HomeMy WebLinkAbout03-0175In the Matter of the Estate
of James H. Amsberger,
Deceased
FEB 2 7
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PA
Orphans' Court Division
No, ,,Tt-O3-1'/5,
Petition for Settlement of Small Estate
TO THE HONORABLE, THE JUDGE OF SAID COURT:
The petition of the undersigned respectfully represents.~
(1) The name, address and relationship of your petitioner to the above decedent:
Name: Fern M. Amsberger
Address: 11 Clearview Road, Dillsburg, PA 17019
Relationship: Daughter and named alternate Executrix in Last Will & Testament
( Ruth E. Arnsberger died 06/14/95);
(2) The decedent died on December 6, 2002, a resident of Claremont Nursing &
Rehab Center, 375 Claremont Drive, Carlisle, Pennsylvania;
(3) Said decedent died Testate, leaving a will, a copy of which is hereto attached, in
which the personal representative named therein is Ruth E. Arnsberger, who died on 06/14/95 -
Fern M. Amsberger, alternate;
(4) The names, relationships and interests of all parties beneficially interested in the
estate are:
Faith Assembly of God Church, 806 Fishing Creek Road, New Cumberland, PA
17070 - 10% of residuary estate;
Fern M. Amsberger, 11 Clearview Rd., Dillsburg, PA 17019 - 90% of residuary
estate;
(5) The following person is entitled to, and claims, the family exemption of $3,500.00
by virtue of being a member of the same household as the decedent:
Nanle:
Relationship:
(6) Said decedent died owning property (exclusive of real estate and of wages, salary,
pension or vacation benefits) of a gross value not exceeding $35,000.00, which is itemized as
follows:
Item
Citizens Bank Account #610074-531-7:
Citizens Bank Account #6140-178436:
Highmark Refund Check:
Amount
$ 9,197.85
$14,429.17
$ 161.28
Total $ 23,788.30
(7) An itemized statement of all claims against the estate is as follows:
(a)
following:
Claims heretofore paid by Wiley, Lenox, Colgan, & Marzzacco, P.C. to the
Claimant
Nature Amount
Register of Wills
Register of Wills
Register of Wills
Inheritance Tax
Filing Fee (tax return):
Filing Fee (Petition):
$ 773.73
$ 15.00
$ 51.00
Total $ 839.73
(b) Claims remaining unpaid:
Claimant
Nature Amount
West Shore EMS
Claremont Nursing & Rehab
The Wiley Group
Last Illness $ 109.15
Last Illness $2,003.18
Attorney Fee $1,500.00
Total $ 3,612.33
(8) The Petitioner will cause to be paid all Pennsylvania inheritance taxes due on all
property to be awarded.
(9) All parties beneficially interested in the estate other than the petitioner have
(strike inapplicable words)
a. Signed the joinder in this petition which is attached hereto.
b. Been mailed written notice of the date when this petition will be presented,
a copy of which notice is attached hereto.
WHEREFORE, your petitioner prays that the above property of the decedent be
distributed under Section 3102 of the P-E-F Code as follows:
(a) On account of the family exemption:
Name: Amount:
(b) In reimbursement of claims against the estate heretofore paid:
Name:
Wiley, Lenox, Colgan, & Marzzacco, P.C. (Reimbursement): $
Amount:
839.73
(c)
Name:
West Shore EMS
Claremont Nursing & Rehab
The Wiley Group
Total
For payment of claims against the estate remaining unpaid:
Last Illness
Last Illness
Attorney Fee
$ 839.73
Amount:
$ 109.15
$2,003.18
$1,500.00
Total
(d) In distribution in accordance with the interests in the estate:
Nalne~
Faith Assembly of God Church:
Fem M. Amsberger:
(*Plus any additional interest earned, or less any
Bank charges assessed)
$ 3,612.33
Amount:
$ 2,011.00
$17,325.24'
Total: $ 19,336.24
for Petitioner Petitioner ' -
~/j~t~omey ~
VERIFICATION
This ~.-q4~ day of ;~bgLlag'(d ,2003, the foregoing petitioner hereby
verifies, subject to the penalties of 18 Pa.C]SJ4904 (relating to unswom falsification to
authorities), that the facts set forth in the foregoing petition which are within his/her knowledge
are true, and as to the facts based on information received, after diligent inquiry, he/she believes
them to be true.
Petitioner
JOINDER
We, the undersigned, being all the parties, other than the petitioner, beneficially interested
in the estate of the foregoing decedent, do hereby certify that we have read the foregoing petition
and join the prayer thereof.
.ORDER --
AND NOW, TO WIT: This _~2ay of ~~,, 2003, upon consideration
of the foregoing petition and on motion of the attorney for the petitioner, it is ordered that the
property of the decedent be distributed under Section 3102 of the P-E-F code as follows:
Sallie
West Shore EMS
Claremont Nursing & Rehab
Wiley, Lenox, Colgan, & Marzzacco, P.C.
Wiley, Lenox, Colgan, & Marzzacco, P.C. (Reimbursements)
Faith Assembly of God Church:
Fern M. Arnsberger:
(*Plus any additional interest eamed, or less any
Bank charges assessed)
[~mount
109.15
2,003.18
$ 1,500.00
$: 839.73
$'- 2,011.00
$17,325.24'
Total: $ 23,788.30
This decree of distribution shall constitute sufficient authority to all transfer agents,
registrars and others dealing with the property of the estate to recognize the persons named herein
as entitled to receive such property without administration, and shall in all respects have the same
effect as a decree of distribution after an accounting by a personal representative.
IV~r [/s *'' ~ ~o Judge
OF
JAMES H. ARNSBERGER
BE IT REMEMBERED, that I, JAMEs H. ARNSBERGER of R.D. 1,
Dillsburg, Franklin Township, York County, Pennsylvania, being
of sound mind and disposing memory, full legal age, realizing
the uncertainty of this life, and with full confidence and trust
in our Lord and Saviour, Jesus Christ, in H~'~death for my sins
on the cross and in His shed blood as an atonement for my sould,
and knowing that by faith in His sacrifice on ~e cross for me
I have eternal life, but not acting under duress, menace, fraud,
restraint, or undue influence of any person Whomsoever, I hereby
make, publish, and declare this instrument to be mY Last Will
and Testament, hereby revoking and cancelling all former wills
and codicils made by me.
ITEM 1: I direct that all my just debts and funeral expenses
be paid as soon after my demise as may be convenient.
ITEM 2: Ail the rest, residue and remainder of my Estate,
of whatsoever nature and wheresoever situate, whether it be real,
personal or mixed, including property over which I have a power
of appointment, I give, devise and bequeath unto my wife, Ruth
E. Arnsberger, absolutely, provided she survives me for a period
of thirty (30) days.
ITEM 3: Should my wife, Ruth E. Arnsberger, predecease
me, fail to survive me for a period of thirty (30) days, or should
we die simultaneously, I then give, devise and bequeath all of
my estate of every nature and wheresoever situate as follows,
to wit:
A. I give and bequeath ten (10%) percent of my residuary
estate unto the Faith ASsembly of God Church of New Cumberland,
WITNESS:
JAMES H. ARNSBERGER
Pennsylvania.
B. I give and bequeath the remaining ninety (90%) percent
of my residuary estate unto my daughter, Fern M. Arnsberger,
absolutely, provided she survives me for a period of thirty (30)
days.
C.. I'n the event my daughter, Fern M. Arnsberger, predeceases
~me, or fails to survive me for a period of thirty (30) days,
I then give, devise and bequeath her ninety (90%) percent share
of my residuary estate to my brothers and sisters and the brothers
and sisters of my wife, Ruth E. Arnsberger, in equal shares.
In the event any of my brothers and sisters, or brothers
and sisters of my wife, shall predecease me, I then give, devise
and bequeath their share, to be divided equally among their children,
per capita.
ITEM 4: I direct my Executrix to pay all inheritance,
estate, succession and legacy taxes o~ whatsoever nature and
kind, to which my Estate or the transfer of any property passing
hereunder or otherwise passing by reason of my demise, may be
subject and to charge such taxes against my residuary estate,
it being my intention that none of the aforesaid taxes, either
federal or state, on any property required to be included in
my gross estate, under the provisions of any state or federal
law now in force or hereafter enacted, shall be prorated among
the persons interested in my Estate to whom such property is
or may be transferred or to whom any benefit accrues.
ITEM 5: I appoint my wife, Ruth E. Arnsberger, as Executrix,
of this My Last Will and Testament. Should my wife, Ruth E.
Arnsberger, predecease me, fail to qualify, cease to act or renounce
probate, I then appoint my daughter, Fern M. Arnsberger as alternate
JAMES H. ARNSBERGER
-2-
~xecutor of this My Last Will and Testament. Should my daughter
predecease me, fail to survive me, I then appoint Robert Beamer
Jr., as alternate Executor of this my Last Will and Testament.
ITEM 6: I direct that my Executrix, guardian and their
successors shall not be required to give bond for the faithful
performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereun%o set my hand and seal
this day of ~J~~ , 1984.
/~AMES H. ARNSBERGER
-3-
COMMONWEALTH OF PENNSYLVANIA:
: SS
COUNTY OF YORK :
We, JAMES H. ARNSBERGER, JAN M. WILEY, ESQUIRE, and GLENDA
M. WETHINGTON, the Testator and the witnesses respectively, whose
names are signed to the attached or foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority
that the Testator signed and executed the instrument as his Last
Will and Testament and that he had signed willingly (or willingly
iirected another to sign for him), and that he executed it, as
ils free and voluntary act for the purposes therein expressed,
and that each of the witnesses, in the presence and hearing of
the Testator signed this Last Will and Testament as witnesses
and that to the best of their knowledge, the Testator was at
the time, eighteen (18) years of age or older, of sound mind
and under no constraint or undue influence.
~>~AMES H. ~RNSBERGER
Sworn to and subscribed to before me
this /~ day of ~f_~~, 1984.
!
(SEAL)
MY COMMISSION EXPIRES:
ill v tamvnt'
O~
J~ES H, ARNSBERGER
BE IT REMEMBERED, that I, J~S ~. ~SBERGER of R.D. 1,
Dillsburg, Franklin Township, York county, Pennsylvania, being
of sound mind and disposing memory, full legal age, realizing
the uncertainty of this life, and with full confidence and trust
in our Lord and Saviour, Jesus Christ, in H~%death for my sins
on the cross and in His shed blood as an at0~/~ent for my sould,
and knowing %ha% by faith in His sacrifice on ~he cross for me
I have eternal life, but not acting under duress, menace, fraud,
restraint, or undue influence of any person ~homsoever, I hereby
make, publish, and declare this instr~ent to be my Last Will
and Testament, hereby revoking and cancelling all former wills
and codicils made by me.
ITEM 1: I direct that all my just debts and funeral expenses
be paid as soon after my demise as may be convenient.
ITEM 2: All the rest, residue and remainder of my Estate,
of whatsoever nature and wheresoever situate, whether it be real,
personal or mixed, including property over which I have a power
of appointment, I give, devise and bequeath unto my wife, Ruth
E. Arnsberger, absolutely, provided she survives me for a period
of thirty (30) days.
ITEM 3: Should my wife, Ruth E. Arnsberger, predecease
me, fail to survive me for a period of thirty (30) days, or should
we die simultaneously, I then give, devise and bequeath all of
my estate of every nature and wheresoever situate as follows,
to wit:
A. I give and bequeath ten (10%) percent of my residuary
estate unto the Faith ASsembly of God Church of New C~berland,
'~ss:
JAMES H. ARNSBERGER
Pennsylvania.
B. I 'give and bequeath the remaining ninety (90%) percent
of my residuary estate unto my daughter, Fern M. Arnsberger,
absolutely, provided she survives me for a period of thirty (30)
days.
C.~ In the event my daughter, Fern M. Arnsberger, predeceases
me, or fails to. survive me for a period of thirty (30) days,
I then give, devise and bequeath her ninety (90%) percent share
of my residuary estate to my brothers and sisters and the brothers
and sisters of my wife, Ruth E. Arnsberger, in equal shares.
in the event any of my brothers and sisters, or brothers
and sisters of my wife, shall predecease me, I then give, devise
and bequeath their share, to be divided equally among their children,
per capita.
ITEM 4: I direct my Executrix to pay all inheritance,
estate, succession and legacy taxes of whatsoever nature and
kind, to which my Estate or the transfer of any property passing
hereunder or otherwise passing by reason of my demise, may be
subject and to charge such taxes against my residuary estate,
it being my intention that none of the aforesaid taxes, either
federal or state, on any property required to be included in
my gross estate, under the provisions of any state or federal
law now in force or hereafter enacted, shall be prorated among
the persons interested in my Estate to whom such property is
or may be transferred or to whom any benefit accrues.
ITEM 5: I appoint my wife, Ruth E. Arnsberger, as Executrix,
of this My Last Will and Testament. Should my wife, Ruth E.
Arnsberge'r, predecease me, fail to qualify, cease to act or renounce
)robate, I then appoint my daughter, Fern M. Arnsberger as alternate
JAMES H. ARNSBERGER
-2-
executor of this My Last Will and Testament. Should my daughter
predecease me, fail to survive me, I then appoint Robert Beamer
Jr., as alternate Executor of this my Last Will and Testament.
ITEM 6: I direct that my Executrix, guardian and their
successors shall not be required to give bond for the faithful
performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this /~ day of ~]1.C2.~~' , 1984.
-3-
COMMONWEALTH OF PENNSYLVANIA:
: SS
COUNTY OF YORK :
We, JAMES H. ARNSBERGER, JAN M. WILEY, ESQUIRE, and GLENDA
M. WETHINGTON, the Testator and the witnesses respectively, whose
names are signed to the attached or foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority
that the Testator signed and executed the instrument as his Last
Will and Testament and that he had signed willingly (or willingly
directed another to sign for him), and that he executed it, as
his free and voluntary act for the purposes therein expressed,
and that each of the witnesses, in the presence and hearing of
the Testator signed this Last Will and Testament as witnesses
and that to the best of their knowledge, the Testator was at
the time, eighteen (18) years of age or older, of sound mind
and under no constraint or undue influence.
?
C~JAMES H. ARNSBERGER
(SEAL)
~--WITNESS 6/
Sworn to and subscribed to before me
this /~ day of ~~, 1984.
!
MY COMMISSION EXPIRES:
GLE~UA ~. WETHINGTGI~, NOTARY PUBLIC
DIL~BURG BOROUGH, YGR~ COUN~
~y COMMISSIO~ ~PIRES 0~. 27,
~, pe~sytvs.is ~sociatlen of
1-888-g IO-41OO
CaU C~zees' PhoneBank am~me for account information,
current rotes and answers to your questions.
US05g BR319 3
JAMES H:ARNSBERG.ER
11 C~LEARV[.EW RD
DI-LLSBURG PA 17019-9776
Account Statement
OOF 2
Beginning November 06, 2002
through December 04, 2002
Contents
Cheddng Page
Savings Page
Checking
SUMMARY
Balance Calculation
Previous Batance
Checks
Withdrawals
Deposits & Additions
Interest Paid
Current Balance
6,84~.12
3,745.64
.00
6,O98.66
.64
9,197.85
~a/ance
Average Daily Balance
Interest
Annual Percentage Yield Earned
Number of Oays Interest Earned
~nterest Earned
Interest Paid this Year
TRANSACT/ON DETAILS
Checks* r~e'e Js a/~eek in ~ece seque~e
Check ~ Amu~ O~e
529 23.85 11~08
530 126.79 11/13
Check
531
Amount
3,595.00
Deposits & Additions
Date A~ont
11/.18 5,000.00
11/29 25.49
12/02 25.17
12/03 978.00
OescflpUon
LleposK
Rps-PrJndpa[ Pfindpa[ 021129
Equitable Life Ac0733py01 021201 07330000002830e
US Treasury 303 Soc Sec I20302 180011943a SSA
Interest
Date Amount
11/19 .6~
Destu4pUon
Interest
Oa~iy Balance
Date Bo(once
11/08 6,820.34
11113 6,693.55
11/18 11,693.55
Date B~ance Date
11~19 11,694.19 12~02
11/29 8,194.68 12/03
9,002.79
.25%
I2.92
Date
n/2g
B~ance
8,219.85
9,197.85
3AMES H ARNSBERGER
CJUzens Basic Checking
610074-531-7
Previous Balance
6,844.19
Total Checks
3,745.64
Tot~ Deports & Additions
6,098.66
(~~~ntal Interest P;dd
Current Balance
9,197.85
BANK
1-888-910-4100
CaU Cffizens' PhoneBank anytime for account informaUon,
current rates and answers to your questions.
Account Statement
OoF 2
Beginning November 06, 2002
through December 04, 2002
Savings
SUMMARY
Balance Calculation
Previous Balance
WithdrawaLs
Deposits & Additions
Interest Paid
Current Balance
lg,425.63
5,000.00
.00
3.5/,
14,42g.17
Balance
Average Daily Balance
Interest
Current Znterest RuLe
Annual Percentage Yield Earned
Number of Oays Interest Earned
Interest Earned
Interest Paid this Year
16,495.08
.25~
.25%
.3.28
43.96
TRANSACTION DETAILS
Withdrawals
Other Withdrawals
Dote Amount OescfipUon
11/18 5,000.00 Withdrawal
]ntere~
Date Amount Description
11/2~ 3.54 Interest
Daffy Balance
DOTe B~ance DOTe B~ance
11/18 14,425.63 11/29 14,429.17
Date
B~an~
] NEWS FROM CITIZENS
-- Evenj time you use your Citizens Bank Debit Card for purchases between 11/1 and 12/31,
you'Ll be automaticaLLy entered into the C~tizens I~ank Debit Card ~odday Sweepstakes. Visk
cifizensbank, com for Official Rules. No purchase necessan~. Open to U.S. residents who reside
in PA, DE, and N3 and who are 18 years of age oT older as of 11/1/02. Void where prohibited.
Sweepstakes ends 12/31/02.
-- Cat[ our EducaUon Finance Department at 1-800-708-~68~ to Learn about products and sewices
for your fami[y's education finance needs.
JAMES H ARNSBERGER
Statement Savings
61~0-178436
Previous BaLance
19,425.63
Total Withdrawals
Tatal Interest Paid
3.54
Current Balance
14,42g.17
ONE HUNDRI;,D .SIXJ'}'-ONI:- DOI, LAR5 ,~ND28 CEN.F.$
ESTATE OF: JAMES..ARNSBERGER
11 CLEARViEW ROAD
DILLSBURG~ PA 17019
CHECK NO 3
.pATE ~F cHECK.
01'/t 5/2 0
NATURE itigt~matl~
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 2~0601
HARRISBURG, PA 17128-0601
REV-I$00
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
21 YEAR
COUNTY CODE 02
NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INiTIAL)
Arnsberger, James H.
DATE OF DEATH (MM-DD-YEAR) DATE OF SIRTH (MM-DD-YEAR)
12/06/2002 [ 09/29/1908
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
]80-01-]943
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
I~;~ 1. OriginalRetum [] 2. Supplemental Retum
[] 4. Limited Estate [] 4a. Future interest Compromise (date of death after
12-12-82)
[] 6. Decedent Died Testate (Attach copy [] 7. Decedent Maintained a Living Trust (Attach
of Will) copy of Tn.mt)
[] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit (date of death between
__ ,[ 12-31-91 and 1-1-95)
~AME
Jan M. Wiley, Esq.
:IRM NAME (if applicable)
The Wiley Group
'ELEPHONE NUMBER
717/432-9666
[] 3. Remainder Return (date of death pdor to 12-13-82)
[] $. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
[] 11. Election to tax under Sec. 9113(A) (Attach Sch O)
I COMPLETE MAILING ADDRESS
1 S. Baltimore St.
Dillsburg, PA 17019
9.
11.
12.
14.
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank D~posits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
[] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
Total Gross Assets (total Lines %7)
Funeral Expenses & Administrative Costs (Schedule H) (9)
Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
Total Deductions (total Lines 9 & 10)
None
None
None
None
23,788.30
None
None
3,678.33
Net Value of Estate (Line 8 minus Line 11)
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
Net Value Subject to Tax (Line 12 minus Line 13)
OFFICIAL USE ONLY
23,788.30
3,678.33
20,109.97
2,011.00
18,098.97
(11)
(12)
(13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2)
x .00 (15)
16.Amount of Line 14 taxable at lineal rate
18,098.97 x .045 (16) 814.45
x ,12 (17)
x .15 (18)
(19) 814.45
17.Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
JS.TR~'r ADDRESS
CiTY Carlisle
375 Claremont Drive
] 7013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
773.73
40.72
814.45
Interest/Penalty if applicable D. Interest
E. Penalty
Total Credits (A + B + C) (2)
Total Interest/Penalty (D + E)
814.45
0.00
(3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page I Line 2{) to request a refund
5. If Line l + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ; .............. ................................................................... r"-] ~
b. retain the right to designate who shall use the property transferred or its income; ....................................
c. retain a reversionary interest; or ...........
d. receive the promise for life of either payments, benefits or care? ..............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... [] []
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... [] []
4. Did decedent own an individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................... [] []
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under pec.=;[;as of perjury. I ~H~_~e that I have examined this return, including a~.~.ui.,p~.ytng schedulas and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of
preparer other than t~e personal rapresentative is based on al[ information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Fern M. Arnsberger ] l Clearview Rd.
Dillsburg, PA 17019
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
DATE
DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
ADDRESS
Jan M. Wiley, Esq. DATE
I S. Baltimore St.
Dillsburg, PA 17019
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. {;9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. {}9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax ratum are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9t 18
1.2) [72 P.S. §9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116 (a) (113)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Ciaremont Nursing & Rehab~
375 Claremon% Drive
Carlisle PA'17013
...(717) 243-2031
12 PATIENT NAME
FED. TAXNO, T6 STATEME~T'~'- tOD ....................
23-6003115) 1!260J2 1129012
13 PATIENT AODRES5
James H
11260
CO~
ArnsDer¢
t4 BIRTHDA~
0929190
23 MEDICAL RECORO NO.
4259
E SPAN
TH~H
VALUE (]ODES
OCCURRENCE
James H Arnsberger
Fern M Arnsberger
11 Clearview Road
Dillsburg, PA 17019
43 DESCRIPTION
44 HCPCS/RATES 45 SERV, DATE46 SERV. UNITS 47 TOTAL CHARGES
50 PAYER
i PRIVATE PAY
58 ~NSUREO'S NAME
Arnsberger James H
PROVIDER NO. 54 PRIOR PAYMENTS 56
CLAREMONT
! 60 CERT. - SSN - HIC.- tD NO.
67 PRIN. DIAG. cn.~
4389I 2
PRiNCiPAL PROCEDURE
CODE DATE
/ *' GROUP NAME
EMPLOYER LOCATION
48 NON-COVERED CHARGES
CODE DATE
7~ ADU. mS. CD,12 5OO~11 ,W E4::Or~E t¢~--
HARM, MD KENNETH R
84 REMARKS
C27772
X 12/12/2002
JB-92 HCFA-1450 APPROVED OMB NO. O938.-O279 OCFUO RIOINAL I CEf~ THE CER~F;CA'flON~ ON THE REVERE APPLY TO THiS I~ILL AN) ARE If~ A PART HEREO~.
Cla~emon% Nursing & Reha~
.375 ClarDm~ Drive
Carlisle PA t7013
(717) 243-2021
12 PA~ENT ~E
ArnsDer¢
14 81RTHDATE
0929190;
James H
120
4259
13 PATIENT ADDRESS
23 MEDICAL RECORD NO.
4259
31
James H Arnsberger
Fern M Arnsberger
11Clearview Road
43 DESCRIR1ON
44 HCFC8 / RATES
R & B NURSING CARE -
185
45 SERV, DATE 46 SERV. UNITS
47 TOTAL CHARGES 48 NON-COVERED CHARGES
925[00
PAYER
51 PROVIDER NO.
PRIVATE PAY
CLAREMONT
54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56
57
58 INSURED'S NAME
Arnsberger James H
63 TREATMENT AUTHORIZAT~Ofl COOES
65 EMPLOYER NABE
60 CERT. - S~fl. HlC.. ID NO,
180011943
61 GROUP NAME 62 INSURANCE GROUP NO.
68 EMPLOYER LOCATION
87 PRIN, DIA(
4389 25000
PRINCIPAL PROCEDURE
COOE DATE
84 REMARKS
C27772 HARM
ADM. ~. ~. 1 ~ E~DE
25000]
MD KENNETH R
PATIENT NAME:
INSURANCE:
WEST SHORE EMS - BLS
503 N ;'1ST ST
CAMP HILL, PA
Phone #: (800) 3674}51:2 Federal Tax ID:
JAMES ARNSBEF~GER
MEDICA~E B
CAPITAL BLUE CROSS
JAMES ARNSBERGER
11 CLEARVIEW RD
DILLSBURG. PA 17~19
80011943A
PATIENT NUMBER: 30g WCS
CALL NUMBER: ~,=,u,.,~.,,nnc=°°~ ~ ;, ?,;~
DATE OF CALL: 11/'19/2002.
TIME OF CALL: 1 ~:00 A~'~
CALLER: HOLY SPIRIT HOSPITAL
FROM: HOLY SPIRIT HOSPITAL
TO: CLAR. EMONT NRSG REHAB CTR
REASON(S)
FOR
TRANSPORT
ACCIDENTAl FALL
; DESCRIPTION OF CHARGE : QUA~ UN~ PRICE AMOUNT
STRETCHER TRanSPORT-NON MEI~ Aogg9 I ,O 81.15 81.15
~.~ .~ ~R ~
INFECTION COh~OL SUPPUES A0382 1.0 3.00 o~.~.~O
fobl Charaes 1B,15
DESCRIPTION OF PAYMENT REcEI~ : PAY~NT DATE : ~MOUNT
T at'~! (~redif~
PLEASE PAY THIS AMOUNT ~ $1t~.15
DETACH ALONG PERFORMATION A~D RETURN STUB WITH PAYMENT
AMOUNT DUE
tPATIENT NAME: CALL NUMBER AMOUNT $
iPATIENT NUMBER: .ARNSBERGEE, JAMES H 9gB88W
! 309 BILLING DATE: 12,'20/2002 ENCLOSED
THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL
ASSISTANCE.
VISA
AND
MASTER CARD
ACCEPTED
WEST SHORE EMS - BLS 503 N 21ST ST CAMP HILL. PA 17011
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD 002232
WILEY JAN M ESQUIRE
1 S BALTIMORE STREET
DILLSBURG, PA 17019
........ fold
ESTATE INFORMATION: SSN: 180-01-1943
FILE NUMBER: 2103-01 75
DECEDENT NAME: ARNSBERGER JAMES H
DATE OF PAYMENT: 02/27/2003
POSTMARK DATE: 00/00/0000
COUNTY: CUM BERLAN D
DATE OF DEATH: 12/06/2002
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $773.73
TOTAL AMOUNT PAID:
$773.73
REMARKS: JAN MWILEY ESQUIRE C/O
THE WILEY GROUP
SEAL
CHECK//1 9521
INITIALS' SK
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
C ON~MON~fl~.ALTH OF PENNSYLVANIA
'3EPARTMENT OF REVENUE
DEPT. 280601
I'{~RISI~URG, PA 17128-06~1
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
~ILE NUMBER
2!
COUNTY CODE
OFFICIAL USE ONLY
¥~R NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
---Amsberger, James H. 180-01 - 1943
U~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM~DD-YEAR)
¢~ THIS RETURN MUST BE FILED IN DUPUCATE WITH THE
~ 0 9/2 9/1 9 0 8 REGISTER OF WILLS
uJ
~<~
12/06/2002
F APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
[] 1. Original Return [] 2. Supplemental Retum
[] 4. Limited Estate [] 4a. Future Interest Compromise (date of death after
12-12-82)
[] 6. Decedent Died Testate (Attach copy [] 7. Decedent Maintained a Living Trust (Attach
of Will) copy of Trust)
[] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit (date of death between
12-31-91 and 1-1-95)
IAME
Jan M. Wiley, Esq.
FIRM NAME (If applicable)
The Wiley Group
TELEPHONE NUMBER
717/432-9666
SOCIAL SECURITY NUMBER
] 3. Remainder Return (date of death prior to 12-13.82)
[] 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
[] 11. Election to tax under Sec. 9113(A) (Attach Sch O)
COMPLETE MAILING ADDRESS
1 S. Baltimore St.
Dillsburg, PA 17019
10.
11.
12.
13.
14.
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
[] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines %7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
Total Deductions (total Lines 9 & 10)
None
None
None
23,788.30
None
None
3,678.33
Net Value of Estate (Line 8 minus Line 11 )
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
Net Value Subject to Tax (Line 12 minus Line 13)
OFFICIAL USE ONLY
(8)
23,788.30
3,678.33
20,109.97
2,011.00
18,098.97
(11)
(12)
(13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
x .00 (15)
16.Amount of Line 14 taxable at lineal rate
18,098.97 x .045 (16) 814.45
17.Amount of Line 14 taxable at sibling rate x .12 (17)
18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19) 8 ]4.45
20. []
Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
IS~T ~ss
CITY Carlisle
375 Claremont Drive
!STATE iZIP 17013
i P^ ~
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
773.73
40.72
(1)
Total Credits (A + B + C) (2)
814.45
814.45
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page I Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
A. Enter the interest on the tax due. (5A)
B Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 0 o 0 0
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; .................................................................................. ~ ~
b. retain the right to designate who shall use the property transferred or its income; ....................................
c. retain a reversionary interest; or ..................................................................................................................
d. rece ve the prom se for fe of ether payments, benefits or cam? ..............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... [] []
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... [] []
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................... [] []
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of
preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Fern_M. Arnsberger/'}
SIGNATURE OF'PERSON RESPONSIBLE FO~ FILING~I~N - ADDRESS
11 Clearview Rd.
Dillsburg, PA 17019
Sf~NATURE OF PREPARER OTHER THAN REPRESENTATIVE
ADDRESS
DATE
DATE
DATE
Ja# M. Wiley, Esq.
! tn 1 S. Baltimore St.
~ l....J~ Dillsburg, PA 17019
(F~ dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
"-,,x~rviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. {}9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. {}9116
1.2) [72 P.S. §9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116 (a) (1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
OF
JAMES H. ARNSBERGER
BE IT REMEMBERED, that I, JAMES H. ARNSBERGER of R.D. 1,
Dillsburg, Franklin Township, York county, Pennsylvania, being
of sound mind and disposing memory, full legal age, realizing
the uncertainty of this life, and with full confidence and trust
in our Lord and Saviour, Jesus Christ, in H~,'~death for my sins
on the cross and in His shed blood as an atonement for my sould,
and knowing that by faith in His sacrifice on t'~e cross for me
I have eternal life, but not acting under duress, menace, fraud,
restraint, or undue influence of any person ~homsoever, I hereby
make, publish, and declare this instrument to be my Last Will
and Testament, hereby revoking and cancelling all former wills
and codicils made by me.
ITEM 1: I direct that all my just debts and funeral expenses
be paid as soon after my demise as may be convenient.
ITEM 2: All the rest, residue and remainder of my Estate,
of whatsoever nature and wheresoever situate, whether it be real,
personal or mixed, including property over which I have a power
of appointment, I give, devise and bequeath unto my wife, Ruth
E. Arnsberger, absolutely, provided she survives me for a period
of thirty (30) days.
ITEM 3: Should my wife, Ruth E. Arnsberger, predecease
me, fail to survive me for a period of thirty (30) days, or should
we die simultaneously, I then give, devise and ~equeath all of
my estate of every nature and wheresoever situate as follows,
to wit:
A. I give and bequeath ten (10%) percent of my residuary
estate unto the Faith Assembly of God Church of New Cumberland,
~t.~NESS:
~>-~g/Z.i~../~ ~.~/.~.-? z~41~. ~ ~;~Q,' (SEAL)
JAMES H. ARNSBERGER
Pennsylvania.
B. I give and bequeath the remaining ninety (90%) percent
of my residuary estate unto my daughter, Fern M. Arnsberger,
absolutely, provided she survives me for a period of thirty (30)
days.
C. In the event my daughter, Fern M. Arnsberger, predeceases
me, or fails to survive me for a period of thirty (30) days,
I then give, devise and bequeath her ninety (90%) percent share
of my residuary estate to my brothers and sisters and the brothers
and sisters of my wife, Ruth E. Arnsberger, in equal shares.
In the event any of my brothers and sisters, or brothers
and sisters of my wife, shall predecease me, I then give, devise
and bequeath their share, to be divided equally among their children,
per capita.
ITEM 4: I direct my Executrix to pay all inheritance,
estate, succession and legacy taxes of whatsoever nature and
kind, to which my Estate or the transfer of any property passing
hereunder or otherwise passing by reason of my demise, may be
subject and to charge such taxes against my residuary estate,
it being my intention that none of the aforesaid taxes, either
federal or state, on any property required to be included in
my gross estate, under the provisions of any state or federal
law now in force or hereafter enacted, shall be prorated among
the persons interested in my Estate to whom such property is
or may be transferred or to whom any benefit accrues.
ITEM 5: I appoint my wife, Ruth E. Arnsberger, as Executrix,
of this My Last Will and Testament. Should my wife, Ruth E.
~rnsberger, predecease me, fail to qualify, cease to act or renounce
probate, I then appoint my daughter, Fern M. Arnsberger as alternate
,:/~TC~/~J~'~-c"~'J;*~"'c":'~r'/~ (SEAL)
JAMES H. ARNSBERGER
-2-
executor of this My Last Will and Testament. Should my daughter
predecease me, fail to survive me, I then appoint Robert Beamer
Jr., as alternate Executor of this my Last Will and Testament.
ITEM 6: I direct that my Executrix, guardian and their
successors shall not be required to give bond for the faithful
performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this .. /~ day of ~_~_~_~ , 1984.
WETNESS:
\
/~AMES H. ARNSBERGER
-3-
COMMONWEALTH OF PENNSYLVANIA:
: SS
COUNTY OF YORK :
We, JAMES H. ARNSBERGER, JAN Mo WILEY, ESQUIRE, and GLENDA
M. WETHINGTON, the Testator and the witnesses respectively, whose
names are signed to the attached or foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority
that the Testator signed and executed the instrument as his Last
Will and Testament and that he had signed willingly (or willingly
directed another to sign for him), and that he executed it, as
his free and voluntary act for the purposes therein expressed,
and that each of the witnesses, in the presence and hearing of
the Testator signed this Last Will and Testament as witnesses
and that to the best of their knowledge, the Testator was at
the time, eighteen (18) years of age or older, of sound mind
and under no constraint or undue influence.
~>'~JAMES H. ARNSBERG~R
(SEAL)
Sworn to and subscribed to before me
Nota~
MY COMMISSION EXPIRES:
SCHEDULE E
CASH, BANK DEPOSITS,& MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERiTANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF i FILE NUMBER
Amsberger, James H. ,
21 - 02 -
Include the proceeds of Iitiga. tion and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE OF
NUMBER DESCRIPTION
DEATH
Citizens Bank Checking Account #610074-531-7:
Citizens Bank Savings Account #6140-178436:
Highmark, Inc. (refund):
TOTAL (Also enter on Line 5, Recapitulation)
9,197.85
14,429.17
161.28
23,788.30
U$0'Sg BR319
11:C L.EA-R¥:'IE.W RI)
o.i t-tseuea PA
Account Statement
OF 2
Beginning November 06, 2002
through December 04, 2002
Contents
Checking Page
Savings Page
Checking
Batance Catcu~ation
Previous Batance
Checks
Withdrawats
Deposits & Additions
Interest Paid
Current Balance
3,7~5.64
,00
6,098.66
..64
9,197.85
Balance
Average Daily Balance
In teres t
Annual Percentage yield Earned
Number of Days Interest Earned
Interest Earned
Interest Paid this Year
TRANSACT[ON DETAILS
Checks~ The~e ~s e break fn check sequence
Check I1 Ameunt
529 23.85
530 3Z6.79
Check
Amount
3,595.00
9,,002.79
.25%
.64
I2.92
Date
3AMES H ARNSBERGER
Citizens Basic Checking
610074-531-7
ere-Aous Batance
6,B~,.l~
Tatar Checks
3,745.64
Deposits&Additions
Date Amouet
11/18 5 000.00
11729 ' 95.~9
12~02 25.17
12703 978.00
Description
ORep~i't .... -'-ti-at 021129 180011943-001
ps-Yrmopat tH. ~,
'tabte Life AcO7~3py01 021201 0733000000zs~ue
EuC~U~reasunj 303 Soc Sec 120302 180011943a SSA
Totat Oepestts & Adoqflon~s
6,098.6b
Interest
D~e Amount
U/l~ .64
Daffy Balance
B~ance
Oate
11~08 6,820.34
11/13 6,693.§5
11/18 11,693.55
Oesc~ptton
Interest
~ance O~e
Date
11~19 11,694.19 12~02
11/29 8,194.68 12/03
BaEance
8,219-85
9,197.85
Total Interest ~atd
Cerrent Bahnce
9,197.8b
1-888-9i0-4100
Ca(L Citizens' PhoneBank anytime for account information,
cunent ~ates and answers to your questions~
Account Statement
OF 2
Beginning November 06, 2002
through December 04, 2002
Savings
SUMMARY
Balance CaLcuLation
Previous BaLance
Wit~hdrawal. s
Deposits & Additions
Interest Paid
Current Balance
19,425.63
5,000.00
.00
3.54
14,429.17
Average Daily Balance
laterest
Current Interest Rate
Annua! Percentage Yield Earned
Number of Days Interest Earned
Intent Earned
~te~t Paid ~ Year
16
.25~
29
3.28
43.9~
TRRNSACTZOtl DETAIL5
WithdrawaLs
Other Withdra~raLs
Date Amount Description
1i/18 5,000.00 Withdrawal
Interest
Date AmOunt DeSt~iption
11/29 3.54 Interest
Dail~ BaLance
O~e Balan~ O~e Balance
11/18 14,425.63 11/29 14,429.17
[ NEWS FROM CITIZENS
Date
-- Every time you use your Citizens Bank Debit Card for purchases between 11/1 and '12/31,
you'[[ be automaticaLLy entered into the Citizens Bank 'Debit Card HoLiday Sweepstakes. V'isic
dtizensbank, com for Offida[ RuLes. No purchase necessary. Open to U.S. residents who reside
in PA, DE, and N,1 and who am 18 years of age or older as of 11/1/02. Void where prohibited.
Sweepstakes ends 12/31/02.
-- Ca[[ our Education Finance Department at 1-800-708-6684 to learn about products and se~ces
for your famffy's education finance needs.
3AMES H ARNSBERGER
Statement Savings
6140-178436
P~ous BMance
19,425.63
Total Withdrawals
Total Interest Paid
3.54
Current BaLance
14,42P.17
Camp lilt! PA 17~89-0U89 .-
ESTATE OP~ JAM~S aRNS~E~OER
~1 C[EARV'iEW ROAD
DILLSBURG, PA 17019
MUST BE CASHED WITHIN 6 MONTHS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
~H
~EXPENSES&
COSTS
[FILE NUMBER
ESTATE OF Arnsberger, James H. '
21 - 02 -
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State Zip
Year(s) Commission paid
Attorney's Fees Wiley, Lenox, Colgan, & Marzzacco, P.C.:
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
C~y
Relationship of Claimant to Decedent
Probate Fees
State ~ Zip
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
West Shore EMS (last illness):
Claremont Nursing & Rehab:
Total of Continuation Schedule(e)
TOTAL (Also enter on line 9, Recapitulation)
1,500.00
109.15
2,003.18
66.00
3,678.33
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
,~h~lule H
Funeral Expenses &
ESTATE OF ~FILE NUMBER
Arnsberger, James H. I ;2 ] - 0;2 -
4
Register of Wills (filing fee - inheritance tax return):
Register of Wills (filing fee - Small Estate Petition):
15.00
51.00
Page 2 of Schedule H
PATIENT NAME:
INSURANCE:
Phone
JAMES AF~..NSBEF;~GER
MEDIC,~,J::~E B
CAPITAL BLUE
JAMES ARNSBERGER
11 CLEARVIEW RD
DILLSBURG. PA
WEST SHORE EMS - BLS
CAMP HILL, PA ~70~I
iNVOICE
80011 g43A
PATIENT NUMBER: 30g WCS
CALL NUMBER:
DATE OF CALL: 11tl 912002
TIME OF CALL:
CALLER: HOLY SPIRIT HOSPITAL
FROM: HOLY SPIRIT HOSPITAL
TO: CLAREMONT NRSG REHAB CTR
REASON(S)
FOR
TRANSPORT
ACCIDENTAL FALL
: :':: ' ': DESCRIPTION OF CHARGE : ': . :'~NtT PRICE : : , :' AMOUNT
Sq'RETCHER TRANSPORT-NON MEf, Aoggg 1 .O 81,15 81.15
T,"an~po~ Van '"'-~- &nc, nc, ~n n 4 ~
INFECTION COf~ROL ~PPUES A0382 l .O 3.00 3.OO
r~f Charg¢~ 1~.t5
:RECEIPT:: ,: PAYMENT DATE : AMOUNT
PLEASE PAY THIS AMOUNT ~
DETACH ALONG PERFORMATIO. A~D RETURN sTUB WITH PAYMENT
IPATIENT NAME:
PATIENT NUMBER:
AMOUNT DUE
ARNSBERGEE, J.~ES H CALL NUMBER AMOUNT $
99888W
309 BILLING DATE: ~ 2~2002 ENCLOSED
THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL
ASSISTANCE.
~ VISA ~}
MASTER CARD
ACCEPTED
WEST SHOEE EMS - BLS 503 N 21ST ST CANIP HILL, PA 170t
Ctaremon% Nursing & Rehab
375 Clarem~'~ Drive
Carlisle PA i7(D13
(717) ~43-2~3!
12 PA~ N~E
Arnsb~
14 BJR'~IDATE
09291
James H
12010~
23 MEDICAL RECORD NO.
4259
James H Arnsberger
Fern M Arnsberger
11Clearview Road
R & B NURSING CARE -
i
44 HCRC. S/RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAl. CHARGES
185.
48 NON*COVERED CHARGES
925[00
50 PAYER
PRIVATE PAY
58 INSURED'S NAME
Arnsberger James H
51 PROVIDER NO.
CLAREMONT
80 CERT.- ~N-HIC.-ID NO.
180011943
65 EMPLOYER N/~E
54. PRIOR PAYMENTS 55 EST. AMOUNT DU
81 GROUP NAME 62 INSURANCE GROUP NO.
66 EMPLOYER LOOATION
4389 25000
PRINCIPAL PROCEDURE
CODE
84
76 Al)M, DIAG. CD. 77 E-CODE
25000
::'!! C 27772 MD KENNETH R
Ctaremont Nursing &
375 Clarem~n% Drive
Carlisle PA 17013
,, (717} -243-203!
PATIE~
ArnsDerger~ James
t 0929190~ ~~ [4,. 11260~2
James H Arnsberger
Fern M Arnsberger
11 Clearview Road
4~ R~V, OD. ~ ~ D5SOB~ON
,_ ~ ...... ~ 4259
FED TAXNO ';~'~.A, ~8~ROD "~ ~VD n
23-6ee31!~ 112' 6e'b 1129¢i e~
13 PATIENT ~DRE~ '
i 50 PAYER
PRIVATE PAY CLAREMONT
57
58 INSURED'S NAME
51 PROVIDER NO. 54 PRIOR PAYMENTS
60 CERT. - SSN - HIC. - ID NO.
3t
48 NON-COVERED CHARGES
84 REMARKS
925.00
9i.3i
~B22.3i1
i '
61 GROUP NAME 62 II~SURANCE GROUP NO.
ArnsDerger James H 1800~11943
PRIN. 7e
PRINOIPA/PROOEDU~ .,
~DE ~TE
C27772 ~RN~ HD KENneTH R
~ I DA~
X 12/12/2002
REV-1E13 EX+ (94)0) ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF 'FILE NUMBER
Arnsberger, James H.
i 21 - 02 -
NUMBER
II.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Fern M. Amsberger
11 Clearview Road
Dillsburg, PA 17019
RELATIONSHIP TO
DECEDENT
Do Not Ust Trustee(n)
Daughter
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
Faith Assembly of God Church
806 Fishing Creek Rd., New Cumberland, PA 17070
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
AMOUNTORSHARE
OF ESTATE
18098.97
2,011.00
2,011.00
BUREAU OF ZNDZVZDUAL TAXES
][NHERI'TANCE TAX D'r¥1'Si'ON
DEPT. 280601.
HARRTSBURG, PA ].?'128-0601
JAN N WZLEY
I S BALT ST
DZLLSBURG
CONNONWEALTH OF PENNSYLVANZA
DEPARTNENT OF REVENUE
PA 17019
NOTZCE OF ZNHERZTANCE TAX
APPRAZSEHENT, ALLONANCE OR DZSALLONANCE
OF DEDUCTZONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FZLE NUNBER
COUNTY
ACN
REV-16~i7 EX AFP (gl-D3)
Oq-1q-2005
ARNSBERGER JANES N
12-06-2002
21 05-0175
CUMBERLAND
101
Amount Remitted I
HAKE CHECK PAYABLE AHD RENZT PAYNENT TO:
REGZSTER OF WZLLS
CUNBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THZS LZNE ~ RETAZN LOWER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03} NOTZCE OF ZNHERZTANCE TAX APPRAZSEHENT, ALLOWANCE OR
DZSALLOWANCE OF DEDUCTZONS AND ASSESSHENT OF TAX
ESTATE OF ARNSBERGER JAHES N FZLE NO. 21 03-0175 ACM 101 DATE 0q-1~-2005
TAX RETURN NAS: (X} ACCEPTED AS FZLED { ) CHANGED
RESERVATZON CONCERNZNG FUTURE ZNTEREST - SEE REVERSE
APPRAZSED VALUE OF RETURN BASED ON: ORZG/NAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
$. Closely Held Stock/Partnersh/p Znterast (Schedule C) ($)
q. Mortgages/Notes Rece/vable (Schedule D) (q)
$. Cash/Bank Dapos/ts/M/sc. Personal Property (Schedule E) (5)
6. Jo/ntly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVED DEDUCTZONS AND EXENPTZONS:
9. Funeral Expenses/Adm. Costs/H/sc. Expenses (Schedule H) (9)
10. Debts/Mortgage L/ebilit/es/L/ans (Schedule Z) (10)
11. Total Deduct/ohs
12. Net Value of Tax Return
25~788.30
.00
.00 NOTE: To /nsure proper
.00 credit to your account,
.00 subeit the upper port/on
.00 of th/s form w/th your
tax payment.
.00
(8)
3,678.33
.00
25,788.:30
(11) 3 .&7fl. 33
(la) 20,109.97
13.
lq.
NOTE:
ASSESSMENT OF TAX:
15. Amount of L/ne lq at Spousal rate
16. Amount of L/ne lq taxable at Lineal/Class A rate
17. Aeount of Line lq at S/bl/ng rata
18. Amount of L/ne lq taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDZTS:
PAYMENT RECE/PT DZSCOUNT (+J
DATE NUMBER ZNTEREST/PEN PAZD (-)
02-27-2003 CD002232 qO.7Z
CharitabZa/Oovarnmental Bequests; Non-elected 9113 Trusts (Schedule J) (13)
Net Value of Estate Subject to Tax
Z~ an assessment was lssued prev/ously, lines 1~, 15 and/or 16, 17,
reflect f/gures that include the total of ALL returns assessed to date.
2,011.00
18,098.97
18 and 19 will
(15) .00 x 00 = .00
(16) 18,098.97 x 0q5= 8lq.q5
(17) .00 x 12 = .00
(ze) .00 x 15 = .00
(19)= 81q.q5
ZF PAID AFTER DATE ZND/CATED, SEE REVERSE
FOR CALCULATZON OF ADDZT/ONAL ZNTEREST.
AHOUNT PAZD
773.73
TOTAL TAX CREDZT
BALANCE OF TAX DUE
ZNTEREST AND PEN.
TOTAL DUE
8lq.q5
.00
.00
.00
( ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS RE~UZRED.
IF TOTAL DUE ZS REFLECTED AS A 'CREDZT' (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE S~DE OF THIS FORM FOR ZNSTRUCTZONS.)
RESERVATION:
PURPOSE OF
NOTICE:
PAYNENT:
REFUND (CR):
OBJECTIONS:
ADNIN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December lg, 198Z -- if any future interest in the estate is transferred
in possession or enjoyment to Class B icollateral) beneficiaries of the decadent after the expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class D (collateral) rate on any such futura interest.
To fulfill the requirements of Section g160 of the Inheritance and Estate Tax Act, Act g$ of ZOO0. i72 P.S.
Section 9160).
Detach the top portion of this Notice and submit with your payaent to the Register of Hills printed an the reverse sida.
--Make check or money order payable to: REGXSTER OF MILLS, AGENT
A refund of a tax credit, which wes not requested on the Tax Return, may bo requested by completing an "Application
for Refund of Pennsylvania Xnharitanca and Estate Tax" iREV-[51$). Applications are available at the Office
of the Register of Hills, any of the 25 Revenue District Offices, or by calling the special gq-hour
answering service for forms ordering: 1-800-56Z-Z050; services for taxpayers with special hearing and / or
speaking needs: 1-800-467-3020 iTT only).
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions) or assessment
of tax (including discount or interest) as shown on this Notice must object within sixty I60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. Z80601, Harrisburg, PA 17128-0601
Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (RE¥-1501) for an explanation of administratively correctable errors.
If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (SI) discount of
the tax paid is allowed.
The 157. tax amnesty non-participation penalty is computed on [ha totml of the tax and interest assessed, and not
paid before January 18, 1996, tho first day after the end of tho tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became de[inquant before January 1, 19ag bear interest at the rate of
six (6Z) percent par annum ca[cu[ated at e dai[y rate of .000164. A[I taxes which became da[inquent on and after
January 1, [982 wi[[ bear interest at a rate which wi[I vary free colander year to ca[endar year with that rate
announced by the PA Doper[man[ of Revenue. The applicable interest rates for 1982 through 2003 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Yea..__r Rate Factor Yea__r Rate Factor
1982 ZOZ .000568 1987 91 .000247 1999 71 . O00191
1983 162 .000658 1988-199[ 1ZZ .000301 ZOOO 8Z .000119
1986 111 .000301 1991 97. .000167 ZOO1 91 .000247
1985 15Z .000556 1995-1996 71 .000191 ZOOZ 6Z .000166
1986 lOX .000176 1995-1998 97. .000167 1005 51 .000157
--Interest is calculatmd as follows:
XNTERBST = BALANCE OF TAX UNPATD X NUMBER OF DAYS DEL/N{~UENT X DAILY TNTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen ilS) days
beyond the date of the assessment. [f payment is made after the interest computation date shown on tho
Notice, additional interest must be caIculatmd.