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Home My WebLink About04-08-1015056041114 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN /~(~~ . ~ ,~ ~ j / Harrisburg, PA 17128-0601 V / RESIDENT DECEDENT 21-09-00751 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 165-28-2206 07292009 07161935 Decedent's Last Name Suffix Decedent's First Name MI WAGNER THOMAS R (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 REGISTE R OF WILLS FILL IN APPROPRIATE OVALS BELOW 0 1. Original Return Q 2. Supplemental Return Q 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of 0 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 0 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death 0 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONr'IDENT IAL TAX INFORMATION SHOULD BE DIRECTED T0 : Name Daytime Telephone Number rya ca STEPHEN D. TILEY 717-243-5. o -~T~ :' Firm Name (If Applicable) y. REGISTER ~•~ IE3~.7SE Y F . _; ~' `~ ~``° ~ r~~r '~ FRY AND TILEY ~~ ~ a~ ~ -,;~~: First line of address ~~~~ ~ " r;'~~• ~;- ~ ~ 5 SOUTH HANOVER STRET O ~ tC.7C-c~ ~ . ~ r ''c "i .C ~~ ~~ Second line of address ~ _ C~ City or Post Office State ZIP Code DATE FILED CARLISLE PA 17013 Correspondent'se-mail address: Stiley@freytiley.COm 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 com let . eclaration of re arer other than the ersonal re resentative is based on all information of which re arer has an knowletl e. SIGNATURE OF P N~~SI E FAG RETURN ~~~ q/ a ADDRESS JEFFRE~A. WAGNER, 22 SOUTH WALNUT ST. , MT. HOLLY SPRINGS, PA 17065 SIGNAL THER~HAN REPRESENTATIVE / QATE ADDRESS STEPHEN D. TILEY, 5 SOUTH HANOVER STREET, CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041114 15056041114 L J REV-1500 EX 15056042115 Decedent's Social Security Number ~ecedent'sName: THOMAS R WAGNER 165-28-2206 RECAPITULATION 1. Real estate (Schedule A) . . ............................ ............ 1. NONE 2, Stocks and Bonds (Schedule B) ................................ . ..... 2. 2 7 8 31.5 9 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. NONE 4. Mortgages & Notes Receivable (Schedule D) ................ . .. . ... . ... . 4. NONE 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 11 6 9 O . 13 6. Jointly Owned Property (Schedule F) OSeparate Billing Requested .. , ..... 6. NONE 7, Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) OSeparate Billing Requested ...... ,. 7 2 4 0 2 6. 0 0 8. Total Gross Assets (total Lines 1-7) .................................. 8. 6 3 5 4 7. 7 2 9. Funeral Expenses & Administrative Costs (Schedule H) .... . ...... . ...... .. 9. 112 6 8 . 3 7 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. . 10. 6 5 5 2 . 5 8 11. Total Deductions (total Lines 9 & 10) ................................ . 11. 17 8 2 0 . 9 5 12. Net Value of Estate (Line 8 minus Line 11) ............................ . 12. 4 5 7 2 6 . 7 7 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... . 13. 0 . 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... . 14. 4 5 7 2 6 . 7 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 .0 O 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate x .0 4 5 $ 3 3, 713.4 9 1 g. 1517.0 0 17. Amount of Line 14 taxable at sibling rate X • 12 17. 0 . 0 0 18. Amount of Line 14 taxable at couateral rate x • 15 $12 , 013.2 8 18. 18 0 2 . 0 0 19. TAX DUE ............................................ "......... . 19. 3 319.0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056042115 15056042115 REV-1500 EX Page 3 165-28-2206 Decedent's Complete Address: DECEDENT'S NAME THOMAS R WAGNER DECEDENT'S SOCIAL SECURITY NUMBER 165-28-2206 STREET ADDRESS 421 CHESTNUT STREET CITY MOUNT HOLLY SPRINGS STATE PA Z I P 17065 Tax Payments and Credits: 1, Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments $1,550.00 C. Discount $81.58 3. Interest/Penalty if applicable D. Interest E. Penalty File Number 21-09-00751 (1) 3319.00 Total Credits (A + g + C) (2) 1631 Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. 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. (5) 1687.42 A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 1687 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 life of either payments, benefits or care? ............................. 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................. .. 3. Did decedent own an "in trust for" or payable upon death bank account 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 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. 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. §9115(x)(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(x)(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(x)(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. 217 REV-1503 EX+ '6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS & BONDS FILE NUMBER Thomas R Wagner 21-09-00751 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Pershing/Financial Network Invesment Corp. 200 N. Sepulveda Blvd., Suite 1300 EI Segundo, CA 90245-5672 See Exhibit "C" Personal Brokerage Account No.: 4N2114417 Brokerage Money Market Account Cash 675 First Trust/Four Corners SR at $10.17 145 Hershey Company at $40.50 1,735 Liberty All-Star Equity Fund at $3.84 1,845 Zweig Total Return Fun at $3.66 $368.28 $1,310.96 $6,864.75 $5,872.50 $6,662.40 $6,752.70 TOTAL (Also enter on line 2, Recapitulation (If more space is needed, insert additional sheets of the same size) 217 REV-1508 EX+(5-98) SCHEQULE E CASH, BANK DEPOSITS, & MISC. CO~d NOERITANCETAXRETURNANIA PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Thomas R Wagner 21-09-00751 Include the proceeds of Iltigatlon and the date the proceeds were received by the estate. All property jointly-owned_with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Household furnishings located at 421 Chestnut St., Apartment No. 1, Mount Holly Springs, PA 17065. See Exhibit "A" attached $1,475.00 2. Orrstown Bank Checking Acct. No. 146000020. See Exhibit "B" attached DOD Balance $975.02 Accrued Interest to DOD $0.02 3. Orrstown Bank Savings Act. No. 746000026. See Exhibit "B" attached DOD Balance $2 81 Accrued Interest to DOD N/A 4. 12003 Chevrolet Trailblazer automobile. Title No. 59098663001 WA Kelly Blue Book Value $8,480.00 (See Exhibit "D"): Less damage estimate regardng accident: $1,751.00 (See Exhibit "E") Net Value of Vehicle $6,728.14 5. Erie Insurance Exchange Damage Claim Regarding 2003 Chevrolet Trailblazer $1,501.86 (See Exhibit "E") 6. Landlord's (James H. Slyder Contractng) Security Deposit Refund $575.00 7. AIG Cancer Insurance Refund $32.60 8. Cumberland County Veteran's Burial Benefit $100.00 9. Highmark Blue Shield Refund $127 68 10. Adams Electric Cooperative, Inc. 1338, Biglerville Road, P.O. Box 1055, Gettysburg, PA 17325 Patronage Capital 172 TOTAL (Also enter on line 5, Recapitulation) $ 11,690 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+(OS-09) SCHEDULE G pennsy{vania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS & INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Thomas R Wagner 21-09-00751 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION pFnvaucne~el TAXABLE VALUE 1. IRA 0 Pershing/Financial Network Investment Corp. 0 200 N. Sepulveda Blvd., Suit 1300 0 EI Seguno, CA 90245-5672 0 (Orrstown Bank/Gibb Financial Services) 0 See Exhibit "C" 0 0 IRA Retirement Brokerage Account No.: 4N211637 0 Brokerage Money Market Account $3,440.06 100.00% 0 3,440 1,125 Enhanced S&P CV Call Fund @ $9.09 $10,226.25 100.00% 0 10,226 2,050 Helios High Income Fund @ $1.26 $2,583.00 100.00% 0 2,583 675 Helios Strategic Income Fund @ $1.07 $722.25 100.00% 0 722 4,250 Managed High Yield Plus Fund @ $1.66 $7,055.00 100.00% 0 7,055 0 BENEFICIARIES: 0 A. Jeffrey A. Wagner 0 22 South Walnut Street, Mount Holly Springs, PA 17065 p 25% IRA $6,006.50 0 0 B. Anthony S. Wagner 0 28 Nailor Road, Dillsburg, PA 17019 0 25% IRA $6,006.50 0 0 C. Jane Ege 0 345 West Ridge Street, Carlisle, PA 17013 p 50% IRA $12,013.28 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL (Also enter on Line 7, Recapitulation) 5 24 026 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX + (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Thomas R Wagner 21-09-00751 Decedent's debts must be reported on Schedule I. ITEM A B. 1 FUNERAL EXPENSES: Hollinger Funeral Home & Crematory, Inc. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address DE City Year(s) Commission Paid: State ZIP 2 3 4. 5. 6. 7. Attorney Fees: Frey and Tiley Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Frey and Tiley Tax Return Preparer Fees: Frey and Tiley Advertising -The Sentinel 8. Advertising -Cumberland Law Journal 9. Register Of Wills -Filing Fee, Inheritace Tax Return 10. Reserve for filing fee to Register of Wills -Account TOTAL (Also enter on Line 9, Recapitulation) ~ $ If more space is needed, use additional sheets of paper of the same size. ZIP NT $8,203.59 $2,500.00 $136.00 $0.00 $0.00 $208.78 $75.00 $15.00 $130.00 11.268 REV-1512 EX+(12-OB) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Thomas R Wagner 21-09-00751 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. it more space is neeaea, insert aaamonai sneers of the same size. REV-1513 EX+ (11-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN SCNEDULEJ BENEFICIARIES ESTATE OF FILE NUMBER Thomas R Wa ner 21-09-00751 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 2116 (a) (1.2).] Frey A. Wagner South Walnut Street, Mount Holly Springs, PA 17065 2. Anthony S. Wagner 28 Nailor Road, Dillsburg,PA 17019 3. Jane Ege 345 West Ridge Street, Carlisle, PA 17013 n Son (Sister-In-Law) of IRA ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 50% 50% TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, insert additional sheets of the same size. Pennsylvania 17316 do hereoy md«c. ~~~---" - r'. Por my last will and testament, and I do hereby revolve and declare void any time heretofore made. will or wills by me at any ~ II~'• FIRST' I direct that all my just debts, funeral expenses and ~ 6 administration expenses shall be paid from the assets of my estate. I direct ~ j that all federal, state and other death ta~:es payable by reason of my death, with respect to the property forming my gross estate for tax purposes, cuhether or not passing under this will, including any interest or penalty F imposed in connection with such taxes, shall be considered a part of the ~ expense of the administration of my estate, and shall be paid from the i residue of my estate, without apportionment or right of reimbursement. All such taxes on present or future interests shall be paid at such time or times as the personal representative of my estate deems best, regardless of wY~en such taxes are due. i SECOND' I give, bequeath and devise all of the rest, residue and i! • E remainder of my estate, both Xeal and personal property, of whatsoever kind ~ and nature and wheresoever situate, to my wife, Dorothy E. Wagner, if she I ~ ~ i ~ ~~ survives me for a period of at least thirty (30) days. e I ~ THIP.D: If my wife, Dorothy E. Wagner, fails to survive me for a !~ ive, bequeath and devise all of the period of at least thirty (30) days, I g !i {II II estate, both real and personal property, of ~ rest, residue and remainder of my whatsoever kind and nature and wheresoever situate, in equal shares to my children as may be living at the time of my death and to the issue then then be deceased; per stirpes. living of such of my children as may ~ ~I FOURTH: I appoint Adams County National Bank, of Gettysburg, j I~ uardian of any property which passes either under this will or i ` Pennsylvania, g I otherwise to a minor, and with respect to which I am authorized to appoint a i guardian and have not otherwise specifically done so. Such guardian shall ~i, Thomas R. Wagner ~~' - - _ _ - -_ f have the power to use principal as well as income from time to time for any ~ such minor's education, support and welfare, and to make payment for these pur- i poses to such minor or to any person or persons providing education, support, ~ ", ~ r or services for such minor without obtaining the approval of any Court whatsoever.! FIFTH: I appoint my wife, Dorothy E. Wagner, executrix of this my last will. Should my said wife fail to qualify or cease to act as e~:ecutrix, I appoint my son, Jeffrey A. Wagner, executor of this my last will. Should my said wife and my said son, Jeffrey A. Wagner, fail to qualify or cease to act as executors, i I appoint my son, Anthony S. Wagner, executor of this my last will. Should my said wife and my said sons, Jeffrey A. Wagner and Anthony S. Wagner, fail to qualify or cease to act as executors, Z appoint my son, Troy Richard Wagner, executor of this my last will. Should my said wife and my said sons, Jeffrey A. i s Y 4?agner, Anthony S. Wagner and Troy Richard Wagner, fail to qualify or cease to act as executors, Z appoint Adams County National Bank, of Gettysburg, Pennsyl- d vaaia, executor of this my last will. I direct that none of the persons named f in this paragraph nor the said Banlc shall be required to give bond in order to ~ qualify as or perform the duties of the personal representative of my estate in any jurisdiction. I authorize and empower my personal representative to sell any or all of the assets of my estate, both real and personal property, at public or private sale or sales and to make, execute, acknowledge and deliver unto any `~ I purchaser thereof good and sufficient deeds and bills of sale for the transfer and; conveyance thereof. i f! ZN t,?ITNESS WHEREOF, I, Thomas R. Wagner, the testator have to this my '' j'. last will and testament, subscribed my name and affixed my seal this 18th j: ~ [! day of February 1987; this will being typewritten upon two (2) j is 'i i sheets of paper which are affi::ed together and each of which bears my signature e ~ ~ i at the bottom thereof. l f i i n ~ ~ d"C ~f ( SEAL ) i ~" ~ Thomas R. Wagner I I. Signed, sealed, published and declared by ~ .- the above named testator, Thomas P.. Wagner, as f i and for his last will and testament, in the i ~ presence of us, who in his presence, and at I his request, and in the presence of each other, ~ I have hereunto subscribed our names as witnesses thereto. ~ ~/ ~ ~6 ) ~ , /,r I ;~- i _,_ ~ r COPL^10NWEALTH OF PENNSYLVANIA, COUNTY OF ADAMS. ~' ~'. ~ We, Thomas R. Wagner, Pobert G. Bigham and Marv P Sham the testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his last will and that he had signed willingly, and that he executed it as his free and voluntary act for the purposes therein e~:pressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as witness and that to the best of the l;nowledge of each of the witnesses, the testator was at that time eighteen years of ale or older, of sound mind and under no constraint or undue influence. Thomas R. Wagner _ ~ '~ Witness ~~ yS ,i Witness i ~ ~ -, Subscribed, sworn to and acknowledged before me by Thomas R. Wagner, the testator, and subscribed and sworn to before me by P.obert G. Bieham and riarv P Shin witnesses, this 18th day of February, 1987. i~ :~ /r 1 Notary Publi My commission e~:pires: Ed~NCq F: t;EPnER, ~otsy Public ~ettsy6uY~, Hdsms County, Pa. ~`~~C.Qmmissian Exp'rss rcov. "s,19~30 ry ,~.~ _ (1 ~~~n ~.~ ~-- ---- __ .__ _ _ __v~~l-~------- __ __ --- - _ ~~~C~V ll~~'1'l._ _- ~------___-_ - --- ---- --- - - - -5- - - _ ____ _____G~ ~sK _~~G~~_~ - --- _ _ - --- ----.. ._ _ _~~ q~ s~ _~ ~.~--- ---_ _ _ _-____ r~sse ~'-- -------------------1 _~.L~ ~-------------- - --- . ~~ (,~: -`~~~ '~~~ - -C~`~~' ' _t~cy lam'-------------------- ~~~~~~~ ~,.,ou~ - -- T~ ~. SEP-29-2009(TUE) 09;27 ~~ Frey & Tily 5 South Hanover Street Carlisle, PA 17013 Fax 243-6441 September 29, 2009 Re: Estate of Thomas R. Wagner Social Security Number 165-28-2206 Date: of death July 29, 2009 IT IS HERERBY CERTIFIED THAT THE ABOVE NAMED DECEDENT, GN THE ABOVE DATE, HAD THE FOLLOWIlVG ACCOUNT(S) WITH ORRSTOLVN BANK: CHECKING ACCOUNT Account - Title of Account - Date opened - Joint Account (name/date) - Balance - Acerued Interest - SAVINGS ACCOUNT Account - Title of Account - Date opened - Joint Account (name /date) - Balance - Accrued Interest - ~~ ORRSTOWN FINANCIAL SER`JICES, INC. ATraditon,ofE.:cellence . 146000020 50+ Interest Check 5/20/04 None $975.04 $.02 746000026 Statement Savings 5/20/04 None $2.81 None -acct dormant since 3 / 09 est Regards Vicki L. Gullixon Customer Service Specialist P. 001 /001 77 East F~n~ Sr: ee[, Shippcnsb~:rR, Pc:xzsylvazia 17257 Holdings by Investor Thomas R Wagner Mr Von R Jaymes Combined Account Portfolio 614a N Baltimore Ave Gibb Financial Services Date: 07/29/2009 Mt Holly Spgs, PA 17065 427 Village Drive Created: 09/04/2009 Carlisle, PA 17015 717-249-3737 Thomas R Wagner Acct Name:IRA FBO THOMAS R WAGNER PERSHING LLC AS CUSTODIAN 614A N BALTIMORE AVE MT HOLLY SPGS PA 17065-1901 Acct No:4N2116347 Acct Type:Retirement Account Rep No:8UG Asset Name Ticker Asset Type Mgt. Name Quantity Price($) Vafue($) BROKERAGE MONEY MARKET CASH OR BROKERAGE 3,440.06 1.00 3,440.06 EQUIVALENTS MARKET ENHANCED S&P500 CV CALL FD I BEO EQUITY 1,125.00 9.09 10,226.25 COM RECTOS HIGH INCOME FD INC COM HIH FIXED INCOME 2,050.00 1.26 2,583.00 RECTOS STRATEGIC INCOME FD I HSA FIXED INCOME 675.00 1.07 722.25 COM MANAGED HIGH YIELD PLUS FUND HYF FIXED INCOME 4,250.00 1.66 7,055.00 INC Account Total: Acct Name:THOMAS R WAGNER 614A N BALTIMORE AVE MT HOLLY SPGS PA 17065-1901 Acct No:4N2114417 Rep No:8UG $24,026.56 =p~~ Acct Type:lndividual Ticker Asset Type Mgt. Name Quantity Price($) Value($) Asset Name BROKERAGE MONEY MARKET CASH OR BROKERAGE 368.28 1.00 368.28 EQUIVALENTS MONEY MARKET CASH OR 1,310.96 1.00 1,310.96 CASH EQUIVALENTS FIRST TRUST/FOUR CORNERS SR FCT FIXED INCOME 675.00 10.17 6,864.75 FLTG II 00 145 40.50 5,872.50 HERSHEY CO COM HSY EQUITY . LIBERTY ALL-STAR EQUITY FUND USA EQUITY 1,735.00 3.84 6,662.40 ZWEIG TOTAL RETURN FD INC COM ZTR BLEND 1,845.00 3.66 6,752.70 Account Total: $27,831.59 NOnI ~, ... r._ InvestorTotal: $51,858.15 Page 1 of 2 Incomplete rf presented without accompanying disclosure page f =,a~n ~~~~~~ tc~~f Holdings by Investor Thomas R Wagner 614a N Baltimore Ave Mt Holly Spgs, PA 17065 Disclosure: Mr Von R Jaymes Gibb Financial Services 427 Village Drive Carlisle, PA 17015 717-249-3737 Combined Account Portfolio Date: 07/29/2009 Created: 09/04/2009 Securities offered through Financial Network Investment Corporation, member FINRA/SIPC. Financial Network Investment Corporation and Gibb Financial Services are affiliated companies. Values are as of 07/29/2009 unless otherwise noted. We believe the sources to be reliable, however, the accuracy and completeness of the information is not guaranteed, as it is a compilation of information from various financial sources (mutual funds, direct participation programs, correspondent brokers, etc.). In the event of any discrepancy, the sponsor's valuation shall prevail, Performance data quoted represents past performance and does not guarantee future results. The investment return and principal of an investment will Fluctuate so that an investor's shares when redeemed may be worth more or less than the original cost. The values represented in this report may not reflect the true original cost of the client's initial investment. For fee-based accounts only: the figures may or may not reflect the deduction of investment advisory fees. If the investment is being managed through afee-based account or agreement, the returns may be reduced by those applicable advisory fees. Refer to your Advisor's Form ADV, Part II. The information contained in these reports is collected from sources believed to be reliable. However, you should always rely on your statements received directly from product sponsors. If you have any questions regarding your report, please call your representative. Page 2 of 2 2003 Chevrolet TrailBlazer -Private Party Pricing Report -Kelley Blue Book Page 1 of 3 i _. _ , _. g ~~'.' TNF TRt1STED RESOi:RtE ~:% ;a ;r.. ?a_t~Lna~ UsedCal_ ;3."---.,v~ ,. ~iJ§~;._ ,. _,c~.~s_s~__.~ .~.,_I_._itzln°:re:•-.c:,! 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A 1;5:": r~'.l; On Blue Book Classifleds`^ Average Consumer Rating (1995 Reviews) Read Reviews ~Chevrolet~ V ~~~-N.,,6y .-. .__ _: ~?~~~ ~p~_ 4.3 o9t of S Revie~.v this Vehicle ;TrailBlazer w. _ ____ Numf3ar ~f; P! Ve'i'~:CieS 150 Miles _~__ 12009 Chevralet TrailBlazer 2909 Ford E xplorer ZIP Code ;17019 To View Ads, Click Photos Revie~y C Photos Re~~iie+q Prating Pricing PAor2 Results '~.. Eltli; i.`.ic'il~?I .~? I J Compare Used vs. New -__.....__-___._._ _.__...__ .._..__._ _._ ..___ __._. _._.- 55,000 Cc 510,000 ~ ~„ ____,____ ~ Vehicle Highligfits ~. both New and Used ISUV ~^ Mileage: 50,000 - - Engine: 6•Cyl. 4.2 Liter Transmission: Automatic To View Lisa, Click Drivetraln: 4WD 'ilE4•+ ~,H+litEy !;tifC1E Select Year... •~ Se3ected Equipment Change Equipment _..-...._ ~._ Standard Cr search b/ Category ~, =har.ne =1P Code ',Save Vehicle Pl~in-. Email -. B9G(MRRK r' ~~- -.__. advertisement __... http://www.kbb.com/KBB/UsedCars/PricingReport/2003_Chevrolet TrailBlazer 2056 Pr... 8/11/2009 g~~>~ - - - 08/10/2609 AT 02:43 PM Rea: VARNES ,? 01017104801200 ERIE INSURAiVCE GROUP FIELD OFFICE-017 4901 LOUIS.DRIVE P.O. BOX 2013 MECHANICSBURG, PP. 17055 (717)646-8275 FAX: (717)646-8276 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: KATHERINE ZIMMER #514856 08/10/2009 02:43 PM ADJUSTER: KATHERINE ZIMMER #514856 INSURED: THOMAS WAGNER CLAIM #010171048012001 OWNER: THOMP_S WAGNER POLICY #Q081200174 ADDRESS: 421 CHESTNUT ST APT 1 DATE OF LOSS: 07/23/2009 AT 12:00 AM MT HOLLY SPRINGS, PA 17065-0000 TYPE OF LOSS: COLLISION EVENING: (717)486-4837 POINT OF IMPACT: 4. RIGHT QTR POST INSPECT SONS RES LOCATION: REPAIR UNKNOWN FACILITY: OTHER 4 DAYS TO REPAIR LICENSE # 2003 CHEV TRAILBLAZER 4X4 LT 6-4.2L-FI 4D UTV DK GREEN INT:CLOTHE VIN: 1GNDT13S832224662 LIC: 00659 PA PROD DATE:-11/2002 ODOMETER: 49141 CONDITION: GOOD AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL INTERMITTENT WIPERS CLIMATE CONTROL ELEC. INSTRUMENTATION KEYLESS ENTRY ALARM REAR WINDOW WIPER BODY SIDE MOLDINGS DUP_L MIRRORS PRIVACY GLASS CONSOLE/STORAGE OVERHEAD CONSOLE LUGGAGE/ROOF RACK FOG LAMPS CLEP.R COAT PAINT METALLIC PP_INT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER MIRRORS HEATED MIRRORS AM RADIO FM RADIO STEREO SEARCH/SEEK CD PLAYER ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG 4 WHEEL DISC BRAKES CLOTH SEATS BUCKET SEATS RECLINE/LOUNGE SEATS REAR STEP BUMPER RUNNING BOARDS/SIDE STEPS TRAILERING PACKAGE POWER TRUNK/TAILGATE AUTOMATIC TRANSMISSION 4 WHEEL DRIVE OVERDRIVE ALUMIN"LTM/ALLOY WHEELS N0. OP. --- DESCRIPTION ---------------------- QTY EXT. PRICE LABOR PAINT -------------------------------- ---------------------- 1 FRONT DOOR 2* RPR RT DOOR SHELL INNER EDGE * 3.0* 2.4 3 ADD FOR CLEAR COAT 1.0 4 ADD FOR EDGING 0.5 5 R&I RT BELT W'STRIP 0.3 6 R&I RT R&I S IDE MLDG 0.3 1 assn ,•.r R -~~? b''e ., .. ,~/20Ci9 F_T 02:43 PM Rea: VARNES ,R 010171048012001 SUPPLEMENT OF RECORD 1 WITH SUMVL?RY 20C3 CHEV TRAILBLAZER 4X4 LT 6-4.2L-FI 4D UTV DK GREEN INT:CLOTHE NO. OP, DESCRIPTION QTY EXT. PRICE LABOR FAINT 7 R&I RT MIRROR ASSY W/POWEP. 0.3 W/HEATED 8 REPL RT I-:ANDLE, OUTSIDE BLACK 1 66.18 0.4 9 R&I RT R&I TRIM PANEL 0.6 10# R&R RAIN GUARD 1 0.5 11 REP.R DOOR 12 R&I RT R&I DOOR ASSY 1.3 13* RPR RT DOOR SHELL W/LONG WHEEL 7.0* 2.3 BASE CHEVROLET 14 OVERLAP MAJOR ADJ. PANEL -0.4 15 ADD FOR CLEAR COAT 0.4 16 R&I RT R&I SIDE MLDG 0.3 17 RBI RT I-~~ANDLE, OUTSIDE BLP_CK 0.4 18 R&I RT R&I TRIM PANEL 0.6 19# R&R RAIN GUARD 1 0.5 20# R&I LT EMBLEM 1 0.2 21 QUARTER PANEL 22* RPR R.T QUARTER PANEL W/LONG WHEEL 1.5* 2.6 BASE 23 OVERLAP MAJOR ADJ. PANEL -0.4 24 ADD FOR CLEAR COAT 0.4 25 ADD FOR EDGING 0.3 26 ADD FOR LOCK PILLAR 0.5 27 R&I RT WHEELHOUSE LINER SHORT 0.3 W~:EEL BASE 28 REAR LAMPS 29 R&I RT TAIL LAMP ASSY CHEVROLET 0.3 3 0 REP.R BUMPER 31 R&I R&I BUMPER COVER 1.2 32** REPL A/M BAG CAR * 1 10.00* 0.2* 33# UC 1 10.00 34# ROPE OFF QT GLASS 1 0.5 35# MASK JAMB 1. 0.2 36** REPL A/M SOUND DEAD PAD FR DOOR * 1 9.00* 0.0* 37# SO1. OPENED TO ADD INFO 1 38 OTHER CHARGES 39# E.P.C. ----------- 1 5.00 --------- ----------- ------ -------------------- SUBTOTALS =_> 100.18 19.7 9.8 2 Req: VARNES ,R x/2009 AT 02:43 PNI 010171048012001 SUPPLEMENT OF RECORD I WITH SUMMARY 2003 CHEV TRAILBLAZER 4X4 LT 6-4.2L-FI 4D UTV DK GREEN INT:CLGTHE ESTIMATE NOTES: UNRELATED DAMAGE: FRONT BUMPER RUBBED AND DENT AT FRONT OF RT FENDER,GOUGE IN REAR BUMPER. REPAIR SHOP IS ALWAYS OWNER S CHOICE: BELOW ARE TWO SHOP THAT WILL HONOR THE REPAIR ESTIMATE. PIFERS AUTO BODY (KEITH) 717-528-4186 ULTIMATE AUTO BODY (MATT) 717-292-6060 PARTS 95.18 BODY LABOR 19.7 HRS @$ 44.00/HR 866.80 PAINT LABOR 9.8 HRS @$ 44.00/HR 431.20 PAINT SUPPLIES 9.8 HRS @$ 26.00/HR 254.80 OTHER CHARGES 5.00 ----- SUBTOTAL $ 1652.98 SALES TAX $ 1647.98 @ 6.0000% 98.88 TOTAL COST OF REPAIRS $ 1751.86 ADJUSTMENTS: DEDUCTIBLE 250.00 TOTAL ADJUSTMENTS $ 250.00 NET COST OF REPAIRS $ 1501.86