1994 FORD RANGER BLUE 1FTCR15XSRTA61371 icenae Plate Reg.Stete Est Speed Vehide Towed - Towed BY YSG-3657 PA 055 YES JERRY'S TOWING nsurance Insurance Company Polity Number Expiration Date YES ALLSTATE 90159551711122 05/22/2009 uection of Travel Vehide Position Vehicle Movement Initial Impact Point WEST RIGHT LANE "CURB" GOING STRAIGHT 12 O'CLOCK ,, Damage Indicator Gradient Road Alignment Possible Vehicle allures D13ABLING LEVEL STRAIGHT UNKNOWN o aY of Units Type Unit 1 Tag Number Tag Year Tap Stale r Y ~ 0 - n e Unit Make Unit Owner e Type Unit 2 Tag Number Tag Year Tag State E Unit Melee Unil Owner Engine Size Passenger? Saddle Bag?runk7 Trailer? Driver Educalion7 r ~ Driver Helmet Type Helmet Stayed On? DOT/Shell Designation? Eye Protection? Long Sleeves? Long Pants? ver Ankle Boots? 0 0 f aasenger Helmet Type Helmet Stayed On? DOT/Shell Designators? Eye Protection? Long Sleeves? Long Pants? Over Ankle 8oots7 Passenger? Helmet? Head Lights? Rear ReOeclors? a Printed At: PA State Police -Newport 07/2tM00910:02 AM Paga 2 Form #: HOB-18ti6889 iw-ouu r x Incident Number: NOS-1855889 Commonwealth of Pennsylvania PAGE 3 crash Involves: Police Gash Report REPORTABLE CRASH O OUI OQ Fatality O Hit and Run O Commercial Vehicle O State Police Vehtele O Local Pollee Vehicle O NIA O Work Zone O ATV O Snowmobile O Commonwealth Vehicle n Local Gov Vahlda Unit # Driver Reslridiona Compliance Driver Endorsement Compliance Driver License Complance ~ _ _ 01 NO RESTRICTIONSMOTAPPLlCABLE NONE REQUIRED VALID LICENSE FOR CLASS ~ Prindpal knead Point voidance Maneuver ' Under Ride Indicator LL 12 O CLOCK INCONCLUSIVE NO UNDERRIDE OR OVERRIDE Emergency se Drug Test Type Drug Test Results NOT IN EMERGENCY USE BLOOD NO DRUG REPORTED Unit # Person No. First Name MI Last Name Sufix DOB 001 001 GREGORY A BRETZ 10HO11989 UeetAddress 1222 GROSS DRIVE City State ZipCotle o` a Phone Number EMS T MECHANICSBURG PA 17D50 E ransport (717) 697-5819 YES Person Type Gender DRIVER Injury Severity MALE MAJOR INJURY = Seat Position Safety Equipment 1 o a DRIVER -ALL VEHICLES NONE USED /NOT APPLICABLE Safety Equipment 2 Exuication NONE USED /NOT APPLICABLE NOT EXTRICATED EJedbn EjecOOn Path NOT EJECTED NOT EJECTED/NOT APPLICABLE Unit # Person No First Name . MI Last Name Suflbt DOB 001 002 EMILY K TRUMP 04H2H990 oast Address 1780 S. MEADOW DRIVE City MECHANICSBURG State Zip Code c - Phone Number E PA 17055 Y ransport P - Gentler Injury Severity c ES PASSENGER FEMALE KILLED Seat Position Safety Equipment t 3 a FRONT SEAT RIGHT SIDE NONE USED1 NOT APPLICABLE a Safety Equipment 2 ~~~ NONE USED /NOT APPLICABLE FREED BY NON-MECHANICAL MEANS Ejecton Ejedlon Path NOT EJECTED NOT EJECTED/NOT APPLICABLE UnR # Person No. Firs! Name MI Last Name Suffix DOB 001 003 JONATHAN R QUIGLEY 10110!1989 !reel Address City ` 11 CHARLE3 CIRCLE MECHANICSBURG State Zip Code PA 1 o A Phone Number EMS T 7055 o ransport (717) 766-8449 NO Person Type Gender PASSENGER Injury Severity MALE KILLED E m Seat Position Safety Equipment t SECOND ROW -LEFT SIDE OR MOTORCYCLE PASSENGER a NONE USED /NOT APPLICABLE Safety Equipment 2 NONE USED 7 NOT APPLICABLE Extrication NOT EXTRICATED sedan Ejection Path NOT EJECTED NOT EJECTEDlNOT APPLICABLE First Name d MI MICHAEL J Las! Name Suffix Phone Number JUMPER (717) 582.8465 5 VeetAddress City 3 90 FOX HOLLOW RD. SHERMANS DALE Stste Zip Code PA 17090 a Ownero Fust Name , MI i w MICHAEL Last Name Suffix Phone Number J E JUMPER (717)582-8465 S SueetAddress City ~ 90 FOX HOLLOW RD. SHERMANS DALE State ipCode PA 17090 ~ ProOeM Description a` ~ SHRUBBERY AND TREE PrlMed At: PA Stag Pollee -Newport 07!21/200910:03 AM Page 3 Fonn N: HOti-1865889 AA-500 TX Incident Number: H05-1855889 COI7111'10nWt?alth Of P@r1nSylVanla PAGE 4 crash Involves: Police Crash Report REPORTABLE CRASH !~ DUI Q Fatality Q Hlt and Run Q Commercial Vehicle Q State Pollee Vehicle Q Local Police Vehiela Q NfA Q Work Zone Q ATV Q Snowmobile Q Commonwealth Vehkla Q Local Gov Vehicle o = Personl8uainess Notfied STEVE QUIGLEY Reason for Notiflt:ation DEATH NOTIFICATION FOR PASSENGER Phone Number Date Notified vne Notfied (717) 788-8449 06/06/2009 11:06 hrs H hbr ro S>r'ALS y T-303 (Fox Hollow Rd.) Tree Unit 1 ~ U nit 1 ~. Unit 1 ' Unit 1 ~'~ 1--Unfit 1- Row Of Shrubbery E Unit 1 Impact Unit 1 Undercarriage Impac t With Shrubbery ~ With Tree s •-~IVitness Residence Village Of Shermans Dale approx. 2 miles SR 34, approx. 114 mile Unit 1 was traveling west on Fox Hollow Rd. when it veered to the left, crossed the eastbound lane and traveled off the roadway. Unit 1 ran over some bushes before impacting a tree head-on. Operator 1 and Passenger 1 were taken by Shermans Dale EMS to the Life Lion, where they were flown to Hershey Medical Center for their injuries. Passenger 2 was pronounced dead at the scene by Perry County Coroner Michael SHALONIS. Unknown if alcohol was a factor in this crash. Assisted at the scene by Shermans Dale EMS and Shermans Dale VFD, who provided traffic control. Unit 1 was towed by Jerry's towing. Cellular phone present in Unit 1, not in use. PAnted At: PA State Polee • Newport 07!211200910:03 AM Page 4 Form *: HOS•7855889 A/1-~VU I J( Incident Number: H05-1855889 Crash Involves: O DUI Q Fatality O N/A O work Zone Commonwealth of Pennsylvania Police Crash Report Q HK and Run O Commerelal Vehiele Q ATV O Snowmobile REPORTABLE CRASH PAGE 5 O Stab Police Vehicle O Local Poiica Vehicle O Commonweslth Vehicle O Loeal Gov Vehicle At the location of this crash, T-303 (Fox Hollow Rd.) is a 2-lane blacktop, single-line roadway with no usable berms. At the time of this crash,. it was daylight and the roadway was wet. Measurements were taken of this roadway by Cpl. Gary MAINZER, PSP Collision Analyst and Reconstruction Unit, reference his report. This crash occurred as Unit 1 was traveling west on T-303 (Fox Hollow Rd.). Unit 1 crossed the center yellow fine into the eastbound lane. Unit 1 continued west and veered off the left side of the roadway, traveling through several feet of shrubbery before impacting a tree head-on. After impact with the tree, Unit 1 came to rest facing northwest, Just southeast of said tree. Unit 1 was not moved from lts point of final rest prior to my arrival. Upon my arrival at the scene, I witnessed Unit 1 at its final rest. 1 also observed major damage to the front end of Unit 1. EMS personnel were attending to Operator 1. At 0638 hrs. same date, I asked Operator 1 what had happened. Operator 1 indicated that he couldn't remember how the crash happened. Operator 1 advised that he nor his passengers were wearing seatbelts. I asked Operator 1 if he had been drinking, at which time he responded that he had 2 (drinks). When asked when he had those drinks, he responded with "earlier." Operator 1 did not indicate when or where he consumed these drinks. Operator 1 was then taken to the ambulance, to be transported to Hershey Medical Center for his injuries. Passenger 1 TRUMP was en route to Hershey Medical Center upon my arrival, 1 did not speak to her. Passenger 2 QUIGLEY was deceased in the back seat of Unit 1 upon my arrival. QUIGLEY was pronounced dead at the scene at 0730 hrs. same date by Perry County Coroner Michael SHALONIS. After being extricated from Unit 1, QUIGLEY was removed by SHALONIS and Perry County Chief Deputy Coroner Michael HOKE. QUIGLEY's wallet, which included his driver's license, was also taken by SHALONIS. The scene was photographed by Tpr. Matthew FRAMPTON, PSP Harrisburg Forensic Services Unit, reference his supplemental report. Witness JUMPER was interviewed at the scene at 0820 hrs. same date. JUMPER advised that he was inside his house when he heard a loud bang outside. JUMPER advised that he looked out the window and saw Operator 1 kicking open the driver's side door. JUMPER said that Operator 1 went around the vehicle and pulled the female out from the passenger's side door. JUMPER said that the boy in the back seat remained there until the fire department and EMS arrived. I was assisted at the scene by Cpl. Kempton PRESTON, PSP Newport. Cpl. Douglas HOWELL and Tpr. Scott KOVACH from PSP Carlisle made notification to the next of kin of Passenger 2 QUIGLEY, speaking to QUIGLEY's father Stephen V. QUIGLEY of 11 Charles Circle, Mechanicsburg, PA, 17050, at 1106 hrs. same date. Entry in the PSP fatal crash system made on 06!08/09. Blood results were requested and obtained by Cpi. MAINZER for Operator 1 from NMS Labs. There were no positive findings for alcohol or drugs in Operator 1's blood. Printed At: PA State Police -Newport 07f21r100910:03 AM Page 5 Form t1: HOS•1855889 ~ pennsylvania DEPARTMENT OF REVENUE September 22, 2009 Richazd H. Wix . Wix, Wenger & Weidner, P.C. 4705 Duke Street Harrisburg, PA 17109-0341 Re: Estate of Jonathan Ryan Quigley File Number 2109-0587 Court of Common Pleas Cumberland County Dear Mr. Wix, The Department of Revenue received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It was forwazded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, -the 19 year. old: decedent died. as a result of a motor vehicle accident. The sole heir to decedent's estate is his parents. Therefore, any proceeds paid to settle the survival action would pass to decedent's pazents and would be subject to a zero percent inheritance tax rate. 72 P.S. §9116(a)(1.2). Accordingly, regazdless of the allocation of the subject proceeds, there would be no inheritance tax consequences. Please be advised that based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $325,000.00 to the wrongful death claim and $325,000.00 to the survival claim. Proceeds of a survival action aze an asset included in the decedent's estate and, although subject to the imposition of a zero percent inheritance tax rate in this instance, they must be reported on decedent's Pennsylvania inheritance tax return. 42 Pa.C.S.A. § 8302; 72 P.S. § 9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of M an, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending the hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. S' Eerely, 1C~~cn.c~- ~~~c.c.~~ E. Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes Bureau of Individual. Taxes ~ PO Box 280601 ~ Harrisburg, PA 17128 ~ 717.783.5824 ~ shabaker@state.pa.us Exhibit "B" OCT ~ 5 2005 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA IN RE: N O. Oq - (a55`J Civ i L lP.~ ESTATE OF JONATHAN RYAN QUIGLEY, Deceased ORDER AND NOW, this 2 day of ~G~ ~~~_ , 2009, upon consideration of the Petition for Approval of Wrongful Death and Survival Settlement, and finding that the proposed settlement is adequate to protect the interests of the estate and beneficiaries, IT IS THEREFORE ORDERED AND DECREED that payment of Six Hundred Fifty Thousand and 001/00 ($650,000.00) in settlement of the Wrong Death and Survival Actions is APPROVED. The settlement proceeds shall be distributed as follows: TO: Wix, Wenger & Weidner, Attorneys at Law, $283.78 for reimbursement of costs; and TO: The Estate of Jonathan Ryan Quigley,. deceased, $649,716.22 for payment of any claims, debts, inheritance taxes, and attorneys fees of the Estate, with the balance to be distributed to the beneficiaries of Decedent's Estate. BY THE COURT: J. Distribution: Richard H. Wix, Esq., 4705 Duke Street, Harrisburg, PA 171O4~F,~p~ ir;'~?v1 Ri~Cti°iD _ .: - - _ In Testin;ony whereof, Lhare unto set my hand • ~ ~ and the seal ofi szid Court at Czrlisle, Pa. This ................ a of -~...., ... t thonotary REV-1509 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE F JOINTLY-OWNED PROPERTY Jonathan R. Quigley 21 09 0587 M an asset was made joint wkhin one year of the decedsrd's dale of duth, k must be reported on Schedule G. 11 Charles Circle Mechanicsburg, PA 17055 TO DECEDENT ADDRESS SURVMNG JOINT TENANT(S) NAME A. Judith K. Quigley e c JOINTLY-OWNED PROPERTY: Mother ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. 7/11/05 PNC Bank, 2 East Main St., Mechanicsburg, PA 17055 454.29 50. 227.15 Savings Account #5004753504 {See Schedule F, Exhibit 1) TOTAL (Also enter on line 6, Recapitulation) I S 227.15 more space Is needed, Insert addiBonal sheets of the same size) .. ,~ . - .,~ ,_ _ . ~ .. -. , _ .. ~, ....~ , ~~~.~.~~~~ ~~ ~~E ~.~_.~ ,, ~~~ LfAiBM1f18M6~Y November 10, 2009 Theresa I, Sbede-Wi~c Faq 4705 Doke 3t I~ieburg PA .17109 RE; Name: Job Ryan Qaigley ' SSN: 204-70-6466 DOD:. 06.Ob-2009 Deer Me. Wix: In response to your roclneat for Date of Death (DOD) balances far the noted above, o~ n:carde stbowthe'following: Cog Aoeostut Accoma # I0255b5264 Eetabliehed: Ob-17-2008 JONATHAN RYAN QUIGLEY' JUDITH R QUPG~Y DOD balenoe: $12123 mn interest bearing Aoeopa# Aa~nad #5004753504 Esmbli~ed: 07_11-2005 . ~ JONATHAN RYAN QUICfLEY JUDITH 1C QUIGI~Y DOD balance: 545428 + 0.01 acerged interest Please Hobe the this o$ce p~avidee dime of death beLnces fa deposit a (I1tAe, CDs, (fig end Seviogs}. We do arot pe~eeeee m4 Seudel ~ or prdvirN lfycu need eesismoe wnh snY of tbase items, pl~se celi~ 1-888-P3JC-BANG (1-8E8-762-22b5) a ~oP by Your bcel PNC Bank b~aoch office. Sincerely, National Fi~anc5el Services Center PNC Benlr, N.A. Malabar FDIC Page 1 of 1 ~ I Schedule F, Exhibit 1 REV-1511 EX+(10-OB) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE H FUNERAL EXPENSES S ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Jonathan R. Quigley 21 09 0587 Dsbb of decedent must be reported on Schedule [. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1, Malpezzi Funeral Home, 8 Market Plaza Way, Mechanicsburg, PA 17055 6,778.15 (See Schedule H, Exhibit 1) B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representatlve (s) Street Address City State Zip Year(s) Commissbn Paid: 2. 3. AttomeyFees Wix, Wenger& Weidner Family Exemption: (It decedents address is not the same as daimanrs, attach explanation) Claimant Street Address City State _ Relationship of Claimant to Decedent 5,675.00 4. Probate Fees 66.00 5 AcsountanYs Feea 6. Tax Retum Preparer's Fees 7. Cumberland County Prothonotary, 1 Courthouse Square, Carlisle, PA 78.50 Filing of Petition for Approval of Allocation of Proceeds of Settlement Under the Pennsylvania Wrongful Death and Survival Action (See Schedule H, Exhibit 2) 8. Sentinel, 457 East North Street, Carlisle, PA 17013 208.78 Estate Advertising (See Schedule H, Exhibit 3) 9. Cumberland Law Journal, 32 South Bedford Street, Carlisle, PA 17013 75.00 Estate Advertising (See Schedule H, Exhibit 4 TOTAL (Also enter on line 9, Recapitulation) S 12.960.15 Zip (If nare space is needed, insert additional sheets of the same size) ,. Continuation of REV-1500 Inheritance Tax Return Resident Decedent Jonathan R. Quigley 21 09 0587 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses ~ Administrative Costs - B7. ITEM NUMBER DESCRIPTION.. AMOUNT 10. Register of Wills, One Courthouse Square, Carlisle, PA 17013 Short Certificates (See Schedule H, Exhibit 5) 12.00 11. Register of Wills, One Courthouse Square, Carlisle, PA 17013 30.00 Fees for filing Inheritance Tax Return and Inventory 12. I Wix, Wenger & Weidner, 4705 Duke Street, Harrisburg, PA 17109 I 36.72 Postage and Copying SUBTOTAL 8CHEDULE H-87 I 78.72 ,. ., ,~ .o. ~:; . ..: za- ~ L A °..~.." .-Y>ALi . .s.d Pis a.~.ei,'~ i~t1a. , _ rz~„~u ,u..:~aA ~' ~~~`,~ rasa Iwa • AlaAaalra-rry, re Insa ~ a w~~s,•,Vtfr~ IA...: rlrY.~sn FUNERAL HOME MieAar!!. Mayevi; ol.ae. JenJny J Sharper, Funeral JFhrerrnr STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Cktarges are only for tlaase hems that you selected or thaz are required. If w'c are required by law or by a cetned~ry or crematory to use any items, we will explain the season in writing belerov. IF ynu selected a funeral that may require embalming, such ore a funeral viewing, you may have to pay for embalming. You do not love en pay for etnb:dm- ing yew did not approve if ynu sel~ artangrraxnu such as direct cremation or immcdiazc burial. If we charged for embalming, we w~l explain why below. Fur the Service of M1++F,;~v C-vvr~. l..r Date of Death -~~ G, Ct`c'% Charge tot __ ,~,~c.,1..w ~>,.,/h~ ~~ Nanrc Arlrln A. CHARGE FOR S®IVIl~,4 SHIBCfED: 1. I'ROFEStiTONAL SCRVICFsS Services nF Funeral Dirator/S7aff ....... 4 s+t 1 Embadmng .... ................ S ,.N 1. OdJer pmpan[km of body u, .,- c _ .. n..n.. ..... rt'. el ~:.« -n...W ~.. s w.~ ..~ V.~- n.0.+'1 { ... ~ .:.. f_ \ SU87YYfAL OP FROFESMONAL 9ERVIfffi .....AI z. PACn.mES AND sERVICEs Use of facidries and services for viewing (Visitauon~f'ikc) ... .. .... S rv\ Use uF Fxiliues and services for (Urletal ceremony .... ...... f ' , ~ t . Use of lacilitles and services fnr Memndal Senhre .... ... . ...... S Clse of equipmrnt end services for graveside service ..... ~ . ...... 5 Othet use of facilities ~, ,t r'.:,t. f ,,,~., L. SUB•7YYI'AL OP FACR171F4/EQ[1~R~'1' ...........A2 f r. r 1, 3~ ALrfOM07IVE EQUIPMENT Vehick ro trar.fa remains to Funeral Fbme Loa! ........ ~ ............. .. S r .<.. Heatse ((:asks Coach) Loral ...... . ..... .......... .. 3 , 1.\. Limousine Loal ..............__..._. .f Family car Loal .. ...... ...... .. ........ .5 Plnwa ar or Rural dispJSidon Ioal . ...................... . S r .r \. ..._._. _.. .. t,Fld iSr/tkigy Cie' .:...,,.. . ...:, °. :-.::::' . , Loaf ....................... , .5 J.el Car fm palBxatas focal ... .......... .... . 3 Out r>f town transpMation ........ . f !:. '.:1.. ~Ic ltH~.r.wl...y r f J.t (. - SUBTOTAL ~ AUPOM[YI1YE EQi1RMBNP AS f , ., s . TOTAL OP PROFESSIONAL SERVICES, FACHIIIBS AND AIJIOM071VE yZ~r B. CHARGE POR R~M ca,alta ........ ... IDLSE _ ..... ...... 3 `1 7 S "- Clthrr Raepdde .... v. . - ...... $ (IXauiption) [Nns httdal crntainer .. ........... 3 U)esrsiprksn) AcknowledgeJnen[ seas ........... f Memory folders .................. f Z Prays star .. ..... .......... f _. , ~.. SY. `..-~; City Oths Nahing __ _ Cremation um . --.. , .. , . , , 3 ZSS~ (DCSmlwurJ) t ~r,<Y '-:I ,W G,:[ F A OTHER N^~ . -.(,-%.I~ 6'.. r... Jg J t I f ~~~. x s 1 ~73,fN..-. G 9PECfAL CHARGES: Porwardmg of mmauas ro 3 (IWual Home) -~~ ~--- Receiving M rermlr<s from -.._ 3 (I§tttenl Home) httmed'nte &uial ............... . S Dirrxt CrsruWn ........ ...... 3 r ,c\. S 9U&TOTAL OP SPECIAL CHARGES ................C 5 ' ^s t. D. ('A4H ADVANCED Opening Grave ............. . f <:anserv Pquipmrnr ........... .. 3 Iat and Dee ~ ...... ... f ~ NOticesa.osal . Pax f~'I Newspaper NutinwOataf-[own ... ... 3 2 jf.. F1Z Telephone A Telegrams .......... .. S Mhre ...................... ..5 Getgy/Mass Offering .... _ . ... _ f_ _ _ Pallbearers ........ .. . .. 3 CertB3ed Copies d the Death .. .. .. $ Certifirue !c: r.'.:a.(~. G. w,,.. ,, f l•c. PuEm Escort ... .............. .. f Flowers.. ~:.'v!'.:-J:`:'.i....... ..3 li Vaud Service Charge ....... . . . . . . g J; , r~ t z~_. zv s f 90E-TOTAL OF ADVANC89 ........... _ _ . _ _ .D f_ 1 H7z. Z~ We charge ynu fnr our servke.< in tJbtaining: UFsHfy raab adrxincns tbargre rnerlnq+tP) SUMMARY OF (7IARGffi A. Pmfnssirsnl Ssvlces, PacEides and Equipment, and Au[omodve Equipment .... ....... ...... .. 3 `12 7S H. Menbandise ...... ...... .. f 7: ~ 44 C Spedal Charges ................ .. f s I D. Cash Advances ................ .. 3 / C , [' TOTAI.OP ALL SECRONS ...... ................ f 7 2 Z 1. L Z PAID AT TOfE OF OR ~pR TQ A~ANGBMffiYf3 ...Y+''t~.r. N~ , ••-. G• e:' ... " . S ~/3. 07 EAIANCl DUE ............... ............. _ .4~~ If any law, «meiery, orciedYartry Jequiremenrs havt required ate purchase ` h:.aFnGthe.itm3S,l~st?d'?:s]x-4wratbdtnv. . f agree that 1 have examined the Bette d gaadi and auviees selMed above and found them m be mrren and according ro dJe~tW I have rcqurated. I acknowledge receipt of'3iropy of the Sta[ement of Punetal Goods and 3~I,F~t~d I rep that I have suR'rdart funds available for psyrnetr d the rash peke for the goods and scrviaro sulerls~rl. I also agree ~ [take [ d 3 ~~~. r + ~ Sc f ~ IxiY~ svdjn~ days. I agree ro he jointly and severvlly Iul>k wad tr~rrJne else ahu signs below. A late chagge d per rnontd amounting ro ~'LC Pt* Ytar wW hc; applkxl to the tmpakl bahurce beginning _ _ days fmm the date of this agreement. I will also pay m the PLrml Hearne all reasonable suss paid by the Purrcnl Dirator to colle¢ atrtrutus I owe urtder this agreement. Tlwse <veb moy indudc annnJeys' fees court ttufa and other cuss. My addBional services or merclurdise ordered ur n:grreded spar the date d [dls agreemrnt will be pad of dra a //~e oosr thaenf will be rcAesed on [he final biR rr smtemenc (recto :.:-~ 1 ~'~ ; -- ___.- lrr fl Ji:e~ ~ lrunaaUUJ CSeW) ~ r • D>,~~~ e Paimyhaw P~ani ~ i.waam form •600 Revised 1/ V',< / (DPI 'U.tanaea FanrraJ, irecta) 41rJS Pwnal Il~rtiinr YPn11M P,rcenl larcnrn PPIa Curramer Schedule H, Exhibit 1 RECEIPT FOR PAYMENT Cumberland Countyy Prothonotary's Office Carlisle, Pa 17013 QUIBLEY JONATHAN RYAN ESTATE (VS) Case Number 2009-06559 Received of PD ATTY WIX DKB Total Non-Cash..... + Total Cash......... + Change ............. - Receipt total...... _ 78.50 Check# .00 .00 $78.50 ------------------------ Distribution Of Payment Transaction Description Payment Amount Receipt Date 10/01/2009 Receipt Time 12:00:51 Receipt No. 231311 3739 PETITION 55.00 CUMBERLAND CO GENERAL FUND TAX ON PETITION .50 BUREAU OF RECEIPTS AND CONTROL SETTLEMENT 8.00 CUMBERLAND CO GENERAL FUND AUTOMATION FEE 5.00 CUMBERLAND CO AUTOMATION FUND JCP FEE 10.00 BUREAU OF RECEIPTS AND CONTROL $78.50 Schedule H, Exhibit 2 RETAIN THIS PORTION FOR YOUR RECORDS - LBGl1L WIX WENGER & WEIDNSR ATTY 372603 10 PUBLIC NOTICES cartc 08/17/09 38 * 2 AD DES ON START DATE S OP DATE NOTICE LETTERS OF ADMINISTRATION O 08/01/09 08/15/09 PUBLI TION MSERTt NS TE NET AMOUNT GROSS AMOUNT 3 THE SENTINEL - LEGAL 3 LGL 201.78 TOTAL AD CHARGE 201.78 3 PROOF OF PUBLICATION Est J. Quigley O1PRF I 7.00 PAY THIS AMOUNT I zo8.7s 250.54* MESSAGE: Thank you for advertising with The Sentinel. Deadlines for in-column legal advertisements: Monday is Thursday at 5 p.m; Tuesday is Friday at 5 p.m.; Wednesday is Monday at 5 p.m; Thursday is Tuesday at 5 p.m; Friday is Wednesday at 5 p.m Saturday is Wednesday at 12 Noon; Sunday is Wednesday at 5 p.m. If you have any questions regarding your Legal bill please call Classified Manager at 717-240-7176 Fax your legals to 717-243-3754 attention Classified Manager You can also ELNAIL your legal to Classified ads: classified~cumberlink.com Please send a cover letter including your name and address as an attachment Schedule H, Exhibit 3 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tale: (717) 249.9188 Fex: (717) 248-2898 August 21, 2009 Cumberland Law Joumal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the offiaal legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Theresa L. Shade Wix, Esquire RE: Jonathan Ryan Quigley Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: August 7, August 14, and August 21, 2009 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director Schedule H, Exhibit 4 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17Q13 QUIGLEY JONATHAN RYAN Estate File No.: 2009-00587 Paid By Remarks: WIX WENGER WEIDNER CJ Receipt Distribution Receipt Date: 7 01/2009 Receipt Time: 2:04:44 Receipt No.: 1057337 Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE 12.00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 3619 $12.00 Total Received......... $12.00 Schedule H, Exhibit 5 REV-1513 EX + (9-00) SCHEDULE) COMMONWEALTH OF PENNSYLVANW BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Jonathan R. Quialev 21 09 0587 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 [ndude ht spousal distributions, and transfers under 9116 1 S 2 . ) ec. (a ( ] 1, Judith Quigley - Parent/Mother Lineal 156,194.12 11 Charles Circle, Mechanicsburg, PA 17055 2. Stephen Quigley - Parent/Father Lineal 156,194.11 11 Charles Circle, Mechanicsburg, PA 17055 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. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET = (If more space is needed, insert additional sheets of the same size) INVENTORY REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA ~ SS COUNTY OF CUMBERLAND File Number 09 00587 Personal Representative(s) of the Estate of Jonathan Ryan Quigley deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- ` tory are true and correct. I understand that false state- menu herein are made subject to the penalties of t 8 Pa. C.S. § 4904 relating to unsworn falsification to authorities. Attorney -(Name) Theresa L. Shade Wix, Esq. (Supreme Court I.D. No.) 43089 (Address) 4705 Duke Street Harrisburg PA 17109 (Telephone) (717) 652-8455 DATE OF DEATH LAST RESIDENCE DECEDENTS SOC. SEC. NO. 11 Charles Circle 6/8/2009 Mechanicsbur PA 17055 204-70-6466 FIGURES MUST BE TOTALED Settlement Proceeds received from Wrongful Death/Survival Action 325,000.00 PNC Bank 348.38 etr o -f z o Z 7s G ` ~~> ~ C..... E~~7 rr" t"~ r-. s,. -~, ~ :mss ~ ~'~ r» .. ~ <',a iV (Adach addlttonal sheens as needed) TOTAL: 325,348.38 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S. § 3301(b)J Form RW-09 rev. 10.13.06