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HomeMy WebLinkAbout03-1066 PETITION FOR PROBATE and GRANT OF LETTERS Estate of _ ~)~. ~t~ /[/]. d ~t_ lI/t· ~A No. t~/- tS~)~ ~/t~ ~ also_known s L]dgJQ. I~a~' ./~or'Te_ ~.[ej,[/e_j9 To: Register of Wills for the -- , Deceased. County of (~~t'//tZg/O~n the Social Security No...fflg~>- ~'/,,~ _ d t~ Q .... Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut t/~/~9~ named in the last will of the above decedent, dated f)~_e_~o__~ b ~./- l ~ ~ ~ , . ana codicil(s) dated - - /' _ . 19 (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent wa_s domiciled at death in ~ ~t .t?t ~,,,y ]~ q~ County, Pennsylvania wlt~ h e_..r" last family or principal residence at_ ' ' ' ...... (list street, number and muncipality) Decendent, then ,Z~f"~, years of a~e, died F~ ~ e~ ~ ~-r / ? t-9-~ ~ ~ at (~ ~ f ,~ ] ¥ g'l (~ r" ~ X -]-'~g k~ , ~"]d'_~ r, -]-~t-t0.~' Lgf~,p. ' " Excelan'as ~'oll~ws, de~edent'c~i~l ~c~t-ma~r3), ~s~ot ~ii~or~ed and did not have a child born or adoptec~ after execution of ~11 incompetent: ~ offered for probate; was not the victim of a killing and was never adjudicated Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: $ WHEREFORE, petitioner(s) respectfully presented herewith and the grant of letters. theron. request(s) the probate of the last will and .codicil(s) (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) >4,"M, ' P 19~ " Sworn to or affirmed and subscribed ~ae~ore me this ~ ~',4~ day of ~ ~-- ~£~,- ' ~~/ OATH OF' PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. r/ ~ ,>? : Estate Of ""~ r, r~ ~, vox_ Q .,-, \\~-~ _, Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW~ the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated !,-71--- I m ~D~-~_~ described therein be admitted to probate and filed of record as the last will of and Letters ~ are hereby granted to '~s~.~, in consideration of the petition on FEES Probate, Letters, Etc .......... $ S~orkCertificates( ) .......... $ I R~ntlnclatlon ................ $ 4oo~P s lO. TOTAL . Fil~-'.--~' '~' .... ~-~ '-~ ....... ATTORNEY (Sup. Ct, I.D. No.) ADDRESS PHONE v 9/,6 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 9817_091 No. cai Registrar Date Rev 2/87 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH ' ~!...___.E__xe.c. Coordinate i~_ ~=ue. ,'~ MA~UNG AOORESS (su~. c,~r ~ 171 Tory Circle ~r SEX SOCIAL SECURITY NUMBER OATE OF DEATH Moult1 Day Donn_~a Marie Cullen ~,.female L 208-- 42 -- 6067 ' Dece'mber',7 200 52 } I ! JJuly 9,1951J Harrisburg,Pa ]7~;~ ~m~,..~ ~ ]W~ ~  71_ Tot ~nola, Pt 17025 ~m .....~ ,~.~ Cumberland ~" Adam gartner~ - .~.o~.,~ , ew cumue land PA 1 IMMEDIATE CAUSE (F,nm ~ ~, ~ ~ ~le ~ DUE ~ INJURY AT WORK? ESCFUBE HOW INJURY OCCUR,RED. of I, Donna M. Cullen, of Enola, Cumberland County, Pennsylvania, being of lawful age, sound mind and memory, and under no restraint, do publish this as my Last Will, revoking all other Wills or Codicils previously made by me. FIRST: All expenses, fees and costs related to this estate shall be paid from the probate estate assets, including but not limited to funeral expenses, grave marker and the costs of my final illness. Inheritance, Estate and Fiduciary Taxes shall be apportioned to and paid from each probate estate asset distributed. SECOND: My house shall be sold and I give the proceeds from such sale, in equal portions, to my son~ Christopher E. Cullen and my daughter, Pamela M. Cullen. THIRD: I give my furniture, household and personal effects, and other tangible personalty of like nature, other than cash or securities, together with any existing insurance thereon, is as nearly equal shares as practicable, to my daughter, Pamela M. Cullen, and my mother, Thelma M. Gartner. This personal property subject to this gift shall be distributed in the sole discretion of my Executrix. FOURTH: I give, devise and bequeath the rest, residue and remainder of my estate, of every kind and nature, wherever situated, which I may own, or hereafter acquire, or have a right to dispose of at my death ("Residuary Estate") in equal portions to my daughter, Pamela M. Cullen, and my mother, Thelma M. Gartner. FIFTH: Any girl made herein to or for the benefit of my daughter, Pamela M. Cullen, I give devise and bequeath to my Trustees, hereinafter named, to be held in trust for that Pamela M. Cullen. The trust shall be administered as follows: (1) Special Needs. In making distributions of either principal or interest from this Trust, my Trustee is authorized to consider, in my Trustee's sole and absolute discretion, the reasonableness or advisability of making distributions in satisfaction of Pamela M. Cullen's special needs. As used in this instrument, "special needs" refers to the requisites for maintaining Pamela M. Cullen's good health, safety and welfare when, in the discretion of my Trustee, such requisites are not being provided by any governmental agency, office or department, non-profit organizations, or are not otherwise being provided by any other public or private source. While my Trustee is authorized to consider these other sources, and where appropriate and to the extent possible endeavor to maximize the collection of such benefits and to facilitate distribution of such benefits for the benefit of Pamela M. Cullen, my Trustee may also, in the exercise of my Trustee's discretion, disregard these other sources when making distributions to, or for the benefit of Pamela M. Cullen. Distributions may be made from the Trust Estate without securing prior Court approval. (2) Best Interest Standard. General distributions shall be based primarily on Pamela M. Cullen's best interest and in accordance with the terms of this Agreement. 293385-1 293385-1 (3) (4) (5) No Right to Direct Distribution. Pamela M. Cullen shall have no right to direct a distribution from this Trust to make any provision for her food, clothing and shelter or to direct a distribution from this Trust for any other purpose. Preference. Pamela M. Cullen is the preferred beneficiary and her interests shall be given priority over the interests of any Remainder Beneficiaries. Supplemental Fund. It is my intention that this Trust create a special and/or emergency fund for the benefit of Pamela M. Cullen and not to displace or supplant public assistance or other sources of support which may otherwise be available to Pamela M. Cullen. Pamela M. Cullen may have "special needs" such as medical, dental, ophthalmic, auditory care, psychological support services, supplemental nursing or physical therapy care, rehabilitation, medical procedures that are desirable, in the discretion of my Trustee, even though the procedures may not be necessary or life-saving, differentials in cost between housing and shelter for a shared or private room in an institutional setting, expenditures for travel and transportation, companionship, entertainment, cultural and educational experiences, bringing members of Pamela M. Cullen's family and other for visitation for her, and similar care which other assistance programs may not otherwise provide. It is my intent that assets held in this Trust are not for the Beneficiary's primary support. They are to supplement the Beneficiary's care only. My Trustee may retain the services of a Care Manager and the services of such providers as may be selected by Care Manager from a Primary Care Agency. This list is not meant to be exhaustive, but rather illustrative of the kind of special needs that this trust is designed to meet. My Trustee is authorized to consider these and any other requisites of Pamela M. Cullen when making distributions. It is important to me that Pamela M. Cullen maintain a level of human dignity and humane care. My Trustee should bear this in mind when making distributions from the Trust while simultaneously considering that the Trust is not to be invaded by creditors, subjected to any liens or encumbrances, or administered in such a way as to cause public benefits not to be initiated or to be terminated. To the extent reasonable or advisable, my Trustee may deplete the Trust corpus prior to Pamela M. Cullen's death, thereby giving preference to the interests of Pamela M. Cullen while simultaneously considering the interests of the Remainder Beneficiary(ies). In considering the interests of the Remainder Beneficiary(ies), my Trustee is admonished to refrain from distributing property of the Trust to or on behalf of Pamela M. Cullen which will then be retitled in the name of Pamela M. Cullen. My Trustee shall hold title to all property comprising the Trust even when that property is distributed to Pamela M. Cullen for her use. My Trustee may liquidate property of the Trust at any time. No part of the Trust shall be used to supplant or replace benefits due from any insurance carrier under any insurance policy covering Pamela M. Cullen. Prior to the death of Pamela M. Cullen, my Trustee shall give special consideration to paying any outstanding expenses of administration related to the Trust, including Page 2 of 4/~l~ reasonable attomeys' fees, and shall further consider purchase a reasonable burial plan/disposition of remains plan to pay expenses relating to the funeral and associated memorial expenses of Pamela M. Cullen. It is the intention that my Trustee provide income in-kind from this Trust, including in- kind support and maintenance, if such distributions are necessary in the sole and absolute discretion of my Trustees. (6) Emergency or Material Change of Circumstances. If there is an emergency or any other condition which my Trustee reasonably believes threatens the life, safety or security Pamela M. Cullen's security full-time, competitive employment and/or a significant change in Pamela M. Cullen's status, or in the laws or regulations affecting her), my Trustee has full and unrestricted discretion to administer this Trust so as to alleviate the condition and address the change of circumstances. In exercising the discretion granted under this Agreement, which is of prime importance in the administration of this Trust. By referring to remainder beneficiary(ies), I refer to Stanley E. Gartner, Thelma M. Gartner and Frederick A. Gartner, or those of the aforementioned who may survive the death of Pamela M. Cullen. Upon the death of Pamela M. Cullen, my Trustee shall distribute any remaining principal and interest of the trust, in equal shares, to the aforementioned remainder beneficiary(ies) that survive Pamela M. Cullen. (7) I appoint my mother, Thelma M. Gardner, Trustee of the trust created herein. In the event that she shall for any reason decline to serve, or fail to qualify for anyreason, I appoint my brother, Frederick A. Gartner, the Alternate or Successor Trustee. The Alternate or Successor Trustee shall have all of the same rights and obligations as set forth above as the rights and obligations of the Trustee. I direct that upon application, Trustees shall receive yearly, a reasonable fee commensurate with the services rendered relative to management and administration of any trust created herein. SIXTH: I nominate and appoint my mother, Thelma M. Gartner, and my brother, Frederick A. Gartner, Co-Executors of my Last Will, granting to them authority to sell and convey any or all of my estate, real and personal, or mixed, upon such terms and prices as they shall deem proper, without obtaining any prior order of the court therefore. I also grant them full power and authority in the settlement of my estate, to compromise, adjust, and settle any and all debts and liabilities due to or from my estate, for such sums, and upon such terms and Conditions as they shall deem best. In the event that either Thelma M. Gartner or Frederick A. Gartner shall for any reason decline to serve, or fail to qualify for any reason, or having qualified and been appointed, fail to complete the administration of my estate, then I nominate the other of them as the sole Executor(tflx) of my estate. SEVENTH: I direct that no bond or surety shall be required of any guardian, trustee, executor, administrator or fiduciary named herein. IN WITNESS WHEREOF, I .have hereunto subscribed my name, and acknowledge and pu¢ish this instrument as my Last Will in the presence of the undersigned witnesses, on this /.s: day /.~'d'~-~t'vtJ~'/?---. , 2003.dO) ~ LI. ~J? Donna M. Cullen 293385-1 Page3 of 4 ~ ~ DONNA M. CULLEN METZgER eWICKERSHAM e KNAUSS & ERB, P.C. ATTORNEYS AT LAW 3211 NORTH FRONT STREET P. O. Box 5300 HARRISBURG, PeNNSYlVANIa I 7 I I0-0300 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent · Date of Death · Will No.: 2003-01066 Donna M. Cullen December 17, 2003 Admin. No.: To the Register: I hereby certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on January 26, 2004 Name Christopher Cullen Pamela Cullen Stanely E. Gartner Frederick A. Gartner Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: Address 1308 Camphill Way; West Carrollton, OH 45449 730 Hillcrest Avenue, Room 109; Carlisle, OH 45005 163 Hickory Road; Dillsburg, PA 17019 84 Honeysuckle Drive; Mechanicsburg, PA 17055 None Date: January 26, 2004 Signature Name David H. Martineau, Esquire Address 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 __ Personal Representative X Counsel for Personal Representative Telephone Capacity: 296299-1 March 17, 2004 Ms. Glenda F. Strausbaug Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 '04 t~/if~ 19 ~2:06 SINCE 1888 3211 North Front Street EO. Box 5300 Harrisburg, PA 17110-0300 717-238-8187 Fax: 717-234-9478 Other Offices Colonial Park Mechanicsburg 717-652-7020 717-691-5577 Millersburg Shippensburg 717-692-5810 717-530-7515 Re.' Estate of Donna M. Cullen No. 2003-01066 PA No. 21-03-1066 Dear Ms. Strausbaug: Enclosed please find a check in the amount of $3,000.00 in pre-payment of the estate's Pennsylvania Inheritance Tax. So that I may know that this payment has been received, please time stamp the copy of this letter which is enclosed and return in to me in the self addressed, stamped envelope which I have provided. Thank you for your assistance in this matter. Very truly yours, METZGER, WICKERSHAM, KNAUSS & ERB, P.C. David H. Martineau Enclosures CC: Thelma M. Gartner, Co-Executor Frederick A. Gartner, Co-Executor 300881-1 James E Carl Edward E. Knauss, IV* Jered L. Hock Steven P. Miner Clark DeVere Milton Bemstein Bruce J. Warshawsky Francis J. Lafferty, IV David H. Martineau Andrew W. Norfleet Andrew C. Spears Young-Suh Koo * Board Certified in civil trial law and advocacy by the National Board of Trial Advocacy David H. Martineau, Esquire SINCE 1888 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 '04 M~R 19 ?'i2:06 Ms. Glenda/F~;~Strausbaug . Register o~illts~- ;~': · - Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 [ ,.' ~ t .2. + 3 -2. '.Z-2. I,,,llh,,llh,,,,,'tl,,il;,,ih,,il,,,hh,ll,l,h,l,I, , ~OMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE :: BUREAU OF INDIVIDUAL TAXES , DEPT, 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. REV-1162 EX(11-96) CD 0O3700 GARTNER THELMA M 55 KENSINGTON DRIVE CAMP HILL, PA 17011 f01d ESTATE INFORMATION: SSN: 208-42-6067 FILE NUMBER: 2103- 1066 DECEDENT NAME: CULLEN DONNA M DATE OF PAYMENT: 03/19/2004 POSTMARK DATE: 03/1 712004 COUNTY: CUMBERLAND DATE OF DEATH: 12/17/2003 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 ~3/000.00 REMARKS: TOTAL AMOUNT PAID: 93,000.00 SEAL CHECK//3784 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS The preceding instrument consisting of two pages was on the date thereof signed, published and declared by in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our nartaes as witnesses hereto. Commonwealth of Pennsylvania · · SS County of · I, Donna M. Cullen, the Testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will, that I signed it willingly and that I signed it as my bee and voluntary act for the purposes therein expressed. D°n~a~M.'Culle~ SW/~DRN or affirmed to and ~/J/e~e_~. _J~ ~ ,2003. Commonwealth of Pennsylvania County of Cumberland acknowledged before me by the above named Testatrix this /,~t day of Notary Public - N~i~af~mi~iu- ~,pires: _ Rita C. Anstead~ Notary Public ~ Hill Boro~ Cumberland Courtly / My Cbrllnlission Expires Apr. 18, 20d5 j ~,a~,~er. Pennsvlwm~ ~OCiat~ofl of Notaries We, the undersigned witnesses whose names appear above, being duly qualified according to law, do depose and say that we were present and saw Donna M. Cumberland, the Testatrix sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the heating and sight of the Testatrix signed the Will as witnesses and that to the best of our knowledge the Testatrix was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. S~qDz.c~RN or affirmed to and acknowledged before me by the above named Testatrix this /xJ day of .~x~-4~. ,2003. 293385-1 I Notadal Sea~ I Rita C. Anstead Notary Public I Ca_rap Hill Boro Cumberland County ~ My C0rnmission Eyplres Apr. 18, 2005 Member. Pennsvlvania Assoc~at~t,~l~,ltt~l~ Notary Public My commission expires: COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 r REV-1500 oFP,O,^.usE INHERITANCE TAX RETURN F,,E RESIDENT DECEDENT £ I - J. 0 DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NLIMBER CULLEN, DONNA M. 208-42-6067 DATE OF DEAl1-1 (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DMPUCATE wI'rH '~E 12-17-2003 07-09-1951 REGISTER OF WILLS F APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITtAL) SOCIAL SECURITY NUMBER [] 1. Original Return [] 4. Umiteq Estate [] 6, Decedent DieqTestate(A~d~copyolWill) [] 9. Litigation Proceeds Received [] 2. SupplementelRetum ] 4a. Fu[ure Intersat Compromise (da~e d d~h aler 12.12.&~) [] 7. DecedentMaintainedaLivingTrusl(.~=hcowo~T,~st) [] 10. Spousal Poverty Credit (dae~' deathbeiwee~ 12-31-91 and 1-1-95) N~E DAVID H. MARTINEAU [] 3. RemainderReturn{~ea'~p~a-to12.13-~) [] 5. Feda'al Estete T~ Return Required -- 8. Total Numba' of Safe Deposit Boxes [] 11. ElectiontetsxsaderSec. 9113(A)(^e~hs~o) FIRM NAME (If A~,lca~) METZGER WICKERSHAM TELEPHONE NUMBER (717) 238-8187 1. Re~ Estate (Schedule A) (1) 2. Slocks and Bonds (Schedule B) (2) 3. Closely Held Ca'porafion, Par~ership or Sale-Proprietorship (3) 4. Mortgages & Notes Ra:eivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personel Prope~ (5) (Schedule E) 6. JoinlJyOwned Properly(Schedule F) (6) [] Separate Billing Requost~KI 7. Intar-VNos Transfers & Miscellaneous Non-Predate Properb/ (7) (Schedule G or L) 8. T~ml G~3ss,Assets (total Lines I - 7) 9. Funeral F_xpeessa & AdminielratNe Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (t0) 11. Total Deductions {total Lines 9 & 10) 12, Ne~ Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental BequestsJsec 9113 Trusts for which an electwe to tsx has tel been made (Schedde J) 14. Ne{ Value Subject to T~x (Line 12 minus Line 13) COMPLETE MAILING ADDRESS 3211 NORTH FRONT STREET P.O. BOX 5300 IHARRISBURG, PA 17110-0300 133,500. 1,666. 42, 921. (S) 31,609.72 79,883.42 (11) (12) (13) (14) SEE INSTRUCTIONS FOR APPUCABLE RATES 15. Amour~t of Dne 14 taxable at the spousal tax rate, or Ea~sfers under Sec. 9116 (a)(12) × .0 (15) 16. Amosnt of Line 14 tsxable at lineal rate 66, 594 . 96. × .0 45 (16) 17. Amouet of Line 14 taxable at sibling rate x ,12 (17) 18. Amount of Line 14 taxable at cellaterel rate X .15 (18) 19. Tax Due (19) 20. [] I (:;HEC;~ IF YOU ~ ~i~UESTi~ D oF ONLY 178,088.10 111,493.14 66,594.96 66,594.96 ~ STF PA42021F.1 2, 996.77 2, 996.77 Decedent's Complete Address: ADDRESS 171 TROY CIRCLE C~Y ENOLA Tax Payments and Credits: 1. TaxDue(Page I Une 19) 2. Credits/Payments A. Spousal Povaty Credit B. Pdor Payments C. Discount 3,000.00 3. Intemsf/Penalty if applicable D. Interest E. Penalty 4. If Line 2 is greater than Line I + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page I Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the di~ronce. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BAL/INCE DUE. JsTATE PA I ZIP 17025 (1) 2,996.77 3,000.00 3.23 0.00 0.00 Total Credits (A + B + C) (2) Total InterestJPona~ (D + E) (3) (4) (5) (5A) (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLO~ING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decadont make a transfer and: Yes No a. retain the use or income of the property transferred; ........................................ [] [] b. retain the fight to designate who shall usa the prope~ transferred or its income; ................... [] [] c, retain a reversiona7 interest; or ....................................................... [] [] d. receive the promise for life of either payments, bonefits or care? ............................... [] [] 2, If deeth occurred alter December 12, 1982, did decadent transfer preperty within one year of death w thout rece v ng adequate cons derat on? .................................................. [] [] 3. Did decedent own an '~n trust fo~' or payable upon death bank account or security at his or her death? ..... [] [] 4. Did decadent own an Individual Retirement Ascount, annuity, or other non-prebate preperty which contains a beneficiary designation? ....................................................... [] [] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G ANB FILE IT AS PART OF THE RETURN, Under penallJas of perjuu, I declare that I have examined this refure, including accompanying schedules and statements, and to the best d my knowledge and belief, it is flue, correct and complete. Decleratioo d preparer atha' thas toe perseeal repr~entative is based on all information of which preparer has a~ krle~vledge. SIGNATU_~.. OF PERSON RF.~PONSIBLE..~FOR FILl N~'-lJ~- I ~RN / I'~ DATE PA 17011 ADDRESS c/o THELMA M. GARTNER, 55 KENSINGTON DRIVE, CAMP HILL, SIG NATU~[~(~RE PARE R ~-tE R ~ ~TAI]yE ADD 'R~ '~'' ~:~ "~ 3211 North Front Street, P.O. Box 5300, Harrisburg, PA 17110-0300 For dates of death on or after July 1, 1994 and before Jenua~y 1, 1995, the tax rate imposed on the nat value Of transfers to or for the use of the surviving spouse is 3% [12 P.S. {}9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the ststntor~ raduirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is th~ only beneficiary. For dates of death on or after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparsnt of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the dscedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decadent's siblings is 12% [72 P.S. §9116(a)(1.3)]. A sibling is definad, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. S7~: PA42021F.2 ~OMM~DNWEALTH OF PENNSYLVANIA RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX(11-96) HAR 2 2 200~ NO. CD 003700 il.GARTNER THELMA M : 55 KENSINGTON DRIVE CAMP HILL, PA 17011 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 ~3,000.00 ESTATE INFORMATION: SSN: 208-42-6067 'FILE NUMBER: 2103- 1 066 _DECEDENT NAME: CULLEN DONNA M DATE OF PAYMENT: 03/1 9/2004 F~OSTMARK DATE: 03/1 7/2004 :C. OUNTY: CUMBERLAND DATE OF DEATH: 12/17/2003 ! I~EMARKS: ~-~ SEAL CHECK# 3784 TOTAL AMOUNT PAID: INITIALS: JA RECEIVED BY: ~3,000.00 GLENDA FARNER STRASBAUGH REGISTER OF WILLS . TAXPAYER REV-1502 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX REFR~RN RESIDENT DECEDENT ESTATE OF CULLEN, DONNA M. SCHEDULEA REAL ESTATE FILE NUMBER All reel ~,,u~), owned solely or as & I...,,[ In ~,~dr ~,,. must be re~orted at fair mmfmt value. Fair market value is defined as the price at which property would be exchanged behYeen a willing buyer and a willing seller, nei~er being compelled to buy or set[, beth having reasonable kno~edge of the relevanl facts, Real properly which Is jointly-owned with right of suwivorshlp must be dlsct~asd on Sd~edoie F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 133,500. O0 171 TROY CIRCLE ENOLA, PA 17025 VALUE BASED ON SALE (SEE ATTACHED HUD-l) PRICE OF PROPERTY TOTAL (Also enter on line 1, Recapitulation) $ 133,500.00 (If more space is needed, inser'~ additional sheets of the same size) STF PA4202 ~ F.3 OMB NO., ~..' B. TYPE OF LOAN: U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 1.r-[FHA 2.~--[FmHA 3. E]CONV. UNINS. 4.~]VA 6. FILE NUMBER: J 7. LOAN NUMBER: SETTLEMENT STATEMENT 04077J 2004001297 8. MORTGAGE INS CASE NUMBER: 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 "[POC]" were paid outside the closing; they are shown here for informational purposes and are not included in th~totals. l.o :~e (o4077e4o~?q3) D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F, NAME AND ADDRESS OF LENDER: Brett E. Walden Estate of Donna M, Cullen Gateway Funding Diversified Mortgage Services 300 Welsh Road Horsham, PA 19044 G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 25-1878915 L SETTLEMENT DATE: 171 Tory Circle Keystone Land Transfer, Ltd. Enola, PA 17025 March 22. 2004 Cumberland County. Pennsylvania PLACE OF SETTLEMENT 3421 Market Street Camp Hill, PA 17011 I 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 120. GROSS AMOUNT DUE FROM BORROWER 143,220.24 420. GROSS AMOUNT DUE TO SELLER 134,166.56 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to 204. 504. P, ayolf o, t,rst Mo,"~gage ,o Sovereign BanI,J~01,6,8 207. 507, (Deposit dish. as proceeds) 209. Closing Costs By Seller 4.500.00 509. Closing Costs By Seller . f~ 500.00 Ad/ustments For Items Unpaid By Seller Adjustments For Items Unpaid By Seller 70.. L. SETTLEMENT CHARGES OTAL COMMISSIO, N Based on Price ~ $ @ % 7,740.00 lulvrslon at (Jornmtsston (line/uu) as ~-OllOWS: 800. ITEMS PAYABLE IN CONNECTION WtTH LOAN SE~rLEMEI~T SETTLEMENT = PAID FROM PAID FROM BORROWER'S SELLER'S FUNDS ATI FUNDS AT u.uuI - 801. Loan uriglnabon Pea U.OO0U % to 802. Loan Discount % to UUU. Mortgage Ins. App, Fee 1~5.0£ 901.1nterest From 03/22/04 to 04/01/04 @ $ 22.196000/day ( 10days 9{)z. Mortgage Insurance ;-'mmlumtor months to'oateway I-una~ng ulversmee Mortgage services 19' Hazard Insurance Premium tar 1.0 years toAdvances Insurance 9051 1000. RESERVES DEPOSITED WITH LENDER %) 2;21.96 POC $219.00b 4'4JJU'UU 1001. Hazard Insurance 1002. Mortgage Insurance 1003. Ci~y/lown Taxes 1004. County Taxes 1007. 1008. Aggregate Adjustment t 100. TITLE CHARGES 1101. Settlement or Closing Fee 1102. Abstract or Title Search 4.000 months months months 3.000 months 11.000 months monms months mantles 23.33 per month per month per month 30.24 per month 112.70 per month per month per monlh per month 93.32 ~0.72 1,24.0.30 -4~)3.93 1103. Title ExaminaUon 1104. Title Insurance Binder 1105. Document Preparation 1106. Notary Fees CASH 1,0~13.7~ 12.o~ 1107. Altomey's Fees to (inclu(le$ above item numbers: .......... ' ......... lo Keystone Land Transter, Ltd. REV-1F~3 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTA1E OF CULLEN, DONNA M. SCHEDULE B STOCKS & BONDS FILE NUMBER NI pmpegty jointly-owned with the right of suwlvorship must be dlsdosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL (Also enter on line 2, Recapitulation) i (If more space is needed, inse~ additional sheets of the same size) STF PA42021F 4 REV-1504 EX + (1-97) (I) SCHEDULE C CO..O,W~LTU OF P~..$~.W~ CLOSELY-HELD CORPORATION, INHERITANCE TAX RETURN RESIDENT DECEDENT PARTNERSHIP or SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER CULLEN, DONNA M. Schedule C-1 or C-2 (bduding all suppeCdng informalJoo) mst be atlached for each dossty-held cot porati~n/par tnership interest of the decedent, other than a ,sole-proprietorship. See im for the supporting information to be submilted for sde-pro~iaorships. ITEM NUMBER DESCRIPTION TOTAL (Also enter on line 3, Racapitulation) VALUE AT DATE OF DEATH s73:PA42021F.5 (If more space is needed, insect additional sheets of the same size) REV-1505 EX + (1-97) (I) COMMONWEALTH OF PEN NSYt.VN~IIA INHERITANCE TAX RETURN RESIDENT DEC~DENT ESTATE OF CULLEN, DONNA M. SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT FILE NUMBER 1. Name of Corporation Address City State Zip Code 2. Federal Employer I.D, Number 3. Type of Business Produat/Senrice State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Vo~ng / Non-YoUng SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Preferred $ Provide all dghts and restrictions pertaining to each class of stock. 5. Wes the decedent employed by the Corporation? If yes, Position 6. Was the Coq)oration indebted to the decedent? If yea, provide amount of indebtedness $ 7. ~Yea []No Annuel Salary $ E~]Yes E~No Time Devoted to Business Was there life insurance payable to the onrporation upon the death of the decedent? [] Yes [] No If yes, Cash Surrender Value $ Nat proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31.827 []Yes [~]NO If yes, [~]Transfer ~]Sele NumherofSheres Transferee or Purchaser Consideration $ Date Altach a separate sheet f~' additioeal ~'ansfers and/or sales. 9. Was there a wdttea shareholder's agreement in elfant at the time of the decedent's death? [] Yea [] No If yes, provide a copy of the agrsement. 10. Wes the decedect's stock sold? [] Yes [] No If yes, provide a copy of the agreement of sale, etc. 11. Wes the corporsfion dissolved or liquidated after the decedent's death? [] Yes [] No If yes, provide a breakdown of distributions rec~ved by the estate, including dates and amounts received, 12, Did the coq)oration have an interest in other corporations o,' partnerships? [] Yes [] No If yes, report the nanessery information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Datailed calculations used in the valuation of the danedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete sddrese/es and estimated feJr market value/s, If real estate abpraisals have been secured, attach copies. D. List of pdecipal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other bane~ts received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. STF PA4202 IF.6 REV-ISa6 EX + (1-97) (I) C..C~MONW~5~LTH OF PENNSYLVANIA INHERITANC~ TAX RETURN RESlO~NT DECEDENT ESTATE OF CULLEN, DONNA M. SCHEDULE C-2 PN I'NERSHIP INFORMATION REPOET I FILE NUMBER 1. Name of Pattnerehip Address 2. Federal Employer i.D. Number State Zip Code Date Business Comreenced Business Reporting Year 3. Type of Business Product/Sen/ice 4. Decedent wes a [] General [] Limited partner. If decedent was a limited partner, provide initial investment $ _ PERCENT OF PERCENT OF BALANCE Of PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Patnership indebted to the decedent?. [] Yes [] No If yes, provide amount of indebtedness $ 8. Wes there life insurance payable to the partnership upon the death of the desedent?. [] Yes If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy [] No 9. Did the decedent sell or transfer an interest in this partnership within one year pdor to death or within two years if the date of death wes pdor to 12-31-827 [] Yes [] No If yes, []Transfer [] Sale Percentage transferred/sold Transferee or Purchase' Consideration $ Date Altech a separae sheet for additional l~aesfers and/or sales. 10, Wes there a written partnership agreement in effect at the time of the decedant's death? [] Yes [] No if yes, provide a copy of the agreement. 11. Wes the desedent's p~nerehip interest sold? []Yes [] No If yes, provide a copy of the agreement of sale, etc. 12. Was the pattnership dissolved or liquidated after the decedent's death? [] Yes [] No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the d~cedent related to any of the partners? [] Yes [] No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships?[] Yes [] No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest, ~ORMATION MU ~HEDU~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraissts have been secured, attach cpaies. D. Any other information relating to the valuation of the denedect's partnership interest. STFPA42021F.7 REV-1507 EX * (1-97) (I) SCHEDULE D I ~.C~W~T, OF.E..S~VAN~ MORTGAGES & NOTES INHERITANCE TAX RETU~ .~s,oE.T OEC~T RECEIVABLE ESTATE OF FILE NUMBER CULLEN, DONNA M. All pmpelty Jointly-owned with the right of suwlvorshlp must be dlsclmed on Schedule £ ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CULLENt DONNA M. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER Include the proceeds o~ litJgalk~ and the date the proceeds wsre received by the es'tale. All propon~ Jointly-owned with the right of suwlvorshlp must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 2. 3. 4. FURNITURE AND MISC. PERSONALTY OF DECEDENT PRORATED COUNTY PROPERTY TAX FROM SALE OF 171 TROY CIRCLE, ENOLA, PA PRORATED SCHOOL PROPERTY TAX FROM SALE OF 171 TROY CIRCLE, ENOLA, PA PROTATED SEWER / REFUSE BILL FROM SALE OF 171 TROY CIRCLE, ENOLA, PA 1,000.00 282.61 373.40 10.55 TOTAL (Also snter on line 5, Reeapitulation) $ 1, 6 6 6.5 6 (If more space is needed, insert additional sheets of the same size) REV-1509 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CULLEN, DONNA M. SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER If an ass~ was made Joint within one year (~ the decedents date of death, It must be repealed off Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A.THELMA M. GARTNER MOTHER 55 KENSINGTON DRIVE CAMP HILL, PA 17011 JOiNTLY-OWNED PROPERTY: 1. A. CHECKING ACCOUNT 19,771.38 50 9,885.6~ COMMERCE BANK 100 SENATE AVENUE CAMP HILL, PA 17011 ACCOUNT #0082004763 Accrued Interest 0.38 50 0.1~ 2. A SAVINGS ACCOUNT 66,046.62 50 33,023.3] COMMERCE BANK 100 SENATE AVENUE CAMP HILL, PA 17011 ACCOUNT #0480003166 Accrued Interest 24.70 50 12.35 ~T~(AI~ ~ronline6, R~apitul~iON) $ 42,921.54 S~: PA42021F.10 (If more space is needed, insert additional sheets of the same size) Commerce DONNA M CULLEN 171 TORY CIRCLE ENOLA, PA 17025 Commerce Bank/Harrisburg N.A. 100 Senate Avenue Camp Hill; PA 17011 888-937-0004 20 CYCLE-022 ***'CHECKING *** 50 PLUS CLUB BEGINNING RATE 0.15000 ACCOUNT NUMBER 0082004763 PREVIOUS STATEMENT BALANCE AS OF 12/10/03 ....................... 1,771.38 PLUS 4 DEPOSITS AND OTHER CREDITS ................... 19,608.63 LESS 21 CHECKS AND OTHER DEBITS ...................... 15,870.78 CURRENT STATEMENT BALANCE AS OF 01/14/04 ......................... 5,509.23 NUMBER OF DAyS IN THIS STATEMENT PERIOD 35 *** CHECK TRANSACTIONS *** SERIAL DATE AMOUNT SERIAL DATE 422 12/26 594.52 3180 12/23 424* 12/26 289.69 r// 3481' 01/02 425 01/05 17.14 ~/ ~ 3482· 01/07 448* 01/05 720.00~'// 3483 01/07 3173' 12/18 55.00~// 3484 01/13 3174 12/23 28.06'~'; j 3485 01/08 3175 12/29 33.55~'"~./~ 3486 01/08 3177' 12/22 600.00~,"~...~/ 3488* 01/09 3178 12/19 29.13// 3489 01/12 3179 12/19 39.64 .~' 3490 01/14 AMOUNT 870.00 8,751.00 340. oo 378. O0 1,959.21,~/ 278.44 43.99 ~;. oo *** CHECKING ACCOUNT TRANSACTIONS *** DATE DESCRIPTION 12/1S DEPOSIT 12/23 AC-UNUM OF AMERICA -LTD-BEN 12/31 DEPOSIT 01/05 AC-AARP HEALTH CA~E-PREMIUM 01/14 INTEREST PAYMENT DEBITS CREDITS j 18,ooo.oo ~.~ 1,106.75 104.7~s 500.00 .... ,,. 1.88 *** BALANCE BY DATE *** 12/10 1,771.38 12/15 '19,771.38 12/18 19,716.38 12/19 12/22 19,047~6I ~2/23 I9~256.30 I2/26 - 1W, 372:09 12/2~ 12/31 18,838.54 01/02 10,087.54 01/05 9,245.65 01/07 01/08 8,117.86 01/09 7,606.55 01/12 7,562.56 01/13 01/14 5,509.23 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE 23-2324730 1.88 19,647.61 8,527,65 5,603.35 *** INTEREST EARNED THIS STATEMENT PERIOD *** DAYS IN PERIOD ......................... 35 INTEREST EARNED ........................ 1.88 ANNUAL PERCENTAGE YIELD EARNED (APZ) .... 0.15% NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION Member FDIC DONNA M CULLEN THELMAM GARTNER 171 TORY CIRCLE ENOLA, PA 17025 Commerce Bank/Harrisburg N.A. 100 Senate Avenue Camp Hill, PA 17011 888-937-0004 12/31/03 0480003166] ACCOUNT NO. CYCLE-052 *** SAVINGS *** PREMIER SAVINGS BEGINNING RATE 0.99500 ACCOUNT NUMBER 0480003166 PP~EVIOUS STATEMENT BALANCE AS OF 11/30/03 ........................ 41,123.58 PLUS 2 DEPOSITS AND OTHER CREDITS ................... 43,218.09 LESS 2 WITHDRAWALS AND OTHER DEBITS ................ 18,250.00 C%rRP, ENT STATEMENT BALANCE AS OF 12/31/03 ......................... 66,091.67 NUMBER OF DAYS IN THIS STATEMENT PERIOD 31 *** SAVINGS ACCOUNT TRANSACTIONS *** DATE DESCRIPTION 12/04 WITHDRAWAL 12/15 WITHDRAWAL 12/16 DEPOSIT 12/31 INTEREST PAYMENT DEBITS CREDITS *** BALANCE BY DATE *** 11/30 41,123.58 12/04 40,873.58 12/15 22,873.58 12/16 66,046.62 12/31 66,091.67 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE 23-2324730 470.11 *** INTEREST EARNED THiS STATEMENT PERIOD *** DAYS IN PERIOD ......................... 31 INTEREST EARNED ........................ 45.05 ANNUAL PERCENTAGE YIELD EARRED (APy) .... 1.00% REV-1510 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CULLEN, DONNA M. SCHEDULE G INTER-VIVOS TRANSFERS & UISC. NON.PROBATE PROPERTY FILE NUMBER This schedule must be completed and filed ii the answer to any d qusef~ons 1 through 4 on the reverse side d the REV-1500 COVER SHEET is y~s. DESCRIPTION OF PROPERTY % OF ITEM INCLLOE ~ t~E OF ~ 3RN~SFEREE, T~IR RELA~]ONSH P TO DEC~DENT AND ~I-~ DATE DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER OF TRANSFER. ATTACH A COPY OF 'D'E DEED FOR REAL E$TATE~ VALUE OF ASSET INTEREST (IF AF~_ICAJ~_E) 1. 1990 OLDSMOBILE REGENCY 2,357.00 100 2,357 0.0£ Value based upon NADA Guide, Average Retail Value. TOTAL (Also enter on tine 7, Recapitulation)$ 0.0 0 (If more space is needed, insert additional sheets of the same size) S~3= PA42021F.11 · Build and Price aNew Car - NADAguides.com Page 1 of 2 Close Window I WPrint 4-Door Sedan 1990 Oldsmobile Ninety-Eight Regency Sedan 4D Base Price Low Retail Average Retail High Retail $1,325 $2,225 $2,925 Mileage 65,000 miles $132 $132 $132 TOTAL $1,457 $2,357 $3,057 Other Vehicle Information Model Number: CX5 Weight: 3325 The free consumer values on NADAguides.com are based on the Consumer edition of the N.A.D.A. Official Used Car Guide ®, and should not be utilized for industry purposes. The consumer values may vary from the N.A.D.A. Official Used Car Guide values presented to you by insurance companies, banks, credit unions, government agencies and car dealers due to vehicle condition, regional market differences and fi-equency ~£updates Low Retail Value A low retail vehicle may have extensively visible wear and tear. The body may have dents and other blemishes. The buyer can expect to invest in bodywork and/or mechanical work. It is likely that the seats and carpets will have visible wear. The vehicle should be able to pass local inspection standards and be in safe running condition. Low retail vehicles usually are not found on dealer lots. Average Retail Value An average retail vehicle should be clean and without glaring defects. Tires and glass should be in good condition. The paint should match and have a good finish. The interior should have wear in relation to the age of the vehicle. Carpet and seat upholstery should be clean, and all http://www.nadaguides`c~m/uv/viewresu~ts.aspx?L~=~-~~-~-2~32-~-~-~&wSec=~~&wPr... 07/19/2004 EV-1511 EX + (1-97') (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CULLEN, DONNA M. SCHEDULE H FUNERALEXPENSES & ADMINISTRA VECOSTS FILE NUMBER D~ of decedent mu~ be repeded on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT 2. 3. 4. 5. 5. 6. 7. 8. FUNERAL EXPENSES: ROLLING GREEN (GRAVE OPENING) FUNERAL LUNCHEON GINGRICH MEMORIALS PARTHEMORE FUNERAL HOME PARTHEMORE FUNERAL HOME (OBITUARY NOTICE) ADMINISTRATIVE COSTS: Personal Repmsentadve's Commissions NameofPersoealRepreaentative{s) FREDERICK A. Social Security Number(s) / EIN Number of Personal Repreaentativ~(s} SlreatAddreas 84 HONEYSUCKLE DRIVE GARTNER 179-44-7985 City MECHA.N I C S BURG State PA Year(s) CommissJea Paid: 2 0 0 4 Attorney Fees Family Exemption: (if decadegt's address is ne{ the same as claimant's, attach explanation) Claimant Zip17055 Sffeat Address City State Relationship of Claimant to Decadent Probate Fees Accoun~eat's Fees Tax Return Pmparer's Fees ADDITIONAL SHORT CERTIFICATES SETTLEMENT CHARGES FROM SALE OF HOUSE (SEE ATTACHED HUD-1 FOR DETAILS) Zip. TOTAL (Also enter on line 9, Recapitulation) 870.00 289.69 720.00 8,751.00 122.10 1,500.00 5,000.00 272.00 18.00 14,066.93 $ 31,609.72 (If more space is needed, insert additional sheets of the same size) s~: PA42021F.12 REV-1512 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CULLEN, DONNA M. SCHEDULEI DEBTS OFDECEDEN MORTGAGE LIABILITIES,& LIENS FILE NUMBER Indude unr~mb~:l medical expense~. ITEM NUMBER 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. DESCRIPTION BOSCOV'S - CREDIT CARD DEBT OF DECEDENT COBRA - HEALTH INSURANCE DISCOVER - CREDIT CARD DEBT OF DECEDENT EAST PENSBORO TOWNSHIP - SEWER / TRASH BILL HOLY SPIRIT HOSPITAL PP&L - UTILITY BILL OF DECEDENT PA AMERICAN WATER - UTILITY BILL OF DECEDENT PULMINARY AND CRITICAL CARE SOVERIGN BkNK, MORTGAGE LOAN NO. 0176786651 UGI UTILITY BILL OF DECEDENT VERIZON - UTILITY BILL OF DECEDENT WEST SHORE EMS-BLS TOTAL (Also enter on line 10, Recapitulation) (if more space is needed, insert additional sheets of the same size) S37:PA42021 F.13 AMOUNT 1,959 21 278 44 594 52 96 00 54 06 183 74 29 01 10 00 76,003 81 151.80 11.52 511.31 $ 79,883.42 SCHEDULE J P N.S LV .,A BENEFICIARIES INHERITN'~CE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER CULLEN DONNA M. RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Ust Trustee(s[ OF ESTATE 3 o TAXABLE DISTRIBUTIONS [include outright spousal disMbutJons, and tmnsf~s under Sec. 9116 (a) (1.2)] CHRISTOPHER E. CULLEN 1308 CAMPHILL WAY WEST CARROLLTON, OH 45449 PAMELA CULLEN 730 HILLCREST AVENUE, ROOM 109 CARLISLE, OH 45005 THELMA M. GARTNER 55 KENSINGTON DRIVE CAMP HILL, PA 17011 SON DAUGHTER MOTHER 1/2 OF REALTY 1/2 OF REALTY 1/2 PERSONALTY ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTN. OF PN~T II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, inse~ additional sheets of the same size) REV-1514 EX + (1-97) (I) ESTATE OF CULLEN, DONNA M. SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTNN (Check Box 4 on Rev-1500 Cover Sheet) FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. [~Will r--Ilntervivos Deed ofTrust r--IOther NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE I--]Life or [~Term of Years __ [] Life or [] Te~ of Years [] Life or [] Term of Years __ r-]Life or [~Ta'rn of Years __ 1. Value of fund from which life estate is payable $ 2. Actuarial factor per appropriate table Interest table rate - []3 1/2% I'-I 6% [] 10% [] Vadable Rate % 3. Value of life estate (Line I multiplied by Line 2) $ NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE [] Life or [~Te~rn of Years __ I--~Life or [~Term of Years __ []Life or []Term of Years __ []Lifeor [~Term of Years __ 1. Value of fund from which annuity is payable 2. Check appropriate block below and enter corresponding (number) Frequency of payout- [] Weekly (52) [] Bi-weekly (26) [] Monthly (12) [] Quarterly (4) [] Semi-annually (2) [] Annually (1) [] Other ( ) 3. Amount of payout per period $ 4. Aggregate annual payment, Line 2 multiplied by Line 3 5. Annuity Factor (see instructions) Interest table rate []3 1/2% []6% [] 10% []Variable Rate % 6. Adjustment Factor (see instructions) 7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of pedod, calculation is: Line 4 x Line 5 x Line 6 $ If using variable rate and pedod payout is at beginning of pedod, calculation is: (Line4 x Line5 x Line 6) + Line3 $ NOTE: The values of the funds which create the above future interests must be repoded as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16 and 17. (If mom space is needed, insert additional sheets of the same size) STF PA42021F.15 REV-1647 EX + (9-00) COMMONWEALTH OF PENNSYI.VANJA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CULLEN, DONNA M. SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on Rev-1500 Cover Sheet) FILE NUMBER This schedule is appropriate only for estates of decedents dying after December 12, 1982. This scheduta is to be used for all future interests where lhe rata of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicata below the type of inslrument which created the futura interest and attach a copy to the tax retum. []Will [-ITmst I-]Other Beneficiaries AGE TO NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY 1. 2. 3. 4. 5. II For decedents dyfng on or after July 1, 1994, if a su~,i~4ng spouse exerdsed or intends to exerdse a right of withdrawal whhin 9 months of the deeedent's death, check the appmpriata block and attach a copy of the document in which the surviving spouse exerdses such withdrawal right. [] Unlimited rightofwithdrawal [] Limited right of withdrawal lB Explanation of Compromise Offer: Summary of Compromise Offer: 1. Amount of Futura Interest .................................................................... $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ........... $ 3. Value of Line 1 passing to spouse at appropriate tax rate CheckOne []6%, []3%, []0% .......................... $ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One [-~6%, [~]4.5% ................................. $ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 Taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ........... $ 6. Value of Line 1 Taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ........... $ 7. motal value of Futura Interest (sum of Lines 2 thru 6 must equal Line 1) ................................ $ (If mom space is needed, insert additional sheets of the same size) STF PA42021 F.16 REV*1649 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CULLEN, DONNA M. SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) FILE NUMBER Do not complete this schedule unless the estate is making the election to tax assets under Section 91t3 (A) of the Inheritance & Estate Tax Act. If the dentJon applies to more than one trust or similar arrangement, a separate form must he filed for each trust. This etaclion applies to the Trust (marital, residual A, B, By-pase, Unified Credit, etc.). If a trust or similar amangemest meets the requirements of Section 9113 (A), and: a. The trust or similar arrangement is listed on Schedule O, and b. The value of the trust or similar arrangement is entered in whole ar in part as an asset on Schedule O, then the transferors personal representative may specifically identi~' the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar pmpely treated as a taxable transfer in this estate. If less than the entire value of the trust or similar propely is included as a taxable transfer on Schedule O, the pemonal representative shall be considered to have mede the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. Part A Total $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. Part B Total $ (If more space is needed, insert additional sheets of the same s~ze) STF PA42021F.17 I, Donna M. Cullen, of Enola, Cumberland CoUnty, Pennuylvania, being of lawful age, sound mind and memory, and under no restraint, do publish this as my Last Will, revoking all other Wills or Codicils previously made by me. FIRST: All expenses, fees and costs related to this estate shall be paid fi:om the probate estate assets, including but not limited to funeral expenses, grave marker and the costs of my final illness. Inheritance, Estate and Fiduciary Taxes shall be apportioned to and paid from each probate estate asset distributed. SECOND: My house shall be sold and I give the proceeds from such sale, in equal portions, to my son, Christopher E. Cullen and my daughter, Pamela M. Cullen. THIRD: I give my furniture, household and personal effects, and other tangible personalty of like nature, other than cash or securities, together with any existing insurance thereon, is as nearly equal shares as practicable, to my daughter, Pamela M. Cullen, and my mother, Thelma M. Gartner. This personal property subject to this gift shall be distributed in the sole discretion of my Executrix. FOURTH: I give, devise and bequeath the rest, residue and remainder of my estate, of every kind and nature, whcrever situated, which I may own, or hereafter acquire, or have a right to dispose of at my death ( es~duary Estate ') in equal portions to my daughter, Pamela M. Cullen, and my mother, Thelma M. Gartner. FWIIt: Any girl made herein to or for the benefit of my daughter, Pamela M. Cullen, I give devise and bequeath to my Trustees, hereinafter named, to be held in trust for that Pamela M. Cullen. The trust shall be administered as follows: (1) ~. In making distributions of either principal or interest fi:om this Trust, my Trustee is authorized to consider, in my Tmstee's sole and absolute discretion, the reasonableness or advisability of making distributions in satisfaction of Pamela M. Cullen's special needs. As used in this instrument, "special needs" refers to the requisites for maintaining Pamela M. Cullen's good health, safety and welfare when, in the discretion of my Trustee, such requisites are not being provided by any governmental agency, office or department, non-profit organizations, or are not otherwise being provided by any other public or private source. While my Trustee is authorized to eousider these other sources, and where appropriate and to the extent possible endeavor to maximize the collection of such benefits and to facilitate distribution of such benefits for the benefit of Pamela M. Cullen, my Trustee may also, in the exercise of my Tmstee's discretion, disregard these other sources when making distributions to, or for the benefit of Pamela M. Cullen. Distributions may be made from the Trust Estate without securing prior Court approval. (2) Best Interest Standard. General distributions shall be based primarily on Pamela M. Cullen's best interest andin accordance with the terms of this Agreement. 29538~d (3) (4) (5) No Right to Direct Distribution. Pamela M. Cullen' shall have no right to direct a distribution from this Trust to make any provision for her food, clothing and shelter or to direct a distribution from this Trust for any other purpose. Preference. Pamela M. Cullen is the preferred beneficiary and her interests shall be given priority over the interests of any Remainder Beneficiaries. Supplamental Fund. It is my intention that this Trust create a special and/or emergency fund for the benefit of Pamela M. Cullen and not to displace or supplant public assistance or other sources of support which may otherwise be available to Pamela M. Cullen. Pamela M. Cullen may have "special needs" such as medical, dental, ophthalmic, auditory care, psychological support services, supplemental nursing or physical therapy care, rehabilitation, medical procedures that are desirable, in the discretion of my Trustee, even though the procedures may not be necessary or life-saving, differentials in cost between housing and shelter for a shared or private room in an institutional setting, expenditures for travel and transportation, companionship, entertainment, cultural and educational experiences, bringing members of Pamela M. Culien's family and other for visitation for her, and similar care which other assistance programs may not otherwise provide. It is my intent that assets held in this Trust are not for the Beneficiary's primary support. They are to supplement the Beneficiary's care only. My Trustee may retain the services cfa Care Manager and the services of such providers as may be selected by Care Manager from a Primary Care Agency. This list is not meant to be exhaustive, but rather illustrative of the kind of special needs that this trust is designed to meet. My Trustee is authorized to consider these and any other requisites of Pamela M. Cullen when making distributions. It is important to me that Pamela M. Oullen maintain a level of human dignity and humane care. My Trustee abonld bear this in mind when making distributions from the Trust while simultaneously considering that the Trust is not to be invaded by creditors, subjected to any liens or encumbrances, or administered in such a way as to cause public benefits not to be initiated or to be terminated. To the extent reasonable or advisable, my Trustee may deplete the Trust corpus prior to Pamela M. Cullen's death, thereby giving preference to the interests of Pamela M. Cullen while simultaneously considering the interests of the Remainder Beneficiary(ies). In considering the interests of the Remainder Beneficiary(les), my Trustee is admonished to refrain from distributing property of the Trust to or on behalf of Pamela M. Cullen which will then be retitled in the name of Pamela M. Cullon. My Trustee shall hold title to all property comprising the Trust even when that property is distributed to Pamela M. Cullen for her use. My Trustee may liquidate property of the Trust at any time. No part of the Trust shall be used to supplant or replace benefits due from any insurance carder under any insurance policy covering Pamela M. Cullen. Prior to the death of Pamela M. Cullen, my Trustee shall give special consideration to paying any outstanding expenses of administration related to the Trust, including P,~2 of 4 ~})T/q~-2 reasonable attorneys' fees, and shall further consider purchase a reasonable burial plan/disposition of remains plan to pay expenses'reining to the funeral and associated memorial expenses of Pamela M. Cnilen. It is the intention that my Trustee provide income in-kind fi.om this Trust, including in- kind suppor~ and maintenance, if such distributions are necessary in the sole and absolute discretion of my Trustees. Emergency or Material Change of C~eumstanees. If there is an emergency or any other condition which my Trustee reasonably believes threatens the life, safety or security Pamela M. Cullen's security full-time, competitive employment and/or a significant change in Pamela M. Cullen's status, or in the laws or regulations affecting her), my Trustee has full and unrestricted discretion to administer this Trust so as to alleviate the condition and address the change of circumstances. In exercising the discretion granted under this Agreement, which is of prime importance in the administration of this Trust. By referring to remainder beneficiary(ies), I refer to Stanley E. Gartner, Thelma M. Gartner and Frederick A. Gather, or those of the aforementioned who may survive the death of Pamela M. Cullen. Upon the death of Pamela M. Cullan, my Trustee shall distribute any remaining principal and interest of the trust, in equal shares, to the aforementioned remainder beneficiary(les) that survive Pamela M. Cullen. (7) I appoint my mother, Thelma M. Gardner, Trustee of the trust created herein. In the event that she shall for any reason decline to serve, or fail to qualify for any reason, I appoint my brother, Frederick A. Gartner, the Alternate or Successor Trustee. The Alternate or Successor Trustee shall have all of the same rights and obligations as set forth above as the rights and obligations of the Trustee. I direct that upon application, Trustees shall receive yearly, a reasonable fee commensurate with the services rendered relative to management and administration of any trust created herein. SIXTH: I nominate and appoint my mother, Theima M. Gartner, and my brother, Frederick A. Gartner, Co-Executors of my Last Will, granting to them authority to sell and convey any or all of my estate, real and personal, or mixed, upon such terms and prices as they shall deem proper, without obtaining any prior order of the court therefore. I also grant them full power and authority in the settlement of my estate, to compremise, adjust, and settle any and all debts and liabilities due to or from my estate, for such sums, and upon such terms and conditions as they shall deem best. In the event that either Thelma M. Gartner or Frederick A. Crartner shall for any reason decline to serve, or fail to qualify for any reason, or having qualified and been appointed, fail to complete the administration of my estate, then I nominate the other of them as the sole Executor(trix) of my estate. SEVENTH: I direct that no bond or surety shall be required of any guardian, trustee, executor, administrator or fiduciary named herein. · IN WITNESS WHEREOF, I have hereunto subscribed my name, and acknowledge andpublish this ~mstrument ~ m_y Last Will in the presence of the undersigned witnesses, on this /~rdav of /,,'~'~'~t~'~'/ ,2003· ~ . -- --' -- Donna M. Cullen ~ 2955,~$.1 Page3 of 4 ~ ~ The preceding instrument consisting of two pages was on the date thereof signed, published and declared by in the presence of ns, who, at her request, in her presence, and in the Presence of each other, have subscribed our narfles as witnesses hereto. Commonwealth of Pennsylvania : County of : Commonwealth of Pennsylvania County of Cumberland I, Donna M. Cullen, the Testatrix, whose name is signed to the foregoing insh'ument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will, that I signed it willingly and that I signed it as my free and voluntary act for the purposes therein expressed. Dorma- .'Cull ed to and acknowledged before me by the above named Testatrix this ~.~ day of lqotary Public I _ n~¢,ar~ma, .uo~. pu~ I We, the undersigned witnesses whose names appear above, being duly qualified according to law, do depose and say that we were preeent and saw Donna M. Cumberland, the Testatrix sign and execute the imtrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of ns in the hearing and sight of the Testatrix signed the Will as wimesses and that to the best of our knowledge the Testatrix was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence.  ed to and acknowledged before me by the above named Testah'ix this ./,~.t day of [ ~ uo~mon ~ a~.. is, ~ ! . My commission expires: REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA INVENTORY Estate of Donna M. Cullen also known as , Deceased No. 21 03 1066 Date of Death 12/17/2003 Social Security No. 208-42-6067 Pemonal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/VVe vedfy that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unswom falsification to authorities. Name of Attorney: David H. Martineau~ Esquire I.D. No.: 84127 Address: 3211 N. Front St., PO Box 5300 Harrisburg PA 17110 Personal Representative: c/o Thelma M. Gartner 55 Kensington Dr.~ Camp Hill, PA 17011 Dated Telephone: (717) 238-8187 Description House and lot located at 171 Tory Circle, Enola, Cumberland County, Pennsylvania Furniture and miscellaneous personalty of decedent Pre-rated County Property Tax from sale of real estate Pro-rated School Property Tax from sale of real estate Pre-rated sewer/refuse bill from sale of real estate (Attach Additional Sheets if necessary) Value Total ~'3~ 129,000.00 ~: ~ :1 000.00 282.61 co 373.40 10.55 130,666.56 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the va~ue of each item, but such figures should not be extended into the total of the Inventory. RW-4 In the matter of the 'G4 ESTATE OF DONNA M. CULLEN, : Deceased. : i~Lt~l :IXJtE!CD'~T OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 2003-1066 RECEIPT: RF.I,EA~E: ANI} RF~lCl'INDINC'. IIOND~ IN ADVANCE OF I hereby agree to accept from Thelma M. Gartner and Frederick A. Gartner, Co-Executors, the stun of Fourteen Thousand Seven Hundred Ninety and 59/100 Dollars ($14,790.59), representing my total net distributive share of the Estate. I request that the Fiduciaries send the check to me in this amount, payable to me, by first-class mail, addressed as follows (Releasor to fill in address in Releasor's own handwriting): X--~t:~ ~.o,-,~,~.x~,XX x..~--x,~ Upon receipt of the aforesaid check, I do hereby release the said fiduciaries of and from any and all claims I have under the laws of the Commonwealth of Pennsylvania, or of any other jurisdiction and under the Last Will and Testament of the above-captioned decedent with respect to the aforesaid Fourteen Thousand Seven Hundred Ninety and 59/100 Dollars ($14,790.59) and with respect to the administration of said estate. I also acknowledge that I am hereby advised that the estate has not received a final clearance of fiduciary income tax from the Internal Revenue Service or the Pennsylvania Department of Revenue. If there is a further assessment or claim from either of these taxing bodies or any other governmental body or any other party or creditor with alienable claim or other claim, I hereby agree to pay to the governmental body or other party or creditor my share of any amount which may be necessary to discharge the estate or fiducimy, and I agree to refund to the estate or fiduciaries my share of any amount the estate or fiduciaries may pay to 314798-1 discharge such debts or claims. IN WITNESS WHEREOF, I have hereunto set my hand and seal this /~ ~/~/r/~t~-~, 2004. /~- ~'gday of WITNESS: In and for the State of Ohio My Commission Expires May 29, 2005 Christoph~-'~. Cullen 314798-1 STATE OF /~)/-/.Z.O : : SS. COUNTY OF /~o ~-r~' ~,,~r ~,t. ct, : On this, the /2~'~/day of t~/ou~'/t4~e~t--, Anno Domini 2004, before me, the undersigned officer, personally appeared Christopher E. Cullen, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within insmunent, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand an~ Notary Public ROBERT A. JORDAN, Notary Public In and for the State of Ohio My Commission E. xl~ires May 29, 2005 314798-1 In the matter of the ESTATE OF DONNA M. CULLEN, Deceased. ~N THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ~.; QRPHANS' COURT DIVISION · ~ ~TO. 2003-1066 RECEIPTr REI ,EASE: AND RE, FI fNI}INC~ ROND.. IN ADVANCE CIE CHECK: FI~I,I, I hereby agree to accept fi.om Thelma M. Gartner and Frederick A. Gartner, Co-Executors, the stun of Fourteen Thousand Seven Hundred Ninety and 59/100 Dollars ($14,790.59), representing the total net distributive share of the Estate to be held by me in trust, under the provisions of the Will of the decedent, for the benefit of Pamela M. Cullen. I request that the Fiduciaries send the check to me in this amount, payable to me, by first-class mail, addressed as follows (Releasor to fill in address in Releasor's own handwriting): ~4",.ff' _/?~~&~ ~ Upon receipt of the aforesaid check, I do hereby release the said fiduciaries of and fi.om any and all claims I have under the laws of the Commonwealth of Pennsylvania, or of any other jurisdiction and under the Last Will and Testament of the above-captioned decedent with respect to the aforesaid Fourteen Thousand Seven Hundred Ninety and 59/100 Dollars ($14,790.59) and with respect to the administration of said estate. I also acknowledge that I am hereby advised that the estate has not received a final clearance of fiduciary income tax from the Internal Revenue Service or the Pennsylvania Department of Revenue. If there is a further assessment or claim from either of these taxing bodies or any other governmental body or any other party or creditor with alienable claim or other claim, I hereby agree to pay to the governmental body or other party or creditor the 314798-1 trust's share of any mount which may be necessary to discharge the estate or fiduciaries, and I agree to retired to the estate or fiduciaries the trust's share of any amount the estate or fiduciaries may pay to discharge such debts or claims. IN WITNESS WHEREOF, I have hereunto set my hand and seal this -i'-'~d day of ~ -'t,.-~,~ ., 2004. WITNESS: Thelma M. Gartner, Trustee for Pamela M. Cullen under the LW&T of Donna M. Cullen 314798-1 COMMONWEALTH OF PENNSYLVANIA : : SS. COUNTY OF [3hctPC--x: ~d : On this, the .~,3 day of A)tJ~v~,~,~ , Anno Domini 2004, before me, the undersigned officer, personally appeared Thelma M. Garmer, Trustee for Pamela M. Cullen under the Last Will and Testament of Donna M. Cullen, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and seal. Notary Pul~ic Notarial Seal Angela M. Miller, Notary Public City of Harrisburg, Dauphin County My Commission Expires Oct. 15, 2006 314798-1 STATUS REPORT UNDER RULE 6.1~ Name of Decedent · Donna M. Cullen Date of Death · Will No. 2003-1066 Admin No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: go Did the personal representative file a final account with the Court? Yes No X account is: bo The separate Orphans' Court No. (if any) for the personal representative's in interest? Yes Did the personal representative state an account informally to the parties X No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: Signature Name David H. Martineau, Esquire Address 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 Telephone (717) 238-8187 Capacity: X Personal Representative Counsel for Personal Representative 315701-1 BUREAU OF /NDTVTDUAL TAXES TNHERTTANCE TAX DI*VTSTON DEPT. Z80601 HARRTSBURG, PA 171ZS-06nl COMMONNEALTH OF PENNSYLVANTA DEPARTMENT OF REVENUE ZNHERZTANCE TAX STATEMENT OI= ACCOUNT REV-1607 EX AFP (01-0S) DAVID H MARTINEAU HETZSER NICKERSHAM PO BOX 5500 HB$ PA 17110 DATE ESTATE OF DATE OF DEATH FZLE NUMBER COUNTY ACN 11-01-Z00q CULLEN DONNA 12-17-Z003 21 05-1066 CU~.LAND Amoun~ MAKE CHECK PAYABLE AND R~ZT PAYHENT TO: REGISTER OF HILLS CUH~ERLAND CO 'COURT :;~OUSE : CARLISLE, PA 1701~ H NOTE: To insure proper credi~c ~o your account, sub.i~ ~he upper portion of ~his for. wi~h your ~ex pey.en~. CUT ALONG TH'rS LZNE ~ RETA'rN LONER PORT'rON FOR YOUR RECORDS ~ ESTATE OF CULLEN DONNA M FZLE NO. 21 05-1066 ACN 101 DATE 11-01-200q THZS STATEHENT ZS PROVTDED TO ADVZSE OF THE CURRENT STATUS OF THE STATED ACN ZN THE NAHED ESTATE. SHONN BELON ZS A SUHHARY OF THE pR'rNCZPAL TAX DUE, APPLZCATZON OF ALL PAYHENTS, THE CURRENT BALANCE,, AND, ZF APPLZCABLE, A PROJECTED ZNTEREST FZGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 09-15-Z00~ PRINCIPAL TAX DUE: ........................................................................................................................................................................................................................... PAYMENTS (TAX CREDITS): 2,996.77 PAYMENT RECEZPT DISCOUNT (+) { AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-)1 1~9.8~ 05-17-Z00~ 10-1Z-200q CD005700 REFUND .0O 3,000.00 153.07- ZF PAZD AFTER THZS DATE, SEE REVERSE SZDE FOR CALCULATZON OF ADDZTZONAL ZNTEREST. ( ZF TOTAL DUE ZS LESS THAN $1, NO PAYHENT ZS REQUZRED. ZF TOTAL DUE ZS REFLECTED AS A "CREDZT" (CR), TOTAL TAX CREDZT 2,996.77 BALANCE OF TAX DUE .00 ZNTEREST AND PEN. .00 TOTAL DUE .O0 YOU HAY BE DUE A REFUND. SEE REVERSE STDE OF THI'S FORH FOR TNSTRUCTZONS. ) PAYMENT: Oatach fha top portion of this Notice and submit with your payment made payable to the name and address printed on the reverse side. -- If RESIDENT DECEDENT make check or money order payabla to: REGZSTER OF NILLS, AGENT. -- If NON-RESIDENT DECEDENT make check or money order payable to: COMMONNEALTH OF PENNSYLVANIA. REFUND (CR): A refund of a tax credit, which Nas not requested on tha Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1515). Applications ara available at the Office of tha Register of Wills, any of the 23 Revenue District Offices or from the Department's [q-hour ansmmring service for fores ordering: 1-BO0-561-ZO50; services for taxpayers with special hearing and / or speaking needs: 1-BOO-qqT-30ZO (TT only). REPLY TO: guestions regarding errors contained on this notice should be addressed to: PA Department of Revenua, Bureau of Individual Taxes, ATTN: Post Assessment Raviee Unit, Dept. 18060i, Harrisburg, PA 171Z8-0601, phone (717) 787-6505. DISCOUNT: If any tax due is paid within throe (5) calendar months after the decedent's death, a five percent (51) discount of tha tax paid is allowed. PENALTY: The 151 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid bafora January 18, 1996, the first day after the end of the tax amnesty pariod. INTEREST: Interest is charged beginning mith first day of delinquency, or nine (9) months and one (1) day from the date of death, to tha date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of six (62) percent par annum calculated at a daily rate of .O0016q. All taxes which became delinquent on and after January 1, 1982 will bear interest at a rate ehich will vary from caZendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1981 through 200¢ ara: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year~ Rate Factor 1982 Z02 .O00Sq8 1988-1991 112 .000301 ZOO1 92 .0002~7 1983 162 .000q38 1992 9Z .O00Zq7 ZOOZ 62 .00016q 1984 112 .000501 1993-199~ 72 .000192 2005 52 .000137 1985 15Z .000356 1995-1998 92 .OOOZ~7 ZOOq 42 .000110 1986 10Z .O00Z7q 1999 7Z .000192 1987 92 .O00Zq7 ZOO0 82 .000219 --Interest is calculated as follows: TNTEREST = BALANCE OF TAX UNPATD X NUNBER OF DAYS DELTNQUBNT X DA/L¥ INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (la) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. Glenda Farner Strasbaugh Register of Wills and Clerk of Orphans' Court Marjorie A. Wevodau First Deputy Kirk S. Sohonage, Esq Solicitor Register of Wills and Clerk of the Orphans' Court County of Cumberland One Courthouse Square Carlisle, PA 17013 (717) 240-6345 FAX (717)240-7797 INVOICE Bill To: InvoiceNo: 257 Invoice Date: 3/17/2005 Estate of: FL ORENCE D SHELLENBERGER Estate No: 21-03-1066 EDMUND G. MYERS 301 MARKETST P.O. BOX 109 LEMOYNE, PA 17043 JA Qty 1 Fee Description EXEMPLIFIED OOP Fee Total 40.00 $40.00 Total: $40.00 -Pel 3 -2/-05 Checks should be made payable to the Register of Wills. Terms: Net 30. Please return one copy of this invoice with your payment. Thank you.