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HomeMy WebLinkAbout04-0632PETITION FOR PROBATE and GRANT OF LETTERS Estate of VASS, Albert L. No. Deceased. To: Social Security No. 204-28-6027 Register of Wills for Cumberland County, Pennsylvania The Petition of the undersigned respectfully represents that: Your Petitioner, who is 18 years of age or older and the Executrix named in the Last Will and Testament of the above decedent, dated December 10, 2001. Decedent was domiciled at death in the Borough of Carlisle, Cumberland County, Pennsylvania, with his principal residence at 1236 White Birch Lane, Carlisle, Cumberland County, Pennsylvania. Decedent, then 67 years of age, died May 28, 2004, at M.S. Hershey Medical Center, Dauphin County, Pennsylvania. Except as follows, decedent did not 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: N/A. Decedent 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: 400,000.00 Total $ 400,000.00 WHEREFORE, Petitioner respectfully requests the probate of the Last Will and Testament present.ed herewith and the~frant of letters TESTAMENTARY thereon. L~ ~/ COMMONW .E4J_~ TH OF PENNSYLVANIA ) COUNTY OF CUMBEi~AND ) Constance A. Vass, Executrix 1236 White Birch Lane Carlisle, Pennsylvania 17013 OATH OF PERSONAL REPRESENTATIVE : SS The Petitioner above-named swears or affirms that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of Petitioner and that as personal representative of the above decedent Petitioner will well and truly administer the estate according to law. Sworn to or affirmed and subscribed ~/9~., before me this -] day of Constance A. Vass Estate of Albert L. Vass DECREE OF PROBATE AND GRANT OF LETTERS AND NOW /'1' )~' 04 ,2004, in consideration ofthe petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated December 10, 2001, described therein be admitted to probate and filed of record as the last will of ALBERT L. VASS; and Letters Testamentary are hereby granted to Constance A. Vass. FEES Probate, Letters, Ere ............ Short Certificate(s)~ .......... ..... TOTAL $ Filed ............................................................ Attorney I.D. No. 57976 19 Brookwood Avenue, Suite 106 Carlisle, Pennsylvania 17103-9142 (717) 249-5373 F:\User Folder\Firm Docs\Estates\3612-1 pet.ltrs.wpd his is to certify that the information here given is correctly copied from an original certificate of death duly filed ~ ill. Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent l'ili~ag. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 Local Regisu'a|' Nc). ~ Date H105.143 Rev 2/87 COMMONWEALTH OF PENNSYLVANIA o DEPARTMENT OF HEALTH ' VITAL RECORDS CERTIFICATE OF DEATH BLACK '~ ,. Albert L. Vass ~Male a. 204 -- 28 -- 6027 L~oMa~, 28. 2004 AGE (Last ~u~) UNDER. 1 Y~ ~R t ~y I ~ BIRTH 8rRTHP~ (~ ~ P~CE OF D~TH C~ ~v ~ - s~ inst~s ~ ot~r s~el I I  C~NTY OF O~TH ~, ~RO, ~ ~ ~m FAClLIW ~ME (If ~ ~im. g~ 1~ ~ ~m~) WAS DECEDE~ .... NO~ Yes~ fyes,~C~  ~ DEC~ ~U~ ~PATI~ I KIND OF ~SS IIN~TRY ~ ~CE~ ~R IN ~S E~TION I MARITAL STATUS. Mamd, I SUR~NG S~USE " ~. ~aupm ~. De~ T~. I-. M.S. Hershe ~ Medic~ Center II .... ~"~ .... ' ~o. wnzce ~ (~&~: ~ I u,s. ARMED F~CES? {~ ~ ~.t F,~ ~ N~  1236 ~ite Birch h~e ~L o,~ ~c. ~ ~., ~.~.~, ,~ ~rlisle, PA 17013 ~ ,~ Alert F. Vass ~,. Eugenia Lan$ ~. ~t~ce Vass ~. ~lte Birch Lane, Carlisle, PA 17013 ~,. ~(~) ~. /) ~l~,J~e 2, 2~ ~St. Patrick ~tholic Cem[~, ~rlisle, PA 17013 ,~,~ ~mm~ss o~ ~c,u~off~n-Roth ~neral H~, Inc ~/~ ~~,~ I~' 010~3-L 2~. 219 N. Hanover St., Carlisle, PA 17013 ~ ~ ~ ~. (~ ~ ~) (Momh, ~)~ST CO~ ~ ~E N~ ~ H~m ~t O P~'~.,~ O ~. ~Ob, ~ 3 r ~. ---- ....... ~-, ~ ~ ~, ~, ~ ~ a~ dui ~ ~e cau~l} a~ ~a~ ~ ~ ...................... OF ' ea ameni ALBERT L. VASS I, ALBERT L. VASS, of the Borough of Carlisle, Cumberland County, Pennsylvania, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time made. ITEM I: I direct that all inheritance an~:_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 the Exeeutqr out of the property passing under ITEM IV of this Will, as an expense and administration of my estate. The Executor shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this Will. ITEM II: I direct the Executor to pay the expenses of my last illness and funeral expenses from the property passing under this Will as an expense and cost of administration of my estate. ITEM III: If I predecease my wife, CONSTANCE A. VASS, I give and bequeath to her, absolutely and in fee simple, all of my household furniture and furnishings, books, pictures, jewelry, silverware, automobiles, wearing apparel and all other articles of household or personal use or adornment and all policies of insurance thereon. If I do not predecease my wife, I may leave a written statement or list in my safe deposit box disposing of certain items of my tangible personal property not otherwise disposed of herein. Any such statement or listing in existence at the time of my death shall be determinative with respect to Page 1 ~ all items bequeathed therein. If no written statement or list is found in my safe deposit box or elsewhere and properly identified by the Executor within thirty (30) days after the probate of my Will, it shall be presumed that there is no other statement or list. Any subsequent discovered statement or list shall be ignored. Any such property not listed in such a written statement I give to my children living at the time of my death, to be divided between them as they shall agree. Should there be no agreement, such property shall be divided between them by the Executor in as nearly equal portions as is deemed practical, in the discretion of the Executor, having due regard to the personal preferences of my children. ITEM IV: I give all the rest, residue and remainder of my estate, not disposed of in the preceding portions of this Will, to my wife, CONSTANCE A. VASS, as Trustee (hereinafter referred to as "Trustee"), IN TRUST NEVERTHELESS, to be further divided into two parts, each of which shall be held in trust and constitute a separate Trust Fund to be known as "Trust A" and "Trust B". Page 2 "Trust A": There shall be placed in "Trust A" that fraction of my residuary estate of which the numerator shall be a sum equal to the largest amount that can pass free of Federal estate tax under my Will by reason of the applicable credit amount and the state death tax credit (provided that the use of this credit does not require an increase in state death taxes) allowable to my estate but no other credit and after taking account of dispositions under other items of this Will and property passing outside of this Will which do not qualify for the marital or charitable deduction and after taking account of charges to principal that are not allowed as deductions in computing my Federal estate tax and of which the denominator shall be the value of my residuary estate. For purposes of establishing such fraction, the values finally fixed in the Federal estate tax proceeding relating to my estate shall be used. I recognize that the numerator of such fraction may be zero (0), in which case no property shall pass under "Trust A" and that said numerator may be affected by the action of the Executor in exercising certain tax elections. "Trust B": The balance of my residuary estate not placed in "Trust A" shall be placed into "Trust B" to be held, administered and distributed in accordance with ITEM VI of this Will. "Trust A": ITEM V: The following provisions shall apply to (a) The Trustee shall pay to or for the benefit of my wife, CONSTANCE A. VASS, all of the net income of this Trust in convenient installments, but not less frequently than annually. (b) The Trustee shall also pay to my wife so much of the principal of this Trust as may be necessary in the discretion of the Trustee for the proper support, maintenance and medical care of my wife. (c) Upon the death of my wife, the Trustee shall pay over all of the remaining assets, to one or all, or less than all of my issue, in the amounts, and in the estates, in trust or otherwise, as my wife may direct, making specific reference to this Power of Appointment, either by written instrument filed with the Trustee during her lifetime or by her Will. Page 3 In no event may this Power of Appointment be exercised in favor of my wife, her estate or creditors of either. (d) If this Power of Appointment is not exercised by my wife, in whole or in part during her lifetime, or in her Will, then upon the death of my wife, the Trustee shall divide the unappointed principal into as many equal parts as there are then living children of mine and then deceased children of mine represented by then living issue. The Trustee shall pay one share to each living child, and shall hold one share as a separate Trust for the benefit of the issue of each deceased child, per stirpes. (e) The Trustee shall divide each share set apart for the issue of a deceased child into separate per stirpital shares for each issue (each the "Beneficiary" of his or her Trust), to be held as separate trusts. The Trustee shall administer each share as a separate Trust, as follows: (i) Trustee shall pay to or for the benefit of the Beneficiary so much of the net income, in convenient, at least annual installments, as is necessary, in the discretion of the Trustee, for the proper support, maintenance, medical care and education of the Beneficiary. Income not distributed shall be accumulated and added to principal. (ii) The Trustee shall also pay to or for the benefit of the Beneficiary so much of the principal as the Trustee, in the discretion of the Trustee, considers Page 4 necessary to maintain the beneficiary in the proper station in life, including proper support, maintenance, medical care and college or higher education. (iii) Upon the attainment of the age of twenty- five (25) years by the Beneficiary, the Trustee shall pay to the Beneficiary one-half of the principal of his or her Trust. Upon the attainment of the age of twenty-eight (28) years by the Beneficiary, the Trust shall terminate and the Trustee shall pay to the Beneficiary the remaining assets of the Trust. (iv) Should the Beneficiary die before final distribution of the assets of his or her Trust, the Trust shall terminate and the Trustee shall pay the assets of the Trust to the then living issue of the Beneficiary, per stirpes. However, if any issue has not attained the age of twenty-one (21) years at the time of distribution, the Trustee shall continue to hold the share for that issue as Custodian under the Pennsylvania Uniform Transfers to Minors Act for the benefit of that issue. Page 5 (v) If at any time before final distribution of the assets of any of the Trusts administered under this paragraph, there are no living beneficiaries of the Trust, the Trust shall terminate, and its assets shall be added to the other then existing Trust(s) created under this Will for the benefit of the other issue my deceased child, in the same proportion by which the Trusts were originally funded. However, if any Trust has terminated by payment of its principal to its beneficiaries, the beneficiaries who received the principal of that Trust shall collectively be considered an "existing Trust" for the purpose of this paragraph, and the share which would have been added to that Trust shall be paid directly to the beneficiaries who received the assets in the same proportion by which they received the assets of the Trust. If any beneficiary is deceased, the share of that beneficiary shall be paid to the then living issue of that beneficiary, per stirpes. (vi) If before final distribution of the assets of any Trust established for issue of a deceased child, there is no living beneficiary of that Trust, it shall terminate, and the principal shall be distributed to my then living issue, per stirpes. ITEM VI: No part of the income or principal of any Trust created by this Will shall be subject to attachment, levy or seizure by any creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary prior to his or her actual receipt of income or principal distributed. The Trustee shall pay the net income and the principal to the beneficiaries specified by me, as their interests may appear, without regard to any attempted anticipation, pledging or assignment, and without regard to any claim or attempted levy, attachment, seizure or other process against the beneficiary. Page 6 ITEM VII: The Executor and the Trustee shall each possess the following powers, each of which may be exercised without court approval and in a fiduciary capacity only: (a) To retain any investments I have at my death, including specifically those consisting of stock of any bank even if I have named that bank as the Executor or Trustee. (b) To vary investments, and to invest in bonds, stocks, notes, real estate mortgages or other securities or in other property, real or personal, without being restricted to so-called "legal investments", and without being limited by any statute or rule of law regarding investments by fiduciaries. (c) In order to divide the principal of a Trust or for any other purpose, including final distributions, the Executor and Trustee are authorized to divide and distribute personal property and real property, partly or wholly in kind, and to allocate specific assets among beneficiaries and Trusts so long as the total market value of each share is not affected by the division, distribution or allocation in kind. The Executor and Trustee are each authorized to make, join in and consummate partitions of lands, voluntarily or involuntarily, including giving of mutual deeds, or other obligations, with as wide powers as an individual owner in fee simple. Page 7 (d) To sell either at public or private sale real and personal property severally or in conjunction with other persons, and to consummate sale(s) by deed(s) or other instrument(s) to the purchaser(s), conveying a fee simple title. No purchaser shall be obligated to see to the application of the purchase money or to make inquiry into the validity of any sale(s). The Executor and Trustee are authorized to execute, acknowledge and deliver deeds, assignments, options or other writings as necessary or convenient to any of the power conferred upon the Executor and Trustee. (e) To mortgage real estate, and to make leases of real estate. (f) To borrow money from any person, including the Executor or Trustee, to pay indebtedness of mine or of my estate, expenses of administration or inheritance, legacy, estate and other taxes, and to assign and pledge assets of my estate or any Trust established by this Will. Provided, however, that this paragraph shall not authorize borrowing from "Trust B". (g) To pay all costs, taxes, expenses and charges in connection with the administration of my estate or any Trust established under this Will. If any death taxes are payable with respect to my estate, these taxes shall be paid from "Trust A". (h) To make distributions of income and of principal to the proper beneficiaries, during the administration of my estate, with or without court order, in such manner and in such amounts as the Executor deems prudent and appropriate. (i) To vote shares of stock which form a part of my estate or any Trust established under this Will, and to exercise all the powers incident to the ownership of stock. Page 8 (j) To unite with other owners of property similar to property in my estate to carry out plans for the reorganization of any company whose securities form a part of my estate. (k) To disclaim any interest in property which would devolve to me or my estate by whatever means, including but not limited to the following means: as beneficiary under a will, as an appointee under the exercise of a power of appointment, as a person entitled to take by intestacy, as a donee of an inter vivos transfer, and as a donee under a third-party beneficiary contract. (1) To prepare, execute and file tax returns of any type required by applicable law, and to make all tax elections authorized by law. (m) To employ custodians of property, investment or business advisors, accountants and attorneys as the Executor or Trustee deems appropriate, and to compensate these persons from assets of my estate or trust, without affecting the compensation to which the Executor and Trustee are entitled. (n) To divide any Trust created in this Will into two or more separate Trusts so that inclusion ratio for purposes of the generation- skipping transfer tax shall be either zero or one, in order that an election under Section 2652(a)(3) of the Internal Revenue Code may be made with respect to one of the separate Trusts, or for any other reason. Page 9 (o) To allocate administrative expenses to income or to principal, as the Executor or Trustee deems appropriate. However, no allocation to income shall be made if the effect of the allocation is to cause a reduction in the amount of any estate tax marital deduction or estate tax charitable deduction. (p) To do all other acts in their judgment necessary or desirable for the proper and advantageous management, investment and distribution of the estate and Trusts established under this Will. ITEM VIII: The Trustee is authorized to distribute principal and/or income in any one or more of the following ways if the Trustee, in the sole discretion of the Trustee, considers the beneficiary unable to apply distributions to the beneficiary's own best interests, or if the beneficiary is under a legal disability: (a) Directly to the beneficiary; (b) To the Trustee, or to another person selected by the Trustee, as custodian under the Pennsylvania Uniform Transfers to Minors Act as to a beneficiary under the age of twenty-one (21) years; (c) To a relative of the beneficiary, to be expended by that relative for the benefit of the beneficiary; or (d) By directly applying distributions for the benefit of the beneficiary. Page 10 ITEM IX: The Trustee, on an annual basis, shall provide each income beneficiary who has attained the age of eighteen (18) years, and the Guardian of the person of any income beneficiary who has not attained the age of eighteen (18) years, statements showing transactions each Trust established for the benefit of that beneficiary. The beneficiary, or the Guardian of the person of such beneficiary, may waive this right to receive an annual accounting. The Trustee may, at any time, settle any account, or questions concerning the administration of any Trust established under this Will, by agreement with the then current income beneficiaries of the Trust, if legally competent, or if not legally competent, with the Guardian of the person of the beneficiary, the legally competent spouse of the beneficiary, or the oldest legally competent relative of the beneficiary who would take a portion of the estate of the beneficiary were the beneficiary to die at that time intestate under the laws of the Commonwealth of Pennsylvania. Any settlement made in accordance with this Item shall bind all persons who have an interest in the Trust, and shall constitute a release and discharge of the Trustee with respect to transactions specified in the settlement. ITEM X: In the absence of actual knowledge of a breach of trust, or information concerning possible breach of trust that would cause a reasonable person to inquire, a successor Trustee is under no duty to examine the accounts and records of a predecessor Trustee, or to inquire into the acts or omissions of the predecessor, and is not liable for any failure to seek redress for any act or omission of the predecessor. The successor Trustee shall have responsibility only for property which is actually delivered to him or her by the predecessor and shall have all of the powers conferred upon a Trustee hereunder. ITEM XI: Should my wife, CONSTANCE A. VASS, by Will or Agreement of Trust, establish Trusts similar to the Trusts I have established for the benefit of my issue, the Trustee of each Trust created in this Will / Page 11 shall have the right to merge it with the similar Trust created by my wife for the same beneficiaries. If merged, the Trustee shall operate the merged Trusts as a single Trust. ITEM XII: Any person who has died within thirty (30) days of my death, or under such circumstances that the order of our deaths cannot be established by proof, shall be deemed to have predeceased me. Any person (other than myself) who has died at the same time as any beneficiary under this Will, or in a common disaster with that beneficiary, or under such circumstances that the order of deaths cannot be established by proof, shall be deemed to have predeceased that beneficiary. ITEM XIII: to Executors and Trustees: I make the following provisions with respect (a) I appoint my wife, CONSTANCE A. VASS, to be the Executrix (herein referred to as "Executor") and Trustee. Co) In the event that my wife is unable or refuses to serve as Executor or Trustee, my son-in-law, PAUL TIRJAN, shall serve as Executor or Trustee, or both. In the event that both my wife and my son-in-law are unable or refuse to serve as Executor or Trustee, my children HEIDI V. TIRJAN and VALERIE A. JACKSON shall serve as Executors, or Trustees, or both. Thereafter, each Trustee shall have the power to appoint his or her successor. (c) Each appointment of a successor Trustee shall be in writing and shall be filed with the court in the jurisdiction which is the situs of the Trust. The written instrument shall be signed by the person having the power to make the appointment. Page 12 ~ (d) The Trustee shall have the right to receive reasonable compensation for services rendered. (e) The Trustee shall not be liable or accountable for any loss that may result from the good faith exercise of the authority granted in this Will. (f) The Executor and Trustee are specifically relieved from the duty of filing bond or entering security. IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and Testament, consisting of this and the preceding twelve (12) pages, at the end of each page of which I have also set my initials for greater security and better identification this ~ day of~.~,~,~, 20 . ~ ALBERT L. VASg We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above-named Testator as and for his Last Will and Testament, in the presence of us, who, at his request and in his presence and in the presence of each other, have hereunto set our hands and seals the day and year first above written, and we certify that at the time of the execution thereof, the said Testator was of sound and disposing mind and memory. (SEAL) (SEAL) Residing at ~)~ ~~_~ ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) ) SS: COUNTY OF ~ ) I, ALBERT L. VASS, 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 Testament; that ! signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~]~R~eL. ~ASS , (SEAL) Sworn to and subscribe~i before me this ~O~C~clay of ~ ,200[ My Commission Expires: (SEAL) AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) ) SS: COUNTY OF [j~~-(~-~ ) Witnesses whose names are signed to the attached or forag~ing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator, ALBERT L. VASS, sign and execute the instrument as his Last Will and Testament; that Testator signed willingly and that he executed said Will as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as Witnesses; and that to the best of our knowledge the Testator was at that time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. Witness Sworn to and subscribed before me this~ ~ day of ~ ,20~)/. My Commission Expires: (SEAL) I C, ,~ ~ a.~. ,,. R~,L.k, Notary Fubl,c I Ca~p Hitl Bo¢o., Cumberland Coun~ ~mmiss~on Expires 3an. 24, 2004 Name of Decedent: Date of Death: Will No. To the Register: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) ALBERT L. VASS May 28, 2004 2004-0632 I certify that notice of beneficial interest 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 2004. Name Constance A. Vass Address 1236 White Birch Lane, Carlisle, Pennsylvania 17013 Notice has not been given to all persons entitled thereto under Rule 5.6(a) except: N/A Date: July [9 ,2004 HANFT & KNIGHT, P.C. Attorney I.D. No. 57976 19 Brookwood Avenue, Suite 106 Carlisle, Pennsylvania 17013-9142 Telephone (717) 249-5373 Capacity: Counsel forpersonalrepresentative REV-1500 EX (6-00) OFFICIAL USE ONLY ~ f?~) COMMONWEAL TH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 04 0632 COUNTY CODE YEAR NUMBER DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) !z Vass Albert ~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) ~ 5/28/2004 W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) C Constance A. Vass L SOCIAL SECURITY NUMBER 204-28-6027 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 172-32-0035 W I- lie: :5U) uO:lIe: wo..u ;z:OO uO:..J o..a1 0.. <( IXl 1. Original Retum [J 4. Limited Estate IXl 6. Decedent Died Testate (Attach copy of Will) [J 9. Litigation Proceeds Received D 2. Supplemental Retum D 3. Remainder Retum (date of death prior to 12-13-82) D 4a. Future Interest Compromise (date of daath after 12-12-82) D 5. Federal Estate Tax Return Required D 7. Decedent Maintained a Living Trust (Attach copy oITrust) _ 8. Total Number of Safe Deposit Boxes D 10. Spousal Poverty Credit (date of death between '2-3'.91 and 1-'.95) D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS I- Z W C Z o ll. en w 0:: 0:: o U James D. Hughes, Esquire FIRM NAME (If Applicable) SALZMANN HUGHES, PC 'TELEPHONE NUMBER 717-249-6333 95 Alexander Spring Road, Suite 3 Carlisle, PA 17013 1. Real Estate (Schedule A) (1) 0 8,935 0 0 89,980 0 683,576 (8) 15,491 0 (11) (12) (13) (14) OFFICIAl u: E ONLY 2. Stocks and Bonds (Schedule B) (2) 1"....,. 'r] 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) Z 6. Jointly OlM1ed Property (Schedule F) (6) 0 D Separate Billing Requested j:: ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (7) ~ (Schedule G or L) l- e:: 8. Total Gross Assets (total Lines 1-7) <C () W 9. Funeral Expenses & Administrative Costs (Schedule H) (9) a:::: 10. Debts of Decedent, Mortgage Liabil~ies. & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) CJ ) [1 ) i 1 782,491 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 15,491 767,000 o 14. Net Value Subject to Tax (Line 12 minus Line 13) 767,000 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax 767,000 ~(15) Z rate, or transfers under Sec. 9116 (a){1.2) x .0 0 i= 16. Amount of Line 14 taxable at lineal rate 0 x .0 ~(16) <( I- ::) 0 D.. 17. ."'mount of Line 14 taxable at sibling rate x .12 (17) :!: 0 0 U 18. Amount of Line 14 taxable at collateral rate x .15 (18) )( <( Tax Due (19) I- 19. o o o o o 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < 3W46451.000 Decedent's Complete Address: STREET ADDRESS 1236 White Birch Lane Cumberland CI1Y I STATE I2lP Carlisle PA 17013- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) o o o o Total Credits (A + B + C) (2) o 3. Interest/Penalty if applicable D. Interest E. Penalty o o TotallnterestlPenalty (0 + E) (3) o 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) o 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) o A. Enter the interest on the tax due. (5A) o B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check to: REGISTER OF (5B) o AGENT PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 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? . . . . . . . . . . . . . . . . . . . . . . . . . . .. D 3. Did decedent own an "in trust for" or payable upon death. bank account or security at his or her death? D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ~ D 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 retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Deel aralion of preparer oth er th an the personal representative is based on all Information of which preparer has any knovvledg8 Yes No D D D D ~ ~ og og CXJ Qg Carlisle, PA 17013 Carlisle, PA 17013 For dates of th 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% 16 (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. 99116 (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. 99116(a)(1.2)]. ThEl 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. 99116(1,2) [72 P. S, 99116(1')(1)]. ThEl tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (72 P.S. 99 t 16(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. 3W4646 1.000 REV-1 S03 EX + (6-98) COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER Albert L. Vass 21-04-0632 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. Brookwood Investment Advisors, cash & equity account VALUE AT DATE OF DEATH 8,935 TOTAL (Also enter on line 2. Recapitulation) $ 8,935 3W4696 1.000 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Albert L. Vass FILE NUMBER 21-04-0632 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 DESCRIPTION VALUE AT DATE OF I)EATH 1 Waypoint Bank, checking account #1703001603 89,980 3W46AD 1.000 TOTAL (Also enter on line 5, Recaoitulationl $ (If more space is needed. insert additional sheets of the same size) 89,980 REV-1510 EX + (6-9S) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Albert L. Vass FILE NUMBER 21-04-0632 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY II\CLLCE TI-oE NAlII1E OF TI-E TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND R TI-E DATE OF TRMSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE AIG Annuity Insurance Company, single premium deferred annuity #BX205441, Constance A. Vass beneficairy ITEM NUMBE 1. ----.-J 3W46AF 1.000 DATE OF DEATH VALUE OF ASSET % OF DECO'S INTEREST 15,173 100.000 2 AIG Annuity Insurance Company, single premium deferred annuity #BX202726, Constance A. Vass beneficiary 15,188 100.000 3 M&T Bank IRA, Constance A. Vass, beneficiary 423,349 100.000 4 Provident Life & Accident Insurance Company 100,000 100.000 policy #B3301249; payable to Trust Under Will 5 Transamerica Insurance & Investment Group 129,866 100.000 policy #92230857, payable to Trust Under Will TOT AL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) EXCLUSION (IF APPLICABLE) o o o o o TAXABLE VALUE 15,173 15,188 423,349 100,000 129,866 683,576 REV-1511 EX + (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Albert L. Vass FILE NUMBER 21-04-0632 ITEM NUMBER A. B. 4 Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2 Attorney Fees 3 Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Constance A. Vass Street Address 1236 Whi te Birch Lane City Carlisle Relationship of Claimant to Decedent SPOUSE State PA Zip 17013 5 Accountant's Fees Probate Fees 7 6 Tax Return Preparer's Fees 1 2 3W46AG 1.000 Cumberland Law Journal Hanft & Knight PC, attorney fees paid Total from continuation pages TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) $ AMOUNT 10,000 3,500 417 75 1,341 158 15,491 Schedule H part 2 (Page 2) Estate of: Albert L. Vass Item No. Description Amount :3 Register of Wills ,1 The Sen tinel - Legal Total (Carry forward to main schedule) 25 133 158 . REV-1513-EX + (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Albert L. Vass NUMBER I 1 ~I .t.. NAME AND ADDRESS OF PERSON(S) RECEiVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] TUW 1236 White Birch Lane Carlisle, PA 17013 Constance A. Vass 1236 White Birch Lane Carlisle, PA 17013 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) FILE NUMBER 21-04-0632 AMOJNT OR SHARE OF ESTATE Trust Surviving Spouse remainder named beneficiary ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX is NOT BEING MADE 3W46AI 1.000 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500COVER SHEET (If more space IS needed, Insert additional sheets of the same size) $ o ALBERT L VASS 1236 WHITE BIRCH LANE CARLISLE PA 17013-3580 5CR987123 AcctType: Individual Asset Name Ticker Asset Type CASH OR EQUIVALENTS EQUITY EQUITY OPTION Mgt. Name Quantity Price($) Value($) 491.52 1.00 491.52 89.00 10.16 904.24 200.00 37.00 7,400.00 29.00 0.00 0.03 32.00 4.34 138.88 Account Total: $8,934.67 Investor Total: $8,934.67 Albert L Vass 1236 White Birch Lane Carlisle, PA 17013 Mr John W Carbaugh Reg. Rep. Brookwood Investment Advisors, Inc 19 Brookwood Ave. Suite 103 Carlisle, PA 17013 717-243-8777 Albert L Vass Acct Name: Acct No: CASH DEL MONTE FOODS CO COM HEINZ H J CO COM PILLOWTEX CORP NEW .W EXP 11/24/2009 ROXIO INC COM DLM HNZ PWTQE ROXI EQUITY Incomplete jf presented without accompanying disclosure page Holdings by Investor ~~-------~-._-_.._----._---------_._._-- Combined Account Portfolio Date 07/23/2004 Created 07/27/2004 Page 1 of 2 ______ _l!oldings by Inve!.to,,- Combined Account Portfolio Date 07/23/2004 Created 07/27/2004 Albert L Vass 1236 White Birch Lane Carlisle, PA 17013 Mr John W Carbaugh Reg. Rep. Brookwood Investment Advisors, Inc 19 Brookwood Ave. Suite 103 Carlisle, PA 17013 717-243-8777 Disclosure: Advisory services offered through Cambridge Investment Research, Inc.. Securities offered through Cambridge Investment Research, Inc., member NASD/SIPC. Cambridge Investment Research, Inc., Cambridge Investment Research, Inc. and Brookwood Investment Advisors, Inc are non- affiliated companies. Values are as of 07/23/2004. We believe the sources to be reliable, however, the accuracy and completeness of the information is not guaranteed. Transactions or adjustments that are entered near the end of a month and do not post until the following month could create a discrepancy between the sponsor statement and the CIRStatements.com report. In the event of any discrepancy, the sponsor's valuation shall prevail. Performance data quoted represents past performance and does not guarantee future results. The investment return and principal of an investment will fluctuate so that an investor's shares when redeemed may be worth more or less than original cost. The values represented in this report may not reflect the true original cost of the client's initial investment. For fee-based accounts only: The figures mayor may not reflect the deduction of investment advisory fees. If the investment is being managed through a fee-based account or agreement, the returns may be reduced by those applicable advisory fees. Refer to your Advisor's Form ADV, Part II. The Information contained in these reports is collected from sources believed to be reliable. However, you should always rely on your statements received directly from product sponsors. If you have any questions regarding your report, please call your representative. Page 2 of 2 "'Way~qi!1J 7/21/2004 HANFT & KNIGHT PC 19 BROOKWOOD AVE STE 106 CARLISLE P A 17013 The information which you requested on the account(s) of ALBERT L V ASS (Social Security Number 204-28-6027) is/are as follows: Account Number Class of Account Date Opened Principal Balance Accrued Interest Balance at Date of Death Account Ownership JTO SOLE Name of Joint CONSTANCE Owner, if any A V ASS 100555739 CHECKING 051303 9440.45 4.08 9444.5 3 1703001603 CHECKING 082195 89927.74 51.81 89979.58 Date Ownership 051303 Was Established 082195 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 1755307410 1756278231 1761268489 1761272980 CERTIFICATE CERTIFICATE CERTIFICATE CERTIFICATE 021197 102095 050595 072095 15000.00 15000.00 15000.00 30000.00 44.60 26.29 57.58 54.81 15044.60 15026.29 15057.58 30054.81 JTO JTO JTO JTO CONSTANCE CONSTANCE CONSTANCE CONSTANCE A V ASS A V ASS A V ASS A V ASS 021197 102095 050595 072095 Sincere~ ~... ~.\.;~C\.\ ~EWATTS SENIOR SERVICES REP. P.O. Box 1711. HARRISBURG. PENNSYlVANIA 17105-1711 ,. AIG Annuity Insurance Company PO. Box 871 Amarillo, Texas 79105-0871 800.424,4990 October 20, 2004 Salzmann, Hughes & Fishman, PC Attn: Jacqueline Drawbaugh 95 Alexander Spring Rd, Suite 3 Carlisle, P A 17013 Re: Deceased: Contract: Beneficiary: Albert Vass BX202726 and BX205441 Constance A. Vass (spouse) Dear Ms. Drawbaugh: This will acknowledge receipt of your letter dated October 8, 2004, copy of the court document and authorization to release information. . Enclosed is a copy of the original application. Constance A. Vass is the named primary beneficiary of each annuity. Also enclosed is a copy of our letter dated June 9, 2004. The current value of policy number BX202726 is $15,187.80. The current value of policy number BX205441 is $15,173.49. If you have any questions, please have the contract number available and call 1-800-424-4990 to speak with a Customer Care Representative. Sincerely, - <~-'(j ! \.[ Ll '--1('. "~" t'liLf t~ c3tc (. n{"1.-1 (>"- ~/<- "=::""" Sheila Lockridge Annuity Claims Examiner Enclosure: AIG AnfluiTY lnSUyalll'(-' Comrall) Akmbcr o/AmCl"ft'dll rfll,~nWii(lllli! Gn)[/p. /ih Nov 22 0<4 0<4:51p CIS 130293<42136 p.2 m M&fBank 4W Milchcll Road. Mi1l~h('lro. nl~ 1~66 Mail Code DI;.I\.1I3.12 "hunc (Kille) 5112-4)49 rM (302) 9J4-29S~ R':V,SEI)- New l{equcsl N('IVClllhcr 21. 2004 Fax: 717-249-7334 lIanft & Knight, P .e., Attorneys At Law 19 Brookwood Avenue, Suite 106 Carlisle, Pennsylvania 17013 Re: Estate of Alherl L. Va.\',li Social Security: 204-28-6027 Date of Death: Mav 28. 2004 Dear Sir or Madam: Per your inquiry received dated July 19,2004, please be advisod that at the time of det\th. the above-named deccdcllt had on deposit with this bank the following: I. Type oj'Ac(:()unl Chcckin~ Account ACCOllnt Numher 873/4606 . Owncn.'hip (Namm' uj) tllberll. Va~s Constance A V u~'S Openint:: Date 08l2tJl64 l1a/unnt un Delle tJfD(~ath $1,034.26 Accrued Interest $ O.OH TOlal .~ 8...._""_..~......NR...... ....._M........."_....M............. ............ ....... ....... , $ I,OJ4. 34 Inlerest Paid YlD $ ..... .ii.:~2 '(~i ~:~:~~~Zr;;'i~~~:;l'i;'"MI induded) 2. Type nf Ae.count Saving,~ Account Account Number 015004200V4883U Own(~'shjp (Namc,~ oj) tllbert L Va.",' Constunce A Vass Opening Dule U~123/90 IJalancc on DaJ,! afDeath $9.554. 15 ACCf'lJc!d Imeresl $ ,78 Total $9,554.93 Infcrl/.," Paid YTD $ . ..j,~.i7lA~~~ii~d'i;,j~~;~ii~:.;;~ii;;d;~;/(;~1) . Nov 22 04 04:51p CIS 13029342136 p.3 3. Type of Ikl.'U1II11 flU Accounl Numher OJ500420/76733() OwmJrship (Names uj) Alhert /, Vass C(Jn.~/ance A. Vas:,', Bemjiciary Opening Dale OJI03/r'~3 BalatleL' rm DUff! u/ Dealh $4J3.917.62 Accru~cJ Interest $ 9,431.43 To/al $423,349.U5 In/erest /}aid YTD $ 9.123.2!i"7A~;;'~~d;'{(m:sl i;~~;l'i~cj;,(icd) Please be advised, there was no safe deposit box found for (he abovc decedent. For further account information. rcg;mling ownership, closures and/or reimbursement of funds, plc~ call the Iligh Street Carlisle Office # 7) 7-240.4536. Sincerely. ,.. ...:;(,'? 1"1.,.;,..~...~ "It:?,?-::":"'j{ /7- . / // Nancy Clagett Records Management 11-11-04; 3:45PM;TranSamerICa ;8168555200 # 1/ 2 i TRANSAMERlCA I. INSURANCE & INVESTMENT GROUP Administrative Office Transamerica Occidental Life Insurance Company 1100 Walnut St., Sle. 2400 Kansas City, Missouri 64106.2152 Mailing Address: P.O. Box 419521 Kansas City, MO 64141-6521 FAX Cover Sheet Fax Date: November 11, 2004 Total Pages: 2 Attn: Jacqueline Drawbaugh From: (Mr) Jan Bergman To: Salzmann Hughes & Fishman PC AT: Transamerica Claims Department - KC Telephone Number: 717-249-6333 Telephone Number: 816-855-5222 Fax Number: 717-249-7334 Fax Number: (816)-855-5283 Email Address: Email Address:jan.bergman@transamerica.com Insured: Claim No.: Albert 1. Vass 328101 Policy No.: 92230857 Memo Section: Attached is a copy of our beneficiary designation as requested. The death benefit, subject to final approval and applicable policy provisions is $129866.00. !fyou have any questions, please let us know. The claim will have our further attention upon receipt of the claim requirements. "This facsimile and the related documents and communications contain infonnation which may be confidential, privileged and proprietary to Transamerica Life Companies and its affiliates. Unless you . are the addressee (or authorized to receive the communications on behalf of the addressee) you may not use, copy or disclose to anyone the facsimile or any information contained in the documents/communications. If you have received the facsimile in error, please advise the sender and thereafter, destroy the facsimile and any related documents and communications received." 1111111111111111111111111111111111 . 0 T & 6 9 . 1 1 - 1 1 ~ 0 4-; 3: 45 PM ; T r- a n s@me r I C a ;8168555200 # 2./ 2. l ThANSAMERICA I LIFE COJviPANIES I III~lf IIIIU ~ 111~ rllllll~ ~II -OT173 Beneficiary Designation for Life Insurance Policies M Tnonsamerin Omdeatal Life Jnsunn~ CompallY 0 Tnnmnerica Assuran~ Company 0 Tnasainmca Life llU1II"IIner & Annuity Compllly P.O. Bor 419521 P.O. Bod0851 P.O. Boll 419511 Kansas City, MO 64141-6521 Los Allgeier. C\ '0030 Kansas City, MO 64141-6521 This Policy of insurance is Issued or assumed by ODe oftbecompanies shown abowc, henfn ,called the "Company" \ ( Policy Number: <1 ~ ~ 30 $5, '. Insured's Name: Ii l ber t L. V It ss e recorded desIgnation form will be ma~ed to the address shown at the left, unless otherwise indicated below and initialed by the owner. Owner's Initisls. o General AgencylGA Code OFax to: ( 1 This Beneficiary D~ignatlcm canc:cls all prior Beneficiary Designations and scnlemenl agreemC'lllS for the policy, identified by !he number above, he~in called lite . POlicy " Please see instructions. signarore requirements, speeial prnwisions llJld sample Beneficiary Designations before eompleling this Fonn. The Policy's OcaIh Benefit shall be paid in one sum 10 thl! designated beneficiary (ies), unless olltcrwise requested, BENEfICIARV: rrillt rullllame, addresJ lIDd nbtioashlp to fDSUred. For multiple bcn~f'lCiarle3 of uJlequlIl shares, IDdicate cacb lIenelieiary's sbare 10 parts or a$lI ~lTrDlIIce of the Policy's Death Benelit Dut tD their Dama. (&e r~Q$e lOr IIdditi()nl1l instrNctlp'.d Primary BeneRciary (Ia): Irmo~ tnan ODe lleneneJar)' is name<<, Pll,mcut ..,..;lHle mllde In eqoal ShaRS to the sarvlvOr{s), UDlcu otberwlse indicalcd. Name Address C/(y, Statr, Zip Code RelollortShip Con~~t'lc.€ of -rru~~ A A . V'd.S~ . I u/)cle.~ ot' /,..er Svcce..~s;c4S &A Irvs+ 'e-~ Trc.1~fe.e- I ~+ W ~ Ll '\ -res+ct.~t'\4- ~6 Contingent Bcneficlary (ies), Receives proceeds at lbe death ofllle Insured only if all of tbe Primary &neOd:llies predecease tbe Insured, -. A-. ~~___.. U) ~~ lA j.o :,Nl fC. . <)~ Noll ~ ~ ~ S;~tUi.(SiRna\Ure~a~remen\so/!jibd~~ f '-, L4 S 5 r -r-b":. I^d"f I Print Current Owner's Complete Name 717 :JI.(~- t133 ~".. Sl.! !:l7t'l32~ - ' - .tJ:L Current Owner's DIY time Tdepho umbw berrrax 10 Number DATE SIGNED: CUlTCot Owner's Signature (include Title. if Business or Trust) This Benefiela/)' Oesicllllioa bas been re<:ordcd by the Company's Administrativ. Offices. Th. Comp3lly asSllmcs no legal rCSJlCasibilicy for Ibe suffici=cy or validiJy orch. BcaeReiary o..s.ignlllion. DalC recorded: by: December 19, 200 fJl'1\l1O',FICIARY DESIGNATION C11o.~ Q-4-~' PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY P.Q. Box 9004 Coppell, TX 75019-9004 1-800-874-7496 January 12,2005 SALZMANN, HUGHES & FISHMAN A TTN: JACQUELINE DRAWBAUGH 95 ALEXANDER SPRING RD SUITE 3 CARLISLE, PA 17013 Insured Name: ALBERT V ASS Policy Number: B3301249 Correspondence Number: 0006028521 Dear Ms. Drawbaugh: We are in receipt of your recent inquiry. I am enclosing a copy of the beneficiary designation as requested. The death benefit of this policy is approximately $100,000.00. Please contact our office should you need further assistance. Sincerely, D Reavis Claims Services PROVIDENT Ltfl AND ACCIDENT INSURANC~ COMPANY l FOUNTAIN SOUARE CHA. T T ANOOGA TN 37402.\338 The polleyowner requests the following change on Polley No. 1. 01 Polley Loan Agreement I 0 Maximum amount avall.ble or; 0 t In consideration at the advance by Provident, .11 right, tltle, and Interest In this policy Is hereb~ assigned tD Provident .s sDle security for the repayment ot the lo.n with Interest, subject to the policy provIsions th.t Ire Incorporated Ind made . p.rt of this Igreement. W I ELECTION OF FEDERAL INCOME TAX WITHHOLDING lit applicable, Provident Is required to with- hold 10% ot any taMable portion of the lo.n unless you direct otherwise. Even If you elect to not have federal IncDme tax withheld, you are liable for payment of federal Income tax on the UXlble portion of your distribution. Also, you mey be subject to tine pe".IItJes under the estllMted tax payment rules If your payments of estimated tal< and withholding are not adequate. o "NO", I do not Wint Provid,'" to withhold ',d",' ineom. 'IX. * * 2.0 I Beneficiary Change($) I Full- given ..me, address, -.nd relationship of each beneficiary must be . . provided. Unless otherwise specified, proceeds ere to be plld In equII shares to the surviving beneflclarytJes). If beneficiary Is Info'mI'l Trustee for minor, give name, date of birth and address of minor. Also, furnish relationship of Trustee to minor. If beneficiary Is other than an Individual. Indicate whether: 0 Corporation, 0 PartnershIp or, 0 Trust. If corporation, give the sUite of Incorporation. If plrtnershlp, give names of aU partners. If trust, give name, address and date of trust document. e - LIFE DEPAi11l1ENT 1':@Si~~.~T I CUSiuMER SER-VICE 199' JUN -8- AM S 15 B330 1249 Insured/AnnulUint ALBERT L. VASS RelatIonshIp to Insured PRIMARY BENEFICIARY (IES) Please go to. number 9 on the back of form. Nil"" No/SU..t City Stale lop Na"'. No/St...t City Stat. lip CONTINGENT BENEFICIARY (IES) Nil"" No/S....t City State lip Na"" NO/SU..t City St.l. z.p o children born lawfully to or legally adopted by the Insured .. n :;;:;:;q n 11ft Pnllr.y 0 A..-.lty Po".y Name If Owner Is Trust. Oate of Trust Address Oh.i'98 me Dwner to: Otte of Birth Ho/St...t City St.te Zip Request for Taxpayer (Owner's) Identification Number (In lieu of Federal Form W-9) Owner's Social Security Number - - or Employer's 1.0. Number Certlflcatlon-- Under the penalties of perjury, I certify that this Is mt correct TlXpaye, Identification Number. and that I am not subject to backup withholdIng. If you are subject to backup withholding, then place a check In the box. 0 Signature of New Owner Date From the eftectlve date of this change, all ownership rights provIded In the F'ollcy Ire vested to the new gwnefrl. I Completion of the ownershfp change does not .ffect the beneficiary designation To change ene c ary, complete section 2 -- BeneficIary Chang.(s). . L -5\ 052 (Rew. '0 -91) (See reverse side) 4. 0 I Name CblAg'.', -..:- Chang.: DlnsuredlArvw/tant 0 Owner 0 Payor From If chlnge ot address, show new address '. To .'. ..~,. .;. .. 11..,... .'w NO.lS"..1 Crty Slale 1;1) COM . . . Relson tor chlnge: 0 Marrlllge 0 Divorce 0 Court Order 0 Adoption 0 Correction 0 Other (Describe) .We will need a copy of the leg.1 document tor our records. 5. 0 I Policy Assignment Relelse The undersigned (No. 10) Isslgnee relels.. .11 right, title, .nd Interest In this policy. 6.0 fRequest tor Polley Summary r This polley was lost or destroyed. If a dupllclte policy Is requIred Insteld. I 125 tee will be charged for each policy. 7. D INonforleltQce 'Optlon '1 0 Chlnge } 0 Extended Term . 0 Elect 0 Reduced Plld-Up o Automatic Premium LOin 8. 0 I Common OleaS.ter Clause I Plyment ot Iny clllm by relson of the delth of the Insured. will be . ~ be deterred for I period ot days. It, It the end of the .tlted period. any designated beneflcllry otherwise entitled to the proceeds ot the polley Is not living. settlement of the polley wllJ be mlde IS If the beneficiary did not lSurvlve the Insured, notwithstanding the flct thlt the benetlclary may survive the Insured and dIe betore the end of the stated perIod. 9. 0 Additional Instrae'tlons for"~h.'19'e Requesfed . RE: AL Vass Beneficiary Constance A. Vass, or her successor in Trust as Trustee of the Trust under the will of Albert L. Vass, dated 11-18.92 10. [.slg~tur... . c: I Provident Is luthorlzed to emend this request to correct errors or omissions ( . concerning the Policy LOin Agreement. I (the undersigned) certify thlt there Ire no bankruptcy proceedIngs pending egelnst the pollcyowner. (Xl 17.~ -~,~ ..(XJs..s- Soc;.' Security NumDer ~ 0 If - ~ S'- ( 0')) Soei.. Security Numll.. ~ ~T'" Soc;.. Security:1lfWftll... "I-. VA.)..:l - -, -=- Witness O.le ../' ~L.dM/ Wit s /'~a~ ~ Soei.. Sae....;ty N.-nllat witness Date ASSign.. The following Is requIred It any pollcyowner Dr Isslgnee Is . corporetlon. Corporete-owned policies require two otflcers to sIgn other thin Insured or one otfree" plus corporete se.1 should be .ffheed. If Corpor.te Sell Is not IVllllble, . copy of re.olutlon at the Board of Directors luthorlzlng this request Is required. ~ . TlXpa,., Idlntification Numbl' Dale N""e of Corpol.lion by o President 0 Vice President 0 Other end 0 Secretary 0 Treasurer 0 Other ** HOME OFFICE AMENDMENT THIS ~ 7l~~ ~~. OFFICE USE 01lL Y ~B~so.~Q ~,&.:,--:-, I Vlca PUSlDBNT AND CRIB" Ornca o.te JUN 2 1 1994 rAn DBPAIlTNBN't' . ' . e - Policy Nu.: IOB3301249 Insured: Albert L Vass Attached tu Fonn Dated: JUIIC 3, 1994 . , TESTA"IE~TARY TRUSTEE .. The beneficiary shall be as follows: Contam:c A. 'lass Trustee or to the Successors in Trust. as arc dcsign:ltcd in and who duly qualify according to law as such under Ihe Tru~t created by the instrument prob;tted as the last Will of the Insured. Providcd, however, that if Ihe Insurcd dies intestate, or if the Insured's last Will docs not create a Trust and naJlle a Trustee. or if within six months after the death of the Insured, no Trustee has qualified under the last Will of the Insured, payment shall he made to the Executors or Administrators of the Insured. It is understood and agreed (a) that the Company shall not be obligated to inquire inlo the tenns of any Trust affecting the policy or the proceeds Iherefrom, and shall not be charl,'Cable wilh knowledge of the lenns Ihereof, and (b) that payment to and receipt by said Trustee or Successor Trustee, or by the Executors or Administrators of the Insured, shall constitute a full discharge and release: of the Comp:my to the e:<tent of such payment, binding on all persons and fiduciaries ha\1ng any interest in Ihc policy or the prm:eeJs therefrom. CG-i':G I.FCSUIOllOO MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 RETAIN LOWER PORTION FOR YOUR RECORDS ~ 'rm.!II!'.!WlftAWJlMM.m.AWl1AmMM1'~.~tWJlmM.r,7l'................. ALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ALBERT L FILE NO. 21 04-0632 ACN 101 DATE 05-09-2005 BUREAU OF INDIVI~j;('tA1l~IV\ INHERITANCE TAX DIVISztlif::.~ -::'.' ..,:,,"_...- PO BOX 280601 . ,'- - " HARRISBURG PA 171Z8-0601 'L._ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX 2DD511M i 5 PM 2: I; 4 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 05-09-2005 VASS 05-28-2004 21 04-0632 CUMBERLAND 101 A.-nt R..itted CLERK OF ORPHA."1'C; OJ RT JAMES nc"~I~~( Pi\ SALZMANN HUGHES PC 95 ALEXANDER SPRG R CARLISLE PA 17013 CUT ALONG THIS LINE IfI!V-"M4""ft.~.'l"M~1. DI ESTATE OF VASS I ) CHANGED RETURN liAS: I X) ACCEPTED AS FILED RESERVATION CONCERNING FU URE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Rnl Estoto ISchedulo A 2. Stocks end Bonds ISchod 10 B) 3. Closely Held stock/P.rt rship Interest (Schedule C) 4. "ortgages/Notes Race.!" 1. (SchedtJle D) S. Cash/88nk Deposits/Hi . Personel P~perty (Schedule El 6. Jointly Oonod Proporty ISchedulo F) 7. Transfers (Schedule Ql 8. Totel Assets 11) (2) (3) (4) 15) (6) (7) .00 8.935.00 .00 .00 89.980.00 .00 683,576.00 (8) APPROVED DEDUCTIONS AND 9. FWWlr81 Expenses/Au. ostslHisc. Expenses (Schedule H) 10. Dobts/""rtgogo Liebil1 los/Liens ISchedule I) 11. Totol Deductions 12. Net Value of Tax R. urn 13. Charitable/Gover t.l Bequests; Non-elected 9113 Trusts 14. Not Volue of Estet. Subject to Tax 15,491. 00 .00 111) 112) 113) 114) (9) 110) (Schedule J) NOTE: I~ an assessment re'f1ect 'figures ASSESSMENT OF TAX: 15. ~t of Line 14 at 16. AllOUht of Line 14 t. 17. AlIOUht of Line 14 ot 18. AlIOUnt of Line 14 tex 19. Principal Tax Due T CIS' '*' REV-1547 EX AFP (O~-D5) ALBERT L NOTE: To insure proper credit to your account, subIIit the upper portion of this fora with your tax "".......t. 782,491. 00 1"'.491 nn 767,000.00 .00 767,000.00 was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will hat include the total o'f Abh returns assessed to date. ousal rate (u;) 1. .t lineal/Class A rat. (16) ibllng rete (17) 1. at Collataral/Class Brat. (18) 76LOOO.00 X 00 = .00 X 045- .00 X 12 = .00 X 15 = 119)= DATE AI10UNT PAID IUlBER INTEREST/PEN PAID (-) ~ TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE . IF PAID AFTER DATE INDICAT 0, SEE REVERSE FOR CALCULATION OF ADDITI L INTEREST. .00 .00 .00 .00 .00 .00 .00 .00 .00 I IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REqUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT"' (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RENUNCIATION Estate of ALBERT 1. V ASS, deceased. File #21-04-0632 To the Register of Wills of Cumberland County, Pennsylvania. The undersigned, Constance A. Vass, hereby renounce(s) the right to administer the Trust established in ITEM IV of the decedent's Last Will and Testament dated December 10,2001, effective June 11, 2005. WITNESS my hand this ;;(<ftPu day of September, 2005. CI'>Y? ibvn.r f) J A _ ~ 11 b-l SIGNATURE 1236 White Birch Lane Carlisle, P A 17013 ADDRESS Notarial Seal Jacqueiine L. Drawbaugh, No ry Public South Middleton Twp., Cumberland County Or My Commission Expires Aug. 14, 2007 Member, PBi1nsylvania Association of Notaries Affirmed and subscribed before me this _ day of ,2005. SIGNATURE ADDRESS SIGNATURE L.',J s,~ _) <X) Register of Wills a r--_ Cr- . De~ty b ~;r _ /':'L~ ," ~_~' . ADDRESS C"; j, '" U C:.J C:J L'J <,7~: ) C:..;c) c. .: cJ3:~r u; 0::. 0< -', C5 ESTATE OF ALBERT L. VASS : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS COURT DIVISION NO, 21-04-0632 PRAECIPE FOR ENTER OF APPEARANCE To Glenda Farner-Strasbaugh, Register of Wills: Please enter my appearance on behalf of the Estate of Albert L. Vass, date of death May 28, 2004. Respectfully submitted, Date: January 12, 2006 ,,," -~ "'1 ,- co t~__ :.......--' r- ~_i_. ~ C" , ,~ -' :""' C:C o -J .....r>:') c:-:-) ~..:::-::) <':'-~.l RK. Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 3/29/2006 HANFT MICHAEL J 19 BROOKWOOD AVENUE SUITE 106 CARLISLE, PA 17013 RE: Estate of VASS ALBERT L File Number: 2004-00632 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after July I, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 5/28/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, ~~ ~/.tu~.I Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Personal Representative(s) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 3/29/2006 VASS CONSTANCE A 1236 WHITE BIRCH LANE CARLISLE, PA 17013 RE: Estate of VASS ALBERT L File Number: 2004-00632 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 5/28/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely, ~~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel In Re: Estate of V ASS ALBERT L ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO. 2004-00632 NOTICE OF FAILURE TO FILE STATUS REPORT Personal Representative: V ASS CONSTANCE A Counsel for Personal Representative: HANFT MICHAEL J Date of Decedent's Death: 5/28/2004 The Orphans' Court record indicates that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme Comi Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orphans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report. If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of such delinquency and the undersigned will requests that a Court conduct a hearing to deternline whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. Date: 5/31/2006 I/J "..~., ~d;~~J' .' , // Glenda Farner Strasbaugh Clerk of the Orphans' Court Distribution: Personal Representative Counsel for Personal Representative Estate File In Re: Estate of V ASS ALBERT L ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO. 2004-00632 NOTICE OF FAILURE TO FILE STATUS REPORT Personal Representative: VASS CONSTANCE A Counsel for Personal Representative: HANFT MICHAEL J Date of Decedent's Death: 5/28/2004 The Orphans' Court record indicates that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court Oll1hans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report. If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of such delinquency and the undersigned will requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. Date: 5/31/2006 .~Li~L~~ Glenda Farner Strasbaugh Clerk of the Orphans' Court Distlibution: Personal Representative Counsel for Personal Representative Estate File ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA STATUS REPORT UNDER RULE 6.12 Name of Decedent: Albert L. Vass Date of Death: May 28, 2004 Admin. No. 2004-00632 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: I. State whether administration of the estate is complete: Yes~ 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~No d. 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. Date: June 8, 2006 Respectfully submitted, ~T &AIATES, PC Sean M. Shultz, Esquire Attorney ID No. 90946 11 Roadway Drive, Suite B Carlisle, Pennsylvania 17013 (717) 249-5373 Counsel for personal representatives I' l ,L'[ Foldn riml [),)CsEsldlc,;J612,lstdlusrq)()rl wpJ In Re: Estate of V ASS ALBERT L ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO. 2004-00632 NOTICE OF FAILURE TO FILE STATUS REPORT Personal Representative: VASS CONSTANCE A Counsel for Personal Representative: HANFT MICHAEL J Date of Decedent's Death: 5/28/2004 The Orphans' Court record indicates that neither the above named personal representative nor the above named counsel for the personal representative have filed with the Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orphans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report. If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of such delinquency and the undersigned will requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or counsel for the delinquent personal representative. Date: 5/31/2006 If ~/kJ~) &/11#,. .J ~7 --' Glenda Farner Strasbaugh Clerk of the Orphans' Court Distribution: Personal Representative Counsel for Personal Representative Estate File Register ofWiHs of Cumberland County STATUS REPORT UNDER RULE 6.12 Name of Decedent: Date of Death: Estate 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 0 No 0 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 0 No 0 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 0 No 0 c. Copies of receipts, releases, joinders and approval of fonnal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: Signature Name Address Telephone No. Capacity: 0 Personal Representative o Counsel for personal representative t..,. ....1 (::a J.... (.) .+. (1) tnl. .j;~ 1'\) I (.) ..... '.:tl I::) I.... (1' W --..J o s , o S 0J t) o (f) ("") )::> '000 ~~~=;z z-l -lei> >c~l"ne ~I"nC":l:S:"" mC:C~:!! -I<zl"n:2 o;;jeCI"n ..,,>:s:z~ 0""",,0 :cr-m-l> ::E1"n~:::o::g 5;~eI>~::P c>~::E~ g~zCl> :c-l I"n CI> CI> :; 0 !7: '" >.::< !li ::; a ~~ ~)~~1=~ =- ('D := Ul. 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