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12-22-10
David H. Stone, Esquire Stone, LaFaver 6 Shekletski 414 Bridge Street Ne~v Cumberland, PA 17070 717-774-7435 waTw . stonelaw .net ~.. ~ C ~ ~:~: ....... O ~ ~.., ~~ ~ ~.l !'V ('-s- r _t 4"y. ~ C ~~ . ~~~ ~ o ,: cc~- r THE I~iTTER OF THE APPOINTMENT IN THE COURT OF COITION PLEAS OF A GUARDIAN FOR CUI~ERLAND COUNTY, PENNSYLVANIA SVEN O. JENSEN, AN ALLEGED ORPHANS COURT DIVISION INCAPACITATED INDIVIDUAL NO. 21-09-0807 PETITION TO INVADE ASSETS FOR PP~I~ARRANGED PREPAID BURIAL TO THE HONORABLE JUDGE EBERT: AND NOW, this day of 2010, comes the Plenary Permanent Guardian of the Estate, Keystone Guardianship Services, of the above-captioned alleged incapacitated individual, and respectfully requests that the Honorable Judge Ebert grant a request to invade Principal assets held in the Guardianship of Seven 0. Jensen, to pay the prearranged prepaid burial expenses for Sven 0. Jensen. In support thereof, said Guardian aver as follows: -1- 1. Keystone Guardianship Services (hereinafter referenced to as "Guardian") was appointed Guardian of the Estate of Sven 0. Jensen, an alleged incapacitated person by the Cumberland County Orphans' Court by Order dated September 29, 2009, a copy of which is attached as Exhibit 1. 2. Sven 0. Jensen is a resident at Arden Courts - Susquehanna of Harrisburg, located at 2625 Ailanthus Lane Harrisburg, Dauphin County, Pennsylvania since December 7, 2009. 3. An Inventory of Assets for Sven 0. Jensen was filed by the Guardian on December 22, 2009, a copy of which is attached as Exhibit 2. 2. An annual report as filed with the Register of Wills of Cumberland County on October 25, 2010, for Sven O. Jensen, a copy of which is attached as Exhibit 3. 4. The present principal assets held for Sven 0. Jensen are $390,861.27 consisting of the following: a) Halifax National Bank - Checking $ 5,631.98 b) Halifax National Bank - Savings 85,000.00 c) Jackson National IRA 260,229.29 d) Halifax National Bank Ctf of Dep 15,000.00 e) Mid Penn Bank Ctf of Dep 10,000.00 f) Mid Penn Bank Ctf of Dep 15,000.00 5. The present income balance held for Sven 0 . Jensen is $10,275.52 consisting of the following: a) Halifax National Bank - Savings 631.24 b) Jackson National IRA 8,587.57 c) Halifax National Bank - Checking 1,056.71 6. The present monthly income for Sven 0. Jensen is $2,660.15; consisting of the following: a) Social Security $1,901.00 b) MRD monthly apx Jackson National IRA $715.63 c) Interest Income 43.52 -2- 7. The anticipated monthly expenses for Sven 0. Jensen are $5,704.99; consisting of the following: a) Arden Courts (Monthly Care) $5,000.00 b> Keystone Guardianship Services $500.00 c) Heartland Pharmacy (medicines) $500.00 d) Comcast (Cable) 62.00 9. Pre-Arrangement Burial expenses for Sven 0. Jensen as estimated by Hollinger Funeral Home, 501 North Baltimore Avenue, Mount Holly Springs, PA 17065-1609 $8,215.00: a copy of which is attached as Exhibit 4. WHEREFORE, the aforementioned Guardian respectfully requests the Honorable Judge Ebert enter an Order allowing her to invade the Principal to prepay the prearranged funeral expenses for Sven 0. Jensen. Respectfully Date : ~ 2 22' 1~ Da~ton~,~ Es~.iire Stone, LaFaver & Shekletski ID 39785 414 Bridge Street New Cumberland, PA 17070 717-774-7435 -3- VERIFICATION I verify that the averments in this Petition to Invade Principal Assets for Prearranged Prepaid Burial are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to unsworn falsification to authorities. KEYSTONE GUARDIANSHIP SERVICES Date : ~o~ 02 !O onstance E. Stoneroad IN Rr : IN THE COURT Or COi`~1P~lON PLEAS Or ;..; CU~f1BERLAi 1D COUNTY. PENNSYL~L_~NiA ".~ v1 : -- t'~ ._~ ~. AN A_LEG~-D INCAPACITATED =° v' PERSON NO. 21-09-007 ORPHANS COURT -- _ : _, ORDER OF COURT -' 0 AND IVOL'J, this 29`h day of September, 2009, this matter haling been called for a hearing, the Court finds, upon clear and convincing evidence, that S'~en O. Jensen is an incapacitated person in that he suffers from a mental impairment that prevents him from recei'iing and evaluating information effectively and prevents him from formulating and communicating decisions to such a significant extent that he is unable to manage his financial affairs or meet essential requirements for his physical health and safety on a daily basis. The Court appoints the Cumberland County Office of Aging and Community Services as Permanent Plenary Guardian of the Person of Seen O. Jensen. Keystone Guardianship Services is appointed Permanent Plenary Guardian of the Estate of Sven O. Jensen. IT IS FURTHER ORDERED AND DIRECTED that Cumberland County Aging and Community Services and Keystone Guardianship Services are authorized to obtain payment for their services pursuant to their fee schedules; and Cumberland County Aging and Community Services and Keystone Guardianship Services are authorized to obtain payment of guardians fees subject to a maximum of 10% of Sven O. Jensen's gross monthly income or $100 per month, whichever is less, at such time, that Sven O. Jensen no longer has sufficient assets to pay for guardianship services and would qualify for medical assistance. The posting of bond will be waived in this case. The EXHIBIT "1" vuar~:BnS Shai! hereafter compiy'~,Vith th° reDOrting re~;uf°mentS Of 2~~ r`~a.C.S. SeCt!0~~ 521 ~;ci. a copy of U~hich is attached. By the Court. 1 ~ ~ I ~~1. L. Ebert, Jr , ~\ ~`,, J .~ Anthony L. DeLuca, Esquire Attorney for Cumberland Co. Aging and Community Se~,ic~s Mark Bayley, Esquire Court-Appcinted for S~~ien O. Jensen Cumberland County Aging and Community Services :. y ttl:,ji (,1.7~Y ri~Oltll i~C~O~~ !r. Tastimany wherof, I hereunto set my hand and the seal ~f said Court at Carlisle, PA .f,yy ~,, ~~ ,rC. ThisT`~, day of ~~, t20~ Cleric of the O ` ans Court Cumbe and County GU~~RDIAIV'S I~'VENTORY COURT OF COtiItiIO~i PLEAS OF CUI~IBERIu~VD COUNTY, PEti~'SYZ.~'AL'~L~ OR.P~L~VS' COURT DI~'ISIOV Estate of Sven O. Jensen ,art incapacitated Person No. 21-®g-o8®^ i. Real Estate: (Location, by whom occupied and rental Estimated Value: terms, applicable) FctimatPr~ L'alue: G. r cr av aaaa a a v a.a ~ Sovereign Bank #3~io6o8~s ~ $1,864.00 ; i Sovereign Bank #ioS4o75o26 Cash found in home $1~8~397.83 $2°2.98 i ~ ~ Jackson National Insurance - IRS #ioo~683323 X260,229.29 2002 Ford Winstar $3,90;.00 , I I i Sub-Total for Personal Property: i $424,99.10 3. Jointly Held Property: Estimated Value: (Setfor<rtft reaf and persona(property owned 5y the lrtcapacitated person JO!_yTLYwith any other oerson(si- State whether held as tenantsoy the entireties; if not, whether the r;ght of suruiuorsht ?StSts./ 3 i7 Carol Street, New Cumberland, Cumberland County, PA , ~ j Parcel #26-23-0543-030 -Assessed value - ~iS9,87o $79,935.00 ~ Held Joint Tenants with Right of Survivorship with his wife, i _ His wife, Barbara Fowler _- _ _ ~ _ - .. Page i of 2 EXHIBIT ..2.. _~ _~:=- - _:_ ___. Estate of Sven O. Jensen , aa~. incapacitated Person 4. Anticipated Assets: !Se[,'our[h proper^~ cl2n~ cnd =_xpecred ,~ ie scqu.nd zeree,-'a^. -cger.._r L'c" QnCCa7QCe2 LLQCe 7J 2C7'1ii2COn..~ Property Anticipated Date of .acquisition Estimated ~~alue: i Sub-Total for Personal Estate ~o.oo L4:tach additioaaL sheets if necessary) TOT_=~I.OF ITEMS i, 2, 3, anal 4 :.................................. ~. Monthly income: ................... 8~0~.334. io Social Security i ~i,864.00 Total of monthly income i' $i,8b4.oo Commor_wealth of Pennsylvania County of Dauphin ss. Keystone Guardianship Services ,says that the foregoing is a full, (Guardian) True and complete Inventory of the Estate of Sven O. Jensen , The aforesaid Incapacitated Person or Minor; and that all of the information set forth herein is True and correct to the best of the Guardian's knowledge and belief. I verify- that the statements made in this ) Inventory are true and correct. I under- ) Stand that false statements herein are ) made subject to the penalties of ) i8 Pa.C.S. § 4904 relating to unsworn ) Falsification to authorities. ) uardian Page a of 2 1r~~IAL ®ti'ERd'i~~`" R~~®~T ®~' G~.rAI~Diar ®~' T~~ ESTaT~ COCRT OE CO~ItiIO~i PL.E~S OF CtivIBERL~~~ COI.,1iT4", PEr1i5~T.`:-~Y~~ ORPIL~vS' COI.~i2T D~TSIO Estate of Sven O. Jeases , an Incapacitated Person ro. ~ 1-09-OSO' I. C~TRODL"CTIOti Keystone Guardianship Service , ,vas appointed x Plenary- ~ Limited Guardian of the Estate by Decree of tit. L. Ebert_ 1r. ,1., dated September 29, 2009. a. This is the Initial Report far the period from S~tember 29. 2009 to December 1. 2009 (the "Report Period"); or _' B. This is the Final Report for the period from to (the "Report Period" j, and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: Name of Personal Representative: 2. The Guardianship was terminated by the Court by Decree of 1., dated Page 1 of 3 Estate of S~-en O. Jensen an Incapacitated Person II. Lr~'02~L~TIO~: A. Keystone Guardianship Services is the Court Appointed Guardian of thz Estate of Sven O Jenszn who resided at ~[anor Care in Carlisle, PA untii December'. 2009 at which time he was moved due to the request of Manor Care to Arden Courts -Susquehanna of Harrisbur„ located at Zo2~ Ailanthus Lane f-Iarrisburg, Dauphin Count; P~nns,~lvania; ard. B. Barbara Fowler, wife of Sven O. Jensen, who is presently residing at Green Ridge ~"illage, ~+~ew~;iile, PA, appointed her sister, Sandra Y"Dung of69 Dennis Drive, Amherst, y(assachusetts 0 i 002. as her went Agent under a Power of Attorney dated Juty 28, 2008; and, C To the best of the Guardian's knowledge Sven O. Jensen and Barbara Fowler held assets solely ir. their individual names with the only known exception being the real estate in which they resided: and, D The real estate known as 31? Carol Street, ti~ew Cumberland, Cumberland County. Pennsylvania is deeded to Sven O. Jensen's wife, Barbara Fowler, joint tenants with right of sun worship; and, E. The Guardian has determined that Sven O. Jensen and his wife, Barbara Fowler, file their Federal and Mate Income Tax Returns jointly; and, F. The Guardian found the largest asset of Sven O. Jensen is an [Ra with Jackson rational Life fixed annuity which Sovereign Bank off rs through there investment services through a contractual agreement with LPL Financial Corporation ('`LPL"), on which the named beneficiary is Barbara Fowler. G. The Guardian's attorney wrote a letter to Joseph Lterrullo, Compliance Administrator , Investment Services at Sovereign Bank and received the attached reply. (Attachment '~A"); and, The major features of the annuity are: 1. First Year interest rate of ~.8%; and, ?. guaranteed care of no less than 3% for as long as the contract is held; and, 3. up to !0% can be withdrawn annually without penalty this amount includes the required minimum withdraw; and, ~. provides for nursing home and terminal illness waivers for access of additional funds without penalty. H. The Guardian met with JefF S. Howe on December 10, 2009, and discussed the Jackson tiational Insurance Annuity purchased through Sovereign $ank in detail confirming and explaining the features of the annuity; and, [. Due to the facts and findings relative to this Vb~ard, the Guardian Ends no need to meet and review the information found with a representative of the Elder Abuse Task Force. Page 2 of 3 Estate of Sven O. Jensen , an Incapacitated Person [ ceriry that the Fore;oin~ information is correct to the best of m~ Icno~ledge. information and belief, and that this L~erification is subject to the penalties of 18 Pa~CS. 3 ~90~ re(ati~e to unsw~orn falsification to authorities. Date / ,~ J lid arure o`vuar~!iar of:he Est3t_ Constance ~. Stoner~a~ Name or'~ruarian of :he Estate '~.pe or gent PO Box .3G4 .-address E1:Z3~eiti`%'.i~e_ P3 1'U?~ Cir.. Stat_, Z;p 1'-ZS:--10=0 Teiepnone _Lotes This report was prepared and submitted to the Court for in,`ormational purposes due to the unusual situation and or circumstances of this I~"and. The Guardian finds this to be an unusual situation w%th different people and or entities responsible for and accountable for treir decisions. The situations to be encountered will be very different, and may be di~acult and sensitive to handle and will ta.~a much time and personal touch . Petitions and Annual Reports will be submitted as needed and required to keep the Court informed. Page 3 of 3 LPL Fir~~.~cial tiovember 18. =009 Rebecca J. tilargerum, Esq. ~0~4 Route 22~ Elizabeth. PA 1'0'3 Re: Sven Jensen Dear tits. ~Iargenum: P2t2~ V~/ Grliies ~SS.,_~ _ ,.,_~~3~i 3~s-;.~ ~~;~a ~~'08-,'..ifi '?~ 35b9 `~,~ This letter is in response to your letter dated 'vovember 10, 2009 to Joseph !~terrullo concerning Mr. Jensen's purchase of a Jackson ~iational Life fixed annuity in July 2009. Sovereign Bank offers investment services at its branch locations through a contractual agreement with LPL Financial Corporation ("LPL"), and NIr. Jensen dealt with LPL registered representative Jeffrey Howe and Sovereign Bank employee Holy Freundel in connection with this transaction. Accordingly; NIr. Vterrullo referred your letter to LPL for review and response. I have reviewed this matter with ~~tr. Howe and tits. Freundel, and reviewed LPL's records of this transaction. Based on my review. the following appears to be an accurate chronology of events. Background Prior being introduced to i/tr. Howe, qtr. Jensen had previously dealt with his. Freundel at the west Shore Plaza branch for approximately fire years (at that time, Sovereign offered investment services through a contractual agreement with IFtiIG Securities, Inc. ("IF~1G'-)). Over that period of time, qtr. Jensen spoke frequently with 'Vts. Freundel about investment options that he might consider when he retired for his retirement assets. These typically included bank certificates of deposit and fixed annuities. 'Vts. Freundel noted that 1~1r. Jensen was attendant to the details of his finances over this period of time, and often requested printouts of his balances so that he could keep track of the rates he was earning and his overall financial circumstances. In ?~ovember 2008- ~Ir. Jensen told her that he planned to retire the following spring or summer. She reviewed with him the process for rolling over his ~Oi(k) v~ith the Pennsylvania Bar Association. In January 2009, she contacted him to let him know that she was transferring to the Harrisburg branch. and that he could continue to work with the personnel at the ~L'est Short Plaza branch, or with her at her new location. In June 2009, 1~Ir. Jensen and his retirement advisor from the Pennsylvania Bar association came to see >Vts. Freundel for assistance with his retirement. along with reviewing the rollover process. they discussed investment options. including IRS certificates of depcsit- money market accounts, and fixed annuities. Both Mr. Jensen and his advisor appeared to be in agreement that the fixed annuity wou{d be a suitable invesnnent, due to its contractual guarantees and higher rates of interest than what was available from the other alternatives. qtr. Jensen stated that he wanted to review these options with his wife. Accordingly, a meeting was scheduled for July 10, 2009 at their home, which 1~Is. Freundel and 1~tr. Howe attended. ~~~aT~~ ~=,,;~;,; ~ a,, ATTACHMENT "A,. LPG Fi~~~~~a~ ~' the Jule 10, 2009 meeting, ~Ir. Howe and 'its Freundel reviewed the ins estment options for the 401(kl rollover. Thee both recall that qtr. Iensen's crincipal investment objective was safety of principal, and that he did not expect to require access to these funds for income. They discussed that the Jensens had approximately ~ ! X0,000 liquid in a money market account. as well as a monthly pension and social security. They discussed that, because it was an IIZ~, he would be required to take minimum distributions annually from the contract; but qtr. Jensen stated that he did not expect that he would need those distributions to fund income needs. They again reviewed [R~ certificates of deposit, money market accounts. and fixed annuities. including the Jackson y;ationai product. They noted that this product offered a fist year interest rate of ~.8%. and then guaranteed him a rate of no less than 3% for as long as he held the contract. They also noted that up to 10°~5 could be withdrawn annually without penaity, and that the product provided for nursing home and terming; illness waiver for access to additional funds without penalty. In connection with this discussion, they reviewed the enclosed Jackson tiational informational brochure. Both l~tr and l~tr. Jensen appeared to be in agreement that this would be a suitable investment, and ~Irs. Jensen stated that it would be'~L. lensen's decision to make :after the meeting. I~Is. Freundel called Mr. Jensen and told him that they would contact him when the rollover check had been received by the bank, and that they would schedule another meeting with tilr. Howe to review the product again. This follow-up meeting occurred at the Harrisburg branch on July 1 ~, 2009, when ~Ir. Jensen came in to meet with his. Freundel and tiir. Howe. They again reviewed his and iVtr. Jensen's financial circumstances, and discussed his investment options. ~1r. Jensen agreed that he w fished to purchase the Jackson ~,ational fixed annuity, and signed the enclosed paperwork. On Augwt 4, 2009, 'dir. Howe met with Mr. Denser, to deli. er the contract, and again reviewed its terms. The current status of the contract is as follows: Total Deposits: $23,882.23 Contract Option Value: X263.092.09 Free Withdrawal Amount: $26;309.20 Cash Surrender Value: $230,?31.39 Discussion Based on my review of this matter, I have found no basis to accede to your request that the contract that :~Ir~ Jensen purchased be rescinded. .as an initial matter. it appear that the transaction was fully- discussed, documented; and authorized. Both tits. Freundel and dir. Howe also do not recall observing any apparent cognitive deficiencies that, ~Ir. Jensen may have been experiencing. As noted above, ~~Is. Freundel had known i~Ir. Jensen for approximately five year, and did not perceive any chan,e in his behavior or apparent cognitive capacity in the 2009 meetings from what she had previously observed. That pereption appear to have been shared. moreover. by the representative of the Pennsy Ivania Bar :~ssociarion who accompanied ~Ir. Jensen to the initial meeting with tits. Freundel at the bank, and by titrs. Jensen, who stated at the July l0, 2009 meeting that this was titr. Jensens decision to make. t intend no disrespect, but if there were any apparent incapacities at the time of the 2009 meetings, it seems likely that would have been noted by one or more of these persons at the time. I also do not agree with your assertion that the investment is not in ~Ir. Jensen's best interests. It provides for guaranteed rates of return on atax-deterred basis that were and are higher than other alternatives, and provides for 10°%o annual surrender-free withdrawals, as well as nursing home and terminal illness waivers for access to additional funds in those eventualities. '~ -sr - ~~.~'~,`. S~~ , LEI, Fir~~.~~~~.~ Conclusion For the above reasons; LPL and Sovereign Bank do not agree t,~ dour request than the contract that qtr Jensen purchased be rescinded. Thank you for ~-our attention to this matter- IT you have am questions. please feet free t~~ contact me. `'erg truf~ ~ ours. ~; Peter `w~ GiPlies ~ Enclosures ~;,,~,,,o~,~~~a~-~,=~ ANNUAL REPORT OF GUARDIAN OF THE ESTATE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION _ r., _ _; ;~~ _ ,; ,i rfll! ~-~~- ~„ - - -,, - (, I `~ _ ,' Estate of Sven O. Jensen , an Incapacitated Person No. 21-09-0807 L INTRODUCTION Keystone Guardianship Service ,was appointed IX~ Plenary _.~ Limited Guardian of the Estate by Decree of M.L. Ebert , J., dated .9/29/ 1.09 __ ___. A. This is the Annual Report for the period from September 30 2009 to _ __ September 29_ 2010 (the "Report Period"); or B. This is the Final Report for the period from to (the "Report Period"), and is filed for the following reason: 1. Tl~e death of the Incapacitated Person. Date of death: Name of Perso-~al Representative: 2. The Guardianship was terminated by the Court by Decree of J., dated Page 1 of 6 Estate of Sven O. Jensen , an Incapacitated Person II. SUMMARY A. State the value of the estate reported on the Inventory $504,534.10 B. State the value(s) of income and principal assets at the beginning of the Report Period. (Same as Inventory if first otherwise, ending balance from last Report.) Principal $504,534.10 Income $.00 C. What is the total amount of income earned during the Report Period? $37,927.70 D. What is the total amount of income and principal spent for all purposes during the Report Period? $(109,913.61) E. Additional principal assets discovered after Inventory filed $2,693.67: F. Sale Price vs. Inventory Price: $(16,685.00) Property at 317 Carol Street $(14,790.00) $ 1,895.00 Personal property in home G. Cost for property settlement & public sale: $(5,620.52) H. What are the balances remaining at the end of the Report Period? 1. Principal $399,812.72 ' 2. Income $ 1,018.62 3. Total of Principal and Income $414,831.34 III. ADDITIONAL INFORMATION (If more space is needed, please attach additional pages) A. Principal 1. How is the principal balance listed above currently invested? (Please specify, e.g., real estate, certificates of deposit, restricted bank accounts, etc.): HNB Checking #100110983 $4,583.43 HNB Savings #200112953 $95,000.00 Jackson National IRA #1005683323 $260,229.29 HNB CD#300114354 $15,000.00 Mid Penn CD #301084438 $10,000.00 Mid Penn CD #301084437 $15,000.00 Total Principal Balance: $399,812.72 Page 2 of 6 Estate of Sven O. Jensen , an Incapacitated Person 2. Have there been any expenditures from the principal during the Report Period? ................................................ [f yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? b. List purpose and amount of expenditures: All principal used is transferred to Income. ..ou. , ppr~ va re.:.. ~ . ,,., r.. _ r to expending the principal? ................. .. ®Yes ~ No ® Yes ~ No ®Yes ~_' No 3. Were additional principal assets received during the Report Period which were not included in the Inventory or a prior Report filed for the Estate? .......................... ®Yes ~' No If ves: a. Was Court approval requested prior to receiving the additional principal? .............. b. State the sources and amounts of the additional principal received: Cash found in home Sale of personal property in home 13. Income I. State sources and amounts of income received during tine Deport Feriod ~e.g., Social Security, pension, rents, etc.): Interest income Annuity income -Jackson National IRA US Treasury -Social Security Refunds of payment Advanced taxes/utilities 'Total income received during Report Period: J Yes ®No $77.67 $2,616.00 $522.28 $8,587.57 $22,666.00 $5,837.45 $314.40 $37,927.70 Page 3 of 6 Estate of Sven O. Jensen ~ an Incapacitated Person How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): HNB Checking #100110983 $5,908.78 HNB Savings #200112953 $522.27 Jackson National IRA #1005683323 $8,587.57 "Total Income Balance: $15,018.62 C. Expenses for Care and Maintenance Specify what expenditures were made from the principal and income for the care and maintenance of the Incapacitated Person (e.g., clothing, nursing home, medicine, support, etc.): Advanced Podiatry Services $16.20 Arden Courts $52,252.25 Butler Medical Transport $121.00 Comm. Of PA Mobile Dentistry $310.00 Darryl Guiswite, DO $209.15 Family Practice Center $85.49 Freedom Blue PPO $12.00 Heartland Healthcare Services $4,367.59 John Hume, MD $225.00 MCHS Carlisle $17,646.43 Pinnacle Health Hospitals $50.40 See Right Paarmacy $27.46 Trust Ambulance $35.00 Wellspan Behavioral Health $25.27 Wellspan Medical $252.32 York Hospital $1,237.03 Total Expenses for Care and Maintenance: $76,872.59 Page 4 of 6 Estate of Sven O Jensen , an Incapacitated Person D. Other Expenditures Specify what other expenditures were made during the Report Period. (Do not include any items stated in response to question C above.) Allstate Insurance $1,132.27 00 298 $5 Barbara Fowler- 2009 fed tax refund . , Borough of New Cumberland $15.00 Cindy Rowe Autoglass $50.00 Cleckner & Fearen, Attys $660.00 $299.29 Comcast Cumberland County -filing fees $30.00 Custer, aust 8c Associates $165.00 $15.50 Drycleaning Service $70.00 Duty's Lock Safe and Security $20.74 Halifax National Bank 523.79 $2 Keystone Guardianship -costs , LB Smith $366.01 Lynn Stoneroad- clean up $1,315.42 $425.00 Mary Hogan- mowing Mary Sultzaberger -deed search $125.00 New Cumberland Borough $305.53 Office of the Sheriff $36.00 PA American Water $117.16 $46.00 PA Department of Revenue $22.50 PennDot $146.26 PPL Scott Archibald P $350.00 . Register of Wills $30.00 $450.00 Richard Cassell -final cleanup Riverside Cleaners $7.50 000.02 $1 Robin Gasperetti, Tax Collector , $119.00 The West Shore Tax Bureau $1,374.05 UGI $433.48 `t'aste i'i'Ianagement Total for Other Expenditures: $16,948.52 E. Guardian's Commissions List amounts of compensation paid as Guardian's commission and state how amount was determined: Court Amount Method of Determination Approval Obtained $16,092.50 Fees ($75 00 per hourl ®Yes ~ No Page 5 of 6 Estate of Sven O Jensen , an Incapacitated Person F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court apCoural was obtained. Amount Approval Obtained ~ Yes J No Yes J No 1 verify that the foregoing information is correct to the best of my knowledge, information and belief, and that this Verification is subject to the penalties of 18 Pa.C.S. § 4904 relative to unsworn falsification to authorities. .~ ~~~ - Si ature of Guardian of the Estate Dore Constance E. Stoneroad .Fame of Guardian of the Estate (type or print' PO Box 804 Address Elizabethville. Pa 17023 City, State, Zip 717-265-40.16 Telephone Page 6 of 6 even Jensen INCOME ST~IT~NI~~VT for Period Se te~tbe~° ~o Zoo9 To Septeml~+er ~~- 2oio Sep 30 20(}9 ~~~~;,Y 5ep 29 2010 -. ~L'.28 ..: `. ~, rc ~ S£CU(iCV 7,4~ is =7 ir. ~.-.. 'i.l ui~ r. _.~ .., .. 5 ., z ?3,?.3?,,C r~"z`;- ~i'-i~0i~t~ ~, -::~,: ~;;r , ,_ ,., _ . 58,~39.i~ ,,..:.:~ l~cS ,.,..~ ~h~... . . "t ` ~~`' . . ,.. ,.. ' ~5 ~~ 'u "'-~ ,,. __ ~ C'OSi ,... .... ..... ._ '~t_: Vli:%±:+ ~JSC ivy ~~ .r .. ,:, ;~? ..__.,334....3 Syen~ensen ~iA~AlVCE SHEET ~s ~~ Sep 29 2~1~3 i:~~~~"° . :.i: n"`c ;.~`+~ [ j-,f,~ndi iriStJrdfiC2- !K~ t 1GG5og?3='-3 _ ; i, „ ~~:~: ,~ =?C0 ~ 12953 ~...::. ,~..~ z ;. ~.., }, ~ti ~i~lt,~ )~. ..'~~il(dilC;e- iRt~ -1GJ7b ~ ~ ~._.., -~,G ~~~ G ;;natures 1~ -~- -. ~':~ ?. ~.~ =01~~ .~.3~, matures _ .. „ i..IA~Z'€.dTi .YES .. .., .. ,_... ir,yb 'i ~ i"~~ E€~t#ITY '~3.~ :~L L:ElB~Z~ITIES & EQUITY Sep 29 2030 ~:9es.~ ~21_.Z 8,87.5' 4,583.43 95; GLG.OG 2eG;Z29.29 ~,~GG.GG iG;^.GQ.GG S,GGG.QG 4i4,a'}.~a.3'~' C4,534.i.0 x,093.67 192;:396.43; 4'.4,83'.. -* 4'4,83'.34 . ;.> _ . . ,... ~ .. , October 20 2010 02-16-2010 Deposit 06-07-2010 Change in Holdings 77.67 77.67 cash found in home 2,616.00 2,693.67 Public Sale for property & personal property October 20 2010 ::., 1 895.00 1,895.00 06-07-2010 Change in Holdings Public Sale for property & personal property 16,685.00 -14,790.00 06-11-2010 Change in Holdings Sale of property at 317 Carol Street ,< ... .. _:> Change in Holdings Data " 06-07-2010 .,.. ......; USD .-.._... ._.,~<~. Public Sate for property >k personal property S:Y_ - .._ -i~S _. -n 1010--"`CHECKING"` 3,413.70 cost for publ 5,800.00 2,616.00 3,905.00 2,616.00 Sale of persc 1,895.00 Gain on sale 3,413.70 Upda[e Post Post as new Schedule New Number Delete D~xt:Y * 06-1i-2010 ;~i~e~cna:~: Change in Holdings ,. ., >:,c~ USD ;,_=;a;;=,r.~.,s Sale of property at 317 Carol Street ~- ., , , :; ~ .... ...~ .. ... r ~-.: , t ... ~ ...., .. ~ ~ ~ .:. 1010--""CHECKING"' 61,357.58 16, 685.00 2,206.82 79,935.00 314.40 Update Post Post as new Schedule New Number Delete .. i a'. il', .J` Advanced Podiatry Services Allstate Insurance Allstate Insurance Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Barbara Fowler Borough of New Cumberland Butter Medical Transport Cindy Rowe Autoglass Cleckner & Fearen, Attys Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comm. of PA Mobile Dentistry Comm. of PA Mobile Dentistry 02-18-2010 Check #158 10-19-2009 Check #107 10-19-2009 Check #108 12-04-2009 Check #121 01-i1-2010 Check #135 02-18-2010 Check #156 03-09-2010 Check #166 04-08-2010 Check #181 05-07-2010 Check #190 06-07-2010 Check #207 07-08-2010 Check #224 08-09-2010 Check #230 09-15-2010 Check #235 08-27-2010 Check #95 01-13-2010 Check #137 10-19-2009 Check #106 01-19-2010 Check #138 01-19-2010 Check #143 01-19-2010 Check #145 01-26-2010 Check #148 02-25-2010 Check #163 03-23-2010 Check #175 OS-07-2010 Check #194 05-27-2010 Check #204 07-08-2010 Check #220 07-22-2010 Check #225 08-25-2010 Check #231 03-09-2010 Check #170 OS-17-2010 Check #200 Cumerland County General Fund 12-22-2009 Check #127 Cumerland County General Fund 05-27-2010 Check #203 Custer, Faust & Associates 05-07-2010 Check #197 Darryl Guiswite, DO Darryl Guiswite, DO Darryl Guiswite, DO ~rycleaning Service i1-25-2009 Check #116 01-i1-2010 Check #136 02-18-2010 Check #159 01-21-2010 Check #142 joint 2009 fed tax return paid to Barbara permit for dumpster replace broken window filinge fee for Inventory 16.20 16.20 392.52 392.52 739.75 739.75 7,032.25 7,032.25 5,000.00 5,000.00 5,014.00 5,014.00 5,028.00 5,028.00 5,024.00 5,024.00 5,051.00 5,051.00 5,038.00 5,038.00 5,028.00 5,028.00 5,023.00 5,023.00 5,014.00 5,014.00 5,298.00 5,298.00 15.00 15.00 121.00 121.00 50.00 50.00 660.00 660.00 44.97 44.97 9.24 9.24 9.24 9.24 9.24 9.24 9.24 9.24 9.24 9.24 9.25 9.25 136.15 136.15 62.72 62.72 155.00 155.00 155.00 155.00 15.00 15.00 15.00 15.00 165.00 165.00 135.01 135.01 43.46 43.46 30.68 30.68 .,1 1... .... 15.50 15.50 70.00 70.00 Duty's Lock Safe & Security 10-19-2009 Check #105 25.49 25.49 Family Practice Center 01-19-2010 Check #144 15.00 15.00 Family Practice Center 04-08-2010 Check #182 15.00 15.00 Family Practice Center 05-07-2010 Check #192 15.00 15.00 Family Practice Center 06-14-2010 Check #212 15.00 15.00 Family Practice Center 08-25-2010 Check #233 6.00 6.00 Freedome Blue PPO 03-23-2010 Check #172 3.00 3.00 Freedome Blue PPO 07-08-2010 Check #222 3.00 3.00 Freedome Blue PPO 07-22-2010 Check #227 9.87 9.87 Halifax National Bank 10-26-2009 auto deduction 10.87 10.87 Halifax National Bank OS-18-2010 Auto deduction 6.10 6.10 Heartland Healthcare Services 10-29-2009 Check #109 214.90 214.90 Heartland Healthcare Services 11-25-2009 Check #115 354.43 354.43 Heartland Healthcare Services 12-14-2009 Check #124 679.67 679.67 Heartland Healthcare Services 01-19-2010 Check #146 186.28 186.28 Heartland Healthcare Services 02-18-2010 Check #157 171.19 171.19 Heartland Healthcare Services 03-09-2010 Check #167 167.87 167.97 Heartland Healthcare Services 04-08-2010 Check #183 182.01 182.01 Heartland Healthcare Services 05-07-2010 Check #191 1,068.11 1,068.11 Heartland Healthcare Services 07-26-2010 Check #228 890.79 890.79 Heartland Healthcare Services 08-25-2010 Check #Z32 446.14 446.14 Heartland Healthcare Services 09-15-2010 Check #237 225.00 225.00 John Hume, MD 10-19-2009 Check #104 78.81 78.81 Keystone Guardianship- costs 11-03-2009 Check #111 42.15 42.15 Keystone Guardianship- costs 12-01-2009 Check #119 144.12 144.12 Keystone Guardianship- costs 01-03-2010 Check #130 187.47 187.47 Keystone Guardianship- costs 02-04-2010 Check #150 g2 gg 92 99 Keystone Guardianship- costs 03-03-2010 Check # 165 60.98 60.98 Keystone Guardianship- costs 04-06-2010 Check #179 157.08 157.08 Keystone Guardianship- costs 05-06-2010 CHeck #188 99.05 99.05 Keystone Guardianship- costs 06-04-2010 Check #206 1,620.25 1,620.25 Keystone Guardianship- costs 07-02-2010 Check #219 23 38 23.38 Keystone Guardianship- costs OS-06-2010 Check #229 17.51 17.51 Keystone Guardianship- costs 09-08-2010 Check #234 2,007.50 2,007.50 Keystone Guardianship -fees 11-03-2009 Check #111 1,203.75 1,203.75 Keystone Guardianship -fees 12-01-2009 Check #119 2,662.50 2,662.50 Keystone Guardianship -fees 01-03-2010 Check #130 2,175.00 2,175.00 Keystone Guardianship -fees 02-04-2010 Check #150 1,350.00 1,350.00 Keystone Guardianship -fees 03-03-2010 Check #165 1,218.75 1,218.75 Keystone Guardianship -fees 04-06-2010 Check #179 1,875.00 1,875.00 Keystone Guardianship -fees 05-06-2010 Check #188 1,500.00 1,500.00 Keystone Guardianship -fees 06-04-2010 Check #206 1,218.75 1,218.75 Keystone Guardianship -fees 07-02-2010 Check #219 375.00 375.00 Keystone Guardianship -fees 08-06-2010 Check #229 506.25 506.25 Keystone Guardianship -fees 09-08-2010 Check #234 366.01 366.01 01-16-2010 Check #141 van repair LB Smith 277.50 277.50 01-11-2010 Check #134 63 99 99.63 Lynn Stoneroad 01-14-2010 Check #139 purchased battery for van . 75.00 75.00 Lynn Stoneroad 01-14-2010 Check #140 127.41 127.41 Lynn Stoneroad 01-26-2010 Check #147 clean up and purchase 210.88 210.88 Lynn Stoneroad 01-29-2010 Check #149 217.50 217.50 Lynn Stoneroad 02-05-2010 Check #151 135.00 135.00 Lynn Stoneroad 02-26-2010 Check #164 37.50 37.50 Lynn Stoneroad 03-09-2010 Check #168 67.50 67.50 Lynn Stoneroad 03-23-2010 Check #177 67.50 67.50 Lynn Stoneroad 03-23-2010 Check #178 300.00 300.00 Mary Hogan OS-19-2010 Check #201 125.00 125.00 Mary Hogan 06-18-2010 Check #218 125.00 125.00 Mary Sultzaberger 10-19-2009 Check #103 16,007.43 16,007.43 MCHS Carlisle 12-14-2009 Check #122 1,639.00 1,639.00 MCHS Carlisle 01-11-2010 Check #132 , 101.55 101.55 New Cumberland Borough 11-05-2009 Check #113 101.55 101.55 New Cumberland Borough 02-18-2010 Check #153 sewer/trash 102.43 102.43 New Cumberland Borough 06-07-2010 Check #209 36.00 36.00 Office of the Sheriff 10-19-2009 Check #102 30.13 30.13 PA American Water 12-28-2009 Check #128 26.06 26.06 PA American Water 03-23-2010 Check #173 27 70 27.70 PA American Water OS-07-2010 Check #193 14.71 14.71 PA American Water 05-27-2010 Check #205 18.56 18.56 PA American Water 07-08-2010 Check #221 04-15-2010 Check #185 2009 State tax due 46.00 46.00 PA Department of Revenue 22.50 22.50 04-21-2010 Check #187 PennDot 50.40 50.40 Pinnacle Health Hospitals 06-14-2010 Check #213 17.41 17.41 PPL O1-i1-2010 Check #133 15.65 15.65 PPL 02-18-2010 Check #155 20 37 20.37 PPL 03-23-2010 Check #174 18.81 18.81 PPL 05-07-2010 Check #196 21.01 21.01 PPL 05-10-2010 Check #198 24.68 24.69 PPL 06-14-2010 Check #215 28 32 28.32 06-18-2010 Check #217 final bill PPL - 350.00 350.00 P. Scott Archibald i1-25-2009 Check #114 _ 30.00 30.00 Register of Wills 02-25-2010 Check #161 file petitions OS-19-2010 Check #202 clean up of property 450.00 450.00 Richard Cassel 7.50 7.50 Riverside Cleaners 03-16-2010 Check #171 22.00 22.00 2obin Gasperetti, Tax Collector 12-03-2009 Check # 120 tax certification 10.00 10.00 robin Gasperetti, Tax Collector 02-12-2010 Check #152 968.02 968.02 03-23-2010 Check #176 2010 Real estate taxes 4.41 4.41 See Right Pharmacy 04-08-2010 Check #184 5.39 5.39 See Right Pharmacy 05-10-2010 Check #199 3.60 3.60 See Right Pharmacy 06-14-2010 Check #214 5 39 5.39 See Right Pharmacy 07-22-2010 Check #226 8 67 8.67 See Right Pharmacy 09-15-2010 Check #236 119.00 119.00 The West Shore Tax Bureau 04-15-2010 Check #186 35.00 35.00 Trust Ambulance 12-28-2009 Check #129 58.71 58.71 UGI 10-19-2009 Check #101 132.63 132.63 UGI 1i-05-2009 Check #112 158.14 158.14 UGI 12-14-2009 Check #123 135.00 135.00 12-17-2009 Check #126 serviced furnace 235 87 235.87 UGI UGI 01-07-2010 Check #131 165.55 165.55 UGI 02-18-2010 Check #154 264.01 264.01 UGI 03-09-2010 Check #169 145.87 145.87 UGI 04-08-2010 Check #180 52.56 52.56 UGI 05-07-2010 Check #189 18.90 18.90 UGI 06-07-2010 Check #208 6.81 6.81 06-18-2010 Check #216 UGI 02-18-2010 Check #160 dumspter drop off charge 28.91 28.91 57 404 Waste Management 02-25-2010 Check #162 dumster for house cleanup 404.57 . Waste Management 25.27 25.27 Wellspan Behavioral Health 11-25-2009 Check #117 252.32 252.32 Wellspan Medical 10-29-2009 Check #110 1,101.81 1,101.81 York Hospital i1-25-2009 Check #118 63.25 63.25 York Hospital 12-14-2009 Check #125 71.87 71.97 OS-07-2010 Check #195 York Hospital AP Transaction Vendor Invoice. October 20 2010 5.78 5.78 i1-05-2009 02-05-2010 Deposit Deposit Comcast refund Verizon refund g 69 197.29 15.47 212.76 07-30-2010 08-18-2010 08-18-2010 08-18-2010 Deposit Deposit Deposit Deposit Medco refund Allstate -refund of cancelled policy PPL -refund of cancelled policy US Treasury - 2009 Federal tax refund 302.00 24.69 5,298.00 514.76 539.45 5,837.45 Hollinger Funeral Home & Crematory, Inc. Eric L. Hollinger, Supervisor 501 North Baltimore Avenue Mount Holly Springs, Pennsylvania 17065 STATEMENT OF FUNERAL (,PODS AND SERVICES SELECTED Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any i[etns, we will explain the reason in writing below. have to a for embalmin .You do not hate [o pav for embalm- s If you selected a funeral that may require embalming, such as a funeral viewing, you tray P Y ing you did not approve if ou selec[e¢ arrangements susba_s direct cre~ ration or immediate burial If we charged forOear~alofin~g,dw~ expla~ why below. 2, ~!J:/ ht's ~:.~;,:!'; For the Service of ~ '`' _~ `` - ~ ~ . : .-- r... ,~ , Charge to: -l. ~1E ~~-~~?` State ~~ Y: v ' Address 1 y~~ , ~ i A. CHARGE FOR SERVICES SELEC'CED: '" 1. PROFESSIONAL SERVICES ~~- Services of Funeral Director/Staff .... $ ~~ Embalming .................$ ether preparation of body, i .,-~ $ '. . . SUBTOTAL OF PROFESSIONAL SERVICES ..... AI $ z i ~ a_ r~ , -~I @rfC6ffim'g4 - ~'~ ".. Cremation urn ................. $ (Description) OTHER $ $ ~ -,- B$ %%'~: TOTALn¢RCHANDLSESELECTED .. G SPECIAL. CHARGES: d~n of remains to 2. FACILITIES AND SERb1CE5 Fornar t g Use of facilities and services for ~ (Funeral Home) viewing (Visitations Wake) ......... $ Receiving of remains from ,~,..~r`~ f Use of facilities and services $ for Funeral ceremony ..... - .. - ~ $ (Fun~esaYHome) Gse of facilities and services for Immediate•$etfial ............. $ Memorial Service ........... $ D' ect.@Femation ................. $ Use of equipment and services ~ $ ). ~r,r -- .. 'r .ter,;-:[,ri'rr.:r,6J C $ for graveside servtce~ i.,.'i. F i?L~dS '''"' C TOTAL OF SPECIAL CHARGES Other use of facilites ~ ~ D. CASHADVANCE13 ~ ;y G ?+ ~~ $ ~ i ~' r - ~ . . .. ; ~ _ ~ ? Opening Grave ~- ~= [ A2 S i, T SUB-TOTAL OF FACILITBS/EQ Cemetery Eqwpmen Lot and Deed ~ AL-I'OMOTIVE EQUIPMENT 3 Newspaper Notice ~~:<fslu~'Li$ ,/.-.~7,~,r } . Vehicle to transfer remains [o Funeral Home ~ Newspaper Notices-0tit-of-town ...... $ l g egrams ... - .. Telephone & Te Local ... ..,....... Hearse (Casket Coach) / $./'" $ AaEare .... ... . ..... - clergy/mss Offering ... $~ Local .................. Limousine ~ - ~"$a116eazers ..... ... $ c.J' t`o ^~ `+ ~ - $ f the Death F Local . . . ............ ......... $ . . Certified Copies o $ Family car . ....... $ ...... l L Certificate $ Police Escpn .. ,~- ... . ,. ' r .......... oca Flower car or floral disposition . J~ ~ ~ - ~ ~ $~° Flowers ; ',. JK.. .~" $ $ vault Service Charge ........... Local ....................... '"~ ' Lead cariclergy car ~ , /i ~f !,~ j~% .~ L. ~'!Y'G~ Local ............$ llbearers f ~ $ L !!C~/ or pa Caz Local ..... ............. S v .... ortation t ans f ~ $ .. -..- $ _'' f % . p town r Out o $ _ .. p $ , SUB-TOTAL OF ADVANCES .................. . SUBTOTAL OF AUTOMOTIVE EQUIPMENT .. n3 $ We charge you for our services in obtaining: TOTAL OF PROFESSIONAL SERVICES, C~jfY crib aArnances that are mantel-upI n ,. AN~ AUTOMOTIVE 3 -, FACQIfIFS asks/,dt ,1-?L.l~ .~v_' A $\. ?..~ EQi1~NT ~" ~ SUMMARY OF CHARGES OR MFRCHe~ISE SELECTED: 7 B. CILARGE F A. Professional Services. Facilities and sy Casket ,f/i(~~ ~ / r .~~` , ... $ ~ Equipment, and Automotive 3 ~ J J - - $ ~,~ (i]~scripuon):- v wiy`J- .?`~v.d i//'L .',::v.sG,1+'/!' ~' Equipment ....... ....... $~~`~ Merchandise B ~ t,i r' ~'ti? ~'=yj.••r~ ~,{, G. `~' $ . C. Special Charges ... ...... $ ` ~ 7~ ' ~ ` Other Receptacle .. .... ` .. $ / " ~~ D. Cash Advances ..... ..... $ % j~/„j ~,,. (Description) Outer burial containers 1:'~J '-"''' "~ rY" • TOTAL OF AIL. SECTIONS . PAID AT TIME OF OR PRLOR TO (Description) i..:SrlC'- /tT.~ ASt1NNGEMENTS $ _ 3 BALANCE DUE Acknowledgement cards .. $ $ Register book(s) .... ~ - 1 REAS(1N FOR F.MBALMIN /~ ~ :-.Lr/ '~%j~ `_if'/G ic"- .7Z'~+~ ~ / ~~ .. _ -. .. - -. h ~ Memory folders ~ ~ ~ ~ ~ ~ -~-__~ - - ,_ _ .. -$ - ~- - - '- lfrayer cards ~ ~ - ~ - ~ - ~ $~ ase the purc _~- -' ' ~~ ~ If any law, cemetery, or crematory requirements have requved of of the items ts[ed ab~+ ~e law rl quuymen~,5~x~laine~,be~p~,~ /1'~'r,~~ !~'-"ITT `' ZZ~/ ~ r1 : % ~ ~y' . Temporary grave marker . .... ~ , ~ ~ , . , Burial clothing ............... i l0~fi%rir"'f!-L t n a rt b for the goods payment of the resh price for strffic ent funds ~ ailable have of thi nStatement of F ~ e~l Gnoods and ServecesdSelbeected.nlrepresente ha~l I agree [o be jointly and severally liable with anyone else day da s l o fa ~ py a eip[ o rec within and services selected. I also agree to make payment of $ f per month amounnng to y . s r ear will be applied [o the unpaid balance beginning Pe Y Collett amounts I owe under [his agreement. t o signs below. A late charge o the date of this agreement. I will also pay [o the Funeral Director all reasonable costs paid by the Funeral Director ordered or requested after [he date of this agreement will ices or merchandise f l l serv rom Those costs may include attorneys' fees, coup costs and other cosu. Any additiona be considered part of this agreement and the cost [hereof will be reflected on the final bill or statement / J ' ~ }~/~ ' / ~ ~ .fir .. (SeaU i ' _ v'r~ ° ~ C - ~G '* t : t'11 _' 4 - t ., (Purchaser) _ .- .. +...~; ~ - `,C ~ ~ -,~ CD"a - ~ ~ ; _. -y r I r „~rY~+~-~- ~a~ Y~'i"~, _ _ (~) ,- r~' ~ r ~ ~ - ~ ~? ~ - ~ ~' ~' ~ (Licensed Funeral D~tor) ewx auama ' (Purchased 0 PennryN F nml D rKt .~xwcun D~m~o, ~w~e~ I~ ^ 1~ form -600 Revised 1/04 ^ ^ PRENEED FUN FUNERAL MERCHAND SE AND FUNERAL SERVICES EXHIBIT 1 -STATEMENT OF ~~ OF INSURANCE BENEFTTS NOTE: THIS AGREEssM~E~~NT IS TO BE FU~iDED~,BYfTHE{ASSI~GyN. ~ ;: r'' FOR THE BENEFIT OF ~-~ A dress (Phone) (Funeral Recipient/Insured) ( ) _.<~ [N AGREEMENT WITH AND ASSIGNMENT TO ~~"'~'~`` ~~ 'ter (Funeral Provider ame) GUARANTEED MERCHANDISE ~,~` . -~- ~. GUARANTEED PROFESSIONAL SERVICES r, $ ;%;..: ~ Casket , ; Services of Funeral Director and Staff $ `'•'i Manufacturer ~ ~ r ~ ~''-~ -~'"'`'{'~ Embalming (See Agreement and Below*); $ Other Prepazation %r'~' P ~ ~'~~"~~ ''~rt~'''~'"" f `~ $ ~ Model Name `, ~ ~?%a ~~~` Visitation Days at $ - ' /Day $ Model Number Funeral Ceremony/ Memorial Service $ ~:„ ~ ~ Exterior Description i ~ ~ ~ ~ Other Use of Facilities.,and Staff (S~ecify ~;e ;.c~.~~= a ,, f ;~ ~,~~,~.~., ~ ~''~ Interior Description ~'f~.z5!' ,,~, ~~,~- Outer Burial Container ; Transfer of Remains to Funeral Home $ %r-4,{.~:~sh:'".+el_'"~~ If beyond a mile radius, which is our service Model Name area, there will be a chazge of $ per mile one way. Model Number Family Caz(s) at $ each $ ~~ ~~ Heazse :r''~ $ ~-~'"~ Manufacturer Limousine __- $ Constructed of Cremation $ Other Guazanteed Merchandise (Specify) Forwarding/Receiving Remains $ Other Services/Facilities/Equipment (Specify$ $ TOTAL GUA~IANTEED_SERVIC:ES $ ,~ ~J3 `"-~ TOTAL GUARANTEED MERCH/~NDISE $ ,,;-,7,,~~rc; . .._..~..-..,e._---~~ ._._--~,-~.~ - _... ._.~.___. _ ~.,.n---~ __._ , NON-GIkA~E~-~AS~~.ADVANCES / ` ~ $ ~~ , G~ Escort -, $ .:..,.-. .,~ Death Certificates . ~ at $ '-~` $ / S~. !,d Grave Opening and Closing;. ~r~~:u.~=~~ + $ "`'~~=' ~--'~ " C"' Flowers;,,, r, ~sx ~`~~ ..~-'_>, ~r $ $ ,G.~~ c:G,- Memorial Cazds/Book Music $ ,,•°~ ~ . ;:;; ~ Clothin (S ea ) $ Honorariums, >, r . ~ ~ ~ 1 $ Fz~ ~ 1blz~num_,..QPtp azker ~-~ u „~ ~ ,~'' ~. -~ Obituaries ~ 4 i RR 4~ r J ~ .+~..rr'~ ") f v U , v ~ ~ ~ ,~~.i! / y~ ~ „+i+R.r/. awing f $ Hairdresser $ ~;~"` - °''°,~' '` ~.-'= d-`=~:~..~:!~ $ c.~"'~~ $ Other (Specify)- i ~:- ~'~! ~"• *-'' $ Shipping Container $ ' Other (Specify) $ $ We charge you for our services in TOTAL TOTAL GUARANTEED *REDUIREt~PC~CHASES-Charges aze only fore o1slleeXe lain the reasons in writing below~uired. It we are requu~eu ~y law or by a cemetery or crematory to use any items, w P EXHIBIT 1 ABOVE AND THE PRENEED NDTfIONS OF THIS AGR~MENTIGNMENT ON THE TTTUTE THE TERMS AND CO REVERSE SIDE SHALL CONS C EPTA~IVCE ~Y• AGREEMENT AND ASSIGNMENT BY: f~/~~% (glg~tur~ f purchaser) ~s t (Date) / K~ ,t j ~ (Phone) (Address) . / ~ ~ ~ ~` /` (Zip) AGf{fEMENT AND A ~ ,~' ,. ~ ,~~r ' (glg~ture of P~OVi~r's Authorized Re tative) L ~ ! (Date) ~f ~ - ~`f /' Y( r i~" LF~Y~~ ~' ~(I i ly,~ I .' f : V ~~L~f• 11'~/. , J / ? (L,ocation) ui (Phoneme ~~ ; ~ (~P) (City, State) - (City, State) HOME SALES ONLY: You, the Buyer, may cancel this transaction at any tune prior to the third business day after e date of this transaction. See the attached Notice of Cancellation form for an explanation of this right. Rev 0310 P001-A ©HLC, 2010, All rights reserved. No use or reproduction wP oo>~~pr~~P ~ wider Copies: Original -Homesteaders Life Company; Canary - NON-GUARANTEED FUNERAL PRICE $,~,r~ ENROLLMENT FOR ~ 00 o ESTE~AD~ERS olW E50 OMPANY GROUP INSURANCE TO iiED INSURED (Pleas Last First esidence - No. and Street Sex Birthdate ( /Y) Age 't SS No. ~fr ~~~~~+ ~ ~rf ~,~ Ciry or Town State Zip Phone No. APPLICANT/OWNER (If Otherllian Proposed Insured) t~„d;l.~r1.~ ~~waer~,'rt~' ~rh"ll sAf.,~ ~- C.°.~.~.~~/.../i Last -' First ,.-, Initial J Ciry St-'`d ate Zip SS No. Relationship to~fnsured BENEFICIARY Relationship to Insured (After payment under any assignments, remaining proceeds are to be paid to the estate of the insured unless a beneficiary is specified above.) R ~ ~ SINGLE PAYMENT PLAN E ^ Certificate Face Amt. $ _ ~ Q ^ Rider Premium $ ~~~~ ~ E ^ MULTIPLE PAYMENT PLAN (The proposed insured must sign the S enrollment form to qualify for the Multiple Payment plan.) .~ Years Premium Face Amt. $ E Payable D Premium $ B DEATH BENEFITS ON THE MULTIPLE PAYMENT PLAN ARE LIMITED E AS FOLLOWS: . N Years Premium Pavable E Less than 5 years 1st Year = 50% of Face Amt. 2nd Year = Face Amt. F 5 years or greater 1st Year = 35% of Face Amt. I 2nd Year = 70% of Face Amt. T 3rd Year = Face Amt. S If death by accident during the limited period, the face amount is payable. Payment Method ^ Monthly If the insured does not sign the enrollment form, the initial face amount of the certificate will be equal to 1.005 times the premium paid for all issue ages. H the following questions are both answered "no," we may issue a certificate providing an immediate death benefit equal to the face amount. OPTIONAL HEALTH HISTORY (Multiple Payment Plans) 1. Is the insured now bedridden, or currently admitted to or been advised to enter a hospital, nursing home, hospice program, or any extended care facility; or been diagnosed as having or been treated for AIDS or ARC? ^ YES ^ NO 2. Within the past five years has the insured been diagnosed or treated for any of the following ailments? Heart Disease Liver Disease Alcohol Abuse Circulatory Disease Kidney Disease Drug Abuse Stroke Anemia Nervous Disorder Lung Disease Cancer ^ YES ^ NO Diabetes ^ Annually ^ Semiannually ^ Quarterly ^ Direct Bill ^ Preauthorized Collection (PAC-See Reverse) ^ Multiple Bill - (List other policies for PAC or MB) Dividends ^ Purchase Additional Insurance ^ Accumulate at Interest ^ Paid in Cash ^ Reduce Premium Replacement-Will the propped certificate replace any existing life insurance or annuity contracts? ^ Yes 9p No (If "Yes,"complete replacement papers) DECLARATIONS-To the best of my knowledge and belief, all statements and answers on this enrollment form are complete and true. It is agreed that no insurance shall take effect until the premium has been paid and a certificate has been issued while the insured is living. I certify, if I am applying for insurance on behalf of the insured, that I have an insurable interest in the pr osed ir~s_ylred's~ this enrolatmentlform. ~rity to use his/her funds as premiums on the insurance applied for. I have paid $ .o' ~:~/ ,~!~ .. ,~!~! f,7'd / ~ Date ~r~f ~ ~'' :.~? J~~ Signed at ~: ~'S 'j State (~ ~;~~r,~. ' 1 a,..,,~ , `~ ,City ~ (~a X1:1 ~,,.,,,; {-t..~ .~ k~ ~'~ tt =- ~~ ~~~-~ ~~-L-~- "" ~"'~ ~`~"' Si nature of Proposed Insured Signature of ApplicanUOwner (If other than Proposed Insured) g Agent's Statement: By my signature I certify that, to the best of my knowledge, all information contained in this enr Ilment form is correct, was` ecord~d accurately, and confirm this enrollment form was signed in my presence. ~; ~~~~ ~ ~ ~ ~~ ~~ ~ ~ _~-3_~7 Security Option ;~ ^ Advantage Option A ent's Signature Agent Number Prod. Code Mkt. Code Rev 0709 GP-201-PA Copies: White -Homesteaders; White -Homesteaders; Pink -Provider; Canary -Owner HOMESTEADERS LIFE COMPANY P.O. Box 1756 I Des Moines, IA 50306-7756 1800-477-3633 1. IRREVOCABLE ASSIGNMENT TO FUNERAL HOME/MORTUARY. The (Note: This form does not assign death/ benefits to,xhefuneral home) transfers, and delivers to ~~ ~ T r (Funeral Home/Mortuary) , ""'~-• .f :.l,,r,,,~ ownership rights under the policy/certificate insuring the life of `--' ~ ~ ' ~' (Insured Name) Said assignment shall be contingent upon the Funeral Home/Mortuary assigning ownership rights to the Trustees of the Funeral Assurance Trust in accordance with paragraph 2 below. I retain the right to change the beneficiary/assignee of the policy/certificate to the funeral home of my choice. Notwithstanding the foregoing, the undersigned shall retain physical custody of the policy/certificate of insurance. 1 UNDERSTAND THAT, BY ASSIGNING MY OWNERSHIP RIGHTS TO THE FUNERAL HOME/MORTUARY, I CANNOT SURRENDER MY POLICY/CERTIFICATE FOR THE CASH VALUE OR RECEIVE ANY REFUND FOR ANY PREMIUMS PAID AFTER THE 30 DAY RIGHT-TO-CANCEL PROVISION DESCRIBED IN THE POLICY/CERTIFICATE. ''~ L.~ ~~~ ~. y ,.~. ~ ... .; ~ is ~ `a _ , .~F ,, , -~ x ~ , w ~ a -~ -Y ._ Signature of Policy/Certificate Owner Date 2. IRREVOCABLE ASSIGNMENT TO TRUSTEES OF FUNERAL ASSURANCE TRUST. In accordance with paragraph 1 the undersigned hereby irrevocably assigns, above and as a representative of the Funeral Home/Mortuary listed above, transfers, and delivers to the Trustees of the Funeral Assurance Trust, as Nominee, th er wnersh'p A ghtsmunderathe April 1, 1995, (conformed copy of which appears on the reverse side hereof), policy/certificate insuring the life of the insured as specified above. This the undersi hneld. The underlsigned helreby be altered, amended, revoked, or terminated, in whole or in part, by g renounces for himself any interest, either vested or contingent, including any reversionary right or possibility of reverter in and to the policy/certificate assigned to Trustees, and any power to determine or control, by alteration, amendment, revocation, or termination, or otherwise, the beneficial ownership or control of the policy/certificate. ~`.. , , Signature of Funeral Home/Mortuary Represe_otative Date Policy/Certificate Number (to be filled in by Homesteaders Life Company) ACCEPTANCE. The Trustees of the Funeral Assurance Trust have agreed pursuant to the terms of said Trust to accept ownership of the policy/certificate assigned herein. The Trustee shall be deemed to have accepted this assignment upon receipt by said Trustees of a properly executed assignment in the Home Office of Homesteaders Life Company and upon issuance of the policy/certificate assigned hereunder. undersigned hereby irrevocably assigns, 1` ~:~~ =-'~ the 3/10 H245-FLEX mHLC, 2007, All rights reserved. No use or reproduction without express permission. Copies: Original -Homesteaders Life Company; Canary -Funeral Establishment; Pink -Policy Owner ,~< Hollinger Funeral Home & Crematory, Inc. Eric L. Hollinger, Supervisor December 8, 2010 Sven O. Jensen One plot in Crossroads Cemetery (2 graves) $200.00 * Perpetual care of cemetery (Donation) $100.00 Total Costs for Cemetery: $~~ Check Payable: Crossroads Cemetery Association: ($300.00) .Attention: Phillip Dodson (Caretaker) 51 4 Bowman Ave . Lewisberry, Pa. 17339 717-938-2772 501 NORTH BALTIMORE AVENUE • MOllNT H~wLhoSPRgerfune allhoSmecomIA 17065 • (717) 486-3433 • FAX (717) 486-3215 NOV-17-2010 13:51 LANDMARK COMM. REALTY 198 O~ ~oRx RoAn P. ~O.~x 19~ NEW Cu~iBE.RLA.N~, PA 17470-0~9? 717-~74-2150 ?1? 731 8?65 P.02 Sale o~ Lots $ 7, 000/per 9raye Cemetery Lots Many choice locations of four grave lots 1 erin device) Interment (Grave opening and backfill -- nv tent or ow 9 $1,000 Services Monday through Friday $1,000 plus $200/per hour Services Monday through Friday arriving after 3pm $1,250 Saturday morning service $1250 plus $250 per hour Saturday afternoon service Confer with Cemetery Staff Stillborn infant Cremated Remains Monday through Friday After 3 .pm Monday through Friday Saturday morning service (before noon) Saturday afternoon services (after noon) $750 (fee varies with con#ainer size) $7.50 plus $200 per hour $850 $850 plus $250 per hour $150 Deed Transfer ayment from interment is being paid by an individual, p payment terms: If the upcoming ment 1/estate must be issued to Mt. Olivet in the a homebs mak ng the pay1 the individua check. Personal checks will hock s acceptable 8 funera of for the interment, company c vial ermits must be given to Mt. Olivet Cemetery before or dunng the y Bu p interment. he winter months (November to April) the request for an opening of a grave During t ast 72 hours prior to the day of interment. Services during should be mad November to April are subject to increase pnc~ng. MT. -OLI~'ET CEbiETER~