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Home My WebLink About03-16-10 (3)V-1500 1505607120 RE EX (os-OS) OFFICIAL USE ONLY PA Department of Revenue County Code Year Flle Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO 80X.280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 0 9 0 5 9 0 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 172015377 06132009 10261914 Decedent's Last Name Suffix Decedent's First Name MI ROUSE CLARA G (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 4. Limited Estate ^ qa, Future Interest Compromise ^ 5. Federal Estate Tax Return Required (date of death after 12-12-82) g Decedent Died Testate ® 7, Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes ® (Attach Copy of Will) (Attach Copy of Trust) ^ 9. Litigation Proceeds Received ^ 10. between i2 3i Y91Dandt (d; tges~f death ^ 11,Election to tax under Sec. 9113(A) 1 (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDEN?'IAL TAX INFORMATION SHOULD BE DIRECTED TO: ame Daytime Telephone Number KEITH D. WAGNER 7178386348 Firm Name (If Applicable BRINSER, WAGNER & ZIMMERMAN First line of address 6 E. MAIN STREET Second line of address P.O. BOX 323 Off St t ::c:~? _~ ;, --, _ra _, ,~ ' ~ .: ~, ._; ,. _.~,i .:---:, ,`~_~ ~::.~ Ctty or Post Ice a e ZIP Code ,.r„ ~ `~'{ PALMYRA PA 17078 Correspondent's email address: k e l t h CLD b W Z 18 W. C O m Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Gerald J. Brinser .~ rs ~ a ADD SS 6 E. Main Street P.O. Box 323, myra, PA 17078 SIGNATURE OF PR OTHER THAN REPRESENTATIVE DATE Keith D. Wagner ~ ~~ - ~, ADDRESS 6 E. Mai treet, Palmyra, PA 17078 Side 1 1505607120 1505607120 J 1505607220 REV-1500 EX Decedent's Social Security Number Decedenrs Name ROUSE , C LA R A G. 17 2 015 3 7 7 RECAPITULATION 1. Real Estate (Schedule A) ........................................................................................... 1. 2. Stocks and Bonds (Schedule B) ................................................................................. 2. 1 7 , 613.18 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .............. 3. 4. Mortgages & Notes Receivable (Schedule D) ............................................................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .................... 5. 1 1 9 , 2 2 8 . 3 5 6. Jointly Owned Properly (Schedule F) ^ Separate Billing Requested .............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested .............. 7, 5 9 4 5 8 5. 2 4 , g. Total Gross Assets (total Lines 1-7) ........................................................................ g. 7 3 1, 4 2 6. 7 7 9. Funeral Expenses & Administrative Costs (Schedule H) ............................................ 9. 1 3 , 6 2 5 . 4 9 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................... 10. 3 , 5 9 2 7 4 11. Total Deductions (total Lines 9 8 10) ..................................................................... 11. 1 7, 2 1 8. 2 3 12. Net Value of Estate (Line $ ~~i°~us E_ine 1 ~ j ............... ................ 12. 714 , 2 0 8 5 4 13. Charitable and Governmental Bequests/Sec 91 ? 3 Trusts for which 0 7 2 7 6 8 9 an election to tax has not been made (Schedule J) .................................................... 13. . , 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................... 14. 6 2 4 , 9 3 2 . 4 7 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 15. 16. Amount of Line 14 taxable at linealrateX .045 17 8 , 552.14 16. 8 , 034.85 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 4 4 6, 3 8 0. 3 3 1 s. 6 6, 9 5 7 0 5 19. Tax Due ..................................................................................................................... 19. 7 4 , 9 91.9 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 150560722 1505607220 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 0 9- 0 5 9 0 DECEDENT'S NAME Rouse, Clara G. STREET ADDRESS Messiah Village 100 Mt. Allen Drive CITY STATE i ZIP Mechanicsburg PA ~ 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable p. Interest E. Penalty 61,750.00 3,250.00 Total Credits (A + B + C) (1) 74,991.90 (2> 65,000.00 (3) 0.00 (4) (s> 9,991.90 (5A) Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 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. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (s6) 9, 991.90 Make Check Payable to: REGISTER OF WILLS, AGENT •:::• •: rv::.•: r::::. ~::.•.::::.•: :•.•.•:. ~::.•:::::::::.•::.•:::::::::: r.•::: •:::::::.•.•::.•.• :•: :. ;... .•.:::: •:.: • .............. .. r:::.•::.:::.• ::•: •r :•::::: :• :•:::::.•:.•:.• •:::::.:•:.•.:.•:.•.•.,........................... . ............ ......... ............ ................. r : •.•r.: .............:.•..• •. .. r.::.•.::...; ....... .. r. r.•.•: r v •.:.•::::.•:.•.•:.: ~ r:.• . .. r.:::: •.::... r•.. .. r...... :.:.:... r....... }:•} ..................... r.:•:v:•}: ~: rrr:.v: ..: r.. . r. r:.•.v.•.•........ r:. ~:.:•: r..: r.r.... ..n.. r.r..r............ .: r •: •.•::: r.:v::'•x :.v::r.:•:: rw:.: r:•:.;:'r'::}ri::$::}:•:ti{:'r'r:~:v:: rr::: rr.•:::: r .v:rrr..:... r.......... • ..: ..:.A~:::: V::.~:::.~::::rr .........:...... J.....: r::...... :: J...... .. r.: v.•::: r v: v: r •. ~:.• •::v. y .......................... ..:. ........ r ...,.r....:...,... ::.,.. • ....:...:. ,:....:.r.. r.•.::.:•.:.~.: e . :•~rx.~.~r.:: r.•: r.•r xr: rr... r. r . .....................:.,,. r . ,.:x. r.,... ..~.•Irr:....:r. ~:.vvr ~•i$:vrj$i$:{: 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 :..................................................................................... U x b. retain the right to designate who shall use the property transferred or its income :......................................... ~ x c. retain a reversionary interest; or ..................................................................................................................... ^ x d. receive the promise for life of either payments, benefits or care? .................................................................. ^ x 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...................................................................... ..................... ~ x i decedent own an "in trust for" or payable upon death bank account or security at his or her death? ............... 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary 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. ~f%' F r {%r..: . r.•'r. r ; r.}•.•.•{./ . •.v::.v.. •.w..v.: •. r.•r: r:. . rr •. rr: • ~r::{ {4 .•.: :•r •r.• •. r.: i rri rf •. r: '::~i.~%i'::: rr.. }.:.. r : • •.•.•r. •.:: •. ~:.:: •r.:::: •.:: r: :v: f ...:::.:: r: .. r. {{•:{•:rf....:.::{%::..I.:}• ~ :{ ~:•'.•} }:•:• ... r... rr rr.•r:•. r r . r:::i: ... r :• :• r . :. f. r rr..•$. r . x r<Ji.•r •}: •r.•.•:•}%:~:~::.w::• ..•...:..... /.. r..{ :.•:.•r.•.: . rFi.. . •..:':. v:}.. }: }. n.. x. r r rrr.. .. r... r ..•.......... r • : r ~ • is . // r'r. •.v.•: • . r........ . : r.... r:.•.•d{v:{.... { r. 4. .::. rr. .:.. 4.: . ~}1. f . . r. r.. . :: }Y: }Y~$•'. .. r: • •: rr : ~vr. rvr::.{...:• •............ j{ •.:4.... r... . . r.... . r. :•r.•:.•.•.•.•:::.•.•:.•:..... . .:.. .:.•. r.. r: . . r.{w... n ..4... .. rr .• j . .~ .: •.{. . /. f.:.:... rn.SC.. ..:. r ............. • ..:•.•.. .wr :..... ~~f/!r'!rrrFrr%rrSrr:. Y' x.•rr . rr.•.• •.• .:::.•.v.r :..r:::•:•:4} :............ .. /... •r.... r..• •.• . ..:. r. •.:. f'•:.. r::.• . • •.:v.................. .:Ih: r..... r::b.:...}:•...::.:....•::Fi..}::.::.... r. rr}i..:........: ~ .v..rx.:...... ..... .:... .. r. r .:. xk f ............. r.:v:..:.::4:;{{.•.:v.}•.•:•:.:r.•.••}: r}:•rli:•:wr.::{.{x•.::ri. r.4/rI.•:{{{G: r.:vr: r'rirr~rl..:ti{.°if:{{{::v'.:errsi%iif{! }}}:•:{ ~:::Yr:}iri.:: is ~:}r:r•}$rr::{::,::'::'~{r:'r}}:6:4:{{{{•:{{4}: For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 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 lineal 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)J. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. SCHEDULE B COMMONWEALTH OFPENNSYIVANiA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER - ESTATE OF ROUSe, Clara G. 21 - 09 - 0590 All property jointly-owned with right of survivorship must be disclosed on Schedule F. __ ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF NUMBER DEATH r -- -------- - -_ - - - - - --_ ___ - ___ __ _ _ 1 Federated Shareholder Services Company - 1,623.3350 Shares @ $10.85 10.85 17,613.18 ', per share TOTAL (Also enter on line 2, Recapitulation) 17,613.18 SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT -- - _- -- FILE NUMBER ESTATE OF ROUS2, Clara G. 21 - 09 - 0590 __ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH ___ ___ 1 PNC Bank -Checking Account #5140054011 56,330.74 (Includes accrued interest of $1.53) 2 PNC Bank -Certificate of Deposit #31100263176 (Includes accrued interest of $1.44) 3 ~ Check on Hand -Brethren In Christ, Gift Annuity 4 ~ U. S. Treasuary - 2008 Income Tax Refund 5 ~ Myers Harner Funeral Home -Refund 6 Brethren In Christ -TAP -Special Account #2235 (Includes accrued interest of $36.54) 7 ~ SEC Specialist Settlement Services -Class Action Suit TOTAL (Also enter on Line 5, Recapitulation) 12,406.26 227.50 3,300.00 1,923.71 45, 036.54 3.60 119,228.35 COMMONWEALTH OF PENNSYLVANIA SCHEC~UL~ G j INHERITANCE TAX RETURN ~I+NTER-VIVOS TRANSFERS ~ ~ RESIDENT DECEDENT IIAISC. NON-PROBATE PROPERTY i ESTATE OF Rouse, Clara G. FILE NUMBER 21 - 09 - 0590 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. DESCRIPTION OF PROPERTY % OF ITEM DATE OF DEATH EXCLUSION NUMBER Include the name of the transferee, their relationship to decedent VALUE OF ASSET DECD'S ! (IF APPLICABLE) TAXABLE VALUE and the date of transfer. Attach a copy of the deed for real estate. INTEREST 1 Merrill Lynch Account No. 898-59579, held "TOD 593,454.20 100% 593,454.20 Beneficiaries on File" 2 ML Life Insurance Company of New York -Balance of 1,131.04 100% 1,131.04 Annuity payable to Sydnae Steinhart as the primary beneficiary. ~ ~ , TOTAL (Also enter on line 7, Recapitulation) 594,585.24 SC~ED~E H FUNS ~"XPErISES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ~.~~~''~'pw ~I~ I IW~ ~ wv ~ ~ v"~, , - RESIDENT DECEDENT ESTATE OF Rouse Clara G. FILE NUMBER , 21 - 09 - 0590 Debts of decedent must be reported on Schedule I. _____ _ _ _ _ __ ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Rolling Green Cemetery 225.00 2 Messiah Village -Funeral Luncheon 344.96 3 CHPC Women -Funeral Luncheon 225.17 4 Rev. David Roquemore 150.00 5 Rev. Marilyn Ebersole 150.00 B. ! ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Gerald J. Brinser 8,000.00 Street Address 6 E. Main Street, P.O. Box 323 city Palmyra state PA zip 17078 Year(s) Commission paid 2010 2. ~, Attorney's Fees Brinser, Wagner & Zimmerman 3. I Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent a. Probate Fees Register of Wills (Ctrs. pd. $90.00 = $25,000 - $50,000) 5. ICI Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 ~ Register of Wills -Additional Cost of Letters TOTAL (Also enter on line 9, Recapitulation) 4,000.00 140.00 170.00 13,625.49 Schedule H Funeral E & COMMONWEALTH OF PENNSYLVANIA ~ M~~/:M~ M.~1 INHERITANCE TAX RETURN VW~ ~1J1 SIN R/GZJ RESIDENT DECEDENT FILE NUMBER ESTATE OF Rouse, Clara G. 21 - 09 - 0590 -- - _ 2 Cumberland Law Journal -Legal Advertising 75.00 3 The Sentinel -Legal Advertising 123.82 4 Postage 5.54 5 Bank Fees -Check Imaging 16.00 Page 2 of Schedule H SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES ~ LIENS INHERITANCE TAX RETURN f RESIDENT DECEDENT FILE NUMBER ESTATE OF ROUSe, Clara G. 21 - 09 - 0590 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM DESCRIPTION AMOUNT NUMBER 1 Alert Pharmacy 224.34 2 ~ Messiah Village ~ 3,368.40 TOTAL (Also enter on Line 10, Recapitulation) 3,592.74 REV-1313 EX+ (11-08) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rouse, Clara G. FILE NUMBER 21 - 09 - 0590 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) SHARE OF ESTATE (Words) AMOUNT OF ESTATE ($$$) I ' TAXABLE DISTRIBUTIONS[include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Douglas Rogers Nephew 1/8 Sched. G; 1/8 89,276.07 1254 Browning Court Residue Lansdale, PA 19446-5385 2 Wayne Rogers Nephew 1/8 Sched. G; 1/8 89,276.07 4151 Old Route 11 Residue Hallstead, PA 18822-9256 3 Paul Rogers Nephew 1/8 Sched. G; 1/8 89,276.07 103 Lakes Valley Road Residue Strasburg, VA 22657-5228 Enter dollar amounts for distributions shown above on lines 15 t hrough 18 on Rev 1500 cover she et, as appropriate. II NON-TAXABLE DISTRIBUTIONS: . A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX tS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 Camp Hill Presbyterian Church, 101 N. 23rd Stre et (1/8 Schedule G; 1/8 of Residue) 89,276.07 Camp Hill, PA 17011 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 89,276.07 REV-1 S13 EX+ (9-00) ~ ~ _ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Rouse, Clara G. FILE NUMBER 21 - 09 - 0590 NUMBER NAME AND ADDRESS OF PERSON(S) RELATIONSHIP TO DECEDENT SHARE OF ESTATE (Words) AMOUNT OF ESTATI ($$$) RECEIVING PROPERTY Do Not List trustee(s) I ' TAXABLE DISTRIBUTIONS include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)J 4 Richard Derr Nephew 1/8 Sched. G; 1/8 89,276.07 1432 Wovern Place Residue Ocean City, NJ 08226 5 James Derr Nephew 1 /8 Sched. G; 1 /8 89,276.07 6324 Baker Blvd., Apt. GS Residue Ft. Worth, TX 76118 6 Sydnae M. Steinhart Stepchild 1 /8 Sched. G; 1 /8 89,276.07 10 Covey Court Residue Charlestown, RI 02813-2803 7 Siri Lalime Step-Grandchild 1/8 Sched. G; 1/8 89,276.07 27 Egan Lake Place Residue The Woodlands, TX 77382 ~ i I Page 2 of Schedule J ~~p~l WILL OF CLARA G. ROUSE I, CLARA G. ROUSE, currently of Upper Allen Township, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any and all prior Wills and Codicils made by me. I. I direct that all my just debts and funeral expenses be-paid from the assets of my estate as soon as practicable after my demise. II. I direct that all estate and inheritance taxes that may be assessed in consequence of my death, shall be paid out of the principal of my general estate to the same effect as if said taxes were expenses of administration and all property includable in my taxable estate whether: or not passing under this Will shall be free and clear thereof. III. I beclueatl-~ unto any of my individual beneficiaries r~~entioned in Paragraph 4 below any of my items of tangible personal property they may desire. The remaining items shall pass as part of my residuary estate below. IV. All the rest, residue and remainder of my estate, of whatever nature and wherever situate, including property over which I hold a power of appointment, shall be divided equally among the following: my nephews, Douglas Rogers, Wayne Rogers, Paul Rogers, Richard Derr, and James Derr; my late husband's daughter and granddaughter, Syndae Steinhart and Siri Lalime; and the Camp Hill Presbyterian Church, Camp Hill, Pennsylvania. V. I appoint Gerald J. Brinser, Esquire, Executor of this my Will. In the event that he fails to qualify or ceases to act as Executor, I appoint Keith D. Wagner, Esquire, Executor in his place. VI. I direct that no bond be required of my fiduciary for the faithful performance of his duties in any jurisdiction. IN WITNESS WHEREOF, I, CLARA G. ROUSE, herewith set my hand to this my Last Will, typewritten on two (2) sheets of paper including the attestation clause and signatures of witnesses, this - a~ ~ day of May, 2004. C'~//.(~~I. ~ `Os n1- (SEAL CLARA G. ROUSE Signed by CLARA G. ROUSE, by her declared to be her Will in our presence, ~;Tho have hereunto subscribed our names as witnesses in her presence and at her request, this /~ ~ day of May, 2004. ~%~..~ residin at C~ , ~ ~ ~_ g ~ _ residing at~`~~~ ~_ QN ~~~~~ ~ ' -2- COMMONWEALTH OF PENNSYLVANIA COUNTY OF i~~' R ~ !vp -~ WE, CLARA G. ROUSE, ~ `r~ ~ ~ ~ ~ ~~''='s ~'` and rn ~4R i ~y,~ K . ~rY$O~, the testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly affirmed, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as witnesses and that to the best of our knowledge the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. C~IkL~ • ~e~wo.~ CLARA G. ROUSE ,.C IT'NESS i WI ES. Subscribed, sworn or affirmed and acknowledged before me by CLARA G. ROUSE, the testatrix, ~ •~~•~.o ~ - ~f~~s~t and Y-~fj-RI~yN iC. 7ySo~c1 ,witnesses, this ~ ~ day of May, 2004. t,'~-~t~ SEAL) o ary Public NOTARIAL SEAL WEND'Y L. CRAWFORD~ Notay Publf~ Palmyra Boro.~ Lebanon County Commission Expires Sept 10, 2005 -3- Federated Shareholder Services Company Pittsburgh, l'ennsyh~ania New York, New York Uostorl. Ma5ial'hUSe Ctti Chlhlin, Ireland FcderatedI nveston.a)rtl July 30, 2009 Brinser, Wagner & Zimmerman Attn Gerald J Brinser 6 East Main St F12 PO Box 323 Palmyra PA 17078 Reference: 00241883 Clara G Rouse Dear Mr. Brinser: Thank you for contacting Federated; we welcome the opportunity to assist you. Federated WORLD-CLASS INVESTMENT MANAGER On June-13, 2009, the value of the referenced account was $17,613.18, based on 1,623.3350 shares at the net asset value of $10.85 per share can that date. This is the only account w~ have for Clara Rouse. This is an individual account and therefore, there are no beneficiaries on file. To transfer or redeem shares of the referenced account, please use the enclosed Change of Ownership or Redemption by Mail Form. Each form outlines all the information Federated requires to process the transaction. The form must be signed by the legal representative(s) of the decedent's estate, including capacity (e.g., Mildred Thompson, Executrix), and bear an original Medallion guarantee. Please be sure to contact your guarantor regarding the documentation required prior to submitting your signature. A Medallion guarantee may be executed by an eligible guarantor. Eligible guarantors include commercial banks, trust companies, savings associations and credit unions, as defined by the Federal Deposit Insurance Act, and registered Broker-Dealers. Please confirm that the institution provides a verifiable STAMP2000 Medallion, affixed with the appropriate surety limit, prior to submitting your signature. A guarantee from a Notary Public is not acceptable. Please return the form that meets your needs with: ~ The enclosed Form W-9 to certify the Tax Identification Number (TIN) for the decedent's estate. The Form W-9 must be signed by the legal representative(s) of the estate, including capacity (e.g., Thomas Greene, Executor). If a TIN has not been established for the estate, and the transaction will be processed under the TIN currently listed on the account. J~i.22. 2009 10:31AM PNC BANK 412-705-2747 ~~~ t,~+cn~c T~se wav July 22, 2009 Briaser, Wagner c~ Zimmermian Gerald J Brinser Esq 6 E Main St 2nd fl PO Box 323 Palmyra, PA 17078 RE: Name: Clara G Rouse SSN: 172-01-5377 DOD: 06-13-2009 Dear Mr. Brinser: No. 6585 P. 1/2 In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Cert~fuate of Deposit Account # 31100263176 CLARA G ROUSE DOD balance: $12,404.82 + 1.44 accrued interest Interest paid 01-O1-2009 thru 06-13-2009 $257.84 YTD Checking Account Account # 51400.54011 CLARA G ROUSE DOD balance: $56,329.21 +~ 1.53 accrued interest Ix~texest paid O 1-O l -2009 thru 06-13-2009 $2.49 YTD Safety Deposit Boz The decedent maintained safe deposit box # 121 CLARA G ROUSE located at: 1Vlessiah Village 939 Oak~Oval Mechanicsburg, PA 17005-8409 717-691-4091 Established: 05-13-2005 Established: 0.1-01-1973 Page 1 of 2 Ju1.22. 2009 10:31AM PNC BANK 412-705-2747 No. 6585 P. 2/2 Please note that this office provides date ~of death balances for deposit accounts (YRAs, CDs, Checking and Savings). We do not process any financial transactions or provide statements. If you need assistance with arry of these items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by your iota] PIVC Bank branch office. Sincerely, National Financial Services Center PNC Banff N.A~. Member FDIC Page 2 of 2 2008 Tax Return Form 1040 as of July 6, 2009 Line Item On Your Return Your Figures IRS Figures Adjusted Gross Income $62,163.00 I $62,163.00 Taxable Income $.00 I $.00 Total Tax $.00 $.00 . Total Payments $3,300.00- Amount of Overpayment $3,300.00- Less: Penalties (computed below, if applicable) $.00 Less: Interest computed through July 6, 2009 (computed below) $.00 Less: Amount applied to next year's estimated tax $.00 Total Amount of Refund Per This Notice (Interest added, if any) $3,300.00 Other Information -1 ~Si!-e.d ~~~~~~i • In general, you must file a claim for refund within three years after you filed your return or two years after you paid the tax, whichever is later. • Your refund may include interest. Please be aware that interest you receive on tax refunds is taxable income to you in the year you receive it. Please retain this notice for your records. • If you are due a refund from the Internal Revenue Service, it should arrive within 6 weeks. Ally interest due you will be added. • Estimated TaY Filers Note: If you pay estimated taxes, check your computation of estimated tax to see if you should adjust your estimated tax payments. For tax forms, instl•uctions and information visit www.irs.~ov. Access to this site will not provide you with any taxpayer account information. Page 2 PNCI~~NI[~ PNC Bank, N.A Southcentral PA 040 D E P O S I T T I C K E T ODEPOS/TS MAY N BE ~ ABLE fOR IMMEOIATE~TNOROAWAL MYERS HARNER FUNERAL HOME, INC. 1903 MARKET ST. PH. 717-737-9961 CAMP HILL, PA 17011-4702 ~:6 ~,00~~~ 40 ~0~: 500000 300 1~~' ;CURRENCY COIN • 0'~3 ~ 7 yQTA/rreMS TOTAL ~ ~~' ~' ~ so ~2~346 313 checks and other items are received for depos- t subject to the provi- >ions of the Uniform "om~n2rcial Code or ,r., applicable collec- tion agreement. ESTATE OF ~ ~ ~~ ,iL ~ . ~~_ 1992 60-1273/313 ~alG D ~~-,.~ 9'49 osl <1" ord~ro/' ®. PNCBANK PNC Bank, N.A. 040 Central PA//'~ ~~ FOR ~e ~1%[~t~+~.-~-.~. ROBERT H HARNER SUP /9z 3.7/ 7~ S.cur~ty 1 ~ ~ F.atur.s SOR ~~ ~ i~'001992u' ~:03L3L2?38~: 5L~2036617u' ,, J 1, • Brethren iii Christ ~~~t11 -y~~Tl~~ POST OFFICE BOX 290 431 GRANTHAM ROAD GRANTHAM, PA 17027 Mr. Gerald J. Brinser Brinser, Wagner & Zimmerman P.O. Box 323 Palmyra, PA 17078 RE: Clara G. Rouse TAP -Special Account No. 2235 Dear Mr. Brinser: 1~~i1<ut~~r~~l.S~~i•~~~r~~s./r'~i• /-r~r~lr/irl.S'~~~«~~ri~<ls• July 27, 2009 The balance of the above account on June 13, 2009, the date of Mrs. Rouse's death, was $45,000.00. The accrued interest was $36.54 and the total date of death value was $45,036.54. There were no beneficiaries named on the account. If I can be of further assistance, please do not hesitate to contact me at 800-726-1448, Extension #5420, or at klehman(cybicfoundation.or~,;. Sincerely, Kimberly J. 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O r v 0 ... a Z D H r 0 I W Z a ~ 3 Q c~ 0 D 3 N a ~ ~ ~ :.°. N O `'' N as v a~ c' a ~ ~ N ''* N ~D C ~ p~ C RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 ROUSE CLARA G Estate File No.: 2009-00590 Receipt Date: 6/24/2009 Receipt Time: 09:39:39 Receipt No.: 1057256 Paid By Remarks: BRINSER ET AL JN --------~---------------- keceipt Distrib ution ----- -------- -------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 90.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 20.00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 -------------- CUMBERLAND COUNTY GENERAL FUN Check# 1323 -- $140.00 Total Received......... $140.00 / Rolling Green Cemetery June 29, 2009 Gerald Brinser Brinser, Wagner, and Zimmerman 6 E. Main Street Po Box 323 Palmyra PA 17078 Re: Estate of Clara G. Rouse Dear Mr. Brinser: Upon the request of Barbara Raffensperger I have en a copy of the contract for the interment services of Clara G. Rouse. The unpaid balance i 225.00. lease mail payment to: Rolling Green Cemetery /~ 1811 Carlisle Road d~ Camp Hill, PA 17011 ~~ Please feel free to call our office should you need any additional information. Regards, Sher Bluma stock Mana Enclosure DignityTM 1811 Carlisle Road • Camp Hill, PA 17011 • 717-761-4055 • Fax 717-761-4826 DignityMemorial.com RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 ROUSE CLARA G Estate File No.: 2009-00590 Receipt Date: 6/24/2009 Receipt Time: 09:39:39 Receipt No.: 1057256 Paid By Remarks: RINSER ET AL --------.---------------- Receipt Distrib uticn ----- -------- -------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 90.00 00 15 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN WILL ERTIFICATE SHOR . 20.00 00 10 CUMBERLAND BUREAU OF COUNTY RECEIPTS GENERAL & CNTR FUN M.D FEE JCP AUTOMATION FEE . 5.00 ---------------- CUMBERLAND COUNTY GENERAL FUN Check# 1323 $140.00 Total Received......... $140.00 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249166 Fax: (717) 249-2663 July 31, 2009 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Keith D. Wagner, Esquire Clara G. Rouse Estate RE: 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: July 17, July 24, and July 31, 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 PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL. (Under Act No. 587, approved May 16, 192}, f'. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law ,Iournal, of the County and State aforesaid, being duly sworn, according. to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borol;glz of Carlisle in tl~e County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: July 17, .Tuly 24, and July 31, 2009 Affiant further deposes that he is authorized to verify this st~~tement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to tinge, place and character of pu~lication are true. ~----- isa Marie Coyne, Editor SWORN TO AND SUBSCRIBED before me this 31 day of July, 2009 Notary Rouae, Clara C}, dec d. Late of Cumberland County. Executor: Gerald J. Brinser, 6 E. Main Street, P.O. Box 323, Palrriy_ ra, PA 17078. Attorney: Keith D. Wagner, Es- quire. NOTARIAL SEAL DEBORAH A COLLINS Notary Public CARLISLE 60R0, CUMBERLAND COUNTY My Commission Expires Apr 28, 2010 PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Erica Peterson, Classified Mana er, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13,1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): Tuly 20, 2009, Tuly 27, 2009, and August 3, 2009 COPY OF NOTICE OF PUBLICATION ~~ _ t :h .1 Notice is hereby given thaf •Letters Testamentary on the Estate of CLARA~G., ROUSE, deceasAd, late of Cumberland County, Pennsylvania, have been granted to the undersigned Executor. ~ :u~: •° All persons therefore indebted to said estate are requested to make immediate payment, and those having just claims will please present the same, duly authenticated, for settlement, without delay. Gerald J. Brinser, 6 East Main Street, P.O. Box 323, Palmyra, PA 17078 -,Executor; Keith D. Wagner - Attorney. . Affiant further deposes that he/she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. RETAIN THIS PORTION FOR YOUR RECORDS I'['HE SENTINEL - LEGAL I BRINSER,WAGNER & ZIMMERMN IP.O. BOX 130, CARLISLE, PA 17013 371942 I10 PUBLIC NOTICES NOTICE NOTICE IS HEREBY GIVEN THAT 3 THE SENTINEL - LEGAL TOTAL AD CHARGE 3 PROOF OF PUBLICATION DAYS RUN PURCHASE ORDER Est C. Rouse MESSAGE: cartc X08/04/09 3 I LGL O1PRF 07/20/09 PAY THIS AMOUNT Thank you for advertising with The Sentinel. NET AMOUNT 116.82 116.82 7.00 123.82 v g~o~ ~e~ ^..~.~ 22 * 2 08/03/09 GROSS AMOUNT 148 . 58* ,~,,~ SEP-10-2009 THU 03 54 PM ALERT PHARMACY SERVICES FAX N0. 17174864410 P. 01/01 ALERT PHARMAC'Y' SERV . INC . A FINANCE CHARGE OF 1.5 0 ~ PER MONTH 219 NORTH BALTI ORE AVE . (AN ANNUAL PERCENTAGE RATE OF 18.0) OR A MT .HOLLY SPRING , PA 17065 MxNIMUM SERVICE CHARGE OF $ 1.00 WSLL IIE CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PART DUE PHONE: 800-266-91954 08/31/ PMT DUE..09/24/09 30 DAYS. 3.27 6 0 ]JAYS . 217.7 5 ALERT PHARMACY S ** THIS AMOUNT IF YOU RECEIVE A NEW INSURANCE CARD FOR YOUR PRESCRIPTIONS DE SURE TO SUPPLY US WTTH A COPY. 2009 ROUSE, CLARA ROUSC BARBARA RAFFENSPERGER GRP-7W PO 80~ 453 PAGE 1 MT WOLF PA 17347 ARV. TNC.2].9 NORTH BALTIMORE AVE. MT.HOLLY SPRINGr~PA 17065 r DUE .oo 22..02 .00 3.32 224.34 .00 ~' 224.34 ~_.... ~ q ~~ .~ ~~ essla 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 BARBARA S RAFFENSPERGER P.O. BOX 453 MT. WOLFE, PA 17347 71 ~a y Form PB-01 QUESTIONS? CALL: 717 697-4666 RESIDENT # UNIT STMT. DATE 98002 266 P 06/30/2009 RESIDENT S Mrs. CLARA G. ROUSE TOTAL AMOUNT DUE $3,368.40 DATE DUE 07/31/2009 .. ~• • -. DATE DESCRIPTION RATE Unit ! CHARGES CREDITS BALANCE Balance Forward 5,334.19 06/12/09 PAYMENT RECEIVED -THANK YOU!!! 5,334.19 0.00 *** Nursing Care **'~ 06/01/09 MOTION MONITOR 06/04-06/12 2.00 1.00 2.00 2.00 06/03/09 RM/ BRD -NURSING -QUAD 251.00 3.00 753.00 755.00 06/01-06/03 06/12/09 RM/ BRD -NURSING -PRIVATE 282.00 9.00 2,538.00 3,293.00 06/13/09 PREVAIL PANT LINERS PL 112 1.30 55.00 71.50 3,364.50 06/30/09. HEALTH SHAKES (PFR CONTAINER) 0.30 1300 3.90 3.368.40 RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL ~4MOUNT DUE 98002 3,368.40 0.00 0.00 0.00 0.00 $3,368.40 RESIDENT NAME Mrs. CLARA G. ROUSE N/q PB 01 A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! . ~ y('~~ , If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank ou!` ~~i 9` ~~ ~,~ `~