HomeMy WebLinkAbout11-02-101505610143
REV-1500 Ex `°'-'°'
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania county code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 60X.280601 INHERITANCE TAX RETURN 21 10 0338
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
172 O1 6323 03 29 2010 09 02 1914
Decedent's Last Name Suffix Decedent's First Name MI
JENKINS DORIS H
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return
4. Limited Estate ~ 4a. Future Interest Compromise
/rlafa of r•aath affar '17_17_A71
6 Decedent Died Testate ~ ~• (Attach Co aiofafined a Living Trust
(Attach Copy of Will) py Trust)
9. Litigation Proceeds Received ~ 1 p• Spousa{ Poverty Credit (date of death
between 12-31 ~1 and t-1-95)
Jon M. Gruber
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JON M GRUBER 717 2 93.92 93 ~
First line of address
930 RED ROSE COURT SUIT
Second line of address
City or Post Office State ZlP Code
LANCASTER PA
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
1 8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
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REGISTER OF~1~IL~t~,~1SE tj.Y
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Correspondent's a-mail address: 1mg@rkglaw.com
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
f-ILING RETURN
ADDRESS
!0l~.G~i~
930 Red Rose Court, Lancaster, PA 17601
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
Jon M. Gruber
ADDRESS
930 Red Rose Court, Suite 300, Lancaster, PA
Side 1
1505610143
1505610143 J
t
J
REV-1500 EX
Decedent's Name: Jenkins, Doris H.
Decedent's Social Security Number
172 O1 6323
RECAPITULATION
14 2, 0 0 0. 0 0
1. Real Estate Schedule A
( ) ....................................................................................... 1.
2. Stocks and Bonds Schedule B
( ) .............................................................................
2. 14 4, 7 7 7. 6 8
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages 8 Notes Receivable (Schedule D) ........................................................ 4.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5.
95,233.66
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers 8 Miscellaneous Ian; Probate Property
arate Billin
^ Se
Re
uest
d
l
S
h
d
G
p
g
q
............
e
(
c
e
u
e
) 7.
8. Total Gross Assets (total Lines 1-7) ..................................................................... g, 382 , 011.34
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9.
52,884.30
10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) .............................. 10.
1,256.61
11. Total Deductions (total Lines 9 8~ 10) ................................................................... 11. 5 4 , 14 0.91
12. Net Value of Estate (Line 8 minus Line 11 } .......................................................... 12. 3 2 7 , 8 7 0 . 4 3
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
l
i
h
82 5
~- 7 7
95
an e
ect
on to tax
as not been made (Schedule J) ............................................... 13. ,
.
14. Net Value Sub'ect to Tax Line 12 minus Line 13
J ( ) ...............................................
14. 15 0 , 0 4 4 . 4 8
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 0 . 0 0 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 . 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 15 0 0 4 4 . 4 8
r 18.
19. Tax Due ................................................. ................................................................ . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
1505610243
0.00
0.00
0.00
22,506.67
22,506.67
a
Side 2
15D5610243 1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-10-0338
DECEDENT'S NAME
Jenkins, Doris H.
STREET ADDRESS
100 St. Johns Drive
CITY
Camp Hill STATE
PA ZIP
17011
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
22,093.84
1,125.33
3. Interest
4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
Total Credits (A + B)
(1) 22,506.67
(2) 23,219.17
(3)
(4) 712.50
(:5)
Make Check Pa able 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? .................................................................................................................... x
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ~~
For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of
assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 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 percent [72 P.S. §9116 (a) (1.2)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1 )].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [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 EXi (11-08)
SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Jenkins, Doris H.
FILE NUMBER
21-10-0338
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which is jointly-owned with right of survivorship must be disclosed on schedule F.
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-08)
(If more space is needed, additional pages of the same size)
Rev-1503 EX+ (6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Jenkins, Doris H. 21-10-0338
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER CUSIP
NUMBER
DESCRIPTION
UNIT VALUE VALUE AT DATE
OF DEATH
1 1,348.71 shares of Evergreen Adjustable -DOD 9.04 12,192.34
2 2,589.539 shares of Evergreen Diversified -DOD 5.4 13,983.51
3 7,130.473 shares of Evergreen PA Tax Free -DOD 10.90 77,722.16
4 1,399.525 shares of Pimco Total Return Fd -DOD 11.01 15,408.77
5 819 Wells Fargo Stock -DOD 31.10 25,470.90
TOTAL (Also enter on Line 2, Recapitulation) 144,777.68
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule B (Rev. 6-98)
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
Jenkins, Doris H. 21-10-0338
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Cash -found in wallet 94.43
2 Commonwealth of PA -refund 316.00
3 Penn Mutual -annuity payment 54.45
4 PSERS -pension payment 479.10
5 M&T Bank Checking Account -DOD 12.998.11
Accrued income on Item 5 through date of death 0.13
6 PSECU Credit Union 5.33
7 Wachovia Checking Account -DOD value 2,369.67
Accrued income on Item 7 through date of death 0.04
8 Wells Fargo -DOD -cash 342.07
9 Personal Property -per sale by Rowe's Auction Service 6,193.50
10 Personal Property -Dinner Ring -price per Finch Jewelers' appraisal 1,500.00
11 Personal Property -Multiple Diamond Rings -price per sale 1,100.00
12 Comcast Cable -refund of overpayment 10.29
13 Commonwealth of PA -Rev. Rebate 250.00
Total of Continuation Schedule See attached page
TOTAL (Also enter on Line 5, Recapitulation) 95,233.66
(If more space is needed, additional pages of the same size)
Copyright (c} 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
Rev-1508 EX+ (6-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN continued
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Jenkins, Doris H. 21-10-0338
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
14 Evergreen Fund Administrator -SEC settlement check recd In the Matter of Evergreen 28.40
Investments Services, Inc. and the Evergreen Investment Mgmt., Co. Administrative
Proceedings File No. 3-13507
15 GGNSC Administrative Services, LLC -refund from Golden Living Center 519.72
16 Golden Living Center -refund 150.01
17 HUD adjustments for items paid by seller in advance 1,696.50
18 Keystone Oil Products Copr -refund of credit on account 446.70
19 Ohio Casualty -refund of premium 98.00
20 Transamerica Life Inc. Annuity #02SFD030541 66,581.21
TOTAL (Also enter on Line 5, Recapitulation) ~ 95,233.66
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
REV-1151 EXt (10-06)
COMMNH~~ITAN~ T~R~T~RN ANIA
R IDEN DE D N
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Jenkins, Doris H. 21-10-0338
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
N
A. FUNERAL EXPENSES:
See continuation schedule(s) attached
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Jon M. Gruber
Street Address 930 Red Rose Court
city Lancaster state PA zip 17601
Year(sl Commission paid 2010
2. Attorney's Fees Russell, Krafft & Gruber, LLP
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. ~ Probate Fees
12,145.02
7,230.34
15,210.34
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 1$,298.60
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 52,884.30
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Jenkins, Doris H. 21-10-0338
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 East Harrisburg Cemetery Co -stone engraving 175.00
2 Facker-Wiedeman Funeral Home 11,970.02
H-A 12,145.02
3 Other Administrative Costs
2010/11 school taxes to Michael Langan, Treasurer
1,586.76
4 Bouder's Trash Removal 800.00
5 Comcast Cable 9.24
6 Cumberland Law Journal -estate notice 75.00
7 Douglas Bowman -lawn maintenance -April 140.00
8 Douglas Bowman -lawn maintenance -May 120.00
9 Douglas Bowman -lawn maintenance -June 200.00
10 Douglas Bowman -lawn maintenance -July 120.00
11 Finch Jewelers -appraisals for rings 200.00
12 GCI Environmental Services -removal of oil tank at 100 St. Johns Drive, Camp Hill, PA 6,180.00
13 Hampden Twp -sewer and trash
150.00
14 HUD adjustments for item unpaid by seller 446.70
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Jenkins, Doris H. 21-10-0338
ITEM
NUMBER DESCRIPTION AMOUNT
15 Jon M. Gruber -reimbursement for drilling costs for safe deposit box (no key) 150.00
16 Michael Langan, Tax Collector -tax cert fee not listed on HUD 5.00
17 Peerless Insurance Company -Homeowner's Insurance #HP3M307117 80.74
18 Penn Mutual -refund of unearned annuity payment 54.45
19 Pennsylvania American Water -water service for billing period 03/22 to 04/22 13.08
20 Pennsylvania American Water -water service for billing period 04/22 to 05/20 13.11
21 Pennsylvania American Water -water service for billing period 05/20 to 06/22 13.11
22 Pennsylvania American Water -water service for billing period 06/22 to 07/22 13.18
23 Pennsylvania American Water -water service for billing period 07/22 to 08/04 (13 days -final 6.51
bill)
24 PP8~L -Balance as of May 13, 2010 20.50
25 PP&L -Balance as of June 14, 2010 21.29
26 PPS<L -Balance as of July 14, 2010 21.69
27 PPS~L -Balance as of Aug. 4, 2010 (final bill) 16.38
28 Rowe's Auction Service -Commission on sale 2,167.72
29 Rowe's Auction Service -auctioneer 4,630.20
30 Russell, Krafft & Gruber, LLP -reimbursement for advance payment to Tri-County Abstract 15.00
for copy of deed
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Jenkins, Doris H. 21-10-0338
ITEM
DESCRIPTION AMOUNT
NUMBER
31 Russell, Krafft $~ Gruber, LLP -reimbursement for advanced probate fees 473.50
32 Russell, Krafft & Gruber, LLP -reimbursement for advanced UPS fees 48.12
33 Russell, Krafft & Gruber, LLP -reimbursement for advanced costs to copy house keys 4.24
34 Russell, Krafft 8~ Gruber, LLP -reimbursement for advanced costs for short certificates 4.00
35 Russell, Krafft & Gruber, LLP -reimbursement for advanced costs for photocopies 97.40
36 State Employees' Retirement System -reimbursement of overpayment of annuity funds 15.84
37 The Sentinel -estate notice 176.92
38 Tri-County Abstract Service -title search 135.00
39 UPS Store -shipping expense for mailing of photos, etc. to cousin 30.21
40 Verizon -final payment 9.71
41 Vital Records -fee for copy of Lewis Jenkins' death certificate 9.00
42 Wells Fargo -fee for estate valuation 25.00
H-B7 18,298.60
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-9$)
Rev-1512 EX+ (12-08)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Jenkins, Doris H. 21-10-0338
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Comcast Cable 9.24
2 Douglas Bowman -lawn maintenance 125.00
3 Fay Bowman -check issued to replace check that was cut prior to death but was not posted 36.00
before account was closed.
4 G.T. Watts, Inc. -Spring rehanging of awning 72.50
5 Hampden Twp -sewer and trash 150.00
6 Peerless Insurance Co. -installment for homeowner's insurance 80.74
7 Pharmerica 121.48
8 PP&L 28.76
9 Verizon 6.15
10 Wachovia Checking Account -Checks cleared after death 626.74
TOTAL (Also enter on Line 10, Recapitulation) I 1,256.61
(If more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV-1513 EX+(11-08)
L SCHEDULE J
COMMN RESEDEN~EO CEDENTRNVANIA BENEFICIARIES
ESTATE OF
Jenkins, Doris H.
FILE NUMBER
21 _~ n_n~~A
NUMBER
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO
DECEDENT
SHARE OF ESTATE
AMOUNT OF ESTATE
(Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 a 1.2
1 Fay Bowman Other Specific Beq. of
540 Icabod Court $5,000.00
Mechanicsburg, PA 17055
2 Larry D. Bryan Other 1/2 of
5353 Puuone Place $123,544.48
Koloa, HI 96756
3 Ronald D. Bryan Other 1/2 of
P.O. Box 36 $123,544.48
Fort Jones, CA 96032
4 Doris Christensen Other Specific Beq. of
12 Cedar Court West $5,000.00
Carlisle, PA 17013
5 Peggy Dean Other Specific Beq. of
422 Kelling Lane $5,000.00
Glencoe, IL 60022
See continuation schedule attached Continuation
Total
Enter dollar amounts for distributions shown above on lines 1 5 throu h 18 on Rev 150 0 cover sheet, as a r o riate.
II NON-TAXABLE DISTRIBUTIONS:
. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FO R WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
~ Christ Evangelical Lutheran Church 177,s25.95
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 177,825 95
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
SCHEDULE J
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Doris H. Jenkins 03/29/2010 172-01-6323
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ($$$)
6 Jean R. Koons Other diamond dinner ring
3845 Brisban Street valued at $1,500
Harrisburg, PA 17111
7 Nancy M. Vincent Other Specific Beq. of
P.O. Box 364 $5,000.00
Burgaw, NC 28425
8 Mary Jane Werner Cousin Specific Beq. of
8 Wingate Court $5,000.00
Stratham, NH 03885
Total
`fit ~u ~a c~P~t
I, DORIS H. JENKINS, of Hampden Township, Cumberland County, Pennsylvania,
revoke my prior Wills and declare this to be my Last Will and Testament.
FIRST: I give a certain multiple diamond dinner ring to JEAN R. KOONS, if she
survives me.
SECOND: I give a legacy of One Hundred Twenty-Three Thousand Five Hundred
Forty-Four Dollars and Forty-Eight Cents ($123,544.48) in equal shares to RONALD D. BRYAN
and LARRY D. BRYAN. If either does not survive me, the legacy shall pass to the other. If neither
survive me, the legacy shall pass with the residue of my estate.
THIRD: I give a legacy of Five Thousand Dollars ($5,000.00) to each of the
following friends who survive me: ALICE BLACK, DORIS CHRISTENSEN, NANCY M.
VINCENT, PEGGY DEAN, FAY BOWMAN and MARY JANE WERNER. If any of the
persons receiving such legacy under this paragraph shall predecease me, that legacy shall lapse.
FOURTH: I give all the residue of my estate to CHRIST LUTHERAN CHURCH
(Harrisburg, Pennsylvania). The gift is to be designated: "In Memory of Lewis P. Jenkins and Ruth
H. Jenkins, and their daughter, Doris H. Jenkins" for its general uses and purposes.
FIFTH: During the administration of my estate, my personal representatives shall
have the following powers in addition to any other powers given herein or by law, each of which
shall be exercised without any order of Court:
A. To retain and to distribute in kind any or all of th.e assets of any estate.
B. To invest in income producing real estate, and any securities, stocks or
other personal property, including common trust funds of a corporate fiduciary, which th.e fiduciary
may deem for the best interest of the estate or trust, according to the standards of prudent investment.
C. To sell at public or private sale, to exchange, to lease, or to give options
for any periods of time, for any or all of the property of my estate, for such prices and
upon such terms and conditions as the fiduciary thinks proper herein.
D. To compromise any claim or controversy.
E. To exercise any option, right, or privilege granted in insurance policies or
in other investments.
F. In the event of abatement, the legacies in paragraphs SECOND and
THIRD shall abate pro rata.
SIXTH: I direct that all inheritance or estate taxes which may becotne payable by
reason of my death on any property passing under this Will shall be paid out of the principal residue
of my estate, and before calculation of the residuary gift to charity, and no part thereof shall be
collected from or charged against any beneficiary.
SEVENTH: I appoint JON M. GRUBER Executor of this Will. If he cannot serve, I
appoint WACHOVIA TRUST COMPANY.
IN WITNESS WHEREOF, I have to this Will, typewritten on three (3) sheets, set my
hand and seal this day of _f~'~r~t'~,~ ~`~,_.... , 2008.
~)
OBIS H. JENI S
Signed, sealed, published and declared by the above-named, DORIS H. TENKINS, as
and for her Last Will and Testament, and in the presence of us, who at her request and in her
presence and in the presence of each other, have subscribed our names as witnesses thereto,
~~
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residing at /'IC ?~ ~. , ~~, ,.~,~ ~'
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS:
r-~ • We, DORIS H. JENKINS, ~: ~. ~ ~ ~ ~(' , ~~ ~ ~' ~ ~ - and
--~ -~., ~,~~' ~;,-wr _ ,the Testatrix anti the wit ' ses, respectively, whose
names r e signed ~ the foregoing instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that
she signed willingly, and that she executed it as her free and voluntary act for the purposes therein
expressed, and that each of the witnesses, in the presence and hearing of the Testatrix signed the Will
as witnesses and that to the best of the witnesses' knowledge, the Testatrix was at that time eighteen
(18) years of age or older, of sound mind and under no constraint or undue influence.
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Witness
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g^ it//
J
fitness ,r
i
D4RIS H. JENKI ,Testatrix;
Sworn to and acknowledged before me by DORIS H. JENHINS, the Testatrix, and
subscribed and sworn to before me by the witnesses, this ..~, day of ;-~~~~f.4 ~~ , 2008.
t
~~ f
Notary Public
C~MM~NWEALTN AF PENNSYLVANIA
td C7-~ARIAL SEAL
Gretchen K.1Noerner - i~ctary Public
to952~.~ CITY GF LANCASTER, LAiCt+S1 cR COUNTY
MY COMMISSICW P~?'RFS p.PR. O8, 2011
-3-
A Settlement Statement s. Department of Housing
_ end Urban Development
OMB No. 2502-0285
B T e of loan
1. ~ FHA 2. ~ FmHA 3. ~ CONV. UNINS.
4. ~ VA 5. ~ CONV.INS. 6. File Number:
10-014349-1 7. Loan Number: 8. Mortgage fns. Case No.:
C. Note; This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.
Items marked "(p.o.c.}" were paid outside the Dosing; they are shown here for informational purposes and are not inGuded in the totals.
D. Name and Address of Borrowers:
Benjamin B. Schmick, III
Carolyn S. Schmick
675 St. John's Drive
Camp Hill, PA 1701 I F. Name and Address of Lender:
None
E. Name and Address of Sellers:
Estate of Dorris H. Jenkins
930 Red Rose Court, Suite 30Q
Lancaster, PA 17601 H. Settlement Agent:
Russell-, &rafft & Gruber, LLP
930 Red Rose Court, Suite 300
Lancaster, PA 17601
G. Property Location:
100 N St. Johns Drive
Cam Hill PA 17011 I. Settlement Date:
08!04/2010
Disbursement Date:
08!04/2010 ace o ement:
Russell, Krafft & Gruber, LLP
930 Red Rose Court, Suite 300 Lancaster, PA 17601
J. Summary of BorrowRrs Transaction K. Summa ry of Sollst's Transaction
100. Gross Amount Due From Borrower 400. Gross Amount Dus To Seller
101. Contract sales rice 142 000.00 401. Contract sales rice 142 .00
102. Personal property 402. Personal property
103. Settlement charges to borrower (line 1400) 2,902.00 403.
104. 404,
105. 405.
Adjustments for items paid by seller in advance
106. Ci /town taxes 08/04/2010 to 12/31/2010 11.79 Adjustments for items paid by seller In advance
406. Cit /town taxes 05/048010 to 12/31/2010 11.79
107. County taxes 08/04/2010 to 12/31/2010 157.16 407. County taxes 08/04/2010 to 12/31!2010 157.16
108. Assessments to 408. Assessments to
109. School taxes 08/04!2010 to 061308011 1,434.60 409. School taxes 08/04/2010 to 06/30/2011 1,434.60
110. Sewerltrash/recycle 8/04/2010 -09/30!2010 92.95 410. Sewer/trash/recycle 8/048010 -09/30/2010 92.95
111. 411.
112• 412.
120. Gross Amount Due From Borrower 5146 98.50 420. Gross Amount Due To Seller 5143 696.50
200. Amounts Paid By Or In Behalf Of Borrower 500. Reductions In Amount Duo To Seller
201. Deposit or earnest money 14,200.00 501. Excess deposit (see instructions)
202. Prinapal amount of new ban(s) 502. Settlement charges to seller (line 1400) 6,216.96
203. Existin loan(s) taken sub'ect to 503. Existing loan(s) taken sub•ed to
2~• 504. Payoff 1
205• 505. Pa off 2
206. 506. Deposit held by Seller 14,20p,00
207• 507.
208• 508.
209• 509.
Adjustments for items unpaid b}f seller djustments for items unpaid by seller
210. Cit !town taxes to 510. Ci /town taxes to
211. County taxes to 511. County taxes tp
212. Assessments to 512. Assessments tta
213• 513.
214. Ke stone Oil -credit for oil bud et lan 446.70 514. Ke stone Oil -credit for oil bud et inn 446.70
215. 515.
216. 516.
217. 517.
21 S. 518.
219• 519.
220. Total Paid B /For Borrower S14 .70 520. Total Reductions Amount Due Seller S20 .66
300. Cash At Settlement From/To Borrower 600. Cash At Settlsmant TdFrom Seller
301. Gross amount due from borrower line 120 5146 98.50 601. Gross amount due to seller line 420 5143 6%.50
302. Less amount aid b /for borrower line 220 S14 .70 602. lass reductions in amount due seller line 520 520 .66
303. CASH E]/ FROM [] TO BORROWER: S131,951.80 603. CASH Q TO [~ FROM SELLER: 5122,832.84
Buyer's Initials /'
Section 5 or the Red Estate Settlement Procedures Au (RESPA) requires the following: ?HUD must develop
a Special Information Booklet t0 help persona borrowing money to finance the purchase of reddentid real
state to betty undasW,d the natwe and cow of red state settlement unicu; ?Each lends must provide
the booklet w all applicants from wham it receives w for whom it prepares a written application to borrow
marry a finance the purchase of «sidentid red estate; 7 Lenders must prepare and distribute with the Booklet
a Good Faith Estimate of Ute aettlanent costs that the borrower is likely to intau in connection with the
saUemeM. Thesc disclosure arc manadatay.
Sellers Initials~1L
Section 4(s) of RESPA mandates that I•IUD develop and prescribe this uandard form to be used at the time of
tan setlletnent to provide fill diecJoaurc of dl chuges imposed upon the btxrowa and adla. There era third
party disclawrcs that arc designed a provide tlw borrower with pertinent information during the settltaoent
proceu in order to be a betty shopper. The Public Repartiag Burden far thin cdlactian of informa6w is
unmated to avenge one how pa response, including the time fa reviewing inanucdons, searching existing
data aowcu, gathering noel maintaining the elan needed, and completing noel reviewing the collection of
information. This agency may nor cellar tiffs information, and you arc nor requirod b canpltm this form,
unless it displays a currently vdid OMB control number.
1030
' e amen aages
Settlement Stat~_nt Page 2
T00. Total 5alestBroker's Commission based un price s no.0o ~ % = Paid Paid From
Division of Commission (line 700) as follows: ,
Borrower's Seller's Funds
701. to Funds at at Settlement
702 to Settlement
703. Commission paid at Settlement
704. Rowe's Auction Service
4,63020
800. Items Payable in Connection nth Loan
801. Loan Origination Fee % Nooe
802. Loan Discount
803. Appraisal Fee
804, Credit Report
805. Lender's Inspection Fee
806. Mortgage Insurance Application Fee
807. Assumption Fee
808. Flood Certification
809.
810.
811.
812.
813.
815.
900. Items Rt3quirt3d By Lender To Be Paid In Advance
901. laterest From to ®S Jday for days
902. Mortgage Insurance Premium for mo. to
903. Hazard Insurance Premium for yrs. to
904. yrs. to
1000. Reserves Deposited nth Lender
1001. Hazard Insurance months cQ per month
1002. Mortgage Insurance months (cb per month
1003. City property taxes months ~ 2.41 per month
1004. County nixes months aQ per month
1005. School taxes months @ per month
1006. months r month
1007. months @ per month
1008. Aggregate Adjustment
1100. Title Charges
1101. Settlement or closing fee to
1102. Abstract or title search to
1103. Title examination to
1104. Title insurance binder to
1105. Document preparation to
1106. Notary fees to Russell, Krafft & Gruber, LLP
ttorney s ees to
(inGudes above item Numbers: ~
1108. Title insurance t0 First American Title Insurance Company
(inGudes above item Numbers:
1109. Lender's coverage
1110. Owners coverage
1111.
1112.
1113.
1200. Government Recording and Transfer Charges
1201. Recording fees: Deed 62.00 ; Mortga a ;Releases 62.00
1202. City/county tax stamps: Deed 1,420.00 ;Mortgage 1,420.00
1203. State tax/stamps: 1,420.00 ;Mortgage
1204.
1300. Additional Settlement Charges
1301. Surve to
1302. pmt Ins lion to
1303. 2010/11 school tares to Michael Langan, Treasurer 1,586,76
1304.
1305.
1306.
1307.
1400. Total Settlement Charges (enter on lines 103, Section J and 502 Section K) S2 902 00 56,216 96
, „a.o w~c,unr ,ov,ewcu u~c nvv-, aciaes~oern ocaceme~u ana ro me oast of my Know~eage ana Heuer, n ~s a true and accurate statement of all receipts and disbursements made on
my account or by me in this transaction. 1 further certify that I have received a copy of the HUD-1 Settlement Statement (pages 1 and 2).
orrowers // ~ Sellers
Benjamin &Schmick, 11I Carolyn Schmick Estate of Dorris H. Jen
~.
The HUD-1 Settlement Statement which I have p ared is a true and accurate account of this transaction. t have caused or will cause the funds to be disbursed in accordance with this
statement.
SetOement Agent Date 08/04/2010
WARNING: It is a crime to kn make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and imprisonment.
For details see: Title 18 U.S. Code Section 1001 and Section 1010.
Previous editions are obsolete
1031
Estate Valuation
Doris H Jenkins
Date of Death: 03129/2010
Valuation Date: 03129/2010
Processing Date: 05/13/2010
Shares Security
or Par Description High/Ask Low/Bid
1) 342.07 Cash (CASH)
2) 2589.539 EVERGREEN STRATEGIC INCOME FD (299918102)
D'VRS INCMBLD A
Mutual Fund (as quoted by NASDAQ)
03/29/2010
3) 7130.473 EVERGREENT PA MUN BD (300326105)
CL A
Mutual Fund (as quoted by NASDAQ)
03/29/2010
4) 1348.71 EVERGREEN SELECT ADJ RATE FD (299913301)
CL A
Mutual Fund (as quoted by NASDAQ)
03/29/2010
5) 1399.525 PIMCO FDS PPC INVT MGMT SER (693390429)
TOTAL RET C
Mutual Fund (as quoted by NASDAQ)
03/29/2010
Total Value:
Total Accrual:
Total: $119,648.85
Titled:
DORIS H JENKINS
100 NORTH ST JOHNS DR
CAb1P HILL PA 17011-1931
Account was opened on 12/12/2001.
Portfolio Endnotes
Estate of: Doris H Jenkins
Account: 4561-6760
Report Type: Date of Death
Number of Securities: 5
File ID: 4561-6760
Mean andlor Div anal Int Security
Adjustments Accruals Value
342.07
5.40000 Mkt
5.400000 13,983.51
10.90000 Mkt
10.900000 77,722.].6
9.04000 M}:t
9.040000 12,192.34
11.01000 Mkt
11.010000 :15,908.77
51 9,648.85
50.00
Paqe 1
This report was produced :,pith EstateVal, a product of Estate Valuations & Pricing Systems, Inc. If you have questions,
please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.1.1)
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~~~~ r~~~~ Reference ID: 3013425
W~~OVia Bank
Balance Confirmation Services
P O Box 40028
Roanoke, VA 24022
April 19, 2010
RUSSELL KRAIFT dt GRUBER LLP
**
SUBJECT: Verification /Confirmation of Account and Balance Information provided for:
Customer: DORTS H JENK.INS (SSN# XXX-XX-b323)
Date of Death: March Z9, 2010
Deuosit Account Information
Acoourrt Account Date of Death Average Balanoc Date Maturity Interest Ac:aved YTD Date
Type Number Balance Opened Date Rate Interest IrQer+egt Paid Closed
CHECKING }QOC}QOO{XX7894 $269.67 ll>/23I2001 $0.04 x0.27
LEGALTITLE: DORIS H JENKWS
ANN J THOMAS POA
Other Accouirt Information
Account Aoeoutt Date of Balance Date Date Ledger Colloctod
Type Number Operred C1oBad
ANNUITY 341
TRANSAMERICA - For inforrraRion ee~rding annuities, please call 1-800-831-7SSS
SAFE DEPOSIT XXX7Q~~0325 2/6/2003
BOX
i LEGAL TITLE: DORIS H JENKIlV5
LOCATTON: CAMP HILL
320 S TRIl~TDLE ROAD
CAMP HILL PA 17011
Page 1 of 2
r~ax •rransm~~tal
W.'l~HOVIA
Re£eretme ID: 301342 S
CAP, BROKERAGE and SELF-DIRECTED IRA ACCOUNTS HAVE BEEN CONVERTED TO WACHOVIA SECURITIES.
YOUR REQUEST HAS BEEN FORWARDED FOR PROCESSING and WILL BE MAILED UNDER SEPARATE COVER
FOR QUESTIONS REGARDING CAP, BROKERAGE, or SELF-DIRECTED IRA ACCOUNTS
PLEASE CALL WACHOVIA SECURITIES at 166-874-2717.
~' Date of death balance does nct include aorxued interest.
+ If date of death oocurrs on a wexJrend or a holiday, date of death balance does not include any transactions that sere made during that time period.
~',M,~, },5~,,,
Jennifez Straub
Setvicenter Associate
Phone: (540)563-?323
js; ja
By accepting this information, the recipient thereof represents and warrants to Wells Fargo Bank, N.A ("Wells Fargo"~ that toe recipient is authorized by the cuatoroer to reoeivae lawfully this infarmatioa
The recipient agrees that it will not disclose this information to any third partip, unless oon:pelled to do so by legal process, and that it will lawfully use this iafottnation The recipient ackrwwledges that
Wells Fargo does not represeai and warrant that the information is complete and accurate. The recipuent further ackoowledgea that the information may not disclose the entire re]ationship between customer
and Wells Fargo. The itt5~rmation is subject tQ without notice to the recipient The recipient agrreas to indetzmify, defend, and hold Wells Fargo harrnlesa $om and agai<ist arty claim resulting frown the
disclosure and use of the infarmatioat by the recipient or from the breach by the recipient of eery agrexsaent, representation, a warnunty ocntained herein.
Wachovia Bank and Wac$~ovia Bank of Delaware are divisions of Wells Farg? Beak, N.A
4/ 1~/ G U l V 3 :.3 ~: V L Y1~7 YAC.r C G/ V U G !' d, X 7 i;, I V C Z
Pts~e 2 of 2
Rowe's Auction Service
2505 Ritner Highway
Carlisle, PA 17015
717-249-2677 249-1978 697-4794
May 12, 2010
To: Jon M. Gruber, Attorney
Russell, Krafft & Gruber
930 Red Rose Ct.
Lancaster, PA 17601
From: Rowe's Auction Service
2505 Ritner Highway
Carlisle, PA 17015
Re: Personal Property Auction
Estate of Doris Jenkins
110 St. Johns Dr.
Camp Hill, PA 17011
Total Sales $6193.50
Less 35% Commission -2167.72
Net Auction Proceeds $4025.78
Less Bouder's Trash Removal Fees -800.00
Net Due Estate ;3225.78
u
William G. Rowe
~;r
,,~
_'~~t,~
~ ~~~1~1
~Vlutual
A better zuay of life
April 13, 2010
Russell Krafft & Gruber
Attn: Jon M. Gruber
Hempfield Center Ste 300
930 Red Rose Ct
Lancaster PA 17601-1981
Re: Policy lnd 4 244 054
Doris H. Jenkins, deceased
Dear Mr. Gruber:
We are writing in answer to your letter informing us of the death of our payee.
Please extend our sympathy to the family.
Ms. Jenkins was receiving 54.45 on the 8th of each month under the Company's
Annuity Option 10 year certain and her life, effective November 8, .1979. Under
~,
~~; March 29, 2010. Consequently, no death benefit is
available.
In order for us to close our file, we require the return of the unearned April 8,
2010 payment. {Gk# ~ 875351) Checks were being mailed out 10 days prior to
the due date.
The date on the check represents the date is was mailed and the date on the
stub represents the month and day the payment is due."
We are sorry we could not advise the family more favorably.
Sincerely,
~Vlary.~t nn ,Slusarczy~,
Mary Ann Slusarczyk
Claims Examiner
Maii Code c3u
Toll Free Number 1-800-523-0650
The Penn Mutual Life Insurance Company
Philadelphia PA 19172 (215) 956-8000 www.pennmutual.com
PSEC~k
April 12, 2010
0172XXXXXX
JON M. GRUBER
HEMPFIELD CENTER SUITE 300
930 RED ROSE COURT
LANCASTER, PA 17601
Dear MR. GRUBER:
You recently informed PSECU about the death of Doris H. Jenkins. Please accept our sincere condolences.
In order to close her account please complete and return the following form(s):
The Authorization to Close Account form. Hers' was an individual account totalling $5.33.
If you have any questions, please call 234-8484 in Harrisburg or our toll-free number (800) 237-7328. At
the menu prompt, enter 6 and then extension 2227.
Sincerely,
~`
Meacie Fairfax
Member Service Representative
Finance Support Unit
encs.
Pennsylvania State Employees Credit Union
Main Address: 1 Credit Union Place, Harrisburg, PA 1 71 1 0-2990 • 717.234.8484 • 800.237.7328
Mailing Address: P.O. Box 67013, Harrisburg, PA 1 71 06-701 3 • 717.777.210() (TDD) • 800.472.1967 (TDD)
psecu.cvm
This credit union is federally insured by the National Credit Union Administration. Equal Opportunity Lender
Q Mt~TBazui
499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12
Phone (888).502-4349
Fax (302)'934-2955
April 16, 2010
Russell, Krafft & Gruber
Jon M Gruber
Hempfield Center Suite 300
930 Red Rose Court
Lancaster, PA 1 ?601
Re: Estate of: Doris H Jenkins
Social Security: 172-01-6323
Date of Death: March 29, 2010
Dear Sir or Madam:
Per your inquiry, please be advised that at the time of death, the above-named decedent had on deposit with this bank the
following:
1. Type of Account
Account Number
Ownership (Names o, f)
Opening Date
Balance on Date of Death
Accrued Interest
Total
Checking Account
9845292912
Doris H Jenkins
06/05109 closed 04/05/10
$12998.11
$ 0.13
$12998.24
Please be advised, there was no safe deposit box found for the above decedent.
* If upon reviewing the information above, you believe there are additional accounts not referenced, please provide
us with an account number andlor name of any possible joint account holder. For any additional information on the
above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contact
our west snore Plaza branch at 1200 Market street, Lemoyne PA 17043 call #7~7-731-»30.
Sin ely,
N issa Sears,
Adjustment Services
0~ ~~ • www.finchjewelrycom
1841 Columbia Ave., Lancaster, PA 17603 • 717.293.3333
TO YVHOM IT MAY CONCERN: Thor is to certify flat we ore ergaged in the ' b~rsiness, aapppprraising fiiomords waldta, jeweky and preoous stones of al desaiplions.
We herewith caNfy Ihat we how this day taefuMy examined the faNowiq ~desaibed alkks. Vye estivate I~e vdues es I'afed for insuranre a other purposes at the
current retail wku, exdudYg federal and other taxes. In making Ilws Appraisal, we do not agree to repbre dre arlides.
\~+
FINCH
JEWELERS
To the Estate of Doris H. Jenkins April 13, 2010
DOD March 29, 2010
Jon M. Gruber, Executor
1. Ladies double diamond ring. Two old mine cut diamonds each have a diameters of 4.30
mm and a combined weight of approximately 0.58 carat. They have quality characteristics of G-
Hcolor, VS2-SIl clarity. Each diamond is secured by four prongs and set beside each other in a
square illusion head. They are set in a 14 karat yellow gold cathedral style ring with open filigree
detail. Inside shank is stamped 14K. See photo. Estate value $325.00.
2. Ladies diamond solitaire ring. One round European cut diamond has a diameter of 4.69
mm and a weight of approximately 0.34 carat (estimated by formula). The diamond has quality
characteristics of G color, VS1 clarity. The diamond is secured by four prongs and set in an 18
karat white gold cathedral style solitaire ring with open filigree detail; inside shank is stamped
18K. See photo. Values $200.00
3. Ladies diamond shield ring. Three round European cut diamonds are bead set vertically
in an 18 karat white gold art deco style ring with engraved detail.. Two of the diamonds have a
diameter of 5.20 mm and one has a diameter of 3.70mm. The ring has a combined weight of
approximately 1.15 carats. They have quality characteristics of G-H color, VSl-VS2 clarity.
One of the 5.2mm diamonds has a chipped girdle. See photo. Values $750.00.
~-...
,.~
;~ ~~ ~ ,,
All values based on cash liquidation estimates
All weight, color, and clarity are provisional insofar as mounting permits examination.
This estate appraisal was completed by Jessica Finch, Graduate Gemologist (GIA). Pricing
determined using Rapaport Diamond Report, Gemworld Price guide and prevailing market.
Ail or some of the following equipment was used at the time of examination. American Optical
stereo star microscope, GIA Duplex II refractometer, GIA Gem Set, Illuminator polariscope, Mettler
CM200 electronic carat/gram scale, Ohaus Scout scale, Tri Electronics GXL-18 electronic gold tester
Master Color diamonds, GIA gem diamond lite and gem fiber lite. Ceres Reliance AC and Ceres
Secure
,~
The foregoing Appraisal is mode with the undersrood'ep that the Appraiser assumes no liobdily with respell ro any action that may be token on the basis of • ~ >
• ~ :~
1841 Colum~ia Ave. Lancaster, PA 17603 717.293.3333 www.{inchjewelry.com
~~~~
~~~
~~0~1 ~7C~T1(~'~ • www.finchjewelry.com NI H
N
~~W~h~Rs
1841 Columbia Ave., Lancaster, PA 17603 • 717.293.3333 T -~
TO WHOM R MAY CONCERN: This a to certify that we are ngoped in the' business,oppraainp d'iamoids wokMs, jeweky and predous stones of aN dasrlip6orK.
Nh herewith cerlilq Ihot sw how this day rnrefuNy exomii~ed the (oNowinp ~desaibed articles. Nh estivate t~e wlues as ksted fa insurance a other purposes of the
anrent rNa1 wkse, ezdudNg hderd and attar taxes. In makiig 11rs Appraisal, we do iat agree ro replace the articles.
To the Estate of Doris H. Jenkins April 13, 2010
DOD March 29, 2010
Jon M. Gruber, Executor
1. Ladies platinum Art Deco style diamond cluster "dinner" ring. Set in the center of the
ring is one European cut diamond with a diameter of S.SOmm; two others graduate in size from it;
they have diameters of 3.35 mm. Fourteen round brilliant cut diamonds are bead set in a
scalloped pattern; the ring has a combined diamond weight of approximately 1.30 carats. The
diamonds are well matched with quality characteristics of F-G color, VS2 clarity. The diamonds
are set in a platinum "dinner" ring; inside shank stamped 100 IRID 900 PLAT. See photo.
Values $1,500.00.
i; ~M_ ,. ~,.. ~
:~;.3.. ~
~~~ 4
*~ a: y,
~;;
All values based on cash liquidation estimates
All weight, color, and clarity are provisional insofar as mounting permits examination.
This estate appraisal was completed by Jessica Finch, Graduate Gemologist (GIA). Pricing
determined using Rapaport Diamond Report, Gemworld Price guide and prevailing market.
All or some of the following equipment was used at the time of examination. American Optical
stereo star microscope, GIA Duplex II refractometer, GIA Gem Set, Illuminator polariscope, Mettler
CM200 electronic carat/gram scale, Ohaus Scout scale, Tri Electronics GXL-18 electronic gold tester
Master Color diamonds, GIA gem diamond lite and gem fiber lite. Ceres Reliance AC and Ceres
Secure
The foregoieg Appraisal a mode with the understandirq that the Approiser assurtas no liob~'rryr wish respect to any action That mar be taken on the bass of this ~ C-~1 b
1841 Columbia Ave. Lancaster, PA 17603 717.293.3333 www.{inchjewelry.com
MetLi f e Metropolitan Life Ins - ce Company _ Notice of Claim Payment
BrJDist. Agency Date of Notice
~''~~ 500 SCHOOLHOUSE -ROAD ~ ,~°~ -000 21 04 20 201
JOHNSTOWN, PA. 15915 - .
NAME OF DECEASED DATE OF DEATH DIST PHONE NUMBER
(717) 763-7027
JON M GRUBER
C/O ATTORNEY JON M GRUBER
HEMPF I ELD CENTER SUITE 3 0 0 9 3 0 RED Please See Important Notice on Reverse Side
LANCASTER PA 17601
Policy Number
Codes Refer to
Messages Below. 137086892
A
Items Payable
Policy Amount 358.57
One-Year Term Insurance
Additional Insurance 104 5.74
Dividends With Interest
Dividend to Policyholder
Terminal Dividend
Premium in Advance
Interest on Claim
Deductions
Premium in Arrears
Loan
Loan Interest
TOTAL
1404.31
A. Our check for the balance due is attached below.
~~ ~~s.
p~
~o~~~.
This claim has been
approved for the total of
the amounts appearing
in the boxes below.
Items determining these
amounts are listed to
the left.
Amount Held for Deferred Payment
Check Issued by Customer Service Center
TR.ANSA-MERICA
s LIFE INSURANCE COMPANY
Transamerica Life Insurance Company
4333 Edgewaod Road NE
PO Box 3183
Cedar Rapids, Iowa 52406-3183
April 16, 2010
Estate of Doris H Jenkins
c/o Jon M Gruber
930 Red Rose Ct Ste 300
Lancaster PA 17601
RE: Annuity Number 02SFD030541
Dear Personal Representative(s):
We have received notification, Doris H Jenkins, annuitant of the above
listed non-qualified tax deferred annuity is deceased. Our office
wishes to extend sincere condolences for your loss.
The following is the current information on this annuity:
Annuitant:
Owner:
Primary Beneficiary:
Annuity Policy Date:
Full Value as of 04/16/2010:
Taxable Portion:
Full Value as of 03/29/2010:
Doris H Jenkins
Doris H Jenkins
Estate of Doris H Jenkins 100
December 11, 2001
$66,473.46
$16,473.46
$66,376.63
The attached document outlines the option available to the estate.
The full value as of the date of death is for tax purposes only and is
not a guaranteed death benefit amount.
Operations performed on an automatic basis when applicable have been
terminated, such as; Systematic Payouts or Automatic Billing.
The attached document contains general tax information based on
Transamerica Life Insurance Company's interpretation and should not be
relied upon for your personal tax planning. If you have questions
concerning the direct tax consequences when selecting an option, you
may wish to consult a tax advisor.
Member of the `~70N. Group
~.
Any additional questions regarding this annuity can be directed to the
Annuity Service Center at 1-800-553-5957. A Transamerica Life
Insurance Company representative will gladly assist you with any
question you may have regarding this annuity and help you meet your
financial goals.
Sincerely,
Nicholas Hayes
Transamerica Life Insurance Company
Claims
Enclosure(s): Annuity Claimants Statement
Death Option Packet
Postage Paid Return Envelope
Death Option Packet
02SFD030541
Please submit the following documents upon selection of an option,
defined below:
• Certified copy of the death certificate indicating the manner of
death
• Original annuity policy
• Annuity Claimant's Statement
• Letters of Testament (Already Received)
The Claimant Information section on the Annuity Claimant's ;Statement
needs to be completed in the name of the estate. Please in,~lude the
estate's tax identification number and signature(s) of the ,Personal
Representative(s).
The following options are available to the estate:
Lump Sum Payment
The death proceeds value, per the terms of the contract, will be
disbursed to you in a lump sum payment.
Delay the Lump Sum Payment up to 5 years from date of death
You will be responsible for notifying the company to remove any
remaining funds prior to the fifth anniversary of the date of death.
Please note, regardless of which option is chosen, the taxable amount
will be reported on a Form 1099-R the January following the
distribution.
Please contact our office for information concerning products
available to you at this time.
DATE: 05/07/2010
RE: TRANSAMERICA LIFE INSURANCE COMPANY
Deferred Annuity Number:
Tax Qualification:
Annuitant Name:
Policyowner(s):
Payee Name:
02SFD030541
NON-pUALIFIED
DORI6 H JENKINS
ESTATE OF DORIS H JENKINS
Please accept our company's sincere condolences on your recent loss. Your request for a
distribution from your tax deferred annuity has been processed. Your check is attached. Following
is information regarding any deductions taken from and the taxable amount of this distribution.
Gross distribution: 6 6 , 5 81.21
Less Federal Income Tax Withheld: . 0 0
Less State Income Tax Withheld: . 0 0
Less delivery fee: . 0 0
Net check amount: 6 6 , 5 81.21
Taxable amount: 16 , 5 81.21
If any portion of this distribution is taxable, this distribution will be reported to the 1RS and to
you on a Form 1099-R.
Please be advised that the release of policy values may affect the guaranteed elements,
non-guaranteed elements, face amount or surrender value of the policy frorr~ which the values are
released.
For your information, state regulations require insurers to monitor unreported replacements of
existing annuity contracts and life insurance .policies by our company. If this distribution is intended
to be used to purchase a new annuity contract or life insurance policy with our company, please
contact us at the number below.
We recommend you seek the advice of your tax consultant concerning the proper reporting of
this distribution. Unless we have been notified of a community or marital property interest in this
policy, we will rely on our good faith belief that no such interest exists; the policyowner agrees
to indemnify and hold the Company harmless from the consequences of accepting this transaction.
If you have any questions please contact your local representative, or the Armuity Distribution
Service Team at
1-800-553-5957.
CHECK NO
16732180
DATE VENDOR NO. PAYEE NAME
05/07/2010 AAIP740371 ESTATE OF DORIS H JENKI1vS
65178 12/09
CHECK AMOUNT
66,581.21
-------- To Rernove Document Fold and Tear Tong This perforation
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mas@rkglaw.com
Register of Wills
Cumberland County Court House
1 Courthouse Square
Room 102
Carlisle, PA 17013
RE: Estate of Doris H. Jenkins
File No. 2010-00338
Dear Sir or Madam:
October 28, 2010
t~~'ra~.ig V. Russell
'gar-y G. l~".rafft
~o~~ M. Gruber
d:`i ristizZa L. Hausner
-~lcally S. ]Filius.
~lulie F~. Miller
Matthew A. Grosh
;`~~~ron. IC. Zeamer
Of Counsel
I?,_~`~id E. Greer
Tl~c~mas L. Goodman
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Please find and original and copies of the Inventory and Inheritance Tax Return for filing.
Kindly time-stamp and return the extra copies in the return envelope provided.
Thank you.
MAS
Enclosures
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Very truly yours,
~~^~.
Melissa-Ann Smith
Paralegal for Jon M. Gruber
Ephrata Office: 108 West Main Street, Ephrata, Pennsylvania I752:~ (% t 7) ;'33-9500 Fax (~~ I i') ;%38-42:56
1Nillow 'Sti-cet Office: 2421 Wiilo~v Street Pilo, Wallow Street, Pennsylvania 17584 (`717) 464-2223
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