HomeMy WebLinkAbout04-0601
Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of James W. Clouser No.;2I- 04 ... l" 01
also known as
,Deceased Social Security No. 721-01-6997
Jack L. Witter
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
[K] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut or named in the last Will of
the Decedent, dated 03/06/2000 and codicil(s) dated None
Patricia L. Clouser, Executrix, died on June 6, 2000
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
N/A
o B. Grant of Letters of Administration
(c.I.a.; d.b.n.c.l.a; pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and
heirs:
.. '~'.
I Name Relationship - Resideilce I
..
L.___
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(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumber land County, Pennsylvania with histher last family
L.,
or principal residence at 96 Clouser Road, Monroe Township, Mechanicsburg, PA 17055
(list street, number, and municipality)
Decedent, then ~years of age, died 06/19/2004 at Mechanicsburg, PA
(Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PAl All personal property $ 10,000.00
(If not domiciled in PAl Personal property in Pennsylvania $
(If not domiciled in PAl Personal property in County $
Value of real estate in Pennsylvania $ 150,000.00
situated as follows: 96 Clouser Road, Mechanicsburg, PA 17055
Jack L. Witter
985 Hauck Road, Mechanicsbur , PA 17055
Prepared by the Pennsylvania Bar Association
Copyright (e) 1996 form software only CPSystems,lne. Form RW-1 (1991)
"-
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true
and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of
the Decedent, Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed -;f~ ~!~
~ J~ck L. Witter
before me thi~ day of V
~:i \kAM~ ~:,
~\F~~
No. ;2 I - D 4 - l# 0'
Estate of James W. Clouser Deceased
Social Security No: 721- 01- 6997 Date of Death: 06/19/2004
AND NOW, ~fLQ rJ5 ;)oo~ ,in consideration
--
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters [!] Testamentary 0 Of Administration
(c.I.a.; d.b.n.c.l.a.; pendente lite; durante absentia; durante minoritate)
are hereby granted to Jack L. Witter
in the above estate and that the instrument(s) dated 03/06/2000
d~";b.d ;, tho P.,,", b::::mod to p'ob... ood fU.d of "'o~. D~ WoII of D"'fk 1Jt
Letters. . . . . . . $, c235 . DD win, :tA Jil ff. '[ ( ~'Ja,t
D('j Register of Wills ~f\
Short Certificate(s). . . .. $ ~ II . () D 1.:2. u0 "0 ' ~. -4-
Renunciation. . . .. $ Attorney: James D. Bogar ~
Affidavits ( ) ... $ I.D. No: 19475
Extra Pages ( ). . .. $,;)4 . DO Address: One West Main Street
Codicil. . . . . . . . . .. $ Shiremanstown, PA 17011
JCPFee. . . . . . . . .. $ /D. CJC) Telephone: 717/737-8761
Inventory. . . . . . . . .. $
Other .. ........ $
'\<?j 00
TOTAL. . . . . . . .. $ c:::><( <:) ,
Prepared by the Pennsylvania Bar Assoeiation Copyright (e) 1996 form software only CPSystems, Ine. Form RW-1 (1991)
Register of Wills of Cumberland County, Pennsylvania
OATH OF SUBSCRIBING WITNESS
Estate of James W. Clouser No..2.., - D 'f - " 0 J
also known as
, Deceased
James D. Bogar Carol A. Bogar
(each) a subscribing witness to the o codicil(s) [!] will(s) presented herewith, (each) being duly qualified according to law
depose(s) and say(s) that she/ he/ they was/ were present and saw the above Testator(rix) sign the same and that she/he/they signed as
a witness at the request of Testator(rix) in his/her/their presence and ~ in the presence of each other DO in the presence of the
other subscribing witness(es).
gar
in Street
wn, PA 17011
(Address)
t!~ U 4-P--r:~
(Signature) Carol A. Bogar LJ .,-
w J
One West Main Street~' --
1..-.--'
Shiremanstown, PA 17011 ,~
(Address) L
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Sworn to or affirmed and subscribed
",)
before me this .:}4+ l--- day . .
..-....
of ~ L. (, Y1...( _:Jecll ,,~C..,
-, NOTARIAL SEAL
1:/ . '..~ lL {.cQ(:) (1 )]1. J
.~j( n() U BONNIE l. WILLIAMS, NOTAR\' PUBUC
Notary Public HIREMANSTOWN BOROl CUMBERlAND CO.
MY COMMISSION EXPlR S APRIL 18 200
My Commission Expires:
(Signature and seal of Notary or other official r~\,)TE: To be taken by officer authorized to administer oaths.
qualified to administer oaths. Show date of Please have present the original or copy of instrument(s)
expiration of Notary's eommission.) at time of notarization.
Prepared by the Pennsylvania Bar Association
Copyright (e) 1996 form software only CPSystems, Ine. FormIlRW-2 (1991)
1-IIn5.RO::; REV Q/Rf,
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00 tZvn..1?~~
.
Local Registrar
,,' n,:,; "'~nr.::C~>. JUN 2 2 2004
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No. Date
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\05.144 Aev. 1/91 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH N
,r (Coroner) 'oJl
IT #29-288 STATE FILE NUMBER ..-;
, SEX SOCIAL SECURITY NUMBER .J DATE Of' DEATH (Monlh. Da,. _I
W 2. Male 3.721-01-6997 4. June 19, 2004
UNDER 1 DAY BIRTHPLACE (City and PLACE OF DEATH (C",",. only <>">0 see InSlrucllQOS on oaheI' Side)
Hours Minut.s Stale or Foreign Country) HOSPITAL'
ew Bloomfield, ,,,,,,,'Ioolo ERIOutpolionl 0 ~,)O
7. PA ...
FACILITY NAME (If /101 rnstllution, Qlve street and number)
Cumberland 96 Clouser Road White
Ie. 18.
DECEDENT'S U AI. OCCUPil\TION Wt.S DECEDENT EVER IN MARITAL STAtUS. Merr. SURVIVING SPOUSE
(~~~.~:O~uC::~~1 U.S, ARMED FORCES? Novo'Uorrlod,_. (tf wife. glV8 maiden name)
Yoao NoW- lli1Iorcod (Speed,)
1. Mechanic 11b. State Police Widowed 1.
DECEDENTS MAILING ADDRESS IS..... Cd,lTown, St.... Z'" Code) DECEDENT'S VA Monroe
96 Clouser Road ACTUAL 171. Slale Oid Iwp
RESIDENCE _ol
Mechanicsburg, 17055 (See ins&ruclions Uveina
PA on other side) Cumberland toWO$hip? 17d.O ~:Cad-:r=of
II. 17b. Coun c _.
FATHER'S NAME (First. Middle, Lasl) MOTHER'S NAME (FIrst. Midde, Malden Surname)
18. Elmer Clouser II. Nellie M ers
INFORMANT'S NAME (Ty~,inl) INFORMANT'S MAILING ADORESS (St,..t. CityllOwn. SIal.. Z;p Code)
. Jack Witter
METHOD Of' DISPOSITION ~
IlurioJ 0 c<......lon RomovoI from Slat. 0 or Other Paac. of
llonoIIon 0 01.... (Specifyl [1- ';)004
. 21.. 21c.
ATU
230. '3b. .
TIME OF DEATH prx. DATE PRONOUNeED DEAD (Month. Da,. _I WAS eASE REFERREDm:~ l~'NE
10:45 AM. June 19, 2004 NoD
24. ... H.
27. PART I: Enter lhe diHues.lnjuries or cornplicaUons which caused the death. 00 not enter the mode of dying, such as cardiac or respiratory arrest, shock or heart lailure. .Approxln\81' PART n: Other algnificant c:ondItiona contributing 10 dNth, but
UM only one cause on each line, : interval between not rQUtting in (he undertying cauu given In PART I.
: 00Ml: and death
.. Occlusive Coronar Disease i
DUE m (OR AS A CONSEQUENCE Qf): I
I
b. I
DUE m (OR AS A CONSEQUENCE QF): 1
1
C, I
DUE m (OR AS A CONSEQUENCE OF): I
I
d, :
WERE Al11llPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED,
A"'llABLE PRIOR m (Month. Day. Yeal)
COMPLETION OF CAUSE ~ 0 ....0 NoD
OF DEATH? Nalurat Homicde
Yo. 0 No [X Accident 0 Pending Inveshgation 0 M. ....
0 o PLACE OF INJURY - AI home. farm. alreel. factOfy, office
Sulcidto Could not be determined building. etc. (Specity)
.... 21b. 21. 300.
CERTIFIER (Check only one)
*ceRTtFYtNG PHYSICIAN (Physician certifying cause of death when anoth8l" physician has pronounced death and completed hem 23) 0 Coroner
TOthebeltotmyknowlldg....thOCcurredd....to....c.....(.).nclmanner.....lId........................................... .......
DATE S1GNEO (Month. Da,. _)
.PRONOUNClNG AND CERTIFYING PHYSICIAN (PhYSICian both pronouOCIl"'IQ dealh and carlllYlng 10 causa 01 death) 031.. June 21, 2004
To &he beel o. my knowiedge, ..th occurr. .. lhel....., dat., and pIKe, and due to the cauH{a) and fRIIn......... atalld.. . . . . . . . . . . . . . .. ........ 3 d.
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUse OF DeATH
'MEDlCAl EXAMINER/CORONER (Item 27) Type or Print Michael L. Norris, Coroner
On the bull o. .xamln_ion and/or Inv_'Datlon,ln my opinion. death occurred at tha time, dIIll, and piKe, and due to the CIU"(I) and IX 32. 6375 Basehore Road, Suite III
mannerl..tated................................................................................................. . Mechanicsburg, Pa. 17050
311.
REGISTRAR'S SIGNATURE AND NUMBER I~/I~I/I
34.
. ,
.21 - oLJ - ~ol
LAST WILL AND TESTAMENT
OF
JAMES W. CLOUSER
-" ~
JS.
I, JAMES W. CLOUSER, of Monroe TOWllship,
(:=
Cumberland County, Pennsylvania, make, publish anti; declare
.. .~!
this as and for my Last Will and Testament, hereby re!oking all
1.,__.
other Wills and Codicils heretofore made by me.
FIRST: I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment
and together with any insurance policies thereon, unto my wife,
PATRICIA L. CLOUSER, provided she survives me by sixty
(60) days.
SECOND: Should my wife, PATRICIA L.
CLOUSER, predecease me or die on or before the sixty-first
(61st) day following my death, I devise and bequeath all the rest,
residue and remainder of my estate of whatever nature and
wherever situate, including any property over which I hold
. .
power of appointment and together with any insurance policies
thereon, as follows:
(A) I give and bequeath the kitchen table and eight
(8) kitchen chairs to my nephew, JACK L. WITTER, provided,
however, that should he predecease me, then to his wife, SHIR-
LEY L. WITTER.
(B) I give and bequeath the sum of One Thousand
and No/l 00 ($1,000.00) Dollars to my neighbor, PAMELA J.
FLECK, of 77 Clouser Road, Mechanicsburg, Pennsylvania,
provided, however, that should she predecease me, then to her
husband, RICHARD L. FLECK, JR.
(C) I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment
and together with any insurance policies thereon, in equal
shares, as follows:
(1) Ten (10%) percent to my sister, MARY E.
WITTER, provided, however, that should she prede-
cease me, I give and bequeath her share unto her issue
2
COMMONWI:ALTH OF PENNSYLVANIA
Dl::PARTMENT Of-' REVENUE
BUREAU OF INDIVIDUAI_ TAXES
DEPT 280601
HARRIS!3URG, PA 17128-0601
-
REV' '62 EXI" .96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 005913
BOGAR JAMES D
1 W MAIN STREET
SHIREMANSTOWN, PA 17011
fold
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
ESTATE INFORMATION: SSN: 721.01.6997
FILE NUMBER: 2104-0601
DECEDENT NAME: CLOUSER JAMES W
DA TE OF PAYMENT: 10/19/2005
POSTMARK DATE: 10/1 9/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 06/19/2004
101 I $104.19
I
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TOTAL AMOUNT PAID:
$104.1 9
REMARKS: JAMES BOGAR, ESQ
CHECK#1920
SEAL
INITIALS: RSK
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
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per stirpes by representation, and if there be a failure
of same, then I give and bequeath her share, pro rata,
to the other surviving individuals named in this Clause
SECOND (C), same being the residuary beneficiaries.
(2) Ten (10%) percent to my sister, PEGGY
LONG, provided, however, that should she predecease
me, I give and bequeath her share unto her issue per
stirpes by representation, and if there be a failure of
same, then I give and bequeath her share, pro rata, to
the other surviving individuals named in this Clause
SECOND (C), same being the residuary beneficiaries.
(3) Ten (10%) percent to my brother,
RICHARD CLOUSER, provided, however, that
should he predecease me, I give and bequeath his
share unto his issue per stirpes by representation, and
if there be a failure of same, then I give and bequeath
his share, pro rata, to the other surviving individuals
named in this Clause SECOND (C), same being the
residuary beneficiaries.
(4) Ten (10%) percent to my wife's sister,
3
.
JOAN C. LADERACH, provided, however, that
should she predecease me, I give and bequeath her
share unto her issue per stirpes by representation, and
if there be a failure of same, then I give and bequeath
her share, pro rata, to the other surviving individuals
named in this Clause SECOND (C), same being the
residuary beneficiaries.
(5) Ten (10%) percent to my wife's sister,
NORMA LOVE, provided, however, that should she
predecease me, I give and bequeath her share unto her
issue per stirpes by representation, and if there be a
failure of same, then I give and bequeath her share,
pro rata, to the other surviving individuals named in
this Clause SECOND (C), same being the residuary
beneficiaries.
(6) Ten (10%) percent to my wife's sister,
JANE WOODSON, provided, however, that should
she predecease me, I give and bequeath her share unto
her issue per stirpes by representation, and if there be
4
.
a failure of same, then I give and bequeath her share,
pro rata, to the other surviving individuals named in
this Clause SECOND (C), same being the residuary
beneficiaries.
(7) Twenty (20%) percent to my nephew,
JACK L. WITTER, provided, however, that should he
predecease me, I give and bequeath his share unto his
wife, SHIRLEY L. WITTER, and ifhis wife, SHIR-
LEY L. WITTER, predeceases him, then to his issue
per stirpes by representation.
(8) Twenty (20%) percent to my nephew's
wife, SHIRLEY L. WITTER, provided, however, that
should she predecease me, I give and bequeath her
share unto her husband, JACK L. WITTER, and ifher
husband, JACK L. WITTER, predeceases her, then to
her issue per stirpes by representation.
THIRD: In addition to all powers granted to them by
law and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all proper-
5
ty, exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease, for
any period of time, any real or personal property and to give
options for sales, exchanges or leases, for such prices and upon
such terms (including credit, with or without security) or
conditions as are deemed proper. This includes the power to
give legally sufficient instruments for transfer of the property
and to receive the proceeds of any disposition of it.
(B) To partition, subdivide, or improve real estate and
to enter into agreements concerning the partition, subdivision,
improvement, zoning or management of real estate and to im-
pose or extinguish restrictions on real estate.
(C) To compromise any claim or controversy and to
abandon any property which is of little or no value.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds,
without restriction to investments authorized for Pennsylvania
fiduciaries, as are deemed proper, without regard to any princi-
6
.
pIe of diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws.
(G) To make distributions to my herein named
beneficiaries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in
order to pay debts, taxes, or estate or trust administration ex-
penses, to protect or improve any property held under my will,
and for investment purposes.
(I) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee
stock ownership plan, or any other type of qualified plan) to the
extent the plan or the law permits them to do so, and to exercise
any other rights which they may have under the plan, in what-
ever manner they consider advisable.
FOURTH: 1 direct that all inheritance, estate, trans-
7
.
. I
fer, succession and death taxes, of any kind whatsoever, which
may be payable by reason of my death, whether or not with
respect to property passing under this Will, shall be paid out of
the principal of my residuary estate.
FIFTH: All interests hereunder, whether principal or
income, which are undistributed and in the possession of the
fiduciaries acting hereunder, even though vested or distribut-
able, shall not be subject to attachment, execution or sequestra-
tion for any debt, contract, obligation or liability of any benefici-
ary, and furthermore, shall not be subject to pledge, assignment,
conveyance or anticipation.
SIXTH: I nominate and appoint my wife, PATRICIA
L. CLOUSER, Executrix of this, my Last Will and Testament.
In the event of the death, resignation or inability to serve for any
reason whatsoever of the said PATRICIA L. CLOUSER, I
nominate and appoint JACK L. WITTER, Executor of this, my
Last Will and Testament. I direct that my Executrix or Execu-
tor, as the case may be, and their successors, shall not be re-
a
.
.
quired to post security or a bond for the performance of their
duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my
hand and seal to this, my Last Will and Testament, this ~
day of ~.~ , 2000.
)' i~ ~ , ?{", ~.; '"" (SEAL)
, . , t...-'
'-- J . S W. CLOUSER
Signed, sealed, published and declared by the above-
named Testator as and for his Last Will and Testament in our
presence, who, at his request, in his presence and in the presence
of each other, have hereunto subscribed our names as attesting
witnesses.
tJwt Ii ~~
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Address
16W-d~
Address ['
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CERTIFICATION OF NOTICE UNDER RULE 5.6 (a)
Name of Decedent: James W. Clouser
Date of Death: June 19, 2004
Will No. 21-04-0601 Admin. No.
To the Register:
I certify that notice of estate administration required by
Rule 5.6(a) of the Orphans' Court Rules was served on or mailed
to the following beneficiaries of the above-captioned estate on
July 1, 2004:
Name Address
Jack L. Witter 985 Hauck Road
Mechanicsburg, PA 17055
Shirley L. Witter 985 Hauck Road
Mechancisburgr PA 17055
Pamela J. Fleck 77 Clouser Road
Mechancisburg, PA 17055
Mary E. Witter 100 Clouser Road
Mechancisburg, PA 17055
Linda Long 4827 Virginia Road
Mechanicsburg, PA 17050
James A. Long 4701 Charles Road
Mechancisburg, PA 17050
Martin E. Long 11501 Briarcliff
Warren, MI 48093
Joan C. Laderach 3293 Heritage Circle
Hendersonville, NC 28791
Norma Love 1706 Sequoia Drive
Prescott, AZ 86301
Jane Woodson 6319 38th Ave. Southwest
Seattle, WA 98126
i - ,r,-'
V'-
. -
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except:
None
Date: 7/1/2004
J mes D. Esquire
One West Ma treet
Shiremansto PA 17011
(717) 737-8761
Capacity: Personal Representative
X Counsel for Personal
Representative
JAMES D. BOGAR
ATTORNEY AT LAW
ONE WEST MAIN STREET
SHIREMANSTOWN. PENNSYLVANIA 170 I I
e-mail mall@bogarlaw.com TELEPHONE
(717) 737,8761
JAMES D. BOGAR FACSIMILE
JENNIFER B. HIPp. (717) 737,2086
-Also admitted to New Jersey Bar Direct e-matljbogar@bogariaw.com
September 15, 2004
VIA HAND DELIVERY
Glenda Farner Strasbaugh
Register of Wills
Cumberland County Courthouse ::JC
One Courthouse Square ~ro g
Carlisle, PA 17013 :::l .~
('7
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The Estate of JameEl'W. rn
RE: Crauser
No. 21-04-0601 ,'" ~
Ul
Date of Death: June 19, ~04
\D
Dear Ms. Strasbaugh: -
0\
I represent the Estate of James W. Clouser. Enclosed is a
check made payable to the Register of Wills in the amount of
$49,909.77, same constituting a prepayment at discount on account
of Pennsylvania inheritance taxes in the above-captioned estate.
The prepayment is determined as follows: $260,820.00 multiplied
by 15% or $39,123.00, plus $111,780.00 multiplied by 12% or
$13,413.60, totaling $52,536.60, less discount in the amount of
5% or $2,626.83, resulting in payment of $49,909.77. Please
provide me with the appropriate receipt in this matter.
Your time and consideration in this matter are greatly
appreciated.
Very truly yours,
~~D~
JDB/blw
Enclosure
cc: Jack L. Witter, Executor
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 004384
BOGAR JAMES D
1 W MAIN STREET
SHIREMANSTOWN, PA 17011
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
nnnn lold ____hhn n_nn_
101 I $49,909.77
ESTATE INFORMATION: SSN: 721-01-6997 I
FILE NUMBER: 2104-0601 I
DECEDENT NAME: CLOUSER JAMES W I
DATE OF PAYMENT: 09/15/2004 I
POSTMARK DATE: 09/1 5/2004 I
COUNTY: CUMBERLAND I
DATE OF DEATH: 06/19/2004 I
I
TOTAL AMOUNT PAID: $49,909.77
REMARKS:
CHECK# 206
INITIALS: JA
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
Marjorie A. Wevodau
Glenda Farner Strasbaugh First Deputy
Register of Wills
and
Clerk of Orphans' Court Kirk S. Sohonage, Esq
Solicitor
Register of Wills and Clerk of the Orphans' Court
County of Cumberland
One Courthouse Square
Carlisle, PA 17013
(717) 240,6345
FAX (717)240,7797
I INVOICE I
Bill To: InvoiceNo: 185
Invoice Date: 1/31/2005
James Bogar Estate of: Tames W. Oouser
1 West Main Street Estate No: 21,2004,00601
"
SHIREMANSTOWN, P A 17011
Qty Fee Description Fee Total
1 Additional Probate 70.00 $70.00
Total: $70.00
Checks should be made payable to the Register of Wills. Terms: Net 30.
Please return one copy of this invoice with your payment. Thank you.
Register of Wills of CUMBERLAND County, Pennsylvania
INVENTORY
Estate of James W. Clouser No, 21-04,0601
also known as Date of Death 06/19/2004
, Deceased Social Security No. 721,01,6997
Jack L. Witter,
Personal Representative{s) of the above Estate. deceased, verify 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 at 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 /VIle verify that the statements made in this rnventory are true and correct. IMe understand that false statements herein
are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Name of James D. Bogar Esquire
Attorney:
1.0, No,' 19475 Signatur
Address: One West Main Street Address: 985 Hauek Road
ShiremanstoWTI, FA 17011 Mechanicsburg, PA 17055
Telephone: 717/737,8761 Telephone: 717/697, 6882
Dated: 1/;)8101j
Description Value
,-.-)
_....
(See continuation page(s) attached) ---.
,--
..
--".-
c~
(Attach additional sheets if necessary) Total: 377,698.54
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.
Prepared by the Pennsylvania Bar Association
Form #RW-7 11992)
INVENTORY
Estate of: James II. Clouser
Date of Death: 06/19/2004
County: Cumberland
CASH:
----.
Comeast Financial Corp. , 24.03
Cable Bill Refund
GE Capital Assurance ' Long 223.97
Term Care Refund
Leffler Energy , Refund 64.84
Members 1st Federal Credit 33.31
Union ' Regular Savings
Account, Account Number
170038,00, date of death
value $33.31, accrued
interest $0.00
Members 1st Federal Credit 20,976.20
Union - Checking Account,
Account Number 170038,11,
date of death value
$20,973.35, accrued interest
$2.85
Merrill Lynch ' Money Market 69,440.86
Account, Account No.
8BA,34B88, date of death
value $$69,415.30, accrued
interest $25.56
Nationwide Mutual Fire 136.50
Insurance Company
Homeowner's Insurance Refund
Nationwide Mutual Fire 531.00
Insurance Company , Refund
,1,
Union Central ' Annuity No. 12,495.64
3060605; Commuted Annuity
Value $12,495.64
Verizon ' Refund 15.09
--------------
103,941. 44
PERSONAL PROPERTY:
------------------
Contents of home and personal 3,917.75
property , sold at public
sale
Contents of farm and shop 6,968.50
items ' sold at public sale
on 10/23/2004
--------------
10,886.25
STOCKS/LISTED:
--------------
2,415.342 shares Janus Capital Group' 22,969.90
Janus Flexible Income Fund,
Aecount No. 49,201011673,
date of death value
$22,969.90
948.315 shares USAA ' Income Stock 14,660.95
Fund, Account No.
35900671930, date of death
value $14,660.95
--------------
37,630.85
STOCKS/CLOSELY HELD:
--------------------
24 shares Cumberland Valley 240.00
Cooperative Association
Shares of Stock
-------.------
240.00
,2,
REAL ESTATE/PA:
- - - - - - - - - - -. - --
All that eertain piece or 225,000.00
parcel of real estate ,
having erected thereon a
dwelling house being known
and numbred as 96 Clouser
Road, Mechanicsburg,
Pennsylvania. The property
was acquired by James W.
Clouser and Patricia L.
Clouser, husband and wife,
by Deed dated July 29, 1961
and recorded in the
Cumberland County Recorder
of Deeds Office, a copy of
said Deed being attached
hereto and incorporated
herein. The said Patricia
L. Clouser died on June 6,
2000, whereupon full and
complete title to the within
real estate became vested
solely in James W. Clouser,
the Deeedent herein. The
above-described real estate
was sold pursuant to an
Agreement of Sale for Real
Estate dated October 5,
2004, a copy of which is
attaehed hereto and
incorporated herein. Final
settlement took place on
December 7, 2004. A copy of
the Deed conveying said real
estate, along with a copy of
the Settlement Sheet, are
attached hereto and
incorporated herein. The
sale priee of the real
estate was $225,000.00.
- - - - - - - - - - - - --
225,000.00
,3,
OFFICIAL USE ONLY
REV-1500 EX + (6-00)
D
E
C
E
D
E
N
T
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Clouser James W.
DATE OF DEATH (MM-DD-YEAR)
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21-04-0601
COUNTY CODE
YEAR
NUMBER
SOCIAL SECURITY NUMBER
721-01-6997
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
Supplemental Return
Future Interest Compromise (date of death after 12-12-82)
Decedent Maintained a Living Trust 0
(Attach copy of Trust)
3 date of death
. Remainder Return prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
010. Spousal Poverty Credit
(date of death between 12-31-91 and 1-1-95)
o 11. Election to tax under Sec. 9113{A)
(Attach Sch 0)
P NAME
C
0 0 James D. Bo ar
R N FIRM NAME (If Applicable)
R D
E E
S N
T TELEPHONE NUMBER
COMPLETE MAILING ADDRESS
uire
One West Main Street
Shiremanstown, PA 17011
-8
1. Real Estate (Schedule A) (1) 225,000.00
2. Stocks and Bonds (Schedule B) (Z) 37,630.85
3. Closely Held Corporation, Partnership or (3) 240.00
Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D) (4) None
R 5. Cash, Bank Deposits & Miscellaneous Personal Property (s) 114,827.69
E (Schedule E)
C
A 6. Jointly Owned Property (SchedUle F) (6) None
P
I 0 Separate Billing Requested 0
T 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property {7} 28,862.89
U
L (Schedule G or L)
A
T 8. Total Gross Assets (total Lines 1-7) (8) 406,561.43
I 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 40,135.59
0
N 10. Debts of Decedent, Mortgage Liabilities. & Liens (Schedule I) (10) 2,518.77
11. Total Deductions (total Lines 9 & 10) (11) 42.654.36
12. Net Value of Estate (Line 8 minus Line 11) (1Z) 363,907.07
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 363,907.07
C
o
M
P
T U
A T
X A
T
I
o
N
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(aX 1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. X
0.00
108,872.12
255,034.95
x
X
X
X
.0 0
.0 45
.12
.15
(1S)
(16)
(17)
(18)
(19)
0.00
0.00
13,064.65
38.255.24
51,319.89
Copyright (c) 2000 form software only The Lackner Group, Inc.
Form REV-1S00 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
96 Clouser Road
CITY I STATE I ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
51,319.89
0.00
49,909.77
2,565.99
Total Credits ( A + B + C) (2)
52,475.76
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB)
MakeCheck Payable to: REGISTER OF WillS, AGENT.
0.00
1,155.87
0.00
0.00
0.00
PLEASE ANSWER THE FOllOWING QUESTIONS BY pLACING AN "X"
1. Did decedent make a transfer and:
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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property
which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [K]
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN.
IN THE APPROPRIATE BLOCKS
Yes No
~~
o
o
~
~
o
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 bellef,lt is true,
correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE F F ING RETURN Jack L. hi i tter DATE
L --~!~h~~i~~b~~-C:~-PA--ii655-U---- u___ _n_u___ 1/ lro 105
James D. Bogar Esquire D~E
One West Main Street
- - -Shir-~man-sto~ - - PA - - ii6ii - - - - - - - - - - - - - - - - - - --
For dates of deat no after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3 0 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 0%
[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 0% [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 4.5%, except as noted in 72 P.S. 9116(1.2)
[72 P.S. 9116(aX1)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(aX1.3)). A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1S00 EX (Rev. 6-00)
REV-1502 EX + (1-97)
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
EST ATE OF FILE NUMBER
James W. Clouser SS# 721-01-6997 06/19/2004 21-04-0601
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price
at which property would be exchanged between a willing buyer and a willing seller. neither being compelled to buy or sell, both having reasonable
knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
DESCRIPTION
NUMBER OF DEATH
1 All that certain piece or parcel of real estate - having erected 225,000.00
thereon a dwelling house being known and numb red as 96 Clouser
Road, Mechanicsburg, Pennsylvania. The property was acquired by
James W. Clouser and Patricia L. Clouser, husband and wife, by
Deed dated July 29, 1961 and recorded in the Cumberland County
Recorder of Deeds Office, a copy of said Deed being attached
hereto and incorporated herein. The said Patricia L. Clouser
died on June 6, 2000, whereupon full and complete title to the
within real estate became vested solely in James W. Clouser, the
Decedent herein. The above-described real estate was sold
pursuant to an Agreement of Sale for Real Estate dated October 5,
2004, a copy of which is attached hereto and incorporated herein.
Final settlement took place on December 7, 2004. A copy of the
Deed conveying said real estate, along with a copy of the
Settlement Sheet, are attached hereto and incorporated herein.
The sale price of the real estate was $225,000.00.
TOTAL (Also enter on line 1, Recapitulation) $ 225,000.00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1502 EX (Rev. 1-97)
\.--'
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P.tll-cy-W........t, .......-8....... r......-Ad ....-An....... ret P.......R~dl""
H.,," lI.n. ..... ,...,IlI.... ra. I
UtljOt ~
1!leeb,
MAm; THE_~'1 ~ ,la1/ of Jul1
01 ollr lArd On/l tl\tJl/salld nillllllllndred and sixtY'-one (1961)
. lIETWf;EN.. m;LLII!:' 01. CLaJSER; widow, of the Township of Monroe, CountY' ot
CWlberland. and State ot PeDnIl71van1a, part! ot the lirst part,
in tlae 1I11ar
G/'lII//or
1lI1d JAMES W. CLaJSER and PATRICIA L. CLaJSER, his wite, of the Township
of Monroe, CountY' of OWlberland and State or PennsY'lYan1a,
WlTNf;SSf:Tll, ./lUL/ ;11 r"'IH;"em/;1II1 01 the SUIII of
. :. -Nine Thousand ($9,000.00) D"lIar.,
;11 h"I/,I/HI;d, /lIt'. rer";/,t 1I'/It""'''1 ill "IlI'e/'ll at'.kn(llt'I,',I{/rd. 'h.,' N,,;,I /l1Y/1I'"'' ""es hu,'b" {/rRnt
,III" rtll"'Il/1 tn thr .7o!,1 {/lYIl1trr's ' I
G I'a nt':t! s:
ALL THAT CERl'AIN piece or parcel ot land situated in the Township or
Monrol, Count7 of CUlllberland and State ot PeMsylvania, bounded and described
as tollowsl
.I..
BEGINNIm at a stone in the public road and lands now or tomerl;r of
David Clark) thence by said Road, North 7, degrees 30 lllinutes East, t.hirty-
one and one-tenths 01.1) perches toa stone at intersection of public road)
thence in the center or said public road and along lands tomerl;r ot Moses
Markle, South 12 degrees 30 minutes West, forty-eight and live-tenths (48oS)
perches to a s.tone in side of road) thence across said road obliqueq, South
32 degrees 30 Jdnutes East, ten and one-tenth (10.1) perches to a stone;
thence in said Road, South 07 degrees 4$ lllinutes West,. five and six-tenths
. ($.6) pdrcbes to a stone in said road; thence by land now or formerlY' ot
Henr,. Ionhaus, North 76 degrees West, thirtY'-one and' seven-tenths 01.7)
perches.to a stone) thence by lands now or tomerly of S1mon Lehman, South
08 decrees 30 minutes West, torty-six and two-tenths (46.2) perches to .
stones, at the place of BEOINNIOO.
CONTA.INING nine (9) acres, more or less, and haVinC thereon erected a
frame barn, outbuildings and frame dwelling house.
BEING the same premises which HaIT1 B. Jumper and A1II\cda A. Jumper,
his wite, by their Deed dated June 1, 1926, and recorded in the Otfice at
the Recorder of Deeds in and for Cumberland County, Pennsylvania, in Deed
Book "K", Volume 10, at Page 383, granted and conveyed unto ElJDer A.
Clouser and Nellie J. Clouser, his wite) the said Elmer A. Clouser died on
the If!!- daY' of April ,1961, whereupon sole title to said prelll1ses
beC8J1\8 vested in the said NelUe J. Clouser, the grantor herain. .
THERE IS EXCWDED trom the above described tract of land, all that certain
lot of ground conveyed b.T the parties of the first part to Wa)'l18 Witter and
Elizabeth Witter, his wite, and as .o~ p81ticularlY' described in said Deed
which is recorded 1n the CUlllberland Counw Recorder's Ottice in Deed Book
" ., Vol~ , at Page .
I
I
I
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-,. '!I..,~,.
t, r "-fJ
-~~.:,,-;.
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This conve:rance is between parent and child, the grantor herein beini
. t."" MturalllOther or. JIJIIll. W. Clouser, one or the grantees herein.
'~;:. .
:~ ...s ., ....'
IN WITNESS WHEREOF, lIaid grantor AA8 Aerellnto lIet her Aand And IIcal
~Ae dAII and Ifear firllt above written.
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. ~<'/J1.'i. ..... 'zZ.....m;r.r 'L~ .~-~
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o. .
State 0/
Pennqbania
Countlf 0/ C1IIIberland cl-
On tlaill, tA~ .:l' -
} 1111.
I 0
~ d41f 0/
J~
, 1961 ,. be/ore me,
tAe underlligned officer, perll07ll1111f appeared
Nellie J. C1ouael', widow,
kno",n to me (or lIatill/actonllf proven) to be tAe pcrllon 111AOIle llCIlfte 18 lIub"cMbed to tAc witA-
ill illllln,ment, and acknowledged that she e:rrcllttd lIame for tAe pllrpcnell tAet.tin t:91ltained.
IN WITNESS WHEREOF, I Aereunto ,et mlf Aand and officialllc,d. ........;;~J .~.::--.. ,
~IJ. ..l,,:~..""'"'' 0 '11- ". ,
-.......~..~+!...e...~,::!.~~,~~
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o ......~(.,..... .... .~.....;;....:.t.~............t~~.,...
M... GIAOVS P. N. Notary ~ i:!"J....~D.t!~~~../:,~..:
...c......c.au"o. cu...a........o co., PA. _.. .'~:.,O:I:.-...f', .:
Ill, Commlllloft '...... Dee. 21. 1M3' ....::: .;~."'\~.......
-............
CUll8UlANO r.'UN'"
"III1SYlva....
r do hcrthr cl',ii/II that tAe prtcil!e re,idencc 0/ tA~ IlIitltin 7ICIlfted "I'lI,dee II
fl. O. 2. I1IFOUlIII;.c~qut!.", rA.
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AGREEMENT OF SALE FOR REAL ESTATE
~
THIS .:1\GREEMENT is entered into this 5'1tL day of :;eptewLeL,
2004, by and between JACK L. WITTER, EXECUTOR OF THE ESTATE OF
J~~S W. CLOUSER, late of Monroe Township, Cumberland County,
Pennsylvania, hereinafter called "SELLER",
AND
WILLI.:l\M E. WITTER and SHP_~ON L. WITTER, husband and wife, of
75 2nd Street, Eilola, Pennsylvania, hereinafter called
" PURCHASER" .
IT IS MUTUALLY AGREED AS ?OLLOWS:
1. PREMISES. The Seller agrees to sell, grant and convey
to the Purchaser, and the Purc~aser agrees to purchase and accept
the conveyance of the following described real estate situate in
Monroe Township, Clli~erland Co~~~y, Pe!h~sylvania, described as
follows:
Being all that certain piece or parcel of land having
erected thereon a dwelling house, barn and other
outbuildings, same being ~~own and numbered as 96
Clouser Road, Mechanicsburg, Cumberland County,
Per~sylvania, the legal description for said real
estate being attached hereto, marked Ex.:.1.ibit "A" and
incorporated herein.
Tax Parcel No.: 22-10-0642-018
2. PURCEP.SE PRICE. The Purchaser agrees to pay the sum of
$225,000.00 to the Seller, as the full purchase price and
consideration for the premises, payable as follows: $22,500.00
down on the signing of this Agreement, receipt of which is hereby
acknowledged, said down payment to be held by James D. Bogar,
Esquire, said account to be a non-interes~ bearing IOLTA account;
and $202,500.00 in cash unless otherwise herein provided at
settlement of this transaction as scheduled and provided
hereinbelow.
3. SETTLEMENT. Final settlement of this traLsaction shall
be made at the Law Offices of James D. Bogar, One West Main
Street, Shiremanstown,~ennsylvania, or any other mutually agreed
upon location, and shall be made on or after November I, 2004,
but in any event, no later than on or before November 5, 2004, at
which time of settlement the Seller shall tender to the Purchaser
a properly drawn and executed deed of special warranty, conveying
to the Purchaser a good and marketable title in fee simple, clear
of all liens and encumbrances, except easements or building and
use restrictions visible on the ground or of prior record, ticle
to be such as will be insured by a reputable title ~nsurance
company in the central Pennsylvania geographical area without
exception or reservation at regular rates. Should Seller be
unable to deliver such title, Purchaser shall have the option of
either cancelling this Agreement of Sale for Real Estate and
receiving back any monies paid as a deposit or accepting such
title as Seller can give without offset, adjustment, or abatement
of the purchase price. Time is of the essence of this Agreement
of Sale for Real Estate.
2
4. TR~SFER TAXES AND APPORTIONMENT OF REAL ESTATE TAXES,
RENTS ~~ EXPENSES. All realty transfer taxes shall be paid
equally by the Seller and Purchaser, with Purchaser paying one
percent (1%) and Seller paying one percent (1%). Current real
estate taxes, utility charges and any municipal service fees or
rents will be prorated at and to the date 0: settlement.
5. POSSESSION. Seller shall deliver possession of the said
premises to Purchaser at the time of final settlement.
6. CONDITION OF PROPERTY AND RISK OF LOSS. The Seller
agrees that the property shall remain in substantially its
present condition until date of settlement, and if it is not, the
Purchaser may rescind this contract.
Seller shall bear the risk
of loss from fire or other casualty until time of settlement.
7. DEFAULT. Should Purchaser default in perfor.ming this
Agreement, any sum or sums paid on account of the purchase price,
by way or down-payment or otherwise, shall be retained by Seller,
as liquidated damages, whereupon this Agreement shall become null
and void.
Should Seller default in performing this Agreement,
Purchaser shall have the right of having this Agreement declared
null and void and, further, having any sum or sums paid on
account of the purchase price, by way of down-payment or
otherwise, returned in full, whereupon this Agreement will be
deemed to be terminated.
3
8. CONTINGENCIES. This Agreement of Sale for Real Estate
is not subject to nor contingent upon the occurrence or
nonoccurrence of any event. Furthermore, Pu~chaser understand
that they have the option to request that the property be tested
and certified free from termites and/or wood-boring insects; to
have the buildings located on the property inspected and/or
certified by a licensed or otherwise qualified professional; to
have the property tested for radon gas; to have the on-lot septic
system pumped, tested and inspected; to have the well and water
tested for workability and potability and any othe~ test or
inspection. Purchaser waives the opportunity to conduct all of
these inspections and tests.
Furthermore, Seller has no reports, records or ~~owledge of
lead-based paint and/or lead-based hazards to the property.
Seller warrants that the dwelling unit in question, as well as
all outbuildings, were constructed prior to 1978. Purchaser
waives the opportunity to conduct a lead-based paint and/or lead-
based paint hazards risk assessment or inspection for the
presence of lead-based paint and/or lead-based paint hazards.
9. SURVEY. If the Pu~chaser should determine the need for
a current survey of the premises, the cost and expense thereof
shall be borne exclusively by the Purchaser.
10. STATUS OF SEw~R ~~ WATER. The property is served by an
on-lot septic system and a well.
4
Seller's Property Disclosure Statement. This provision shall
survive settlement.
14. PERSONALTY. The following specifically enumerated items
of personalty or personal property are included in the within
sale: all window treatments.
15. BROKERS AND AGENTS. Seller and Purchaser both represent
that they have dealt with no real estate brokers or agents in
connection with this sale and that no brokers or real estate
agent's commission is due any person on account of this sale.
Each party shall indemnify and hold harmless the other party from
the claim or demand of any broker or agent for any commission
which any such broker or agent may claim to be due him or her as
a result of this sale.
16. MISCELLANEOUS. It is understood and agreed by the
parties hereto that John C. Witter has farmed a portion of the
real estate in question to be conveyed. Furthermore, John C.
Witter is waiting to harvest, among other things, corn, soy beans
and hay. Purchaser specifically allows and grants permission to
John C. Witter to harvest all crops presently in place. John C.
Witter will have until the end of April 2005 to complete the
harvest of all crops. The provisions of this Paragraph 16 shall
survive settlement. This real estate is not a working farm.
6
~
~
For the performance of this Agreement and intending to be
legally bound hereby, the parties bind c~emselves, their heirs,
personal representatives, successors and assigns, as witness
their hands and seals the day and year first above written.
WITNESS:
~
3<~-C (SEAL)
JACK L. WITTER, EXECUTOR OF THE
ESTATE OF J~~S W. CLOUSER
r--
(SE~~)
7
EXHIBIT "A"
LEG~~ DESCRIPTION
ALL TF~T CERTAIN piece or parcel of land situated in Monroe
Township, Cumberland County, Pennsylvania, bounded and described
as follows:
BEGINNING at a stone ~n the public road and lands now or fornerly
of David clark; thence by said Road, North 75 degrees 30 minutes
East, thirty-one and one tenth (31.1) perches to a stone at
incersection of public road; thence in the center of said public
road and along lands formerly of Moses Markle, South 12 degrees
30 minutes West, forty-eight and five tenths (48.5) perches to a
stone in side of road; thence across said road obliquely, South
32 degrees 30 minutes East, ten and one-tenth (10.1) perches to a
stone; thence in said Road, South 07 degrees 45 minutes West,
five and six-tenths (5.6)perches to a stone in said road; thence
by land now or formerly of Henry Konhaus, North 76 degrees West,
thirty-one and seven-tenths (31.7) perches to a stone; thence by
lands now or formerly of Sa~uel Ler~an, South 08 degrees 30
minutes West, forty-six and two-tenths (46.2) perches to stones,
at the place of BEGI~~I~G.
CONTAINING nine (9) acres, more or less, and having thereon
erected a frfuue barn, outbuildings, and frame dwelling house.
BEING the sa~e premises which Nellie J. Clouser, single person,
by deed dated July 29, 1961 and recorded in the Cumberland County
Recorder of Deeds Office in Deed Book "H", Vol. 20, Page 543,
granted and conveyed unto Ja~es W. Clouser and patricia L.
Clouser, husband and wife. The said Patricia L. Clouser died on
June 6, 2000, whereupon full fu~d complete title to the within
described real estate became vested solely in James W. Clouser,
the decedent herein.
EXCEPTING, THEREFROM, EOviEVER, the following piece or parcel of
land being bounded and described as follows, to wit:
~~L TK~T CERTAIN lot of ground conveyed by Elmer A. Clouser and
Nellie W. Clouser, husband and wife, by deed dated August 3, 1949
and recorded August 6, 1949 in the Cumberland COlli~ty Recorder of
Deeds Office in Deed Book "F", Vol. 14, Page 1, granted and
conveyed unto Mary Elizabeth Witter.
FURTHERMORE, said real estate is more accurately described in an
Agreement dated July 31, 1974, by and between Mary Elizabeth
Witter and Wayne Witter, husband and wife, and James Clouser and
8
Patricia Clouser, husband and wife, said Agreement being recorded
on August 21, 1974 in the Cumberland County Recorder of Deeds
Office in Deed Book "T", Vol. 25, Page 300, as follows:
BEGINNING at a point marked by an iron stone, a corner of lands
formerly owned by Elmer A. Clouser and Nellie J. Clouser, his
wife, and lands formerly owned by Russell Bricker; thence South
seven degrees forty-five minutes West (S 70 45' W) a distance or
ninety-two and forty one hundredths (92.40') reet to a point;
thence North seventy-six degrees West (N 76.000 W) a dis~ance or
one hundred forty-two and ten one hundredths (142.10') reet to a
point; thence North seven degrees rorty-nine minutes forty
seconds East (N 70 49' 40" E) a distance or seventy-six and e~gn~
one hundredths (76.08') reet to a point; thence South eighty-two
degrees thirty-six minutes East (S 820 36' E) a distance or one
hundred forty-one and fifteen one hundredths (141.15') reet to a
point, the place of BEGINNING.
This legal description is in accordance with a survey prepared by
John C. Brilhart , same being denominated as the Map or Property
of Wayne Witter and being dated April 23, 1974, said surveyor
map being recorded along with the July 31, 1974 Agreement.
9
Tax Parcel No. 22-10-0642-018
THIS INDENTURE,
MADE THE
7+"- day of -=zx( f1rvd:Y..:'(L
four (2004)
, two thousand
BETWEEN
JACK L. WITTER, Executor of the Last Will and
Testament of JAMES W. CLOUSER, late of Monroe
Township, Cumberland County, Pennsylvania,
party of the first part,
and
WILLIAM E. WITTER and SHARON L. WITTER, hus-
band and wife, of 75 2nd Street, Enola, Cum-
berland County, Pennsylvania, parties of the
second part:
WHEREAS, the said JAMES W. CLOUSER by his Last Will and Testa-
ment, duly proved and recorded in the Cumberland County Register
of Wills Office, Pennsylvania, in File No. 2004-00601, Letters
Testamentary being issued on July 20, 2004, provided, in perti-
nent part, as follows:
TH~RD: In addition to all powers granted to them by
law and by other provisions of this Will, I give the
fiduciaries acting hereunder the following powers, ~
applicable to all property, exercisable without court
approval and effective until actual distribution of all
property:
(A) To sell at public or private sale, or to
lease, for any period of time, any real or personal
property and to give options for sales, exchanges or
leases, for such prices and upon such terms (including
credit, with or without security) or conditions as are
deemed proper. This includes the power to give legally
sufficient instruments for transfer of the property and
to receive the proceeds of any disposition of it...
S~XTH: I nominate and appoint my wife, PATRICIA L.
CLOUSER, Executrix of this, my Last Will and Testament.
In the event of the death, resignation or inability to
serve for any reason of the said PATRICIA L. CLOUSER, I
nominate and appoint JACK L. WITTER, Executor of this
my Last Will and Testament...
NOW THIS INDENTURE WITNESSETH, that the said party of the first
part, by virtue of the power and authority aforesaid, in said
will contained, and in consideration of the sum of Two Hundred
and Twenty-Five Thosand Dollars ($225,000.00) to him paid by the
said parties of the second part, at and before the ensealing and
delivery of these presents, the receipt whereof is hereby ac-
knowledged, has granted, bargained, sold and conveyed, and does
hereby grant, bargain, sell and convey to the said parties of the
second part, their heirs and assigns forever:
ALL THAT CERTAIN piece or parcel of land situated in Monroe
Township, Cumberland County, Pennsylvania, bounded and described
as follows:
BEGINNING at a stone in the public road and lands now or formerly
of David clark; thence by said Road, North 75 degrees 30 minutes
East, thirty-one and one tenth (31.1) perches to a stone at
intersection of public road; thence in the center of said public
road and along lands formerly of Moses Markle, South 12 degrees
30 minutes West, forty-eight and five tenths (48.5) perches to a
stone in side of road; thence across said road obliquely, South
32 degrees 30 minutes East, ten and one-tenth (10.1) perches to a
stone; thence in said Road, South 07 degrees 45 minutes West,
five and six-tenths (5.6)perches to a stone in said road; thence
by land now or formerly ot Henry Konhaus, Nortp 76 degree~ West,
thirty-one and seven-tenths (31.7) perches to a stone; thence by
lands now or formerly of Samuel Lehman, South 08 degrees 30
minutes West, forty-six and two-tenths (46.2) perches to stones,
at the place of BEGINNING.
CONTAINING nine (9) acres, more or less, and having thereon
erected a frame barn, outbuildings, and frame dwelling house, all
being known and numbered as 96 Clouser Road, Mechanicsburg,
Pennsylvania 17055.
BEING the same premises which Nellie J. Clouser, single person,
by deed dated July 29, 1961 and recorded in the Cumberland County
Recorder of Deeds Office in Deed Book "H", Vol. 20, Page 543,
granted and conveyed unto James W. Clouser and patricia L.
Clouser, husband and wife. The said patricia L. Clouser died on
June 6, 2000, whereupon full and complete title to the within
described real estate became vested solely in James W. Clouser,
the decedent herein.
EXCEPTING, THEREFROM, HOWEVER, the following piece or parcel of
land being bounded and described as follows, to wit:
ALL THAT CERTAIN lot of ground conveyed by Elmer A. Clouser and
Nellie W. Clouser, husband and wife, by deed dated August 3, 1949
and recorded August 6, 1949 in the Cumberland County Recorder of
Deeds Office in Deed Book "F", Vol. 14, Page 1, granted and
conveyed unto Mary Elizabeth Witter.
FURTHERMORE, said real estate is more accurately described in an
Agreement dated July 31, 1974, by and between Mary Elizabeth
Witter and WaYne Witter, husband and wife, and James Clouser and
Patricia Clouser, husband and wife, said Agreement being recorded
on August 21, 1974 in the Cumberland County Recorder of Deeds
Office in Deed Book "T", Vol. 25, Page 300, as follows:
BEGINNING at a point marked by an iron stone, a corner of lands
formerly owned by Elmer A. Clouser and Nellie J. Clouser, his
wife, and lands formerly owned by Russell Bricker; thence South
seven degrees forty-five minutes West (S 70 45' W) a distance of
ninety-two and forty one hundredths (92.40') feet to a point;
thence North seventy-six degrees West (N 76.000 W) a distance of
one hundred forty-two and ten one hundredths (142.10') feet to a
point; thence North seven degrees forty-nine minutes forty
seconds East (N 70 49' 40" E) a distance of seventy-six and eight
one hundredths (76.08') feet to a point; thence South eighty-two
degrees thirty-six minute~ East (S 820 36' E) ~ distance ~f one
hundred forty-one and fifteen one hundredths (141.15') feet to a
point, the place of BEGINNING.
This legal description is in accordance with a survey prepared by
John C. Brilhart , same being denominated as the Map of Property
of Wayne Witter and being dated April 23, 1974, said surveyor
map being recorded along with the July 31, 1974 Agreement.
TOGETHER with all and singular the rights, liberties, privileges,
hereditaments and appurtenances whatsoever thereunto belonging or
in anywise appertaining, and the reversions and remainders,
rents, issues and profits thereof, and all the estate, right,
title, interest, property, claim and demand whatsoever of the
said James W. Clouser at and immediately before the time of his
decease, in law or equity or otherwise howsoever, of, in, to or
out of the same:
TO HAVE AND TO HOLD the said granted premises to the said parties
of the second part, their heirs and assigns forever.
AND the said party of the first part, does covenant, promise,
grant and agree, to and with the said parties of the second part,
their heirs and assigns, by these presents, that the said party
of the first part, has not done, committed, or knowingly or
willingly suffered to be done, any act, matter or thing what-
soever, whereby the premises aforesaid, or any part thereof, is,
are, shall or may be charged or encumbered, in title, charge or
estate, or otherwise howsoever.
IN ~TNESS WHEREOF, the said party of the first part has here-
unto set his hand and seal the day and year above written.
Sealed and Delivered
t e Presence of
~ & (SEAL)
ck L. Witter, Executor of the
Estate of James W. Clouser
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
On this, the ,-J.i.-day ~f~(embeK. , 2004, before ~e, the
undersigned officer, personally appeared Jack L. Witter, known to
me (or satisfactorily proven) to be the person described in the
foregoing instrument, and acknowledged that he executed the same
in the capacity therein stated and for the purposes therein
contained.
IN WITNESS WHEREOF, I hereunto set my hand and official
seal.
~nn lJ; (5(':7 Ct 1QpjCl/(f\/~
Notary Public
My Commission
( SEl~L)
Expires .NOTARlAl SEAl:
(. r... BONNIE L WILLIAMS. NOlAR'( PUBLIC
, !')HIREMANSTOWN BORO. CUMBERlAND CO
, MY COMMISSION EXPIRES APRIL 18 2005
CERTIFICATE OF RESIDENCE
I do hereby certify that the precise residence and complete
post office address of the within named grantees is:
2004
Attorney/Agent for
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF
RECORDED on this day of
200_, in the Recorder's Office of the said County, in
Deed Book , Page
Given under my hand and the seal of the said office,
the date above written.
, Recorder.
...
~
, . ,~,'~I,,}::tl_~i.fi~f.lj~',N'i~,' OMB NO. 2502.0288 err
;.... DEPARTMENT OF HOU8lNG & URBAN ~ ;:O;:;,,";~ '",j!~t 3.DCOHV. UNJfts. 4. OVA 8.f]CONV.INS.
SEnLEMENT STATEMENT~.)Ijll!:I~'~ ~Fl.E~.~~#~f,i~'r'i!U" J 17. lOAN NUMBER:
;,\~t'~ e,j~~,P.NJENUMBER:
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Shenln L WIlIer JMk L WIlIer. EIlllClIkIr .1';; . . CASH
78 Second Street Il8 aoc- Ro8d ,.
EncM, PA 17025 ~' PA 17Olll1
.\. ',I
G. PROPERlYLOCATION:
Il8 CloIMr ROIId
MechIInlcIbulg, PA 17Olll1
CUmberland CounIy, PeMaylmlIa
H. SETTLEMENT AGENT:'
ChelIee ~SerIfcee
,
I. SE111.EMliNT DATE:
DeclJmber 7, ~
101
102
103
104 P
05 p,
PlACE OF SETTLEMENT
Law Olllc:n 01 JamN O. Bog.-
One West Main S1reet, Shlnln1enltown, PA
J. SUMMARY OF BORROWER'S 1RAHSACTION I K. SUMMARY OF SELLER'S TRANSACTION
:-140
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404
405
1118. loCId _
107. Count T_
108 Rmnn T-
109.
110
11f
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120. GROSS AItfOUNT'OUE FROM BORROWER
PaId 8
12107~ \II 01~1108
12107~ \II 01~1108
12107/M 1ft 07/111-
4.43
~
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407 "..........T-
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204
205
208.
207
208
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411.
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420. GROSS AMOUmOUE ro SELLER
_.
228,954.84
228,808.34
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218.
217.
218.
219.
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302. leA ""-" PlIId -or ~ IlInIt nm
303. CASH ( )( FROM) ( ro) BORROWER ".
51n to
811. CcIunIvT_ to
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514
1515.
1518.
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819.
22,1500.00 520. roTAL REDfJCT10N AItfOUNT' OUE SELLER
24,750.00
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'2tiiXl.oo 802. leA RecIudIanI Due SeIer ILIne 5201
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225954 84
2475O.1IIl
201,204.84
The underalgned hereby adcnowledge ~ of, ~ copy of pagee1&2 of.. alatemeftt & any atIIIdin..... refemId to heleln.
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REV-1503 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERIT ANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE B
STOCKS & BONDS
James W. Clouser
88ft 721-01-6997
06/19/2004
21-04-0601
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1
DESCRIPTION
2,415.342 shares Janus Capital Group - Janus Flexible
Income Fund, Account No. 49-201011673, date of death
value $22,969.90
2
948.315 shares USAA - Income Stock Fund, Account No.
35900671930, date of death value $14,660.95
UNIT VALUE
9.51
15.46
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
TOTAL (Also enter on line 2, Recapitulation)
FILE NUMBER
VALUE AT DATE
OF DEATH
22,969.90
14,660.95
37,630.85
Form REV-1503 EX (Rev. 1-97)
~
JANUS CAPITAL
Group
PO Box 173375
Denver, CO 80217-3375
TEL 800 525 3713
WEB janus.com
July 7, 2004
JAMES D BOGAR
1 W MAIN ST
SHIREMANSTOWN PA 17011-6327
REFERENCE: 01489361
JANUS FLEXIBLE INCOME FUND
ACCOUNT NUMBER 201011673
PATRICIA L CLOUSER &
JAMES W CLOUSER JT WROS
Dear Sir or Madam:
Thanks for doing business with Janus.
To process Jack L Witter's request, we require him to sign the enclosed copy of the application
and return it with a copy of this letter in the envelope provided or by fax to 877-319-3852.
The account information provided below is unaudited.
Date
06/19/04
Fundi Account Number
49-201011673
Transaction
Balance
Share Price Shares
$9.51 2,415.342
Dollar Amount
$22,969.90
We appreciate the opportunity to be of service. If we can be of additional assistance, please visit
us online at janus.com or give us a call.
Sincerely,
Summer L Gorman
Investor Services
Enclosure(s): Copy of Original Application (pages 17-21)
'"
USAA ~
()SlJO Frt'd,'rick;;bllrg Road
Sail t\lltollio. Texas 7S2SS
ESTATE OF JAMES W CLOUSER
C/O JAMES D BOGAR, ESQUIRE
ONE WEST MAIN STREET
SHIREMANSTOWN, PA 17011
July 13, 2004
USAA # 1027 40 94
Income Stock Fund
Account # 35900671930
Dear Sir:
USAA is committed to providing excellent service to its members.
As you requested, I am providing the following information for
the account of the late James W Clouser registered as follows:
PATRICIA L CLOUSER
JAMES W CLOUSER
JTWROS
The account value on June 19, 2004 was:
Shares
Share
Price
Accrued
Dividends
Account
Value
948.315
$15.46
NA*
$14,660.95
*Fund does not accrue daily dividends.
If you have questions, please call a member service
representative at (800) 531-8448 (in San Antonio, 456-7200).
Sincerely,
~
.
4"
Adriana Riojas
Account Service An lyst
Investment Operations
1027 40 94-51072-28820-SAS.SAS45
REV-1504 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
James W. Clouser
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP or SOLE-PROPRIETORSHIP
SSf! 721-01-6997
06/19/2004
FILE NUMBER
21-04-0601
Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent,
other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM
NUMBER
1
DESCRIPTION
VALUE AT
DATE OF DEATH
240.00
24 shares Cumberland Valley Cooperative Association - Shares of
Stock
TOTAL (Also enter on line 3, Recapitulation) $ 240.00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1504 EX (Rev. 1-97)
Cumberland Valley Cooperative Association
~
908 MT. ROCK ROAD
POST OFFICE BOX 350
SHIPPENSBURG, PENNSYLVANIA 17257
TELEPHONE: 717532-2197
FAX: 717 532-4353
June 30, 2004
James D. Bogar
Attorney at Law
One West Main Street
Shiremanstown, PA 17011
RE: James W. Clouser Estate
Dear Mr. Bogar:
This is in reply to your correspondence concerning the redeemable stock
certificates that Mr. Clouser owned with the Co-operative.
You do have all the certificates that he earned with us while he was purchasing
from the Co-op. He has a total of twenty-three (23) Preferred Shares and one (1)
Converted Common Certificate for a total of twenty-four (24) shares. Each share is
worth $10, and that value will. never increase or decrease.
Each original certificate needs to be signed on the back by the executor of the
estate. Your office can witness the signature. Once we receive the signed certificates
and a death certificate or short form back from you, we can issue a check to the estate for
$240.00.
Thank you for your time.
Sincerely,
.j~~ re ~Y-~
Tena R. Jones
REV -1508 EX + (1-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
James W. Clouser SS# 721-01-6997 06/19/2004 21-04-0601
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
NUMBER
1
DESCRIPTION
Comcast Financial Corp. - Cable Bill Refund
VALUE AT DATE
OF DEATH
24.03
2
GE Capital Assurance - Long Term Care Refund
223.97
3
Leffler Energy - Refund
64.84
4
Members 1st Federal Credit Union - Regular Savings Account,
Account Number 170038-00, date of death value $33.31, accrued
interest $0.00
33.31
5
Members 1st Federal Credit Union - Checking Account, Account
Number 170038-11, date of death value $20,973.35, accrued
interest $2.85
20,976.20
6
Merrill Lynch - Money Market Account, Account No. 8BA-34B88, date
of death value $$69,415.30, accrued interest $25.56
69,440.86
7
Nationwide Mutual Fire Insurance Company - Homeowner's Insurance
Refund
136.50
8
Nationwide Mutual Fire Insurance Company - Refund
531. 00
9
Verizon - Refund
15.09
10
Contents of home and personal property - sold at public sale
3,917.75
11
Contents of farm and shop items - sold at public sale on
10/23/2004
6,968.50
12
Union Central - Annuity No. 3060605; Commuted Annuity Value
$12,495,64
12,495.64
TOTAL (Also enter on line 5, Recapitulation) $ 114,827.69
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97)
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
Estate of: JAMES W. CLOUSER
Date of Death: 06/19/2004
Social Security Number: 721-01-6997
MEMBERS 1st
FEDERAL CREDIT UNION
170038 -00
08/14/1997
$33.31
$.00
$33.31
None
170038 -11
09/24/1997
$20,973.35
$2.85
$20976.20
None
M~..E. RS 1ST FEDE~L CREDIT UNION
~;Y~ d ,:eU-
Denise A. Wolfe /
Insurance Supervisor
July 16, 2004
5000 Louise Drive · P.O. Box 40 · Mechanicsburg, Pennsylvania 17055 · (717) 697-1161 · www.memberslst.org
Private Client Group
~ Merrill Lyncb
214 Senate Avenue
Suite 501
P.O. Box 0810
Camp Hill, Pennsylvania 17001-0810
717 975 4600
800 937 0735
July 8, 2004
Jack L. Witter, Executor
Estate of James W. Clouser
c/o James Bogar, Esq.
One West Main Street
Shiremanstown, P A ] 70] 1
Dear Mr. Witter:
The following is the final value of the account held at Merrill Lynch for James W.
Clouser as of June] 9,2004.
Money Market/Cash Balance as of May 28 statement:
Additional interest credited to June 19, 2004:
Total value of account:
69,415.30
25.56
$ 69,440.86
If you need any additional information, please give me or Tanya Nicholas a call at
717-975-4619.
Vice President
Senior Financial Advisor
Rick Foreman Auctioneer AU1163L
Shippensburg Pa 17257
717-776-4602
SETTLEMENT STATEMENT
Sale for Cbll~ r Keo..l Eic. fe ~
Date OQ -f, q, 0 L/.
Sale Total All Sheets -!/ 39 ! 7. '7<;- J
Advertising
Lane. Farming
Guide ~~ / (tJ. QO
V.T.S ~.s-;(JO
NeWSChrOnic1e4~. 7s"
All other Adv. <t1 O,CJC) (9!Y1~/te/)
Sale Flyers ~15: CO
TypeSetting / I
Total Adv. sCP5J t./, 7,~ J
Total Adv. Costs -11 5/2 y. 7..sJ
Auctioneer Percentage -11170 .d::)<l 1.:2 ~.
All Other Charges
-----------.
r
----
Net Sale After Expenses
--P:
Cash Amount /(~ .50
Cheek Amount* ~ 7<'/(0. So.
Rick foretllan
huctioneet ,hu11631.
386 springfield Rd.
SbiPpet\SbUt~pa. 17757
(l17)77~
C.l~ ~v
,J~b &#.)3 .J{)tJ~
!J~ q.~p~
b1bg.~
_ ~15 ~ ~
10 -{II-I 5 f} le-
a uc +10 M' e ,e., 4- C I..(le ks
/I d t/. /.... ,; ~8 8
rr grf5
F. oJ I 1 -
(,or {,L l .t"
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........
~i S~e. 531g.1~
.,,-
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~ '117- 7"1/'- Jj6tJ:J-
The Union Central
Life Insurance Company
1876 Waycross Road
Cincinnati Ohio 45240
(513) 595 2200
www.unioncenlral.com
---'11
UnlonCenbal
Insurance and Investments
September 10, 2004
Re:3060605
NOTICE OF PAYMENT UNDER AN ANNUITY CONTRACT, INCOME POLICY
OR SETTLEMENT OPTION AT THE DEATH OF A PAYEE
Name of decedent: James W. Clouser
Date of death: 6-19-04
Residence of decedent: 96 Clouser Road, Mechanicsburg PA 17055
o Annuitant
(X) Beneficiary under Settlement Option
Date of issue of Annuity or effective date of Settlement Option: 7-1-98
Kind of Annuity or form of Settlement Option: Payable in monthly installments for 20 years certain and
life, with the right of commutation - Proceeds from death.
Name of Beneficiary: Jack L. Witter
Relationship: Executor
Residence of Beneficiary: One West Main Street, Shiremanstown, PA 17011
Method of payment to beneficiary:
o Single Sum - Amount of proceeds on deposit
Accrued interest
(X) Single Sum - Commuted value of Annuity or
Installment Option
$12,495.64
() Single Sum
o For Estate Tax purposes the commuted value of
the remaining certain installments is
Other details of settlement:
~W~a~
By
Joseph W. Siebenburgen
Director of Life and Disability Claims
UC 2791 03/95
Securities products offered through Carillon Investments, Inc..
a subsidiary of The Union Central Life Insurance Company,
10..,.1:. \11................. D........a f"';.....i.......... "....;.... AC.,An {(:1"'1\ ,o<_")~nn
The Union Central
Life Insurance Company
1876 Waycross Road
PO Box 40888
Cincinnati, OH 45240
(513) 5952200
u
Insurance and Investments
JAMES D BOGAR
ATTORNEY AT LAW
ONE WEST MAIN STREET
SHIREMANSTOWNPA 17011
July 16, 2004
3060605
James W. Clouser
Dear Mr. Bogar:
Please express our sincere sympathy to the members of the family of James W. Clouser. We are
enclosing the information you requested in your letter of July 1,2004.
Under this contract, Patricia L. Clouser was receiving monthly payments of $121.12 each since July
1, 1998. When the Insured, Patricia L. Clouser, passed away on June 6, 2000, the payments were
continued to James W. Clouser These payments were to be made to James W. Clouser for the
remaining guaranteed period of eighteen years.
As of the date of death, there remain 168 payments to complete the eighteen year guaranteed period.
In accordance with the policy, the remaining guaranteed payments are to be continued to the estate of
James W. Clouser.
To make this payment, we require the following:
. Certified Death Certificate
. Claimant's Statement Form UC 3963 completed by the executor
· Certified Court Order appointing the executor of the estate
. Return of the check dated July 1,2004 in the amount of$121.12
Since the check dated July 1, 2004, which was issued after the date of death, has not been negotiated
we have placed a stop payment on that check and adjusted our records accordingly. If you are in
possession of the original check, we ask that you return it to this office for proper handling.
A return envelope is enclosed for your convenience. If you have any questions concerning this
contract, please do not hesitate to contact this office at 1-800-319-6302.
R.espeCtfullY, ~. /
~ ~~~-
, -~-/
/ ennie L. Egbert .
Claim Approver
Individual Life Claims
Enclosures
jle
Securities products offered through registered
representatives of Carillon Investments, Inc., a
subsidiary of The Union Central Life Insurance
- - - -- -- .
REV-1510 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
James W. Clouser
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
88ff 721- 01- 6997
06/19/2004
FILE NUMBER
21-04-0601
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 RELAt~8~MA>I~ t~b~~~5~MAWJ~~~1f.lT~EJF t~~~RSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
NUMBER ATTACH ACOPYOFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE)
1 Lincoln Financial Group - 28,862.89 28,862.89
Annuity No. 97-5270276 A
TOTAL (Also enter on line 7, Recapitulation) $ 28,862.89
(It more space is needed, insert additional sheets of the same size)
Copyright (e) 1996 form software only CPSystems,lne.
Form REV-1510 EX (Rev. 1-97)
}l~~~~.
PO Box 7880
Fort Wayne IN 46801-7880
August 12, 2004
THE ESTATE OF JAMES W CLOUSER
C/O JAMES D BOGAR, ATTORNEY AT LAW
ONE WEST MAIN ST
SHIREMANSTOWN PA 17011
RE: James W. Clouser
97-5270276 A
Dear Mr. Bogar:
We were sorry to learn of the death of James W. Clouser. Please extend our sympathy to his family and
friends.
Thank you for sending us a copy of the Short certificate and the copy Death Certificate for Mr. Clouser.
Mr. Clouser was receiving a gross monthly benefit payment of $927.34 a Designated Period form of
annuity. This annuity was provided to him as the beneficiary of his late spouse, Patricia Clouser. At
the time of her death he began receiving these benefits effective July 24, 2000. These payments are
guaranteed until April 24, 2007.
Please also note, this annuity was surrendered on April 27, 1987 by Patricia Clouser in order to begin
the monthly annuitization payments. At that time all interest accrual was discontinued.
Jack L. Witter, as Mr. Clouser's beneficiary, will now begin receiving monthly payments effective June
24,2004. These monthly payments will continue to Mr. Witter until the final payment period which is
April 24, 2007. The value on this account as of the date of death is $28,862.89. However, there is not
an option to "roll over" this benefit to another plan. We must continue the payments as they were
previously established.
In order in order to continue processing Mr. Witter's benefits, he must complete and forward the following
document to our attention:
- CERTIFIED DEATH CERTIACATE - This certificate must have a raised seal or colored
border, as photocopies are not acceptable.
- Annuitization Claimant Statement
- W-4P tax form
We will forward the above documents to Mr. Witter at the address we have on file. Upon receipt of
this information, we will then begin to send the benefit payments to Mr. Witter.
If you have any questions, please contact our office toll-free at (800) 454-6265, extension 8200.
s~~re~~
~i6fhns
Annuity Claims
cc: Jack L. Witter
Executor and Power of Attorney
REV-1511 EX +(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
James W. Clouser
SSlI 721-01-6997
06/19/2004
FILE NUMBER
21-04-0601
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
B.
DESCRIPTION
AMOUNT
1
FUNERAL EXPENSES:
Cremation Society of Pennsylvania - Cremation Services
208.34
2
Monroe Township Fire Department - Fire Hall Rental - Funeral
Luncheon
300.00
3
Pastor Howard Garman - Eulogy
75.00
Total of Continuation Schedu1e(s)
190.21
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) Jack L. Witter
Social Security Number(s) / EIN Number of Personal Representative(s) 187 -44 - 9252
Street Address 985 Hauck Road
City Mechanicsburg State PA Zip 17055
14,330.00
Year(s) Commission Paid:
2.
3.
Attorney's Fees James D. Bogar Esquire
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
14,330.00
City
Relationship of Claimant to Decedent
State
Zip
4.
Register of Wills
281.00
Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Amerigas - Fuel Bill - Final
65.35
2
Associated Products - Rental of Portable Toilets for Public Sale
246.56
3
Boyd Diller - Trash Removal
441.96
4
Cumberland Law Journal - Executor's Notice
75.00
5
Forrester & Co. Real Estate Appraisal - Appraisal of Real Estate
(two)
600.00
6
Hospital Services - Miscellaneous Hospital Bill Expense
12.00
Total of Continuation Schedu1e(s)
8,980.17
TOTAL (Also enter on line 9, Recapitulation) $ 40,135.59
(If more space is needed, insert additional sheets of the same size)
Copyright (e) 1996 form software only CPSystems,lne. Form REV-1511 EX (Rev. 1-97)
Estate of: James W. Clouser
Soc Sec #: 721-01-6997
Date of Death: 06/19/2004
Continuation of Schedule H-A
(Funeral Expenses)
Item
#
Description
Amount
4
The Grossery - Supplies for Funeral Luncheon
31.02
5
Wal-Mart - Food for Funeral Luncheon
159.19
190.21
Estate of: James W. Clouser
Soc Sec #: 721-01-6997
Date of Death: 06/19/2004
Item
if
Continuation of Schedule H-B7
(Other Administrative Costs)
Description
Amount
7
Jack L. Witter - Reimbursement for costs relating to property
clean-up and sale-Gas, Trash and assistants for sale
457.68
8
Mary A. Murray, Tax Collector - 2004/2005 Real Estate-School
Taxes
1,610.07
9
Nationwide Mutual Fire Insurance Company - Homeowner's Insurance
623.00
10
Patriot News Co. - Obituary and Executor's Notice
133.67
11
PP&L - Electric Bill-Final
149.55
12
Recorder of Deeds - Realty Transfer Tax
2,250.00
13
Register of Wills - Short Certificates
18.00
14
RESERVES: Costs to conclude administration of Estate including
filing fee for PA Inheritance Tax Return, Inventory and First &
Final Account; preparation of Personal and Fiduciary Income Tax
Returns
1,000.00
15
Rick Foreman Auctioneer - Advertising Expenses
524.75
16
Rick Foreman Auctioneer - Advertising for Sale of Farm Equipment
on 10/23/2004
694.75
17
Rick Foreman Auctioneer - Commission on Personal Property Auction
on 10/9/2004
470.00
18
Rick Foreman Auctioneer - Commission for Sale of Farm and Shop
Equipment on 10/23/2004
875.00
19
The Sentinel - Obituary
65.04
20
u.S. Postal Service - Certified Mailings for redemption of
accounts (6)
28.36
21
Verizon - Telephone Bill-Final
18.09
22
Waste Management - Trash Bill-Final
62.21
8,980.17
REV -1512 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
James W. Clouser
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
SSlft 721-01-6997
06/19/2004
FILE NUMBER
21-04-0601
Include unreimbursed medical expenses.
ITEM
NUMBER
1
DESCRIPTION
Apria Healthcare - Home Health Care
AMOUNT
200.00
2
Associated Cardiologists - Medical Bill
5.22
3
Comfort Care - Holy Spirit Hospital - Home Medical Care
240.00
4
Connor Rich Associates - Medical Bill
26.90
5
Juliana Adjei - Home Health Care
1,600.00
6
Live In Care of Pennsylvania, Inc. - Home Medical Care
306.00
7
PinnacleHealth - Medical Bill
41.24
8
West Shore EMS - Ambulance Service
99.41
TOTAL (Also enter on line 10, Recapitulation) $ 2,518.77
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97)
REV-1513 EX + (9-00)
SCHEDULE J
BENEFICIAR IES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
06/19/2004
ESTATE OF
James W. Clouser
SSfl 721-01-6997
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
NUMBER
I.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [Include outright spousal distributions, and
transfers under Sec. 9116{aX1.2)]
1
Richard Clouser
126 W. Green Street
Mechanicsburg, PA 17055
Brother
2
Pamela J. Fleck
77 Clouser Road
Mechanicsburg, PA 17055
Friend
3
Joan C. Laderach
3293 Heritage Circle
Hendersonvi1le, NC 28791
Sister-in-Law
4
James A. Long
4701 Charles Road
Mechanicsburg, 17050
Nephew
FILE NUMBER
21-04-0601
AMOUNT OR SHARE
OF ESTATE
Ten (10%)
percent of
rest, residue
and remainder
$1,000.00
specific
bequest
Ten (10%)
percent of
rest, residue
and remainder
One third
(1/3) of ten
(10%) percent
of rest,
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- 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)
Copyright (c) 2000 form software only The Lackner Group, Inc.
0.00
Form REV-1513 EX (Rev. 9-00)
Estate of: James W. Clouser
Soc Sec #: 721-01-6997
Date of Death: 06/19/2004
Item
#
Continuation of Schedule J, Part I
(Taxable Bequests)
Name and Address of Beneficiary
Relationship Amount or
Share of Estate
residue and
remainder
5
Lynda Long
4827 Virginia Road
Mechanicsburg, 17050
Niece One third
(1/3) of ten
(10%) percent
of rest,
residue and
remainder
6
Martin E. Long
11501 Briarcliff
Warren, MI 48093
Nephew One third
(1/3) of ten
(10%) percent
of rest,
residue and
remainder
7
Norma Love
1706 Sequoia Drive
Prescott, AZ 86301
Sister-in-Law Ten (10%)
percent of
rest, residue
and remainder
8
Jack L. Witter
985 Hauck Road
Mechanicsburg, PA 17055
Nephew
Kitchen table
and eight (8)
chairs and
twenty (20%)
percent of
rest, residue
and remainder
9
Mary E. Witter
100 Clouser Road
Mechanicsburg, PA 17055
Sister
Ten (10%)
percent of
rest, residue
and remainder
10
Shirley L. Witter
985 Hauck Road
Mechanicsburg, PA 17055
Niece
Twenty (20%)
percent of
rest, residue
and remainder
11
Jane Woodson
6319 38th Avenue Southwest
Seattle, WA 98126
Sister-in-Law Ten (10%)
percent of
rest, residue
and remainder
.
'" .~.
LAST WILL AND TESTAMENT
OF
JAMES W. CLOUSER
I, JAMES W. CLOUSER, of Monroe Township,
Cumberland County, Pennsylvania, make, publish and declare
this as and for my Last Will and Testament, hereby revoking all
other Wills and Codicils heretofore made by me.
FIRST: I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment
and together with any insurance policies thereon, unto my wife,
PATRICIA L~ CLOUSER, provided she survives me by sixty
(60) days.
SECOND: Should my wife, PATRICIA L.
CLOUSER, predecease me or die on or before the sixty-first
(61st) day following my death, I devise and bequeath all the rest,
residue and remainder of my estate of whatever nature and
wherever situate, including any property over which I hold
power of appointment and together with any insurance policies
thereon, as follows:
(A) I give and bequeath the kitchen table and eight
(8) kitchen chairs' to my nephew, JACK L. WITIER, provided,
however, that should he predecease me, then to his wife, SHIR-
LEY L. WITTER.
(B) I give and bequeath the sum of One Thousand
and No/IOO ($1,000.00) Dollars to my neighbor, PAMELA J.
FLECK, of 77 Clouser Road, Mechanicsburg, Pennsylvania,
provided, however, that should she predecease me, then to her
husband, RICHARD L. FLECK, JR.
(C) I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment
and together with any insurance policies thereon, in equal
shares, as follows:
(1) Ten (10%) percent to my sister, MARY E.
. -
WITTER, provided, however, that should she prede-
cease me, I give and bequeath her share unto her issue
2
per stirpes by representation, and if there be a failure
of same, then I give and bequeath her share, pro rata,
to the other surviving individuals named in this Clause
SECOND (C), same being the residuary,beneficiaries.
(2) Ten (10%) percent to my sister, PEGGY
LONG, provided, however, that should she predecease
me, I give and bequeath her share unto her issue per
stirpes by representation, and if there be a failure of
same, then I give and bequeath her share, pro rata, to
the other surviving individuals named in this Clause
SECOND (C), same being the residuary beneficiaries.
(3) Ten (10%) percent to my brother,
RICHARD CLOUSER, provided, however, that
should he predecease me, I give and bequeath his
share unto his issue per stirpes by representation, and
if there be a failure of same, then I give and bequeath
his share, pro rata, to the other surviving individuals
. -
named in this Clause SECOND (C), same being the
residuary beneficiaries.
(4) Ten (10%) percent to my wife's sister,
3
JOAN C. LADERACH, provided, however, that
should she predecease me, I give and bequeath her
share unto her issue per stirpes by representation, and
if there -be a failure of same, then I give and bequeath
her share, pro rata, to the other surviving individuals
named in this Clause SECOND (C), same being the
residuary beneficiaries.
(5) Ten (10%) percent to my wife's sister,
NORMA LOVE, provided, however, that should she
predecease me, I give and bequeath her share unto her
issue per stirpes by representation, and if there be a
failure of same, then I give and bequeath her share,
pro rata, to the other surviving individuals named in
this Clause SECOND (C), same being the residuary
beneficiaries.
(6) Ten (10%) percent to my wife's sister,
JANE WOODSON, provided, however, that should
she predecease me, I give and bequeath her share unto
her issue per stirpes by representation, and if there be
4
a failure of same, then I give and bequeath her share,
pro rata, to the other surviving individuals named in
this Clause SECOND (C), same being the residuary
beneficiaries.
(7) Twenty (20%) percent to my nephew,
JACK L. WITTER, provided, however, that should he
predecease me, I give and bequeath his share unto his
wife, SHIRLEY L. WITTER, and if his wife, SHIR-
LEY L. WITTER, predeceases him, then to his issue
per stirpes by representation.
(8) Twenty (20%) percent to my nephew's
wife, SHIRLEY L. WITTER, provided, however, that
should she predecease me, I give and bequeath her
share unto her husband, JACK L. WITTER, and ifher
husband, JACK L. WITTER, predeceases her, then to
her issue per stirpes by representation.
THIRD: In addition to all powers granted to them by
. -
law and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all proper-
5
ty, exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease, for
any period of time, any real or personal property and to give
options for sales, exchanges or leases, for such prices and upon
such terms (including credit, with or without security) or
conditions as are deemed proper. This includes the power to
give legally sufficient instruments for transfer of the property
and to receive the proceeds of any disposition of it.
(B) To partition, subdivide, or improve real estate and
to enter into agreements concerning the partition, subdivision,
improvement, zoning or management of real estate and to im-
pose or extinguish restrictions on real estate.
( C) To compromise any claim or controversy and to
abandon any property which is of little or no value.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds,
. -
without restriction to investments authorized for Pennsylvania
fiduciaries, as are deemed proper, without regard to any princi-
6
pIe of diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To -exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws.
(G) To make distributions to my herein named
beneficiaries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in
order to pay debts, taxes, or estate or trust administration ex-
penses, to protect or improve any property held under my will,
and for investment purposes.
(I) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee
stock ownership plan, or any other type of qualified plan) to the
extent the plan or the law permits them to do so, and to exercise
. .
any other rights which they may have under the plan, in what-
ever manner they consider advisable.
FOURTH: I direct that all inheritance, estate, trans-
7
fer, succession and death taxes, of any kind whatsoever, which
may be payable by reason of my death, whether or not with
respect to property passing under this Will, shall be paid out of
the principal of my residuary estate.
FIFTH: All interests hereunder, whether principal or
income, which are undistributed and in the possession of the
fiduciaries acting hereunder, even though vested or distribut-
able, shall not be subject to attachment, execution or sequestra-
tion for any debt, contract, obligation or liability of any benefici-
ary, and furthermore, shall not be subject to pledge, assignment,
conveyance or anticipation.
SIXTH: I nominate and appoint my wife, PATRICIA
L. CLOUSER, Executrix of this, my Last Will and Testament.
In the event of the death, resignation or inability to serve for any
reason whatsoever of the said PATRICIA L. CLOUSER, I
nominate and appoint JACK L. WITTER, Executor of this, my
Last Will and Testament. I direct that my Executrix or Execu-
tor, as the case may be, and their successors, shall not be re-
8
quired to post security or a bond for the performance of their
duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my
hand and seal to this, my Last Will and Testament" this L~~,
day of
lJV""'1.. 'r~
, 2000.
('~\ ' "
\ fi . ~ j ,-
, l:' .~_ ....,... ,/._:> .... (~, J .....- -~ "',,,.../,.. /..,.........-;
/ JAMBS vi. CLOUSER ~
(SEAL)
Signed, sealed, published and declared by the above-
named Testator as and for his Last Will and Testament in our
presence, who, at his request, in his presence and in the presence
of each other, have hereunto subscribed our names as attesting
witnesses.
/1/ ;) /; t
f..../fZ,u.L{ ;, i l::;!~.{~ /~
- /... ;
U
Address
Address
, 1~J~
[ (j
Q
COMMONWEAL.TH OF PENNSYL.VANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL. TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX{11-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
WITTER JACK L
985 HAUCK ROAD
MECHANICSBURG, PA 17055
___n___ fold
ESTATE INFORMATION: SSN: 721-01-6997
FILE NUMBER: 2104-0601
DECEDENT NAME: CLOUSER JAMES W
DATE OF PAYMENT: OS/25/2005
POSTMARK DATE: OS/25/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 06/19/2004
NO. CD 005366
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $45.69
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$45.69
REMARKS: J L WITTER
CHECK# 236
SEAL
INITIALS: VZ
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOnCE OF IHHERJ:TANCE TAX
: )'APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
...--
BUREAU OF IHDIVIDUAI.,-!:r~7'--':
IHtIERITANCE TAX DIVISION:; -t_j'~" 'c.',
PO BDX 2B0601
HARRISBURG PA 171t8-0601
MOC lJ'Y "0: p+'I?: 19
LUUJ H]'" Lv II 1,-_
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
C' t:q11 1\)-
'.._1.-1';'\.."
~Rr" ", 'I' \'C NY '''T
JAMES D B~;,g~lt):~'(;;r,.
1 W MAIN ' "', : :, ' '
SHIREMANSTOWN PA 17011
05-23-2005
CLOUSER
06-19-2004
21 04-0601
CUMBERLAND
101
Aolount R...i ttecl
'*
REV-lS47 EX AFP (03-05)
JAMES
W
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
UV-"1'!.r:"Yf.m.m!!'1M'.W't1'l!t.l/I!".!MMArr~M.Y.m.IWl1lmMMf'~.'rt'tW~M.Y.llrr.............. ...
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
JAMES W FILE NO. 21 04-0601 ACN 101
ESTATE OF CLOUSER
TAX RETURN WAS: ( ) ACCEPTED AS FILED
( X) CHANGED
SEE
DATE 05-23-2005
ATTACHED NOTICE
If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of abh returns assessed to date.
ASSESSMENT OF TAX:
15. AIlaunt of Line 1'1 at Spousal 'rate 115)
16. AMount of Line 14 taxable at Lin..l/Class A rat. (16)
17. ADount of Lin. 1'1 at Sibling rate (17)
18. ~t of Line 14 tax8bl. .t Collateral/Class Brat. (18J
19. Principal Tax Due
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Sohedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule OJ
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule GJ
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/AdII. CostslHisc. ExPenses (Schedule H)
10. Dabts/Hortgage Liabilities/Li.ns (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts
14. Net Value of Estate Subject to Tax
(9)
110)
NOTE:
11)
(2)
(3)
('I)
(5)
(6)
(n
225.000.00
37.630.85
240.00
.00
114.827.69
.00
28.862.89
(8)
NOTE: To insure proper
credit to your account,
sub.it the upper portion
of this fOMl ..i th your
tax paYIIBnt.
406,561.43
42.654 36
363,907. 07
.00
363,907.07
00 =
045 =
12 =
15 =
.00
.00
8,017 .06
44,564.73
52,581.79
40,135.59
2.518.77
I1lJ
112)
(13)
11'1)
(Sch.dul. .J)
.00 X
.00 X
66,808.84 X
297,098.23 X
(19)=
rAY CR TS:
"DATE IT '+1 AMOUNT PAID
NUMBER INTEREST/PEH PAID (-)
09-15-2004 CD004384 2,626.83 49,909.77
INTEREST IS CHARGED THROUGH 06-07-2005 TOTAL TAX CREDIT 52,536.60
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 45.19
REVERSE SIDE OF THIS FORM INTEREST AND PEN. .50
TOTAL DUE 45.69
-
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YDU HAY BE DUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PD BOX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
A~Ats~NT, ALLOWANCE OR DISALLOWANCE
"DP:'llI;~TIONS AND ASSESSKENT OF TAX
M,'" 11 f'f "0 P~I'JI' \2: 1.3
Lu\~;) flJ-'.1 L
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
05-23-2005
CLOUSER
06-19-2004
21 04-0601
CUMBERLAND
101
""'aunt R8IJi ttlKl
JAMES D BOGAR
1 W MAIN ST
SHIREMANSTOWN
Cl~')'l nF
\.....! -~i \ -."
Or.:)' 1'.""(' {-..(\\ 10"'1
ESQ HI," r--',.~\\" ,', ,_;'-..J'...-'. 1
i ,,"-. '.- ."
0\H_A:"r'
vl..r'j;
PA 17011
'*
REY-1547 EX AFP (03-05)
JAMES
W
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
"fV-"MC"Yf.'XIWm~'1I!1.mm!t.!II!'.!WlftIl!'l'~M!!.'IW."WJl"mM!m~.'lrC[tI\tI'~M:Y.1I'1t.............. ...
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
JAMES W FILE NO. 21 04-0601 ACN 101
ESTATE OF CLOUSER
TAX RETURN WAS: I
) ACCEPTED AS FILED
I X) CHANGED
I~ an asses~ent was issued previously, lines 14. IS and/or 16. 17. 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
IS. A.ount of Line 14 at Spousal rat. (IS)
16. ~unt of Llhe 14 taxable at Lineal/Class A rate (16)
17. Anount of Line 14 at Sibling rate (17)
18. ~ount of Line 14 taxable at Collateral/Class Brat. (18)
19. Principal Tax Du.
X TS.
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Int.rest (Schedule C)
4. Mortgages/Notes Receivable (Schedule DJ
5. Cash/Bank o.posits/Hisc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule S)
8. Total Assets
11)
(2)
(3)
(4)
IS)
(6)
(7)
225,000.00
37.630,85
240,00
,00
114.827.69
.00
28,862.89
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral ExpanS8s/A~. Costs/Hisc. Expenses (Schedule H)
10. Debts/Hortgage Liabilities/Liens (Schedule 1)
11. Total Deductions
12. N.t Value of Tax R.turn
13. Ch.ritablelGov.r~antal Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Est.te Subject to Tax
(9)
110)
40,135,59
2.518.77
Ill)
112)
113)
114)
NOTE:
.00
.00
66,808.84
297,098.23
X 00 =
X 045 =
X 12 =
X 15 =
DATE
09-15-2004
AKOUNT PAID
49,909.77
NIII1BER
CD004384
INTEREST/PEN PAID 1-)
2,626.83
~
INTEREST IS CHARGED THROUGH 06-07-2005
AT THE RATES APPLICABLE AS OUTLINED ON
REVERSE SIDE OF THIS FORM
THE
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
. IF PAID AFTER DATE INDICATED. SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
SEE
119)=
DATE 05-23-2005
ATTACHED NOTICE
NOTE: To insure proper
credit to your account,
sub.it the upper portion
of this for. with your
tax pay_ni.
406,561.43
4:?,6~4 36
363,907.07
.00
363,907.07
.00
.00
8,017.06
44,564.73
52,581.79
52,536.60
45.19
.50
45.69
IF TOTAL DUE IS LESS THAN $1, NO PAVtlENT IS REllUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR). YOU KAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORK FOR INSTRUCTIONS.)
REV_1470 EY <';..83)
'*'
INHERITANCE TAX
EXPLANATION
OF CHANGES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
PO Box 280601
HARRISBURG PA 17128-0601
DECEDENTS NAME
FILE NUMBER
James W. Clouser
REVIEWED BY
ACN
2104-0601
101
Sheila Megonnell
ITEM
SCHEDULE NO.
EXPLANATION OF CHANGES
G
Transfers are taxable outright to the beneficiary before determining residue.
J
4,5&
6
Changed tax rate from 12 percent to 15 percent since a sister's issue (nieces and
nephews to decedent) are collateral beneficiaries.
I,;;
,1"
ROW
Page 1
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 28Q601
HARRISBURG PA 11128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
lS
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
JAMES D BOGAR
1 W MAIN ST
SHIREMANSTOWN
ESQ
PA 17011
*'
REV-1607 EX AFP (03-05)
06-20-2005
CLOUSER
06-19-2004
21 04-0601
CUMBERLAND
101
A_unt R..1 Had
JAMES
W
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
RESISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credii io your account, subDit the upper portion of this forM with your tax pay..ni.
CUT ALONS THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
...............................................................................................................1
REV-1607 EX AFP (03-05) *** INHERITANCE TAX STATEMENT OF ACCOUNT ...
ESTATE OF CLOUSER JAMES W FILE NO. 21 04-0601 ACN 101 DATE 06-20-2005
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOHN BELOW
IS A sunHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 05-23-2005
PRINCIPAL TAX DUE, 52,581.79
PAYMENTS (TAX CREDITS),
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
09-15-2004 CD004384 2,626.83 49,909.77
05-25-2005 CDOO5366 .41- 45.69
TOTAL TAX CREDIT 52,581. 88
BALANCE OF TAX DUE .09CR
INTEREST AND PEN. .00
IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .09CR
.
~
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
I IF TOTAL DUE IS LESS THAN $1,
HO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ,
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
AEV-1500 EX + (6-00)
CAPB
HpRL
EplO
CRAC
KoTK
ES
C P
o 0
R N
R D
E E
S N
T
D
E
C
E
D
E
N
T
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
DEPT. Z80601
HARRISBURG. PA 17128-0601
DECEDENT'S NAM~(LAST. FIRST, AND MIDDLE INITIAL)
Clouser James W.
DATE OF DEATH (t.n.4.00~YEAA)
FILE NUMBER
OFFlCIAL USE CNI.. Y
21-04-0601
NUMBER
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
721-01-6997
THIS RETURN MUST BE Rl.EDtN QUPUCATEWlTH THE
REGISTER OF WILLS
S A\. , YN M
o
None
None
None
None
38,402.60
None
None
3,855.00
None
x
X
X
X
.0 0
.045
.12
.1S
3 A t8 of death
. emalndet Retum prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of S.J.fe Deposit Boxes
x Z. Supplemental Return
4a. Future Interest Compromise (date of death after lZ- 12-82)
7. Oecedent Maintained a Living Trust
(AttachCOfJ'fofTrust)
010. Spousal Poverty Credit D 11. Election to tax undef See. 9113(A)
(date of death between 12-31-91 and '-1-95) (Attach SchO)
,..::'TlI'S.SEi!:'i'iON.MusT.IilE .i!:OMl>LE1'EO.W:.i!:.Oi'li'lE!lVO"QENCE:&.CO"FIQENTIAi:j~AXI!lItQi'lMA'!'IQ"$l'!Ql/LI:IilE"Qli'lE~'i'i;OltQ!;1
NAME COMPL.ETE MAILING ADDRESS
Copyright (c) 2000 form software only The Lackner Group, Inc.
James D. Bo ar Es uire
FIRM NAME ~f Applicable)
One West Main Street
Shiremanstown, PA 17011
Q
::0
ONLY--j") C)
,-',--) (=>
,'r, =0
-.--{c"J
. i~' r:--,
_TJ C:J
C)
j-I
T1
C)
~rTl
C)
TI
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation. Partnership or
Sole-Proprietorship
4. Mortgages & Notes Receivable (SChedule D)
5. Cash. Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requestecl
7. Inter-Vivos Transfers & Miscellaneous Non-Probate PropertY (7)
(SChedule G or L)
8. Total Gross Assets (total lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabil~ies, & Liens (Schedule!) (10)
11. Total Deductlons (total Lines 9 & 10)
12. Net Value 01 Estate (Line 8 minus line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Sub.ect to Tax (Line 12 .:rnnus Line 13)
L tNt tAL
1. Orlglrtal Return
4. limited Estate
X 6. Decedent OlecHestate
(Attach copy of Will)
o 9. Litigation Proceeds Received
TELEPHONE NUMBER
(1)
(2)
(3)
'-0
:2
'J1
<.r1
(8) 38,402.60
(ll) 3,855.00
(12) 34,547.60
(13)
(14) 34,547.60
(lS)
(16)
(17)
(18)
(19)
0.00
0.00
829.14
4.145.71
4,974.85
R
E
C
A
P
I
T
U
L
A
T
I
o
N
(4)
(S)
(6)
C
o
M
P
T U
A T
X A
T
I
o
N
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, ortranslers under Sec. 9116(aXl.2)
16. Amount of line 14 taxable at lineal rate
17. Amount of line 14 taxable at sibling rate
18. Amount of line 14 taxable at collateral rate
19. Tax Due
20.
0.00
6,909.52
27,638.08
FonnREV-1500 EX (Aev. .-00)
Decedent's Complete Address:
STREET ADDRESS
96 Clouser Road
CITY I STATE I ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayrnents
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
4,974.85
Total Credits ( A + B + C) (2)
0.00
3. InterestlPenalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3. enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 10 request 0 refund (4)
5. If Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE. (s)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
. . . . ................... ......... Mllke~heck Payo~lelo:... ..... ..REGIS.TER.OF WILLS, AGENT
mmmmmmmmmtmmmllllilmmmmmmmmmmmimlmmmlllmmllmmmmmmmmmlmmmmmmmmm!itlmmmmmJiiliiilmmmmmmiiililllfJlitmimmimmmmmlJ!1ii!illl!!lllfmmmmmllimililllllillllmmilllllilmmmlillll!!lll!!llll!!!ffilmllilllliilllilll!llmlll!ii!ll!ii
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes No
~~
0.00
0.00
4,974.85
1. Did decedent make a transfer and:
I. 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his
or her death? .................................... . .. ...... 0
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.
[!]
[!]
o
Under penalties of perJury,1 declare that I have examfned this retum, Including accompanying schedules and statements, and to the best of my knowledge and bellef,lt Is true,
correct and complete. Declaration of preparer other than the personal representative is based on all Information of which preparer has any knowledge.
SIGN TUREOF PERSON RESPONSIBL R FILING RETURN Jack L. Witter
985 Hauck Road
"" Mectiati.lc"sb;";:";" PA"" i"i6ss"""" -" -"""""""""" - -""
James D. Bogar Esquire
One West Main Street
"- "Shlr"ema;'isto~;" PA"" i"i6ii"""""""""""""" """""""
DATE
<l8l\ f{(~)
DATE
<i9IL/f{e7S"
For dates of death on or r uly 1. 1994 and before January 1. 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 9116 (0) (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 0%
[72 P_S_ 9116 (a) (1.1) (un 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 0% [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 4.5%. except as noted in 72 P.S. 9116( 1.2)
[72 P.S. 9116(.X1j}
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(aXl.3)l 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.
Copyright (c) 2000 form SOftwill'8 only The Ladcner Group. lne. Form REV-1500 EX (Rev. 6-00)
REV-1508 EX t (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
James W. Clouser SS# 721-01-6997 06/19/2004 21-04-0601
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
NUMBER
1
DESCRIPTION
Ohio State Life Insurance Company - Annuity
Contract No. 201-00818864A, commuted value of
Supplemental
annuity $38,402.60
VALUE AT DATE
OF DEATH
38,402.60
TOTAL (Also enter on line 5. Recapitulation) $ 38,402.60
(If more space is needed. insert additional sheets of the same size)
Copyrfght(c) 1996 form sottware only CPSystems, Inc. Form REV-15G8 EX (Rev. 1-97)
A
'i_
Ohio State Life Insurance Company
P.O. Bo. 410288. Kans.. City, MO 64141..0288
July 28, 2005
ESTATE OF JAMES W CLOUSER
C/O JAMES D BOGAR
ONE WEST MAIN STREET
SHIREMANSTOWN, PA 17011
Reference: 00294372
Contract Number: 201-00818864A
Annuitant: James W Clouser (Deceased)
Dear Mr Bogar:
This letter is in reference to the above mentioned Supplemental Contract. We extend our sincere
condolences to you and other family members in your loss.
Enclosed is our check in the amount of $38,402.60 Which represents the commuted value of the
above contract ~
If you have questions, please contact our office at (800) 366-6615.
Sincerely,
John Hooper
Sr Claims Representative
REV-1511 EX +(1~97)
SCHEDULE H
FUNERAl EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
James W. Clouser
SSlf 721-01-6997
06/19/2004
FILE NUMBER
21-04-0601
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES,
B. ADMINISTRATIVE COSTS,
1. Personal Representative's Commissions 1,920.00
Name of Personal Representative(s) Jack L. Witter
Social Security Number(s) I EIN Number of Personal RepresentatNe(s) 187-44-9252
Street Address 985 Hauck Road
City Mechanicsburg State PA Zip 17055
Year(s) Commission Paid, -
2- Attorney's Fees James D. Bogar Esquire 1,920.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
-
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Register of Wills - Filing Fee - Supplemental Pa. Inh. Tax Return 15.00
TOTAL (Also enter on line 9. Recapitulation) $ 3,855.00
(If more space is needed. insert additional sheets of the same size)
Copyright (c:) 1996 form sottw.-e only CPSystems. rne.
Fonn REV-1511 EX [Rev. 1-97)
10-10-2005
CLOUSER
06-19-2004
21 04-0601
CUMBERLAND
101
APPEAL DATE: 12-09-2005
( See reverse side under Objections)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
9~!_~~9~~_!~!~_~!~~______~___~~!~!~_~Q~~~_~Q~!!Q~_~Q~_!Q~~-~~~Q~~~--~--------------------
REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
JAMES W FILE NO. 21 04-0601 ACN 101
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX Z80601
HARRISBURG PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
_D~pARTMENT OF REVENUE
...., -r-'''"'., ".
r. ;\-(_.;~NoTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
,> ~I 1"\: ~~l
. I" I..
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
:../
JAMES D BOGAR ESQ
1 W MAIN ST
SHIREMANSTOWN
PA 17011
ESTATE OF
CLOUSER
REV-1547 EX AFP (06-05)
JAMES
W
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
DATE 10-10-2005
NOTE: If an assessment was issued previoUSly, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 = .00
.00 X 045 = .00
73,718.36 X 12 = 8,846.20
324,736.31 X 15 = 48,710.44
(19)= 57,556.64
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
4. Mortgages/Notes Receivable (Schedule D) (4)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
NO. 01
.00
.00
.00
.00
38,402.60
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
3,855.00
.00
(II)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
38,402.60
3.855 00
34,547.60
.00
398,454.67
~,..~" ""'..."'....-. l+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
09-15-2004 CD004384 2,626.83 49,909.77
05-25-2005 CD005366 .00 45.69
08-19-2005 CD005710 .50- 4,974.85
BALANCE OF UNPAID INTEREST/PENALTY AS OF 08-20-2005 TOTAL TAX CREDIT 57,556.64
BALANCE OF TAX DUE .00
INTEREST AND PEN. 104.19
TOTAL DUE 104.19
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. ~ If
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE G V
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
STATUS REPORT UNDER RULE 6.12
Name of Decedent: James W. Clouser
Date of Death: June 19, 2004
Will No.
21-04-0601
Admin. No.
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No X
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes X No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date: ulJ.\~
.-
t<-"",_
James D. Bo ar, Esquire
Name (Pleas. type or print)
One West Maln St.
Shiremanstown, PA 17011
Address
('oJ
,.:..
LL\
c2
L
c)
(717) 737-8761
Te l. No.
l.~J
(--:7-)
c::::::.'l
('-.I
Capacity:
Personal Representative
(MAH:rmf/AM3)
x Counsel for personal
representative
Vf_'
BUREAU OF INDIVIDU.\L:'tAXf;'S'T
INHERITANCE TAX DIVISION -
PO BOX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
REV-1607 EX AFP [03-05)
""("'"1- ~ '~il ~ I'.
.'" j .-r
',: 03
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
11-07-2005
CLOUSER
06-19-2004
21 04-0601
CUMBERLAND
101
JAMES
W
/....\:-- .
"
JAMES Dr-BOGAR ESQ
1 W MAIN- ST
SHIREMANSTOWN PA 17011
Allount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE
--+ RETAIN LOWER PORTION FOR YOUR RECORDS
+-
REV-1607 EX AFP (03-05)
~~~ INHERITANCE TAX STATEMENT OF ACCOUNT ...
ESTATE OF FILE NO. ACN DATE
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 10-10-2005
PRINCIPAL TAX DUE: 57,556.64
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
09-15-2004 CD004384 2,626.83 49,909.77
05-25-2005 CD005366 .00 45.69
08-19-2005 CD005710 .50- 4,974.85
10-19-2005 CD005913 104.19- 104.19
TOTAL TAX CREDIT 57,556.64
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
IE
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1,
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. )
pt