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Home My WebLink About03-0004also known as PETITION FOR PROBATE and GRANT OF LETTERS No. o11-03-0,t To: Register of Wills for the Deceased. County of Cumber] and Social Security No. ~r~,~-k - ~.~C.5 '- [o k'cX~ Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of a~e or older an the execut x" x',~ in the last will of the above decedent, dated '~'o,-c~,.,,.~as Nk~o and codicil(s) dated in the named , ~ 2_~\ (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Q-'-~ x~-.~,e_,c-~ ~._x-~,. ~ County, Pennsylvania, with h c~x7 last family .or princ, ipal residence at N~.'?~ ',o._h. xx_.~c._x.~-N- ~3x-. " (list street, n"~umXber and muncipality) Decendent, then c~ years of age, died ~ ~-o~-e-x----.x'~-~ NoR , at XoX~,o. ~xSxx-'~ax-- Except as~ollo~s, decedent didnot marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: WHEREFORE, petitioner(s) respectfully presented herewith and the grant of letters theron. request(s) the probate of the last will and codicil(s) Testamentary (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 3 COUNTY OF Cumberland J~ ss The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed ff ;~-"~'°'~xe'~°'~ ,3 .) - ~' ~oef, ore me this 2nd da.wof / (,~.~)d anuary_ /h ..... ~t'gl~ u~ J -- ....... '- i'sfe? .. Donna M. Otto,lst Deputy ~ ~-~ ?-//,4- °0' No. 21-2003-0004 Estate Of ELOISE V. BERN , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW January ~nd l~X 200~in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated August 16th, 2001 described therein be admitted to probate and filed of record as the last will of Eloise V. Bern ; and Letters Te s t am e n t a ry Vickie are hereby granted to Lynn Guion FEES Probate, Letters, Etc .......... $ 235.00 Short Certificates(2) .......... $. 6.00 Renunciation ................ x-Pages (5) $ 15.00 JCP 10.00 TOTAL ~ $ Filed .J a~uory., 2~.,-2 0-03.- .2.6..6...99.' Register of Wills / Donna M. Otto, 1st Deputy ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE MAILED LETTERS TO'EXECUTRIX ON 01-02-2003 his is to certify that the information here given is correctly copied fi-om an original certificate of death duly filed with me as Local Registrar. The original certificate will be. fbrwarded to the State Vital Records Office for permanent fiJing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, 52.00 P 8869656 No. Ix)cai Registrar flEC 2 4 2002 Date " Eloise V. Bern 85 '('*. i i Ipec. 24,1916 C~'. BORO, TW~ OF OEATH FAClL L~ E. Pennsboro ~,, , COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH I I~*Female J" 467 -- 20 -- 6148 ,. DECEDENT'$ USUAL O~CUIMTION KINO OF 8USINE$~/INOUS~'Ry AC~ 17L ~m, ~A ~ech~csbu~ PA [7055 ~ ~" John ~. '~,, A~ ~vis Vickie ~ion I [2~,~u,~u~.-%~,m~tz~ .... ~=~,.~.~_~ [ .... .~c. 20~ 2~2 ] .... Blue R[~e Ce~te~ ~,,~. Blue Ri~e, TX 75424 ~ a ~ ~ It la ~lth m ~e~T~ ..... ~~ ~ ~ · J , / ~ ~ / ,-- , i ( 2~,,,..,P,,., ! kc~c+¥ C,a-~,'/'l ~t~/o/ 21-2003-0004 LAST WILL AND TESTAMENT OF ELOISE V. BERN I, Eloise V. Bern, of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time previously made. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my Estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will, which is not specifically devised or bequeathed, as an expense and cost of administration of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though on proceeds of insurance or other property not passing under this Will. ITEM I1: I hereby exercise all powers of appointment that I may have at the time of my death in favor of my residuary estate, and all property subject to all such powers shall be included in my Estate. ITEM II1: I give and bequeath all my household furniture and furnishings, automobiles, books, pictures, jewelry, china, linen, silverware, wearing apparel and all other like articles of household or personal use and adomment to my children, Vickie Lynn Guion of Mechanicsburg, Pennsylvania, and Nancy Edwards of Kaneohe, Hawaii, or the survivor of them, to be divided between them is as equal shares as practicable. Page 1 of 6 ITEM IV: I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, to my children, Vickie Lynn Guion and Nancy Edwards, or their issue, per stirpes, to be divided between them in as equal shares as practicable. ITEM V: In the settlement of my Estate, my Executor shall possess, among others, the following powers to be executed for the best interest of the beneficiaries: (a) To sell either at public or private sale and upon such terms and conditions as my Executor may deem advantageous to my Estate, any or all real or personal estate or interest therein, whether owned by me severally or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other wdtings which may be necessary or desirable in carrying out any of the powers conferred upon my Executor in this Paragraph V(a) or elsewhere in my Will. (b) To pay all costs, taxes, expenses and charges in connection with the administration of my Estate. My Executor shall pay expenses of my last illness and funeral expenses. (c) To distribute my Estate in kind or in money. If any assets are distributed in kind, they shall be distributed at their respective value(s) on the date(s) of their distribution. (d) To retain any investments I may have at my death so long as my Executor may deem it advisable to my Estate so to do. (e) To vary investments, when deemed desirable by my Executor and to invest in such bonds, stocks, notes, money markets, real estate mortgages or other securities or in such other property, real or personal, as he shall deem wise, without being restricted to so-called "legal investments." (0 To mortgage real estate and to make leases of real estate. Page 2 of 6 (g) To borrow money from any party to pay indebtedness of mine or of my Estate, expenses of administration or inheritance, legacy, estate and other taxes. (h) To vote any shares of stock which form a part of the Estate and to otherwise exercise all the powers incident to the ownership of such stock. (i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of the Estate. 0) To distribute my personal property directly to the Guardian of the person of any minor beneficiaries hereunder. (k) To elect such settlement options as deemed most appropriate by my Executor with respect to any pension, profit sharing or other retirement plan in which I am a participant. (i) To do all other acts in the judgment of my Executor necessary or desirable for the proper and advantageous management, investment and distribution of my Estate. ITEM VI: Any person who shall have died at the same time as me, or in a common disaster with me, or who shall fail to survive me by ninety (90) days, shall be deemed to have predeceased me. ITEM VII: If at any time any minor child or legally incompetent person shall be entitled to receive any assets hereunder, I hereby nominate, constitute and appoint my Executor to act as Guardian of the assets payable to such person. Said Guardian may receive and administer all assets authorized by law and shall have full authority to use such assets, both principal and income, in any manner said Guardian shall deem advisable for the best interest of such person, including college, university, post-graduate or other education, without securing court order. Said Guardian shall have all the rights and privileges as to the Guardianship and the assets thereof as are herein granted to my Executor as to my Estate and the assets therein. Page 3 of 6 ITEM VIII: I nominate, constitute and appoint Vickie Lynn Guion to be my Executor. In the event of the death, resignation, refusal or inability of Vickie Lynn Guion to serve as my Executor, I nominate, constitute and appoint Nancy Edwards to serve as Executor in her place. My Executor and Guardian are specifically relieved from the duty or obligation of filing any bond or bonds. IN WITNESS WHEREOF, I have set my hand and seal to this my Last Will and Testament, consisting of this, the next two pages, and the preceding three pages this I~__ day of ¢:~u6 o~ ,2001. ,j Eloise V. Bern SIGNED, SEALED, PUBLISHED AND DECLARED by the above named Testator, Eloise V. Bern, as and for her Will, in the presence of us, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses in attestation thereof. Address Address Address Page 4 of 6 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA · COUNTY OF OP,'ut::' ~ i ~ SS. I, Eloise V. Bern, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by Eloise V. Bern, the Testator, this ~ day of (~,~,., ~,-~ ,2001. ~J Eloise/~. Bern, Testator N d4a'ry Public My Commission Expires: (SEAL) D Notarial Seal em'se B. Willia_mson, No_taQ/Public rmmsou_rg, uau~hin county My Commission Expires May 1, 2004 Member, Pennsylvania Association ot Notaries Page 5 of 6 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA · COUNTY OF 0 I:::~J~ ~ (~\ SS. and/:O..¢~.~_¢~ ~... t./'~¢,,,/...,~ the witnesses Wh(Jse names ~r~ Signed to th; att~., ed or foregoin~l instrument, being duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as her Last Will; that the Testator signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness, in the hearing and sight of the Testator, signed the Will as a witness; and that to the best of our knowledge, the Testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ./~,,~ . Sw~om to or affirme¢~ and subs_c, ribgd to before me by I,-~ ¢,,~V.I .Ali, /f~x z"~ ~, and ~:2.~Z:~; ~ ~-~z_.,.,~, witnesses, this "---- ,2OOl. // day of Witness Witness Vitness N ob3fy Public My Commission Expires: (SEAL) F:\dbw~Wills\Bem\Will.doc Page 6 of 6 Notarial Seal De.n~. B Willlamson, Notary Public Hamst~_rg, Dauphin County My Commission Expires May 1, 2004 Member, Pennsylvania Association of Notaries WIX, WENGER O WEIDNER ATTORNEYS AT LAW 508 NORTH SECOND STREET POST OFFICE BOX 84..5 HARR ISB UR.G, PEN'NSYLVAN Ia 17108- 08zi.5 IN THE REGISTER OF WILLS OFFICE CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF ELOISE V. BERN, Decedent DATE OF DEATH: 12/19/2002 ESTATE FILE NO. 2003-00004 PRAECIPE FOR ENTRY OF APPEARANCF TO THE REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA: Please enter the appearance of David R. Getz, Esquire, and the law firm of Wix, Wenger & Weidner as counsel for Vickie L. Guion, Executor of the Estate of Eloise V. Bern. Respectfully submitted, WIX, WENGER & WEIDNER By: /v'-~¢f¢o,c gl David R. Getz, Esquire Attorney ID No. 34838 508 North Second Street P.O. Box 845 Harrisburg, PA 17108-0845 (717) 234-4182 Dated: January $, 2003 IN THE REGISTER OF WILLS OFFICE CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF ELOISE V. BERN, Decedent DATE OF DEATH: 12/19/2002 ESTATE FILE NO. 2003-00004 CERTIFICATE OF SERVICE I hereby certify that the foregoing document was served via United States first- class mail, postage prepaid, and/or hand delivered this day to the following: Vickie L. Guion 117 Sholly Drive Mechanicsburg, PA 17055 Dated: January C, 2003 WIX, WENGER & WEIDNER By:: Da~/id R. Get~:, Esquire' ,,/' 508 North Second Street P.O. Box 845 Harrisburg, PA 17108-0845 (717) 234-4182 IN THE REGISTER OF WILLS OFFICE FOR CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF ELOISE V. BERN DATE OF DEATH: 12/19/2002 ESTATE CERTIFICATION OF NOTICE UNDER RULE 5.6(a) TO THE REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA: 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 ,,.Tanua]r¥ tO, 2003: Ms. Vickie L. Guion 117 Sholly Drive Mechanicsburg, PA 17055 Ms. Nancy Edwards Box 305 Kaneohe, HI 96744 Notice has now been given to all persons entitled thereto under Rule 5.6(a):.except None ,:.~ Dated: Januaw__~'~2003 Respectfully submitted, WIX, WENGER & WEIDNER By: ~ David R. Getz, Esquire " Attorney ID No. 34838 508 North Second Street P.O. Box 845 Harrisburg, PA 17108-0845 (717) 234-4182 Counsel for Personal Representative RICHARD H. WIX THOMAS L. WENGER DEAN A. WEIDNER STEVEN C. WILDS THERESA L. SHADE WIX * DAVID R. GETZ STEPHEN J. DZURANIN STEVEN R. WILLIAMS TRACY b UPDIKE JEFFREY C. CLARK · AlSo Member Massachusetts Bar WIX, WENGER & WEIDNER A PROFESSIONAL CORPORATION ATTORNEYS AT LAW 508 NORTH SECOND STREET POST OFFICE BOX 845 HARRISBURG, PENNSYLVANIA 17108-0845 (717) 234-4182 TELECOPIER (717) 234-4224 www.wwwpalaw.com 4705 DUKE STREET HARRISBURG, PA 17109-3099 (717) 652-8455 TELECOPIER (717) 652-6290 September 16, 2003 Donna M. Otto, Acting Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 Re: Estate of Eloise V. Bern File No. 21-03-0004 Dear Ms. Otto: We enclose the following documents for filing on behalf of the above-captioned estate: The original and two copies of the Pennsylvania Inheritance Tax Return; Our check in the amount of $15.00, made payable to the "Register of Wills," representing your filing fee for the tax return; Two checks from the estate's beneficiaries totaling $8,459.51, made payable to "Register of Wills, Agent," representing the inheritance tax due; 4. The original and one copy of the Inventory; and Our check in the amount of $10.00, made payable to the "Register of Wills," representing your filing fee for the Inventory. Please process these documents at your earliest convenience and return time- stamped copies of the tax return and Inventory to our office. A self-addressed, stamped envelope is enclosed for your convenience. WIX, WENGER & WEIDNER Donna M. Otto, Acting Register of Wills September 16, 2003 Page 2 Thank you for your assistance in this matter. If you have any questions regarding the above, please call me. /dbw Enclosures cc: Mrs. Vickie Guion David R. Getz, Esquire Sincerely, WIX, WF__~GER & WEIDNER / By: Denise B. Williamson Paralegal WIX, WENGER & WEIDNER ATTORNEYS AT I.AW 508 NORTH SECOND STREET POST OFFICE BOX g45 HARRISBURG, PENNSYLVANIA 17108-0845 Donna M. Otto, Acting Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003024 GETZ DAVID R ESQUIRE 508 NORTH SECOND STREET HARRISBURG, PA 17101 ........ fold ESTATE INFORMATION: SSN: 467-20-6148 FILE NUMBER: 2103- 0004 DECEDENT NAME: BERN ELOISE V DATE OF PAYMENT: 09/1 7/2003 POSTMARK DATE: 09/1 6/2003 COUNTY: CUMBERLAND DATE OF DEATH: 12/19/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $4,229.76 TOTAL AMOUNT PAID: $4,229.76 REMARKS: NANCY B EDWARDS C/O DAVID R GETZ ESQUIRE SEAL CHECK# 1940 INITIALS: DO RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-O601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 003025 GETZ DAVID R ESQUIRE 508 NORTH SECOND STREET HARRISBURG, PA 17101 ........ fold ESTATE INFORMATION: SSN: 467-20-6148 FILE NUMBER: 21 03-0004 DECEDENT NAME: BERN ELOISE V DATE OF PAYMENT: 09/17/2003 POSTMARK DATE: 09/1 6/2003 COUNTY: CUMBERLAND DATE OF DEATH: 12/19/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $4,229.75 TOTAL AMOUNT PAID: $4,229.75 REMARKS' VICKIE B GUION C/O DAVID R GETZ ESQUIRE SEAL CHECK# 639 INITIALS: DO RECEIVED BY: DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS REV-1500 EX + (6-00) z z 0 uJ 0 ~J Z Z COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 DECEOENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL Bern, Boise V. DATE OF DEATH (MM-DD-Year) 12/19/2002 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT IDATE OF BIRTH (MM-DD-Year) 12/24/1916 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) N/A OFFICIAL USE ONLY -[=iLE NUMBER COUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 4 6 7-2 0-6 1 4 8 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER r~l. Odginal Retum [~4. Limited Estate n~6. Decedent Died Testate (^ttach copy orwi~l) [-'~ 9. Litigation Proceeds Received [] 2. Supplemental Return n-] 4a. Futura Interest Compromise tdate of death after 12-12-82) [~]7. Decedent Maintained a Living Trust (Attach copy of Trust) E~10. Spousal Poverty Cradit (d~ of death between 12-31-91 and 1-1-95) E~3. Remainder Return (date of death prio~to t2-13-82) [~5. Federal Estate Tax Return Required 0__ 8. Total Number of Safe Deposit Boxes E~ 11. Election to tax under Sec. 9113(A) (Attach Sch O) NAME David R. Getz, Esquire FIRM NAME (If Applicable) WIX, WENGER & WEIDNER 'TELEPHONE NUMBER /717) 234-4182 COMPLETE MAILING ADDRESS 508 North Second Street P.O. Box 845 Harrisbur~ PA 17108-0845 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Propert7 (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) '--J Separate Billing Requested 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 Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) 11,428.18 OFFICIAL USE ONLY 192,110.46, (8) 203,538.64 (11) 11,696.83 3,852.68 15,549.51 187,989.13 187,989.13 (12) (13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(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 ~ (15) 187,989.13 X .045 (16) X .12 (17) X .15 (18) (19) ' > > BE SURE TO ANSWER:ALLQUESTIONS ONREVERSE SIDE AND RECHECK MATH < < 8,459.51 8,459.51 Decedent's Complete Address: STREET ADDRESS 133 West Locust Street, Apt. 212 CITY Mechanicsburg I STATE PA Tax Payments and Credits: 1. Tax Due(Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount zip 17055 (1) 8,459.51 Total Credits ( A + B + C ) (2) Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 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) 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. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (SD) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ........................................................................... [] [] b. retain the right to designate who shall use the property transferred or its income; ........................................[] [] c. retain a reversionary interest; or ...................................................................................................... [] [] d. receive the promise for life of either payments, benefits or care? ............................................................. [] [] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................................................... [] [] 3. Did decedent own an 'in trust for" or payable upon death bank account or security at his or her death? ................. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... [] [] 8,459.51 8,459.51 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, includin~ accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all reformation of which preparer has any knowledge. SIGNATURE OF PE~,SON RESPONS. IBLE FO~,.FJLING RETURN ADDRESS Vickie L. Guion, Execul'dr 117 Sho, J.l¥ Drive, Mechanicsbur~l SIGNATURE OF PREPAR~Pv'O~'HER THAN REP ~..~NTA~ ADDRESS David R. Getz, Esquire/WiX, WEN~ER & WEIDNER 508 North Second Street, P.O. Box 845, Harrisburcj DATE PA 17055 PA 17108-0845 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [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(a)(1 )]. The tax rate imposed on the net value of transfers to or for the use of the decedenrs siblings is 12% [72 P.S. §9116(a){1.3)]. 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. REV-1502 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Bern. Eloise V. 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 pdce 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 NUMBER None DESCRIPTION TOTAL (Also enter on line 1, Recapitulation) $ VALUE AT DATE OF DEATH 0.00 REV-1503 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE[ B STOCKS & BONDS ESTATE OF FILE NUMBER Bern. Eloise V. All pmperbj jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION None TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH REV-i504 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Bern. Eloi~e V. 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. None TOTAL (Also enter on line 3, Recapitulation $ REV-1507 EX + (6-98) COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER Bern, Eloise V. All property jointly-owned with the right of survivorship must be disclosed on Schedule F, ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. None TOTAL (Also enter on line 4, Recapitulationl $ REV~1508 EX + (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Bern. Eloise V. include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with fight of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION Cash on hand Ordinary household goods and furnishings Ordinary wearing apparel Waypoint Bank Checking Account No. 1800036749 DOD Value: $7,407.56; Accrued Interest: $.51 (valuation letter attached) Bankers Life and Casualty Company Non-Qualified Annuity Policy No. 7,618,657 Estate is beneficiary (valuation letter attached) TOTAL (Also enter on line 5, Recapitulation) $ VALUE AT DATE OF DEATH 10.00 100.00 50.00 7,408.07 3,860.11 11,428.18 (If more space is needed, insert additional sheets of the same size) RE~-1509 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Bern. Eloise V. If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. JOiNTLY-OWNED PROPERTY: L~_ I ~ bR DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTERES' TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) RE~-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Bern, EI0ise V. This schedule must be ~mpleted and filed if the answer to any of questions 1 throu h 4 on the reverse side of the REV-1500 COVER SHEET is DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE, VALUE OF ASSET INTEREST [IF APPLICABLE) VALUE 1. American National Annuity Policy No. LAR0003458 100,819.07 100. 100,819.07 Beneficiaries:Vickie Bern Guion and Nancy Bern Edwards 2. American National Annuity Policy No. LAR0003457 57,464.04 100. 57,464.04 Beneficiaries: Vickie Bern Guion and Nancy Bern Edwards 3. Investors Insurance Corporation Flex Deferred Annuity 31,975.93 100. 31,975.93 Policy No. 3004406 Beneficiaries: Vickie Bern Guion and Nancy Bern Edwards 4. Bankers Life & Casualty Policy No. 7,624,567 1,851.42 100. 1,851.42 Beneficiaries: Vickie Guion and Nancy B. Edwards TOTAL (Also enter on line 7 Recapitulation) $ 192,110.4( REV~1511 EX + (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Bern. Boise v, Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT 8. 9. 10. FUNERAL EXPENSES: Hurst's Fielder-Baker, Inc. (Farmersville, Texas) Canof's Florist (flowers) ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Social Secudty Number(s)/EIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees Wix, Wenger & Weidner (estimated) Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Zip ¸ Street Address City State Zip Relationship of Claimant to Decedent Probate Fees Cumberland County Register of Wills Accountant's Fees Tax Return Preparer's Fees Cumberland Law Journal Sentinel Funeral Home (add'l death certificates) Waypoint Bank (estate checks) 8,245.19 162.37 2,800.00 266.00 75.00 95.27 50.00 3.00 TOTAL (Also enter on line 9, Recapitulation) $ 11,696.83 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Bern, Eloise V. SCHEDULE ! DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Verizon Phone Charges 113.02 PP&L Pinnacle Health Hospitals Comcast Cable John Hancock Life Insurance (premium check written 12/14/02; posted 12/24/02) Check No. 1484 Conner-Rich Associates (check written 12/14/02; posted 12/20/02) Check No. 1489 West Shore EMS Rovegno Real Estate (rent) USAA Federal Savings Bank Visa 98.45 65.81 36.93 805.90 64.91 40.95 640.00 1,986.71 TOTAL (Also enter on line 10, Recapitulation) $ 3,852.68 (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (9-00} COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Bern. EI¢ ~ V. NUMBER [. 1. 2. 1. 1. FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [include outfight spousal distributions, and transfers under Sec. 9116 (a)(1.2)] Vickie L. Guion 117 Sholly Drive Mechanicsburg, PA 17055 Nancy Edwards Box 305 Kaneohe, HI 96744 Daughter Daughter 50% residue 50% residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF ELOISE V. BERN I, Eloise V. Bern, of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time previously made. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my Estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will, which is not specifically devised or bequeathed, as an expense and cost of administration of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though on proceeds of insurance or other property not passing under this Will. ITEM I1: I hereby exercise all powers of appointment that I may have at the time of my death in favor of my residuary estate, and all property subject to all such powers shall be included in my Estate. ITEM II1: I give and bequeath all my household furniture and furnishings, automobiles, books, pictures, jewelry, china, linen, silverware, wearing apparel and all other like articles of household or personal use and adornment to my children, Vickie Lynn Guion of Mechanicsburg, Pennsylvania, and Nancy Edwards of Kaneohe, Hawaii, or the survivor of them, to be divided between them is as equal shares as practicable. Page 1 of 6 ITEM IV: I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, to my children, Vickie Lynn Guion and Nancy Edwards, or their issue, per stirpes, to be divided between them in as equal shares as practicable. ITEM V: In others, the following the settlement of my Estate, my Executor shall possess, among powers to be executed for the best interest of the beneficiaries: (a) To sell either at public or private sale and upon such terms and conditions as my Executor may deem advantageous to my Estate, any or all real or personal estate or interest therein, whether owned by me severally or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in carrying out any of the powers conferred upon my Executor in this Paragraph V(a) or elsewhere in my Will. (b) To pay all costs, taxes, expenses and charges in connection with the administration of my Estate. My Executor shall pay expenses of my last illness and funeral expenses. (c) To distribute my Estate in kind or in money. distributed in kind, they shall be distributed value(s) on the date(s) of their distribution. If any assets are at their respective (d) To retain any investments I may have at my death so long as my Executor may deem it advisable to my Estate so to do. (e) To vary investments, when deemed desirable by my Executor and to invest in such bonds, stocks, notes, money markets, real estate mortgages or other securities or in such other property, real or personal, as he shall deem wise, without being restricted to so-called "legal investments." (f) To mortgage real estate and to make leases of real estate. Page 2 of 6 (g) To borrow money from any party to pay indebtedness of mine or of my Estate, expenses of administration or inheritance, legacy, estate and other taxes: (h) To vote any shares of stock which form a part of the Estate and to otherwise exercise all the powers incident to the ownership of such stock. (i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of the Estate. (J) To distribute my personal property directly to the Guardian of the person of any minor beneficiaries hereunder. (k) To elect such settlement options as deemed most appropriate by my Executor with respect to any pension, profit shadng or other retirement plan in which I am a participant. To do all other acts in the judgment of my Executor necessary or desirable for the proper and advantageous management, investment and distribution of my Estate. ITEM VI: Any person who shall have died at the same time as me, or in a common disaster with me, or who shall fail to survive me by ninety (90) days, shall be deemed to have predeceased me. ITEM VII: If at any time any minor child or legally incompetent person shall be entitled to receive any assets hereunder, I hereby nominate, constitute and appoint my Executor to act as Guardian of the assets payable to such person. Said Guardian may receive and administer all assets authorized by law and shall have full authority to use such assets, both principal and income, in any manner said Guardian shall deem advisable for the best interest of such person, including college, university, post-graduate or other education, without securing court order. Said Guardian shall have all the rights and privileges as to the Guardianship and the assets thereof as are herein granted to my Executor as to my Estate and the assets therein. Page 3 of 6 ITEM VIII: I nominate, constitute and appoint ¥ickie Lynn Guion to be my Executor. In the event of the deathl resignation, refusal or inability of Vickie Lynn Guion to serve as my Executor, I nominate, constitute and appoint Nancy Edwards to serve as Executor in her place. My Executor and Guardian are specifically relieved from the duty or obligation of filing any bond or bonds. IN WITNESS WHEREOF, I have set my hand and seal to this my Last Will and Testament, consisting of this, the next two pages, and the preceding three pages this I~___day of ~ os~ ,2001. Eloise V. Bern SIGNED, SEALED, PUBLISHED AND DECLARED by the above named Testator, EIoise V. Bern, as and for her Will, in the presence of us, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses in attestation thereof. Address Address Add ress Page 4 of 6 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA - COUNTY OF C)¢~'~ I ~ SS. I, Eloise V. Bern, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Swom to or affirmed and acknowledged before me by Boise V. Bern, the Testator, thiS.~L day of i~,j~.~, ~._,, _+-,2001. t Eloise~. Bern, Testator My Commission Expires: (SEAL) Notaxial Seal De~.%W~/~li _a~,on, Notary Public · _ _rg, Paul)bin County My ~ommfssion Expires May 1, 2004 Member, Pennsylvania Association of Notaries Page 5 of 6 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA · COUNTY OF 0 I:~J~ ~¢3 SS. and '/424.c~.d_¢. ~"_. /~,/.~ , the witnesses 'hose na~es ~-signed to th~ att~., ed or foregoin~ inst~ment, being duly qualified ac~rding to law, do depose and say that we were present and saw the Testator sign and execute the inst~ment as her Last Will; that the Testator signed willingly and executed it as her free and voluntaw act for the pu~oses therein expressed; that each subscribing witness, in the headng and sight of the Testator, signed the Will as a witness; and that to the best of our knowledge, the Testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ~ .z S~rn to or a~r~ and sub~rib~d to before me by ~~ ~. ~ ~ ,~ ),~ ~. I ~ ~ ~, and '.~~ ~ y~ witnesses' thi~ ' ~uS~ ~ ,2001. ~ ' , ~ ~ day of Witness Witness ~ .~Vitness 4 N o ~lr-y Public My Commission Expires: (SEAL) F:\dbwWVills\Bem\VVill.doc Page 6 of 6 Notarial Seal Denise B Willlamsa~, Notary Public · Hamst)urg, Daui:)hln County My Commission Expires May 1, 2004 Member, Pennsylvania Association of Nctanes LOOk FOR US. WE'Lt. gET YOU THERE. 06/13/2003 WIX ¥¢ENGER & WEIDNER 508 N SECOND ST HARRISBURG PA 17108 The information which you requested on the account(s) of ELOISE BERN (Social Security Number 467-20-6148) is/are as follows: Account Number 1800036749 Class of Account CHECKING Date Opened 08/21/00 Principal Balance 7407.56 Accrued Interest .51 Balance at Date of 7408.07 Death Account Ownership SOLE Name of Joint Owner, if any Date Ownership Was Established Account Number Class of Account Date Opened Principal Balance Accrued Interest Balance at Date of Death Account Ownership Name of Joint Owner, if any Date Ownership Was Established Additional Information Requested SinceRely, _ KATHY Y-OUN~7 SENIOR SERVICES REP. P.O. Box 171 I. HARRISBURG. P~NNSYLVANIA 1710..~~1711 AMERICAN NATIONAL INSURANCE COMPANY EDITH S. FERGUSON, SENIOR CLAIMS TECHNICIAN, LIFE INSURANCE AND ANNUITY CLAIMS DEPARTMENT P. O. BOX 1840, GALVESTON, TX 77553-1840 BUS: 409-766-6056 FAX: 409-766-6491 July 16, 2003 DENISE WILLIAMSON, PARALEGAL WIX, WENGER & WEIDNER ATTORNEYS AT LAW P. O. BOX 845 HARRISBURG PA 17108 Re: Claim: C569020 - Eloise Bern - Certificate No. LAR0003457 & LAR0003458 Dear Ms. Williamson: This letter is in response to your June 23, 2003 letter. These were non-qualified annuities in which Eloise Bern was the annuitant and owner. We were unable to locate any other contracts on the life of Eloise Bern. The values as of the date of death (along with ali accrued interest) of December 19, 2002 are as follows: LAR0003457 Cash Value: $100,819.07 Death Benefit: $ 92,337.82 Cost Basis: $ 94,418.76 LAR0003458 Cash Value: $57,464.04 Death Benefit: $52,993.51 Cost Basis: $35,574.92 Records reflect Nancy Bern Edwards and Vickie Bern Guion, daughters as the beneficiaries on annuity Certificates LAR0003457 and LAR0003458. If you have any questions please feel free to contact us at 1-800-615-7372. Please refer to claim f'de C569020 in all communications. Sincerely, s. FErgeSON AND LIFE SERVtCES July 16, 2003 WIX, WENGER & WEIDNER ATTN: Ms. Denise B. Wiliiamson Post Office Box 845 Harrisburg, PA 17108-0845 Re: Investors Insurance Corporation Policy Number 3004406 Annuitant/Owner: Eloise V. Bern, Deceased Beneficiaries: Vickie Bern Guion and Nancy Bern Edwards, Daughters, equally Dear Ms. Williamson: Thank you for furnishing the authorization necessary to provide you with information regarding this policy. In response to your request, the information is as follows: 1. Type of policy - Flexible Premium Deferred Annuity 2. Policy number- 3004406 3. Value as of date of death - $31,941.59 4. Accumulated interest at date of death - $7,954.03 Additional interest per Texas requirements - $34.34 5. Sole policy owner- Eloise V. Bern 6. Beneficiaries- Vickie Bern Guion and Nancy Bern Edwards I hope this information is helpful. If you need further assistance, please contact me. Sincerely, Milly Haberly, ACS Specialist Claims and Disbursements P.O. Box 56050 · Jacksonville, Florida 32241-6050 3030 Hartley Road · Jacksonville, Florida 322S7 · 904-260-6990 · 800-749-6992 Investors Insurance Corporation · Investors Marketing Group BANIrERS LIFE AND CASUALTY COMPANY Annuity Service~ · 222 Merchandise Mart Plaza Cbic~ooo, IL 60654--2010 · Telephone: 312-396-6000 Denise B Williamson Paralegal P O Box 845 Harrisburg PA 17108 August 6, 2003 Policy 7,624,567 7,618,657 RE: Estate of Eloise V Bern Dear Ms. Williamson: This is in reply to your June 23rd letter. Please accept our apology for not replying sooner. Policy 7,624,567 was a nonqualified annuity plan. The death benefit va- lue was $1,851.42. The beneficiaries were Nancy B Edwards and Vickie Guion. Policy 7,618,657 was also a nonqualified annuity policy. The deceased was the owner of this policy. The cash surrender value was paid to the estate of Eloise Bern. Our check was for $3,860.11. If we can be of any further help, please let us know. Your friends at BANKERS, Tony Mendes Life/Annuity Claims LCAM 353903 For local service, contact: Branch Sales Office 1052 Ste 100 600 Wilson Ln Mechanicsburg PA 17055 Phone (717)791-9800 INVENTORY Estate of Bern, Eloise V. also known as , Deceased Vickie L. Guion, No. 21 03 0004 Date of Death 12/19/02 Social Security No. 467206148 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 of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Attorney: David R. Getz, Esquire I.D. No.: 34838 Address: 508 North Second Street Harrisbur~l PA 17108 Personal Representative: Vickie L. Guion Dated ~ ~ ;~ ---~ .'~ Telephone: (717) 234-4182 Cash on hand Description Ordinary household goods and furnishings Ordinary wearing apparel Waypoint Bank Checking Account Bankers Life and Casualty Company Non-Qualified Annuity (Attach Additional Sheets if necessary) Value 10.00 100.00 50.00 7,408.07 3,860.11 Total 11,428.18 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. RW-4 BUREAU OF INDIVIDUAL TAXES TNHER/TANCE TAX DTVTSZON DEPT. 280601 HARRISBURG, PA 17128-0601 COHNONNEALTH OF PENNSYLVANIA DEPARTHENT OF REVENUE NOTICE OF ZNHERZTANCE TAX APPRAISENENT, ALLONANCE OR DZSALLO#ANCE OF DEDUCTZONS AND ASSESSNENT OF TAX RE¥-1~47 EX AFP (01-05) DAVID R GETZ ESQ NIX ETAL PO BOX 8~5 .Be 17 08 DATE ESTATE OF DATE OF DEATH FILE NUNBER COUNTY ACN 10-27-2005 BERN 12-19-2002 Z1 05-0004 CUNBERLAND 101 Amoun'~ Remi'l:'~ed ELOISE V HAKE CHECK PAYABLE AND RENIT PAYHENT TO: REGISTER OF HILLS CUHBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLONANCE OR DISALLONANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ESTATE OF BERN ELOISE V FZLE NO. 21 03-0004 ACN 101 DATE 10-27-Z005 TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Reel Es~e~e (Schedule A) (1) 2. S~ocks and Bonds (Schedule B} (2) 3. Closely Held S~ock/Perinership ~. Nor~gages/No~as Receivable (Schedule D) (4) 5. Cash/Bank Deposi~s/Nisc. Personal Proper~y (Schedule E) ($) 6. Jointly Offned Proper~y (Schedule F) (6) 7. Transfers (Schedule G) (7} 8. To~el Asse~s APPROVED DEDUCTIONS AND EXEHPTIONS: 9. Funeral Expenses/Ad,. Cos~s/Nisc. Expanses (Schedule H) (9) 10. Deb~s/Hor~gage Liabilities/Liens (Schedule I) (10) 11. To~el Deductions 12. Ne~ Value of Tax Ra~urn 11~428.18 .00 .00 NOTE: To insure proper .00 credi~ ~o your account, .00 submi~ ~he upper port,on .00 of ~his fora wi~h your ~ax payment. 192~110.46 (8) 205,558.64 11,696.85 15. 14. NOTE: 5,852.68 (11) 15.~19-~1 (12) 187,989.15 DATE 09-16-2005 09-16-2005 Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) Net Value of Estate Subject to Tax (14) If an assessment Has issued previously, lines 14, 15 and/or 16, 17, reflect figures that include the total of ALL returns assessed to date. ASSESSHENT OF TAX: 15. Aeoun~ of Line 14 a~ Spousal re~e 16. Amoun~ of Line 14 ~axable a~ Lineal/Class A ra~e 17. Aeoun~ of Line 14 e~ Sibling ra~a 18. Amoun~ of Line lq ~axeble a~ Collateral/Class B ra~e 19. Principal Tax Due TAX CREDITS: PAYMENT R~g~ZP] D/SCOUNT (+J NUNBER INTEREST/PEN PAID (-) CD005024 .00 CD005025 . O0 .00 187,989.15 18 and 19 will TOTAL TAX CREDZT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE ( ZF TOTAL DUE IS LESS THAN $1, NO PAYNENT ZS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A 'CREDIT" (CR), YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORN FOR ZNSTRUCTZONS.) IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDZTZONAL ZNTEREST. 8,459.51 .00 .00 .00 4,229.76 ~,229.75 ANOUNT PAID (15) .00 x O0 = .00 (16) 187,989.15 x 045 = 8,459.51 (17) .00 x 12 = .00 (~a) .00 x 15 = .00 (19)= 8,459.51 RESERVATION: PURPOSE OF NOTICE: PAYNERT: REFUND (CR): OBJECTIONS: ADHIN- XSTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December 11, 1981 -- if any future interest in the estate is transferred in possession or enjoyment to Class 8 (collataral) beneficiaries of the decedent after tho expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right ta appraise and assess transfer Inheritance Taxes at the lawful Class 8 (collatara1) rata on any such futura interest. To fulfill the requirements of Section ZlqO of the Inheritance and Estate Tax Act, Act 25 of 2000. (71 P.S. Section 9140). Detach tho top portion of this Notice and submit with your payment to the Register of Rills printed on the reverse side. --Make check ar money order payable to: REGISTER OF #ILLS, AGENT A refund of a tax credit, which mas nat requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications ara available at tho Off]ce of the Register of Rills, any of the 25 Revenue District Offices, or by calling the special Z4-hour ansearing service for forms ordering: 1-800-561-1050; services for taxpayers mith special hearing and / or speaking needs: 1-800-q47-$020 (TT only). Any party in interest not satisfied aith the appraisement, alloeanca, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1011, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Raviee Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booktot "Instructions for Inheritance Tax Return for a Resident Decadent" (REV-IS01) for an explanation of administratively correctable errors. If any tax due is paid aithin three (5) calendar months after the decedent's death, a five percent (SX) discount of the tax paid is alloaod. The 1SI tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of tho tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same tiaa period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of six (61) percent per annum calculated at a daily rate cf .00016~. AZ! taxes ahich became delinquent on and after January 1, 1982 will bear interest at e rate ehich mill vary from calendar year to calendar year with that rate announced by tho PA Department of Revenue. The appllcable interest rates for 1982 through 1005 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 1982 ZOZ .0005q8 1987 91 .O00Zq7 1999 71 .O00ZYZ 1985 16Z .000458 1988-1991 Ill .O00$Ol 2000 81 .O00ZI9 198q 111 .O003Ol 1991 9Z .000247 ZOO1 9Z .0001~7 1985 151 .000556 1993-199q 7Z .000192 2002 61 .000164 1986 101 ,00027~ 1995-1998 92 .000247 2003 51 .000137 --Interest is calculated as folloes: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR --Any Notice issued after tho tax becomes delinquent mill reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be celculatad. Name of Decedent: Date of Death: Estate No.: STATUS REPORT UNDER RULE 6.1:2 Eloise V. Bern December 19, 2002 21-03-0004 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: State whether administration of the estate is complete: Yes X No If the answer is No, state when the personal representative reasonably believes that the administration will be complete: N/A 3. If the answer to No. 1 is Yes, state the following: Did the personal representative file a final account with the Court? Yes No X The separate Orphans' Court No. (if any) for the personal representative's account is: N/^ Co Did the personal representative state an account informally to the parties in interest? Yes X No Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Respectfully submitted, Dated: November 3, 2003 WIX, W.F_.I',JGER & WEIDNER David R. Getz, Esquire" Attorney ID No. 34838 508 North Second Street P.O. Box 845 Harrisburg, PA 17108-0845 (717) 234-4182 Counsel for personal representative .